COLUMBIA LIBRARIES OFFSITE 
 
 HEALTH SCIENCES STANDARD 
 
 HX64121330 
 C46 .Sc3 1919 Modem medicine and 
 
 RECAP 
 
 MEDICINE 
 
 {JOM]i MOJ3KRN RJiMEDlES 
 
 I'UOMAS nODl.HY SCOTT 
 
 S15C0ND liDlTlON 
 
Columbia ®mtjergitp\^\5 
 
 in tfje €itv of JSettJ ^ovk 
 
 COLLEGE OF PHYSICIANS 
 AND SURGEONS 
 
 Reference Library 
 
 Given by 
 
MODERN MEDICINE 
 
 AND 
 
 SOME MODERN REMEDIES 
 
MODERN MEDICINE 
 
 AND 
 
 SOME MODERN REMEDIES 
 
 Practical Notes for the General Practitioner 
 
 BY 
 
 THOMAS BODLEY SCOTT 
 
 AUTHOR OF "the ROAD TO A HEALTHY OLD AGE " 
 
 WITH A PREFACE 
 
 BY 
 
 SIR LAUDER BRUNTON, Bart., F.R.S. 
 
 SECOND EDITION 
 
 PAUL B. HOEBER 
 
 67 & 69 EAST 59TH STREET 
 
 NEW YORK 
 
 1919 
 

 [P? luted in England] 
 
AUTHOR'S APOLOGY 
 
 The " Horse Subsecivse '* of a busy doctor are 
 not many, nor are they consecutive. If one 
 could sit down at one's leisure and write 
 currente calamo, a more finished and better 
 thought-out argument could be produced, but 
 one not necessarily more convincing. For these 
 essays, which have been written at odd times 
 and in odd places, I know I can claim the 
 forbearance and sympathy of my professional 
 brethren, for they too are the servants — thank 
 God the willing servants — of their patients 
 night and day. 
 
 T. B. SCOTT. 
 
 Bournemouth, 
 
 February 191 6. 
 
Digitized by the Internet Archive 
 
 in 2010 with funding from 
 
 Open Knowledge Commons 
 
 http://www.archive.org/details/modernmedicinesobOscot 
 
PREFACE 
 
 When the library of Louvain with its precious 
 books and priceless manuscripts was destroyed 
 in August 1 9 14, in the name of their god 
 " Kultur " by the modern Huns, more treacher- 
 ous, more unspeakably mean and more incred- 
 ibly evil, than their prototypes, a cry of horror 
 and execration rose from the civilised world. 
 For this was not only an outrage on Belgium, 
 a country which the Huns had pledged them- 
 selves to respect ; it was a crime against 
 humanity — for the treasures of learning then 
 destroyed were a part of the heritage of man- 
 kind. Great and widespread was the lamenta- 
 tion, and cause enough there was for it, for these 
 lost treasures can never be entirely replaced. 
 Yet we see every day around us a loss of learning 
 going on greater than occurred in the destruc- 
 tion of Louvain, and no one seems to perceive 
 it or hft a finger to prevent it. No doubt some 
 men outlive their usefulness, but many die 
 
 vu 
 
viii PREFACE 
 
 just when they are at their best, just when 
 they have accumulated stores of wisdom and 
 have learned both what to do and how to do it. 
 Most of these men carry their knowledge and 
 power with them to the grave, and leave no 
 record behind them by which posterity might 
 profit. 
 
 In former days this complete loss was 
 prevented to a great extent by the system of 
 apprenticeship. By this system a master im- 
 parted to his apprentices as much as he could 
 of the secrets of his craft, and ensured as much 
 as possible that the best methods he had 
 learned from his own master, or discovered for 
 himself, should be transmitted in full measure 
 to his pupils, who in their turn should do as 
 much for theirs. 
 
 But this system with all its advantages 
 has in great measure disappeared, and serious 
 has been the loss. 
 
 Perhaps no art or craft has suffered more 
 than that of medicine by this change. It is 
 true that the loss has been compensated, and 
 more than compensated on the whole^ by the 
 enormous advances of medical science. Our 
 knowledge of the causes of disease, our power 
 to recognise their presence, and our knowledge 
 
PREFACE ix 
 
 of the action of drugs, have increased so enor- 
 mously within the last fifty years that medicine 
 may now almost boast of being an exact 
 science. 
 
 But while medicine as a science has gained, 
 there has been loss in medicine as an art — loss 
 in the method of applying all this knowledge 
 to the treatment of individual patients. One 
 man may know theoretically all about the laws 
 of perspective and the harmony of colours, 
 and yet be unable to produce anything but a 
 daub, while another who is completely ignorant 
 theoretically may be able to paint a charming 
 picture. In like manner a man may be able 
 to pass the most stringent examination with 
 honours in pathology, pharmacology and diag- 
 nosis, yet he may prove almost useless by the 
 bedside, because he tries to treat the disease, 
 and not the patient. On the other hand a 
 man with far less theoretical knowledge but 
 more common sense and savoir-faire will win 
 his patient's confidence, give him comfort and 
 ease both of mind and bod}^, and even rescue 
 him from a condition so serious as to be well- 
 nigh hopeless. 
 
 The ideal physician is the man who combines 
 theoretical knowledge, practical experience and 
 
X PREFACE 
 
 savoir-faire. In the absence of apprenticeship 
 the best conditions for obtaining this highly 
 desirable combination are those of a general 
 practitioner who, after a thorough training as 
 a student, has an active practice amongst 
 patients sufficiently wealthy to enable him to 
 call the best specialist or specialists into con- 
 sultation in any difficult case. He thus learns 
 all they can teach him either of theory or 
 practice, he has an opportunity of testing the 
 correctness of both by watching the progress of 
 his patient, and from his relations with the sick 
 person he becomes a friend both of the patient 
 and the family. 
 
 It is most unfortunate that such men rarely 
 write down the results of their experience, for 
 they are too much engaged in their daily work 
 while they are in practice, and instead of 
 retiring early, so as to have a few years' leisure 
 before they die, they are apt to work to the 
 very last and die in harness. 
 
 It is a most welcome occurrence when a man 
 fully qualified to do so writes down the ripe 
 experience of his life so as to help his fellow- 
 workers, both general practitioners and con- 
 sultants, who one and all may learn from 
 him. 
 
PREFACE xi 
 
 I feel myself much honoured by the request 
 of my friend Dr. T. B. Scott to write a preface 
 to his book, and in doing this I gladly acknow- 
 ledge myself to be one of the consultants of 
 whom I have just spoken, and to thank him 
 for the knowledge I have gained from reading 
 his book. 
 
 Few, if any, will rise from its perusal without 
 knowing something of which they were pre- 
 viously ignorant ; and if other men qualified 
 like Dr. Scott will follow the example he has 
 set, and write down the results of their experi- 
 ence, the medical profession will gain greatly 
 in knowledge and patients will benefit greatly 
 by improvement in treatment. 
 
 Lauder Brunton. 
 
CONTENTS 
 
 Author's Apology 
 
 
 PAGE 
 
 V 
 
 Preface 
 
 
 vii 
 
 List of Authorities 
 
 
 XV 
 
 Introduction .... 
 
 
 I 
 
 I. Disorders of the Heart . 
 
 
 7 
 
 11. Arterio-sclerosis 
 
 
 49 
 
 HI. Therapeutic Speculations 
 
 and 
 
 
 Doubts .... 
 
 
 97 
 
 IV. Chronic Bronchitis and Bron- 
 
 
 chial Asthma . 
 
 
 i8o 
 
 Xlll 
 
AUTHORITIES 
 
 Allbutt, Clifford, Dr. : Dictionary of Medicine, 
 
 vol. v., p. 961. 
 BiEDL, Professor : Internal Secretory Organs, pp. 70, 
 
 75, 91, 188, 250. 
 Brunton, Lauder, Sir : Therapeutics of the Circula- 
 tion, pp. 89, 90, 295, 307, 335, 433 ; Lancet, vol. 
 
 vii., p. 24, 1915. 
 Elliott, Dr. : Practitioner, February, 1915. 
 Gaskell, Dr. : Article on " Contraction of the Heart 
 
 Muscle " in Schafer's Textbook of Physiology. 
 Mackenzie, James, Dr. : Diseases of the Heart, 
 
 pp. 20, 28, 72, 78, 341, 377. 
 Murray, George, Dr. : Practitioner, January, 191 5. 
 Oliver, George, Dr. : Studies in Blood Pressure, 
 
 pp. 82, 109, 189. 
 Paton, Noel, Dr. : Practitioner, February, 1915. 
 Schafer, Edward, Sir : An Introduction to the Study 
 
 of the Endocrine Glands, Stanford University, 
 
 California. 
 Short, Rendle, Dr. : The Newer Physiology, third 
 
 edition, pp. 82, 144. 
 Whitla, Dr. : Practice of Medicine, vol. i., p. 633. 
 
 XV 
 
ESSAYS ON PRACTICAL 
 MEDICINE 
 
 INTRODUCTION 
 
 The experiences and opportunities for experi- 
 ences that belong to hospital physicians and to 
 general practitioners differ so much, that the 
 study and treatment of disease from their 
 several points of view differ also. As a rule 
 the hospital physician is an able writer and a 
 skilled recorder, while the general practitioner 
 has either not the time, or else not the courage, 
 to record his experiences and results, and so 
 much valuable material and knowledge are lost 
 to the world. A great general will take care 
 to get into touch with his non-commissioned 
 officers and men, as well as with his officers, and 
 will make use of the experiences and observa- 
 tions of both classes. Not a few of our own wiser 
 hospital physicians refuse to sit in the seat of 
 the scornful, and listen carefully to what we 
 I 
 
'2 ESSAYS ON PRACTICAL MEDICINE 
 
 have to say and openly acknowledge their in- 
 debtedness to us. It has been too much the 
 habit of our profession to rely almost entirely 
 on hospital records and results, both of which 
 are necessarily obtained under rather abnormal 
 and favourable circumstances, and it is difficult 
 for the ordinary hospital physicians to gauge 
 the difficulties in diagnosis, in prognosis, and 
 in treatment that meet their humbler brethren. 
 Dr. James Mackenzie in his invaluable work 
 on diseases of the heart says: " The investigators 
 in hospital wards and laboratories have little 
 idea of the difficulties the general practitioner 
 has to encounter. He must ever be on the alert, 
 prepared to make an observation at any hour 
 of the day and night ; attacks of illness which 
 may arise suddenly must find him prepared to 
 take advantage of his opportunities." He goes 
 on to say, " The little I have been able to do 
 in this respect has but opened my eyes to the 
 extraordinarily rich field for investigation that 
 lies before the general practitioner." 
 
 The position that Dr. Mackenzie has won 
 for himself and the magnificent work he has 
 done, though for years only a general practi- 
 tioner, should be a great encouragement and 
 incentive to us all. 
 
INTRODUCTION 
 
 Why, then, should we keep our lights hidden ? 
 Our light, like that of true religion, is meant to 
 shine before men, and to enable both them and 
 us to glorify our Father which is in heaven. 
 Our work, if faithfully done, will surely lead 
 towards the fulfilment of His increasing pur- 
 pose, which I take to be the evolution of human 
 perfection. 
 
 We have some good periodicals that are 
 ready to accept any papers of merit and 
 originality. It is we who see disease in its 
 inception, in its maturity and in its end. We 
 may not have the scientific knowledge and 
 appliances that belong to a well-equipped hos- 
 pital, but in our knowledge of practical thera- 
 peutics we are often in advance of the hospital 
 physician : that this should be so is no honour 
 to us, and no shame to them, for we are in 
 much closer relationship with our patients, and 
 we can observe more accurately the successes 
 and the failures of our methods. We have to 
 treat disease in its natural habitation and sur- 
 roundings, and not in the unaccustomed quiet 
 and luxury of a hospital ward. As our diffi- 
 culties are greater, so must we improve our 
 weapons and resources. Our teachers and 
 examiners are devoted, hard-working, excellent 
 
4 ESSAYS ON PRACTICAL MEDICINE 
 
 men, and good doctors up to their lights, but 
 they have, from the very nature of their posi- 
 tion, their hmitations. 
 
 I think perhaps where we are most deficient 
 is in accuracy of diagnosis. Sometimes we are 
 hurried, and often wearied, and so come to a 
 conclusion too hastily ; sometimes we have to 
 use the stethoscope in such noisy rooms that 
 important points are missed or misread. 
 Whether this be so or not, accuracy of diag- 
 nosis must be the groundwork of success. This 
 may entail more time and trouble than we seem 
 to have to spare, but it is so essential that in the 
 end no time will have been lost. We must not 
 hesitate to call in other aids, especially the aid 
 of the bacteriologist and in some cases that of 
 the specialist. A wise general practitioner who 
 had a very large club and contract practice once 
 said, " The only way to make contract practice 
 pay is to find out what is really the matter with 
 your patients, give them the best medicines 
 you know, even if they be costly, and get them 
 off your list as quickly as possible." That con- 
 tains not only worldly wisdom, but the true 
 spirit also of altruism and righteousness. Good 
 and honest work will always pay in the end. 
 These thoughts must lead us on to see the 
 
INTRODUCTION 
 
 enormous importance of a sound knowledge of 
 therapeutics ; for mere accuracy of diagnosis 
 is, as I have said before, only the groundwork, 
 the foundation of our successful building. 
 Our one and only objective must be, to cure 
 disease, and in so doing to relieve suffering and 
 prolong life. In the great campaign against 
 disease, we should be the eyes and ears of the 
 army ; the scouts, and in treatment often the 
 pioneers. 
 
 We should welcome the wisdom that comes 
 from above, from our teachers and lecturers, 
 but we should not be enslaved by it ; we should 
 rather prove it and improve it. 
 
 Failures must of course come to us, but we 
 should never allow oiurselves to look on failure 
 as inevitable. We must storm and go on storm- 
 ing even what seem to be impossible heights. 
 
 I publish this little book in the hope that it 
 may be of some help to my fellow practitioners, 
 and still more in the hope that it may induce 
 some of them to follow my poor example. 
 
DISORDERS OF THE HEART 
 
 If there is one organ of the body that we are 
 tempted to misread more than another it is, 
 I think, the heart. We are so tied down by 
 traditions and conventions with regard to 
 heart affections that we hardly ever give our 
 common sense full play. And it is not only 
 in conditions of evident disease that we mis- 
 interpret, but also in conditions of apparent 
 health. One chief reason for our errors is, I 
 think, the exclusive reliance on the stetho- 
 scope. In reality the stethoscope tells us but 
 a small part of the whole matter. It tells us 
 the condition of the valves of the heart, and 
 this is, of course, a thing we must know ; but, 
 except in cases of extreme debility or degenera- 
 tion, it tells us very little of the state of the 
 muscle of the heart itself, that great driving- 
 power that keeps going our circulation, and 
 with it our hfe, and to which the valves are. 
 only accessories. 
 
8 ESSAYS ON PRACTICAL MEDICINE 
 
 As a preliminary to the intelligent study of 
 heart disease we must get these axioms firmly 
 into our minds : first that the heart is an organ 
 with enormous natural powers of recuperation, 
 and second that it is an organ with a marvellous 
 power of adapting itself to meet not only 
 emergencies, but also permanently altered 
 conditions. We must all of us have come 
 across many cases in our Hves, in which there 
 was marked valvular abnormality, yet in which 
 no symptoms of ordinary heart disease showed 
 themselves during life. I think the loudest 
 aortic systolic murmru I ever heard was in an 
 old lady, who with the exception of rheumatism 
 had remarkably good health and who Hved till 
 she was ninety-three. 
 
 To give very shortly a clear idea of the 
 functions and special characteristics of the 
 heart muscle I give this extract from Dr. 
 Mackenzie's book on diseases of the heart : 
 " I therefore suggest as a working hypothesis, 
 that, in the evolution of the heart muscle 
 fibres, certain functions of the primitive cell 
 were retained, some of these being more de- 
 veloped than others according to the duties the 
 fibres had to perform, so that while they have 
 come to resemble muscle fibres, they never- 
 
DISORDERS OF THE HEART g 
 
 theless retain, in a varying degree, some func- 
 tions which are highly speciaHsed in the nerve 
 ceU." 
 
 The special functions which Gaskell has 
 demonstrated are five : 
 
 1. The power of producing a stimulus 
 
 which can excite the heart to 
 
 contract .... Stimulus production 
 
 2 . The power of being able to receive 
 
 a stimulus .... Excitability 
 
 3. The power of conveying a stimu- 
 
 lus from fibre to fibre . Conductivity 
 
 4. The power of contracting, when 
 
 stimulated .... Contractibility 
 
 5. The power to retain a certain 
 
 amount of contraction even 
 
 when the activity has ceased . Tonicity 
 
 For the elaboration and description of these 
 five functions, which all go to form the perfect 
 action and function of the heart, I must refer 
 my readers to Dr. Mackenzie's book, or to 
 Gaskell's article on " The contraction of the 
 heart muscle " in Schafer's text-book of physi- 
 ology. Without this physiological explanation 
 and knowledge it is difficult, nay impossible, 
 to rightly weigh the value of abnormalities 
 in the heart's action in clinical work. 
 
 The relative importance of different valvular 
 diseases varies, without doubt ; but that is a 
 point which I shall touch on later. My con- 
 
lo ESSAYS ON PRACTICAL MEDICINE 
 
 tention is this : that the man who in heart 
 affections trusts only to the stethoscope is, 
 of necessity, sure to come to grief, for he is 
 gauging one side only, and that not the most 
 important side, of a complicated problem. 
 The test of a heart's working power Hes not in 
 the perfection of this or that valve, but in the 
 fact of that heart being able to meet the demand 
 of the individual's Hfe or not ; and in testing 
 this the stethoscope will help but little. 
 Careful observation of the patient's breathing 
 and powers of endurance will help, far more, 
 to show what amount of reserve power remains 
 in the heart muscle and what the prospects are 
 of that muscle being able to respond to new 
 demands. I saw an old man lately, who 
 greeted me thus : " To-day is a very im- 
 portant anniversary in my life. It is just fifty 
 years ago that I was rejected for life insurance 
 on account of heart disease." Now a case 
 like this has a humorous side, but it also brings 
 our learned profession into ridicule and dis- 
 repute. 
 
 For further guidance — and I think it would 
 be hard to exaggerate their value — we have the 
 sphygmograph and the sphygmo-manometer 
 (I am not laying stress on the electro-car dio- 
 
DISORDERS OF THE HEART u 
 
 graph, as that is practically out of the reach of 
 the ordinary doctor) ; these will help far more 
 than the stethoscope to get a clear and just 
 understanding of the heart's condition. It is 
 very rarely, for example, that the " pulsus 
 alternans,'* which may be of great diagnostic 
 importance, can be detected by the finger ; the 
 sphygmograph alone can prove its existence. 
 Arterial tension again, high or low, can only 
 be at all accurately tested by the manometer, 
 and in the treatment of a failing heart, of what 
 paramount importance it is to recognise the 
 true condition ! To learn the use of these 
 instruments takes some time and trouble, but 
 it is our manifest duty to do it. When we are 
 able to use them we shall be able to do far more 
 for our patients, for our reputation, and for our 
 peace of mind. Nothing is more unsatisfactory 
 to an honest mind, than to feel that he is trying 
 to solve a problem, which is insoluble, only 
 because of the twilight ignorance of his own 
 mind, or of the imperfection of his weapons. 
 In general practice, especially among busy 
 working folk, these cases of heart disease or 
 heart failure form a large part of our practice, 
 and their continuance leads to much disability 
 and misery. If we can get hold of them in 
 
12 ESSAYS ON PRACTICAL MEDICINE 
 
 their early stages and treat them wisely, we 
 can do very much not alone to prolong life but 
 to maintain a good output of work, and what 
 that means to working people those only who 
 have lived among them know. Let us then cast 
 aside our old preconceived ideas, which were 
 often not in accordance either with scientific 
 knowledge or with experience, and using every 
 weapon of modern science, let us wage a new 
 warfare in the spirit of confidence and hope. 
 Many of our older teachers and brethren will 
 quietly sneer, and throw cold water on our 
 enterprises, but we must comfort ourselves with 
 the thought that the old proverb about putting 
 new wine into old wine-skins still holds good. 
 In the study and treatment of heart diseases 
 we must most strongly bear in mind the fact 
 that the natural heart under ordinary conditions 
 is only working at part of its power, and that 
 there is always a considerable reserve of latent 
 force. This varies, of course, in different 
 individuals, and in the same individual under 
 different circumstances. It is this latent force 
 that enables us in health to make unusual and 
 prolonged physical efforts, and it is the greater 
 or lesser amount of this latent force that 
 enables the heart under conditions of disease to 
 
DISORDERS OF THE HEART 13 
 
 meet and overcome the new difficulties, or to 
 fail in the attempt. In health, by wise physical 
 exercises, and by what we call training, the 
 latent force can be enormously increased, so 
 that marvellous feats of effort and endurance 
 can be performed. In disease also the amount 
 of latent force can be much increased or at 
 least preserved by wise exercise and training. 
 This we see constantly as the result of the so- 
 called Swedish exercises and of those of Nau- 
 heim. With these facts firmly in our minds, 
 we must approach each case of heart disease 
 not so much from the valvular side, the side 
 of obstruction or of leakage, as from the side of 
 the heart muscle itself. The stethoscope will 
 tell us more or less accurately the nature of 
 the valvular defect, but not — which is more 
 important — the power of the great and com- 
 plicated organ to meet that defect. 
 
 We must study the whole problem in a large 
 spirit, and our treatment must be directed to 
 placing the patient and his heart under the best 
 conditions for recovery, or, if that be not pos- 
 sible, for a natural readjustment of the heart's 
 work. Many a heart will do this for itself if it 
 only has the chance. Rest, it goes without say- 
 ing, must be the first step, but to rest a heart 
 
T4 ESSAYS ON PRACTICAL MEDICINE 
 
 is not quite so simple an affair as resting a limb. 
 Staying in bed, or in the recumbent position, is 
 of course good up to a certain point ; but the 
 heart has to go on working and pumping the 
 blood unceasingly, and it often can do this 
 better if the patient change the position from 
 time to time. If by rest in one position the 
 lungs get into a state of hypostatic congestion, 
 the right ventricle has extra work to do and the 
 balance of the whole cardiac and respiratory 
 system gets upset. Stagnation of the portal 
 circulation will soon add another difficulty : 
 comparative, not complete, rest is all one can 
 give the heart, and to give that in the best way 
 common sense and individual observation must 
 be largely used. We all know how a patient 
 with cardiac dyspnoea longs to change his 
 position from time to time, and Nature no doubt 
 tells him aright. The great things to avoid in 
 such a case are hurry and straining ; stooping 
 to pick up something, or to lace boots, will often 
 bring on acute distress. The physician can help 
 this heart to get rest considerably by removing 
 obstructions to the circulation of blood, by 
 keeping the portal circulation free, and by 
 encouraging the thorough action of the bowels 
 and kidneys. It is marvellous to see a tired, 
 
DISORDERS OF THE HEART 15 
 
 overworked and failing heart coming back to 
 efficiency and comfort under the famous old 
 pill, which both Guy's and St. Bartholomew's 
 claim, of mercury, squills and digitalis : the 
 mercury steadily stimulates the liver, and the 
 squill and digitalis both act on heart and 
 kidneys. Experience has often shown that 
 digitalis without the mercury is almost use- 
 less in such a case. If again by the modern 
 methods of testing the arterial resistance — viz. 
 by the sphygmo-manometer — we find, as we so 
 frequently do, that there is high blood-pressure, 
 we can help the heart greatly by reducing that 
 pressure, and with it the peripheral resistance 
 to the flow of arterial blood. After two or three 
 weeks of such intelligent rest treatment, one 
 will be able to form a far better idea of the real 
 state of the heart ; one will know how much 
 true valvular trouble exists, how much of the 
 trouble was due to dilatation, and how much 
 to the state of the heart muscle itself. 
 
 One speaks of these conditions, valvular 
 disease, dilatation and muscular weakness, as 
 separate, but as a rule they are all three bound 
 up together and are interdependent. To arrive 
 at this knowledge one must, besides using the 
 stethoscope, observe carefully the position of the 
 
i6 ESSAYS ON PRACTICAL MEDICINE 
 
 heart's apex and the area of cardiac duUness. 
 K the murmur cease or lessen in intensity ; if, 
 under rest and wise treatment, the dullness 
 diminish and the apex-beat come gradually 
 back to its normal position, one will reasonably 
 hope that the heart's disorder was due chiefly 
 to exhaustion of a temporary nature, and 
 that it possesses a fair amount of reserve 
 power. If, on the other hand, the murmur 
 remain the same, and the dullness and apex-beat 
 remain stationary, one will realise that the 
 heart's condition is probably due to permanent 
 dilatation, or to compensatory hypertrophy, 
 following a long-standing valvular disease ; 
 here the history of the patient, his former ill- 
 nesses and his habits of life will help towards 
 an accurate diagnosis. If the condition is one 
 of hj^ertrophy and old valvular disease, not 
 much can be done by treatment, except to 
 keep up the nutrition and strength of the heart 
 muscle — we must never forget that hyper- 
 trophied muscles are particularly liable to 
 degenerate — iron, arsenic and strychnine, par- 
 ticularly in combination, wiU help much 
 towards this end. Such hearts, if carefully 
 nursed, will often last a long time, but they have 
 to Hve their life at a rather low level. The old 
 
DISORDERS OF THE HEART 17 
 
 proverb says, the strength of a chain is the 
 strength of its weakest Hnk, and such patients 
 have to learn this lesson and to order their work 
 and energies in accordance with their weak link. 
 On the other hand, one must never discourage 
 these cases. A leaky ship will often make a long 
 and successful voyage, and a heart with a leaky 
 valve will often carry its owner to old age, and 
 will help him to do much excellent work. If 
 you tell such a man that he has incurable heart 
 disease (he may happily be blessed with a 
 saving scepticism), you will have done your 
 utmost to ensure the accuracy of your prog- 
 nosis, though your diagnosis may have been 
 grievously wrong. There is no important organ 
 of the body so susceptible to nervous and 
 mental influence as the heart ; hope will buoy 
 it up to make renewed and often successful 
 efforts, despair will kill it. To support my 
 contention I quote Dr. James Mackenzie's 
 words : " Let it always be remembered that 
 frequently sound and healthy hearts show a 
 murmur, and that it is necessary therefore to 
 seek for other evidences on which to base a 
 prognosis. The heart failure which may be 
 present depends upon so many and so varied 
 conditions — as, the extent of the valvular 
 2 
 
1 8 ESSAYS ON PRACTICAL MEDICINE 
 
 lesion, its progressive nature depending on 
 the cicatrising process affecting the valves, 
 the coincident changes in the muscle and in 
 the auriculo-ventricular bundle, the condition 
 of life of the individual — that no rule appUcable 
 to all cases can be made." Later on he says : 
 " Let no single sjmiptom be the ground for 
 forming an unfavourable prognosis. In this 
 respect, the presence of a murmur has so op- 
 pressed the profession that a vast amount of 
 positive harm is continually being done to 
 patients by taking too seriously the prognostic 
 significance of this sign. The field of cardiac 
 response is the only true and safe guide in these 
 cases. Even if for the time being that response 
 is limited, judgment should be suspended until 
 an opportunity has been obtained for ascer- 
 taining to what extent the heart muscle can 
 regain a store of reserve force." The business 
 of a prophet is nearly at all times a dangerous 
 and an unsatisfactory one, whether in medicine 
 or in any other sphere ; but, recognising our 
 fallibility, it is surely wiser and safer to err, 
 like Balaam of old, on the side of blessing rather 
 than of cursing, of optimism rather than of pes- 
 simism. I have no wish to weary my readers, 
 if such there should be, with a dissertation on 
 
DISORDERS OF THE HEART ig 
 
 valvular diseases of the heart and their physical 
 signs ; they probably know as much as I do 
 about them, but I think it will be a help to give 
 this short summary of their incidence and their 
 gravity. 
 
 Firstly, valvular disease, excluding con- 
 genital malformations, is acquired, not in- 
 herited. Secondly, far the most common cause 
 of chronic valvular disease is an infective pro- 
 cess, producing endocarditis ; of these infective 
 processes acute rheumatism is the most com- 
 mon, but the poisons of enteric fever, scarlatina, 
 erysipelas and gout may produce the same 
 effect. Syphilis is another cause, but probably 
 does not act in quite the same way. The only 
 other causes as far as we know of valvular 
 disease are, prolonged and severe muscular 
 strain and in later life atheroma. The diseased 
 condition is primarily an inflammatory thick- 
 ening of the valves, which produces a fibrous 
 cicatricial tissue ; this fibrous tissue has a ten- 
 dency, as life goes on, to contract. This con- 
 traction may never take place, but if it does 
 the symptoms of stenosis or of incompetence 
 become more marked and more serious. 
 
 Thirdly, diseases of the mitral valve form 
 more than half of our cases, and regurgitation 
 
20 ESSAYS ON PRACTICAL MEDICINE 
 
 is more frequent than stenosis ; aortic regur- 
 gitation alone or combined with aortic stenosis 
 forms about one-fifth of the number ; ahnost 
 any combination may occur, but that of aortic 
 regurgitation and mitral regurgitation is the 
 most common. Diseases of the pulmonary 
 valve are very rare and not of great moment. 
 Tricuspid regurgitation is frequent as a late 
 result of mitral disease, but is rarely due to 
 original inflammation ; the closure of this 
 valve is so feeble and often so imperfect that 
 regurgitation is probably frequent without any 
 physical symptoms ; a strong evidence of the 
 existence of tricuspid regurgitation is the occur- 
 rence of the ventricular form of jugular and liver 
 pulsation without any detectable murmur. 
 With regard to the gravity of the different 
 valve affections, one must look on the aortic 
 regurgitation as the most serious, and next 
 to it mitral stenosis — mitral regurgitation and 
 aortic stenosis not being of quite such import- 
 ance as far as life is concerned ; but even with 
 the first two a breakdown can be for a long 
 time postponed — if the heart muscle itself 
 keeps up its tonicity and strength. The 
 Uability to sudden death, which is not com- 
 mon in pure valvular disease, is greater 
 
DISORDERS OF THE HEART 21 
 
 probably in aortic regurgitation than in any 
 other form. 
 
 Aortic regurgitation showing itself first in 
 middle age, and not as the result of rheumatic 
 fever in youth, is always very serious ; it is 
 generally the outcome of overstrain combined 
 with intemperance, of syphilis or cardio- 
 sclerosis, and is frequently foimd with com- 
 mencing kidney disease. Successful compen- 
 sation can hardly be looked for in such cases, 
 and unless the life can be most carefully ordered 
 an early death must be expected. Anginal 
 symptoms often appear, as the coronary ar- 
 teries become involved in the sclerotic disease, 
 Mitral Stenosis. Mackenzie says : " This is per- 
 haps the most common of valvular defects with 
 which heart failure is associated. It is generally 
 the result of acute rheumatism or some other 
 febrile disease. The condition is never recog- 
 nised during the acute process which induces it, 
 for this reason, that the murmur is not pro- 
 duced till the cicatrising process following the 
 inflammation narrows the orifice ; and, on 
 account of its origin in scar formation, it is often 
 a progressive lesion.'* This clear statement 
 shows well the dangerous character of this 
 defect. We practically never see it till it is 
 
22 ESSAYS ON PRACTICAL MEDICINE 
 
 an accomplished fact, and the early symptoms 
 then are so slight that we seldom get the 
 chance of giving the heart the complete rest it 
 needs ; in this way it stands in marked con- 
 trast to mitral regurgitation. Still even in this 
 affection the disease may be non-progressive, 
 and the patient may Hve to a good old age ; but 
 such cases must be considered rare. The usual 
 course is steadily progressive contraction of the 
 valves, and interference with the work of the 
 whole heart ; and not infrequently, the chordae 
 tendineae and the auriculo-ventricular bundle 
 becoming involved, we get auricular fibrillation 
 and other rhythmical defects added to the 
 already embarrassed heart. With such a 
 complication we need not wonder that the 
 heart muscle soon fails to carry on its work. 
 
 The above resmne of valvular diseases is 
 meant only to serve as a reminder of what we 
 most of us already know, but which some of 
 us may have in part forgotten. For the 
 minute discrimination of physical signs, for a 
 complete description of the compHcations that 
 so often arise, and of alterations of rh5rthm, 
 such as auricular fibrillation and auricular 
 flutter, I must refer my reader to the more 
 modern textbooks. It must be seen, then. 
 
DISORDERS OF THE HEART 23 
 
 that our principal aim and object must be to 
 educate and strengthen the heart to stand up 
 against its new difficulties, and if possible to 
 overcome them. If we are fortunate enough 
 to see the patient in the acute or sub-acute 
 stage of the causative illness, the first thing 
 to give is rest, and that as complete as possible. 
 
 In rheumatic fever, we should give salicylate 
 of soda freely. I think it is not sufficiently 
 realised that the beneficial action of salicylate 
 is much more certain if we give bicarbonate of 
 soda with it — the theory being, I believe, that 
 the salicylate acts better if the blood be 
 rendered alkaline : the proportion should be at 
 least two of bicarbonate to one of salicylate, 
 and perhaps two and a half to one would be a 
 better proportion still. 
 
 The old alkaline treatment of rheumatic fever 
 in the pre-salicylic days was chiefly carried 
 out with potash salts ; if we were to use these 
 in the large doses required, we should run a 
 grave risk of depressing the heart muscle, this 
 effect of potash salts being well established. 
 Some writers have doubted if salicylates have 
 any direct action on endocarditis. It is a 
 thing impossible to prove, but I think the 
 logical assumption should be this — that a drug 
 
24 ESSAYS ON PRACTICAL MEDICINE 
 
 which can indubitably relieve and cut short 
 rheumatic inflammation of s3movial membranes 
 should have some similar action on inflamed 
 endocardium arising from the same poison, 
 and further, that a drug which indubitably 
 shortens the duration of the disease should by 
 so much lessen the risk and extent of endo- 
 cardial complication. Salicylate and the 
 bicarbonate of soda should be kept going for 
 some time after fever has gone, but at steadily 
 increasing intervals. In such cases, when signs 
 of valvular implication have appeared, very 
 prolonged rest is most advisable ; three months 
 in bed or on the sofa is none too long in most 
 cases. This gives the heart muscle time to 
 recover its strength, and also, which is most 
 important, gives the inflammatory process in 
 the endocardium time to subside. During the 
 period of rest, even if there be irregular action 
 of the heart and signs of dilatation, I think 
 the extrinsic vegetable heart tonics should be 
 given with great caution, for any drug that 
 increases peripheral contraction of the arterioles 
 throws more work on the heart, and perhaps 
 more than defeats its object. I allude chiefly 
 to digitalis, strophanthus, convallaria, and 
 spartein. If there be faintness and respiratory 
 
DISORDERS OF THE HEART 25 
 
 distress, strychnine may be given hj^odermic- 
 ally in big doses. This rule about heart tonics 
 applies, I think, quite as strongly in those condi- 
 tions of heart feebleness which we find as the 
 result of diphtheria, enteric, scarlet fever, and 
 erysipelas. Rest and strychnine are here, too, 
 most important. Is this cardiac weakness, 
 and the muscle degeneration which causes it, 
 the direct result of the infection ? or is it due 
 to something lacking in the internal secretions ? 
 My own belief is that the failure of the supra- 
 renal secretion is at least a contributory cause. 
 
 The following are extracts from Biedl's book 
 on the internal secretory organs. " According 
 to Langlois the amount of the active substance 
 which raises blood-pressure is apparently un- 
 changed in the hypersemic supra-renal ; while 
 after chronic infective conditions, the capsule, 
 though increased to three or four times its 
 original volume, yields extracts which are 
 totally inactive. According to Luksch the 
 suprarenals of rabbits, poisoned with diph- 
 theria toxins (tuberculosis, typhus), do not con- 
 tain a substance which either raises blood 
 pressure or produces enlargement of the pupil." 
 
 Biedl himself says : " The enormous power 
 which suprarenal extract has of producing 
 
26 ESSAYS ON PRACTICAL MEDICINE 
 
 vaso-contraction forms the rationale of its 
 therapeutic employment in all those conditions 
 where the circulation threatens failure in con- 
 sequence of the sluggishness of the stream. Of 
 these, the most comprehensive are : vascular 
 paralysis, such as may be produced experi- 
 mentally by destruction or inhibition, by 
 means of toxins (chloral hydrate, chloroform), 
 of the vaso-motor centres, and which is fre- 
 quently seen in the last stages of some in- 
 fective diseases, and in many toxic states ; 
 and cardiac asthenia, in which, owing to 
 inadequacy of the heart muscle and to the 
 vascular paralysis, those symptoms of de- 
 creased circulation make their appearance 
 which are known as ' shock ' or ' collapse.' 
 Paralysis of the vessels and cardiac weakness 
 both produce a fall in arterial tension, and 
 lead to a deficiency in the blood supply to the 
 vital nervous centres, as well as to an insuffi- 
 cient filling of the chambers of th€ heart, to 
 cardiac anaemia, and to ultimate arrest of the 
 heart's action. By producing contraction of 
 the engorged vessels in the splanchnic area, 
 and so raising the blood-pressure, adrenalin 
 effects a more favourable distribution of 
 blood ; it promotes the filling of the chambers 
 
DISORDERS OF THE HEART 27 
 
 of the heart, and increases the supply of 
 blood to the nervous system." Later on he 
 says : "In addition to its effect upon the 
 vessels, adrenalin exercises a tonic effect upon 
 the heart muscle, and for this reason its exhi- 
 bition is indicated in all forms of circulatory 
 inadequacy." Kothe's dictum " that adrena- 
 lin is the most powerful analeptic which we 
 possess " is justified by clinical experience. 
 
 The experiments of these able observers and 
 their conclusions should lead us to use this 
 remedy far more than we at present do. It 
 is, to my mind, the safest and most powerful 
 heart tonic that we have, and it has this in 
 its favour, that it is a natural secretion of a 
 mammalian body. My experience has been 
 for the last few years that, in any case of 
 heart failure, arising in the course of some 
 microbic infective disease, and where the 
 arterial tension is below the normal, supra- 
 renal extract is a wonderful help. In pneu- 
 monia, for instance, I use it almost from the 
 start, but I make the arterial tension my 
 guide. For use by the mouth, which I think 
 gives the best results, the extract of the whole 
 gland should be given. There are good tablets, 
 each containing five grains of the freshi gland, 
 
28 ESSAYS ON PRACTICAL MEDICINE 
 
 on the market, and one of these may be given 
 every four hours for many days (i.e. thirty 
 grains daily). A rise of tension above 140"^- 
 will tell one when to stop. Liquor adrenalin 
 given by the mouth seems to have very little 
 lasting effect on the general circulation. 
 
 Oliver and Schafer's original experiments, 
 from which so much valuable knowledge has 
 been derived, were made with a strong glycerine 
 extract of the whole gland given by the mouth. 
 I beHeve that experience will prove this 
 remedy to be of the utmost value in the stage 
 of acute heart failure arising from infectious 
 disease, and that it can be safely used when 
 digitalis and strophanthus would do harm. 
 Unfortunately we are more often called in 
 to treat the results only of these acute and 
 damaging diseases, and the problem then 
 becomes more difficult and complicated. In 
 addition to valvular defects we get probably 
 dilatation or hjrpertrophy, or both, and we 
 must be careful to distinguish and to measure 
 the two conditions. The compensatory hyper- 
 trophy of the ventricles is often sufficient to 
 keep a damaged heart going for a long time, 
 with very few symptoms of distress. It is 
 when this hypertrophy begins to fail and dila- 
 
DISORDERS OF THE HEART 29 
 
 tation ensues that our help is claimed. This 
 failure of power may have come on gradually 
 and almost imperceptibly, or suddenly. In 
 the former case the cause may be an unrecog- 
 nised increase of bodily effort, or insufficient 
 rest, or it may be weakening of the heart 
 muscle by some intercurrent illness, as influ- 
 enza. Again, it may be due to cicatricial 
 contraction of the damaged valves or of the 
 chordae tendinese. A careful investigation 
 and a correct decision will help one much 
 towards giving relief. The first two causes 
 should be removable by rest and a re-ordering 
 of the patient's life ; the third will probably 
 require some medicinal help besides mere rest. 
 If there is, besides dilatation, shortness of 
 breath and irregularity of the action of the 
 heart, with or without a tendency to dropsy, 
 digitalis should be given in doses large enough 
 to produce physiological effects : ten or fifteen 
 minims of the tincture three times a day, and 
 more if necessary. If the liver be congested 
 and the kidneys acting insufficiently (in such 
 cases the urine is high-coloured, scanty, and 
 of high specific gravity), the pill of mercury, 
 squills, and digitalis may be given. One grain 
 of the pulv. digitalis is the equivalent of about 
 
30 ESSAYS ON PRACTICAL MEDICINE 
 
 eight minims of the tincture : some physicians 
 give calomel instead of the blue pill of this 
 combination, and in cases where there is much 
 constipation it is an improvement, I think 
 probably J grain three times a day would 
 be enough. The following formula is gener- 
 ally good : Ft. pil. t,d.s. Pil. Hydrarg. g. i ; 
 Pulv. Digitalis, g. i| ; Pil. Scillse Co., g. 2. 
 Where there is high arterial tension this method 
 of giving digitalis is especially good, as the 
 mercury by its action on the hver tends to 
 keep down the tension, which the digitalis by 
 itself might raise. This should produce shortly 
 a stronger, slower, and more regular pulse, a 
 freer action of the kidneys, and a lessening of 
 dyspnoea ; after a few days, unfortunately, 
 with many patients nausea and sickness set 
 in, and with it frequently a slow, irregular 
 pulse. When these occur digitalis must be 
 left off for a few days and then resiuned in 
 smaller doses. 
 
 Another plan is to alternate strophanthus 
 and digitalis. To get the best result in such 
 cases from strophanthus full doses are needed. 
 There has seemed to me to be a considerable 
 difference in the value of various preparations 
 of this drug. I have got into the way of 
 
DISORDERS OF THE HEART 31 
 
 ordering either Duncan & Flockhart's special 
 tincture or Burroughs & Wellcome's tabloids, 
 for with these I always seem to get good 
 results. 
 
 I dislike mentioning special drug manu- 
 facturers, but the above firms are so well 
 known that nothing I say can benefit or harm 
 them. In this connection I may mention 
 Nativelle's granules of digitalin ; the stronger 
 one of gr. -^ is very useful, and perhaps 
 causes nausea less than other preparations 
 of digitalis. (One granule = n; 15 of tincture.) 
 After a short time of such treatment, we 
 should be able to form a fair idea of the heart's 
 capabilities towards recovery. The physical 
 signs will help us to do this, but we must rely 
 a good deal on the patient's own feelings. An 
 intelligent patient, when being treated with 
 these special heart tonics, knows very well 
 whether he is better or not — in fact, many of 
 them can be trusted to manage their dosage 
 and continuance of digitalis or strophanthus 
 for themselves. In certain cases of heart 
 failure with dilatation, especially in old people, 
 I have found a low arterial tension ; in these, 
 suprarenal extract in alternation with digi- 
 talin answers very well. 
 
32 ESSAYS ON PRACTICAL MEDICINE 
 
 Of the other heart tonics, convallaria, 
 spartein, etc., I have nothing to say ; they 
 seem to be of some use in functional disorders, 
 but their sphere of action is not well defined. 
 
 The remaining helps to a tired, failing heart 
 are, well-planned graduated exercises, and 
 massage. These exercises should never be 
 pushed to the point of exhaustion or of breath- 
 lessness. They comprise various exercises of 
 the arms and legs with or without resistance, 
 and certain body movements. These are in- 
 cluded in the Swedish and Nauheim systems. 
 If very carefully done they help much to 
 restore the tone of the heart muscle. 
 
 Dr. Mackenzie speaks very highly of sea- 
 bathing. If this can be enjoyed in quiet 
 water that is not too cold, it is certainly in 
 some cases a great stimulant to the circulation 
 (probably quite as good as Nauheim water), 
 but many patients seem to get no reaction 
 and to remain blue and cold. These cases can 
 hardly benefit by sea-bathing. The exercise 
 of swimming is one of the best, in fresh or 
 salt water, for a weak, dilated heart. It must, 
 of course, be done slowly, and the distances be 
 gradually increased. A man out of condition 
 improves his wind by this exercise wonder- 
 
DISORDERS OF THE HEART 33 
 
 fully. There is one more exercise, which is 
 perhaps the best of all, and that is sculUng 
 in a fairly light boat, so that no great effort 
 is needed ; sculling is better than rowing, for 
 the reason that it exercises slowly and sym- 
 metrically almost every muscle in the body 
 (care must be taken that the patient knows 
 how to use his leg niuscles against the stretcher, 
 otherwise too much work falls to the arms and 
 the heart may be overstrained). Most of these 
 exercises can only be undertaken by the milder 
 cases of heart weakness. In the more severe 
 cases, especially where signs of dropsy have | 
 appeared, steady upward massage of the legs j 
 will help considerably. Good general massage 
 not only helps to get rid of the oedematous 
 swelling, but improves the tone and the pace 
 of the circulation all over the body. 
 
 By using these various remedies intelli- 
 gently and with careful observation one may 
 hope to see many a failing heart restored to 
 comparative health and usefulness. 
 
 Dilatation of the Heart without Manifest 
 Valve Disease 
 
 In middle life especially, but occasionally 
 also in youth, we meet with cases of dilatation 
 
 3 
 
34 ESSAYS ON PRACTICAL MEDICINE 
 
 of the heart of varying degrees of severity, 
 that come on without any apparent cause. 
 (I am not alluding to those cases that are the 
 result of some violent and prolonged effort.) 
 The subjective symptoms are generally marked 
 shortness of breath on any exertion, a quick 
 sometimes irregular pulse, a feeling of great 
 fullness in the chest, and areas of tenderness 
 and slight pain in the left side of the thorax 
 and sometimes down the arms. The physical 
 signs I need not describe. Roughly, a heart 
 dilates for one of two reasons, or from both of 
 them combined. First from some resistance 
 to the onward easy flow of arterial blood ; this 
 resistance necessitates an increase of vis a 
 iergo, of ventricular action, and this increase, 
 if long maintained, may cause even a healthy 
 heart to dilate, though probably after a pre- 
 liminary period of hypertrophy. Apart from 
 valvular obstruction, arterio-sclerosis, or its 
 earHer stage of increased tension in the arteri- 
 oles causing peripheral obstruction, is far the 
 most common cause. Chronic Bright 's disease 
 comes almost under the same heading. The 
 other cause is the state of the heart muscle 
 itself ; it is generally in the condition known 
 as cloudy sweUing or parenchjmiatous degenera- 
 
DISORDERS OF THE HEART 35 
 
 tion. This often follows the acute fevers, but 
 is especially common after diphtheria and 
 influenza. During the last twenty-five years 
 in which influenza has been so much among 
 us, these cases seem to have been far more 
 frequent. In this state of heart muscle, a 
 very little overstrain will produce dilatation, 
 even where there is no peripheral obstruction, 
 either valvular or arterial. This is sometimes 
 called " the influenza heart," the normal re- 
 sistance being too great for the enfeebled heart 
 muscle to cope with. 
 
 Far more commonly, at any rate in middle 
 life, we get the two causes working simul- 
 taneously, and these cases require very careful 
 and patient handling. Here the manometer 
 is our great guide. Unless we can lower the 
 tension and lessen the peripheral resistance, 
 our efforts to strengthen the ventricular, beat 
 and to produce contraction of the whole organ 
 may do more harm than good. Here, I think, 
 strophanthus is superior to digitalis as a heart 
 tonic. It does not have any effect on the 
 arterioles, as far as we know, and it can be 
 continued, I think, for much longer periods ; 
 at the same time, by attention to the liver and 
 bowels also, we can help to keep down the 
 
36 ESSAYS ON PRACTICAL MEDICINE 
 
 tension. The nitrites and nitro-glycerine may 
 be given, but their effect is generally too 
 transient to be of much help. Erythrol tetra- 
 nitrate seems to be the best of them. An occa- 
 sional dose of blue pill or calomel is of much 
 good. Personally I rely almost entirely on 
 the hippurates in these cases to lower the 
 resistance. I shall refer to these more fully 
 in another essay, and also to the contro- 
 versy as to the action of digitalis in high 
 tension. Thjnroid extract in suitable cases is 
 often of great help also. 
 
 In these cases when the dilatation is ex- 
 treme, we not infrequently get regurgitant 
 murmurs, chiefly mitral ; these will disappear 
 as the case improves, but are rather confusing 
 if one has not seen the patient before. The 
 feeble first sound, the accentuated second 
 sound, and the absence of the heaving systole 
 against the chest wall, will distinguish the 
 condition from that of hypertrophy. The wise 
 and intelligent use of rest, of judicious exercise, 
 of heart tonics combined with vaso-dilators, 
 will generally give in the end very satisfactory 
 results, unless the sclerosis has gone too far. 
 
 The dilatation and the hsemic murmur that 
 one finds in anaemia and chlorosis need no 
 
DISORDERS OF THE HEART 37 
 
 special mention ; the cure of the anaemia is 
 the cure of the heart trouble. The functional 
 heart troubles and their manifold causes are 
 too large a subject for a practical essay of this 
 kind. Angina pectoris remains, a beautiful 
 expression, but with as much and as little 
 meaning in it as " stomach-ache." It may 
 mean the most serious and agonising form of 
 heart disease, causing death very soon, or it 
 may mean nothing but a mild neuralgia. The 
 varied and uncertain meanings given to the 
 term are most unfortunate, for they often cause 
 fear and anxiety where there need be none, 
 and in consequence many lives are rendered 
 miserable for years. If no strict meaning 
 clinically or pathologically be attached to this 
 term, the expression " pseudo-angina " be- 
 comes equally inaccurate and misleading. 
 
 Mackenzie says : '* One thing that is neces- 
 sary to insist on, is that angina pectoris is not 
 a disease ; but that it is merely a group of 
 symptoms which afford no clue as to the real 
 nature of the heart's complaint ; so that in- 
 quiry must be made for other evidences which 
 will elucidate this problem." 
 
 The organic lesions of the heart with which 
 grave anginal symptoms are associated are 
 
38 ESSAYS ON PRACTICAL MEDICINE 
 
 chiefly aortic valvular disease, aortic aneurism, 
 mitral stenosis, cardio-sclerosis, general athe- 
 roma and fatty degeneration of the heart 
 muscle, but there are a few cases in which no 
 organic disease can be detected by physical 
 examination. The atheroma of the coronary 
 arteries, which has been so frequently found 
 after death, can, when existing as the sole cause, 
 be only guessed at. All these conditions may 
 exist and yet there may be no pain. So the 
 solution of the problem lies not entirely in the 
 heart condition. The personal history of most 
 cases shows, as a cause of the first attack, some 
 extra strain, either sudden or continued. A 
 man of forty-five or so tries to do something 
 big in the way of effort, that he has not done 
 for some years, or he makes some exceptionally 
 continuous effort, such as running or quick 
 walking, which he has been able to do in the 
 past without discomfort. Exposure to severe 
 cold is also reported as an occasional cause. 
 The sense of pain may be sudden and severe, 
 or the first few attacks may be mild and short ; 
 but the liability to, and the severity of this 
 pain, steadily increase. The attacks of pain 
 as time goes on may need little or no effort to 
 bring them on. 
 
DISORDERS OF THE HEART 39 
 
 There is another class of cases which I can 
 only call fulminating angina, in which, without 
 any previous warning, the most furious attacks 
 of pain come on, causing the patient to grasp 
 hold of something for support and to remain 
 motionless, scarcely daring to breathe. The 
 face gets very pale and the forehead breaks 
 out into a cold sweat, and there is a feeling of 
 great constriction over the whole front of the 
 thorax. These cases, which are fortunately 
 rare, live as a rule but a short time — death 
 comes suddenly by s5mcope in a very few weeks. 
 These cases, I think, arise from acute degenera- 
 tion of the myocardium, and generally have 
 disease of the coronary arteries. They are not 
 often seen as the end of valvular disease, and 
 they occur in middle age, generally between 
 forty-five and fifty-five, and the condition that 
 causes them is not seldom hereditary. Not 
 much can be done for them except to relieve 
 the spasm by amyl nitrite inhalation, or if that 
 fails by hypodermic injection of morphia and 
 atropine. 
 
 In the average case of angina, connected 
 with one of the before-mentioned causes, 
 much can be done to alleviate and to prevent. 
 The ordering of the life so as to avoid hurry 
 
40 ESSAYS ON PRACTICAL MEDICINE 
 
 and strain must be the first thing. If the 
 arterial tension be high, that should be slowly 
 and carefully reduced. The hippurates may 
 be very useful, and so is Lauder Brunton's plan 
 of giving a good dose of 20 grains of nitrate 
 of potash combined with two grains of sod. 
 nitrite every morning before breakfast. The 
 amyl nitrite or nitro-glycerine will be very 
 helpful in the attack, or the following, which 
 I have found very useful : 
 
 B. Spt. Ether Sulph. Co. . . . HI. 20 
 Liq. Trinitrin . . . • ^ i i 
 
 Tinct. Chloroform Co, (sine Morph.) n\ 12 
 Spt. Ammon. Aromat, ad , . 3 ^ 
 
 3i in half a wineglass of water for a dose. 
 
 But the remedy that in most cases will do 
 more good than any of the above is iodide of 
 potassium in doses of 10 grains or more three 
 times a day ; if given with elixir of lactoj 
 peptine and spirits of chloroform, it will 
 generally digest well and not cause iodism. 
 An anomaly difficult to explain, but generally 
 true, is this. The greater the dose of the 
 iodide, the less is the fear of iodism. It is 
 more than Hkely that iodide works by stimu- 
 lation of th5n:oid secretion, but this will be 
 mentioned in another chapter. It is perhaps 
 
DISORDERS OF THE HEART 41 
 
 in the aortic and atheromatous cases that it 
 answers best. I do not think it acts by any 
 distinct lowering of arterial tension, though 
 some physicians say that it has that effect. 
 It should be continued for a long time, and will 
 often give the most satisfactory results. 
 
 Indigestion which causes flatulence, disten- 
 sion of the stomach, and hyperacidity are both 
 exciting causes of this pain. When once the 
 disease is established, the diet should be care- 
 fully arranged to obviate these discomforts as 
 far as possible. A comparatively dry diet, 
 with no excess of starchy food, should be the 
 central idea, fluid being taken between meals. 
 An intelhgent patient, if shown the reasons, 
 will probably work out a diet for himself. 
 Twice-cooked animal and fish food seems to be 
 a very common cause of flatulence with many. 
 But the great question to solve is the cause 
 of the pain. Under apparently identical con- 
 ditions, one man gets angina and another does 
 not. In some cases there is raised arterial 
 tension and peripheral resistance, in some the 
 tension may be below normal, but I think in 
 the majority of cases the tension is raised. As 
 far as one can judge the pain comes on because 
 the heart is suddenly called on to make a, 
 
42 ESSAYS ON PRACTICAL MEDICINE 
 
 muscular effort which, owing to obstruction or 
 to some faulty condition of the muscle itself, 
 it cannot accomplish. A painful condition of 
 cramp or spasm is produced, beginning prob- 
 ably in the heart and spreading to the inter- 
 costal muscles and perhaps to the diaphragm. 
 It is easy to understand how a severe cramp 
 in the heart muscle becomes a great danger, 
 while a cramp in a leg muscle is of no con- 
 sequence, for the circulation must be tem- 
 porarily arrested, and if the cramp does not 
 pass off, death may ensue in the attack. 
 
 The seat of obstruction may be valvular, 
 arterial, or in the coronary arteries of the 
 heart itself, and in the latter case there seems 
 to be greater danger, because the blood supply 
 to the heart muscle is itself partially cut off. 
 Still the question of the cause of the pain is 
 only partially solved. How far the nervous 
 system enters into the problem is the doubt. 
 
 Mackenzie says : " Pain is usually referred 
 to some portion of the distribution of the upper 
 four left dorsal nerves in the chest and arm ; 
 sometimes the pain may be felt as low as the 
 distribution of the sixth dorsal nerve in the 
 epigastriiun, and as high as the eighth or 
 seventh cervical nerve in the ulnar border of 
 
DISORDERS OF THE HEART 43 
 
 the forearm and hand. It is rarely felt in 
 similar areas on the right side. The pain is 
 usually felt across the chest, and may remain 
 stationary there ; or it may radiate into the 
 axilla and down the arm to the ulnar side of 
 the forearm and hand. On the other hand the 
 pain may start in the arm and radiate to the 
 chest." 
 
 These clear statements point to some centres 
 in the dorsal part of the spinal cord being con- 
 cerned, not as organically diseased, but as in 
 a state of irritability. Some of the nervous 
 s5niiptoms that are usual after an attack, such 
 as the passage of a large quantity of colourless 
 urine and the free expulsion of wind, point the 
 same way. In fact, it seems that in a pre- 
 disposed heart the trouble may arise at the 
 centre as well as the periphery. We must 
 hope that further skilled investigation will 
 throw more light on this problem and help us 
 more to ward off attacks and to treat them 
 more successfully than we do now. So far as 
 our knowledge goes at present we can only 
 advise our patients who suffer from cardiac 
 pain that threatens to be angina, always to 
 have with them capsules of amyl nitrite or 
 tablets of nitro-glycerine, Sir William Whitia 
 
44 ESSAYS ON PRACTICAL MEDICINE 
 
 advises patients who suffer froin frequent 
 attacks of cardiac pain to break up one of 
 the usual tablets of nitro-glycerine into six or 
 eight parts, and to take one of the fragments 
 every hour or so during the day. I have found 
 this plan in my own practice very useful. 
 Though one objects to the word " pseudo- 
 angina/' yet one must recognise that there is a 
 class of person who gets cardiac pain that bears 
 some resemblance to the true thing ; but there 
 are pretty marked signs of differentiation. 
 Such patients are generally women, about the 
 age of fifty, who get other symptoms of vaso- 
 motor disturbance. The arterial tension is 
 often high, but it varies much at different 
 times. I think that nearly every woman, 
 about or after the change of life, gets periods 
 of high tension, and that nature gives relief 
 by the flushings and perspirations that are so 
 common. The flushing has the same effect 
 as amyl nitrite. In such cases there is no 
 evidence of any organic disease, and there 
 may be a history of excessive tea-drinking or of 
 tobacco-smoking. The most important sign is 
 I think, the behaviour when the pain is on. 
 The true angina sufferer remains as still and 
 quiet as possible, almost afraid to breathe or 
 
DISORDERS OF THE HEART 45 
 
 speak ; the false one fidgets about in a rest- 
 less, excited way. Careful examination and 
 observation will in most cases enable us to 
 assure such patients that there is no danger, 
 and attention to the arterial and nervous 
 conditions should soon effect a cure. In the 
 advanced stage of almost any form of heart 
 disease, except, perhaps, in true angina, we 
 shall meet with emergency cases that look like 
 impending death. Such are cases of acute dila- 
 tation, of sudden pulmonary oedema, sometimes 
 called suffocative oedema, and of advanced 
 auricular fibrillation. Here we have to act at 
 once, and, valuable as digitalis is in nearly all 
 these troubles, yet there is no time for it to 
 act when given by the mouth. (The hypo- 
 dermic use of digitalin is generally futile.) 
 We have, however, a very rapid and safe 
 remedy in the hypodermic injection of adrena- 
 lin ; and the action is, I think, much helped 
 if we give with it liq. trinitrin. The best way 
 of giving this is the following : 8 minims of 
 liq. adrenalin, 2 minims of liq. trinitrin, and fill 
 up the syringe with water {boiled if you have 
 time to get it) to 20 or 30 minims. The liq. 
 adrenalin is too concentrated a preparation 
 for most people. It not infrequently brings 
 
46 ESSAYS ON PRACTICAL MEDICINE 
 
 on pallor and a feeling of faintness for a few 
 minutes. This is obviated by dilution. Many 
 of these patients may have a high arterial 
 tension, but this need not deter one, for adre- 
 nalin has none of its characteristic action on 
 the coronary arteries, and the trinitrin helps 
 its effect by lowering the tension in the sys- 
 temic arterioles. Briefly put, the nitrites 
 dilate the coronary veins as well as other 
 systemic veins. The adrenalin dilates the 
 coronary arteries and increases the contrac- 
 tion of muscular fibres, in heart, arteries 
 and arterioles. The laboratory researches on 
 adrenalin vaso-motor mechanisms by Dr. Hart- 
 mann of Toronto {" Endocrinology," vol. ii., 
 no. i) go far to explain and to direct the thera- 
 peutic action of adrenaUn. He shows that vaso- 
 dilatation is the usual response, in certain 
 areas of the body, to adrenalin injections. He 
 says, in the adult, adrenalin poured into the 
 blood in small quantities causes, by its peripheral 
 effects, constriction of the vessels in the skin, 
 mucous membrane and abdominal organs, 
 driving the blood into the vessels supplying the 
 skeletal muscles, which are actively dilated for 
 its reception, through the effect on the sym- 
 pathetic and dorsal root gangliar mechanisms. 
 
DISORDERS OF THE HEART 47 
 
 This increase of blood supply to the limbs 
 is proved by plethysmographic tracings. One 
 can now understand the relief, very great in 
 some cases of dyspnoea, cardiac and asthmatic, 
 that adrenalin gives. The patient is bled liter- 
 ally into his own far-distant vessels, which can 
 accommodate the extra blood without distress ; 
 the congestion of the heart and lung regions is 
 thereby relieved. When the trinitrin is added 
 to the adrenalin, a still further relief is obtained 
 by the dilatation of the blood-vessels of the 
 head and neck. Hypodermically, strychnine 
 may be used to follow the adrenalin, but it 
 is of no value except in full doses — xV to 
 yV gr. By these means many an emergency 
 can be tided over and the opportunity for the 
 steady use of digitalis or strophanthus be 
 established. 
 
 Another most distressing trouble that we 
 often meet with in the advanced stages of 
 heart failure is the inability to get any con- 
 tinuous sleep. One cannot call it insomnia, for 
 the desire to sleep is very strong ; the patient 
 keeps dropping off and waking up again in a 
 few minutes, often in great respiratory distress. 
 Narcotics given by the mouth are of very 
 little good, with the occasional exception of 
 
48 ESSAYS ON PRACTICAL MEDICINE 
 
 paraldehyd. The one great help in these cases 
 is the hypodermic use of morphia and atropine 
 or of morphia and scopalamine ; one or other 
 combination is better than morphia alone. 
 If there be no great clogging of the lungs by 
 oedema, or by bronchial catarrh, it may be 
 used with confidence, both as regards success 
 and safety. The hours of sound sleep that 
 ensue rest, not only the patient, but the 
 patient's worn-out, irritated heart. If there 
 be inaction of the kidneys as a result, a hypo- 
 dermic injection of pituitrin in the morning 
 will probably put things right. 
 
 Though this essay has gone over much that 
 is old ground, and contains little that is new, 
 I venture to hope that it may serve to concen- 
 trate some of the more modern knowledge of 
 heart affections into more practical and useful 
 methods of management and of therapeutics. 
 
II 
 
 ARTERIO-SCLEROSIS 
 
 " Wherefore do ye spend money for that which is not 
 bread, and your labour for that which satisfieth not ? " 
 
 Isaiah. 
 
 When one carefully studies the diseased con- 
 dition we call arterio-sclerosis or fibrosis, as 
 Sir William Gull, its first describer, called it, 
 its complications, its results, and some other 
 disorders with which it is intimately associated, 
 one must see that it enters very largely into 
 the failures of health and into the premature 
 deaths that occur so frequently between the 
 ages of forty-five and sixty. 
 
 Dr. De Havilland Hall, who is an authority 
 on this disease and also on its life-insurance 
 aspects and its statistics, says " that, though 
 the average duration of life has considerably 
 increased during the last fifty years, there has 
 been an actual increase in the mortahty rate 
 among males between the ages of forty-five 
 4 49 
 
50 ESSAYS ON PRACTICAL MEDICINE 
 
 and sixty-five, and that between the ages of 
 fifty-five and sixty-five one-third of the total 
 deaths are due to diseases of the heart and 
 blood-vessels. " These statistics are obtained 
 from the Registrar-General's reports, and, as 
 far as they go, must be accurate. My own 
 feeling is that a good many more deaths could 
 be brought under the same categories, for 
 many deaths from paralysis and cerebral 
 haemorrhage are returned under those headings, 
 but are really the end results of arterio-sclerosis. 
 To the general practitioner it is a very 
 important thing to keep his patients, who are 
 approaching old age, in good health, and to 
 prolong their lives as far as possible. It should 
 not only be his interest to do this, but also his 
 deHght, for one's old patients are often one's 
 best friends. Too many of us have got into the 
 way of looking on this disease as incurable 
 and unmanageable, but this is a great mistake. 
 It is a complicated and intricate problem, no 
 doubt, but that should attract the scientific 
 mind to the elucidation of the problem and 
 to the study of the causes and the treatment. 
 Strictly speaking, arterio-sclerosis is not an 
 entity disease, like tuberculosis or cancer. It is 
 in most cases a structural change due to un- 
 
A RTERIO'SCLEROSIS 51 
 
 natural causes that are not obscure and which 
 to a large extent are removable. I think we 
 must all feel that the causes lie deep in our ways 
 and habits, in the unnatural, high-pressure 
 lives that so many of us seem compelled nowa- 
 days to live, and in the fact that this increase 
 of heart and vascular disease occurs in the male 
 sex so much more than in the female. The 
 competition of business and professional life 
 falls almost entirely on our sex, but when we 
 come into touch with the arduous, nerve- 
 straining life that many society women live, 
 the late hours and the over-stimulation of 
 various sorts that it seems to involve, we see 
 the same morbid results in their train. It 
 is not the hard body worker, not the man who 
 live an outdoor, athletic life, that develops 
 sclerosis, as a rule, but the anxious, care- 
 worn brain worker, who works chiefly indoors 
 and who often takes his work and his worries 
 home with him and to bed with him. For 
 such a man there can seldom be any real 
 rest or freedom from the sense of strain. His 
 sleep is rarely the sound, restoring uncon- 
 sciousness that the body worker gets ; and in 
 very many cases the ability to meet this nerve 
 strain is artificially kept up by stimulants of 
 
52 ESSAYS ON PRACTICAL MEDICINE 
 
 various sorts, but their effect can only act for 
 a time. The physiological result of this life 
 must be, in the first place, fatigue, exhaustion 
 and general impairment of vital energy, but in 
 the second place hypertrophy and subsequent 
 degeneration of the over-used parts of the body 
 (this is a law from which we cannot escape), 
 and the over-used parts are chiefly the heart 
 and blood-vessels. The athlete may call on 
 his heart to do much abnormal work, but it is 
 only for a short time, and the intervals of rest 
 are long and sufficient for restoration ; but the 
 man I am describing is the bow always bent. 
 The activity of his brain is making demands 
 on his heart and on his arteries night and day, 
 and the vaso-motor nerves that govern the 
 blood supply to the cerebral centres have no 
 rest from toil. 
 
 Dr. George Oliver very wisely says : " Ner- 
 vous, anxious temperaments, and occupations 
 which involve much anxiety, worry and nerve 
 strain, tend to produce somewhat higher levels 
 of arterial pressure, especially in the latter half 
 of life. On the other hand, placid tempera- 
 ments and routine occupations — especially of 
 the physical order — dispose to the lower degrees 
 of pressure. I have observed that, as a rule. 
 
ARTERIOSCLEROSIS 53 
 
 in subjects in good condition and training — 
 such as athletes — the arterial pressure is cer- 
 tainly not raised, and is indeed very often 
 somewhat below the average normal point, a 
 fact which shows the importance of maintain- 
 ing the functional activity of the peripheral 
 circulation by exercise. And this conclusion is 
 supported by the observation that in those 
 normal subjects who follow sedentary indoor 
 occupations for many hours daily, the pressure, 
 though generally normal, is more frequently 
 above and less frequently below the mean 
 normal pressure line." 
 
 There can be no doubt, I think, that there 
 is a stage — -probably lasting for two or three 
 years — of almost constantly but moderately 
 raised tension, before any real sclerosis takes 
 place ; and it is in this stage that we can do 
 so much for our patients, to correct their habits 
 of life and so to avert the grave symptoms 
 that otherwise must ensue. Dr. Oliver says on 
 this point : "In diffuse or generalised arterio- 
 sclerosis, the accessible arteries may not be 
 appreciably thickened, especially in the earlier 
 stages of the disease, and yet the arterial pres- 
 sure may be raised persistently and definitely. 
 It would seem as if the disease begins more 
 
54 ESSAYS ON PRACTICAL MEDICINE 
 
 particularly in the terminal divisions of the 
 arterial system — splanchnic and systemic, es- 
 pecially splanchnic. In this stage the peri- 
 pheral resistance is apparently due mainly to 
 muscular contraction in the arterioles ; for 
 these readily respond to vaso-dilator remedies, 
 and the increment of arterial pressure, which 
 is not so high as it subsequently becomes, 
 quickly subsides after each dose. In this 
 hypertonic stage, the stage of pre-sclerosis of 
 Houchard, the diastolic pressure rarely rises 
 above 120 mm. and is often only no mm., and 
 the systoHc pressure does not, as a rule, exceed 
 160 mm. and is frequently only 145 mm. or 
 150 mm., and the arteriometer demonstrates 
 the contraction of the radial caHbre and the 
 favourable effect of treatment in dilating it. 
 But as the disease advances, organic changes 
 in the arterial wall develop, when vaso-dilators 
 only partially reheve the pressure, and when 
 they may ultimately fail to lower it. In 
 this stage the accessible arteries — such as the 
 brachial — as a rule become thickened and the 
 arterial pressure increases considerably ; the 
 systolic armlet readings advancing to such high 
 figures as 200 mm. to 260 mm/' 
 Another cause of hypertension and subsequent 
 
ARTERIOSCLEROSIS 55 
 
 sclerosis, which often goes hand in hand with 
 the "strain of Hf e " and its results, is intes- 
 tinal poisoning or auto-intoxication. Owing to 
 various reasons, excess of food, improper food, 
 lack of proper resting time for digestion, and 
 alcholic or other stimulation, there is set up 
 a chronic dyspepsia, gastric and intestinal, 
 which leads to more or less constant absorption 
 of ptomaines. These affect the liver and its 
 healthy secretion of bile, and so a vicious circle 
 is set up ; they also affect the endocrine glands, 
 especially perhaps the thyroid and the supra- 
 renal, and through them the vaso-motor system; 
 and finally some of the excretory organs, espe- 
 cially the kidneys, which have an extra load 
 thrown on them, a load which they can only 
 carry for a time without injury. 
 
 This intestinal absorption of ptomaines de- 
 mands very serious attention, for it is always 
 frustrating one's efforts to lower pressure. If 
 the diet and life can be wisely regulated, it 
 can soon be put right. The chief remedy should 
 be occasional doses of calomel, in antiseptic, 
 not in aperient doses (for we want chiefly to 
 get its bactericidal action). Mercury in all 
 forms seems to lower blood-pressure, but 
 whether directly or indirectly is not easy to 
 
56 ESSAYS ON PRACTICAL MEDICINE 
 
 say. The frequent use of duodenal extract 
 in some form is very beneficial also ; this is a 
 natural remedy, and is very effective : 2 grains 
 of duodenal extract in a pill three or four times 
 a day about an hour after food, combined, if 
 there be gastric dyspepsia, with half a grain 
 of carbolic acid, will soon give great relief and 
 purify the intestine. Secretogen tablets act 
 very well on the same lines. 
 
 As practical physicians, then, our aim must 
 be to get hold of our patients in this pre- 
 sclerotic condition, to wisely anticipate and 
 prevent the development of the serious organic 
 changes that belong to the later stages. To 
 do this we must be on the look-out, especially 
 at about the ages of forty-five to fifty-five, for 
 any sUght but persistent increase of arterial 
 tension. There are various subjective symp- 
 toms that are often danger signals : viz., 
 slightly increased shortness of breath on exer- 
 tion, laboured action of the heart or slight 
 palpitation ; but perhaps of more significance 
 are the head symptoms, such as vertigo, 
 especially on stooping, occasional noises in the 
 head, and an unaccustomed feeling of brain 
 fatigue without any sufficient cause. At this 
 stage there is, as a rule, no albuminuria. 
 
ARTERIOSCLEROSIS 57 
 
 but the kidney condition should be carefully 
 watched. 
 
 In the earlier days of the study of sclerosis, 
 the kidneys were always regarded as the chief 
 danger-point. My old friend, whose prema- 
 ture death was such a loss. Dr. Mahomed 
 of Guy's, called it pre-albuminuric disease, 
 but there are a large number of cases in which 
 the kidneys never become seriously affected ; 
 the brunt of the disease falls in some cases on 
 the heart, the larger arteries and the coron- 
 aries ; in some on the cerebral arteries ; and in 
 others on the kidneys. The whole of the organs 
 may be involved, but the symptoms of course 
 vary with the functions of the parts affected. 
 In any case death comes more frequently from 
 the rupture of cerebral arteries than from 
 heart and kidney failure. 
 
 To form a clear and accurate idea as to 
 the arterial condition and pathology and as to 
 the relative importance of abnormalities, one 
 must make a careful study of the literature of 
 this subject, and this will not take very long, 
 I would mention two small and inexpensive 
 books, whose authorship is their own guaran- 
 tee : " Studies in Blood- Pressure,'' by Dr. 
 George Oliver (H. K. Lewis) ; and " Thera- 
 
58 ESSAYS ON PRACTICAL MEDICINE 
 
 peutics of the Circulation," by Lauder Brunton 
 (John Murray). If a more elaborate work is 
 wished for and one that goes deeply into the 
 physics of the circulation, Sir Clifford Allbutt's 
 most excellent book on " Diseases of the 
 Arteries ' ' will give us all we need. From these 
 clear and most rehable books the busy practi- 
 tioner will soon get a good working idea of the 
 subject. The estimation and significance of 
 systolic and diastoHc blood-pressure and the 
 use of the manometer and sphygmograph are 
 all carefully explained. I need hardly say that 
 the use of the manometer in arterio-sclerosis 
 amounts to a sine qua non. 
 
 The hypertonic stage of muscular contrac- 
 tion, described above by Dr. OHver, is prob- 
 ably the direct outcome of the over-strenuous 
 life, and should be regarded as only a func- 
 tional disturbance and therefore remediable. 
 It is, of course, in this stage that we can really 
 cure ; in the later stages very much can be 
 done to guide and alleviate, but not to cure. 
 
 To get fixed in our minds a clear idea of 
 the physiology of the arterial system, I cannot 
 do better than quote from Lauder Brimton, 
 Lancet, vii. 24. 15: '* The whole of the 
 arterial system from the aorta down to the 
 
ARTERIOSCLEROSIS 59 
 
 smallest arterioles has the power of contrac- 
 tion, but there is much more elasticity and 
 less contractibility in the aorta than in the 
 arterioles, where the contractibility is great 
 and the elasticity comparatively sHght. The 
 whole system is richly supplied with nerves, 
 some of which, the vaso-motor nerves, induce 
 contraction, while others, the vaso-dilators, 
 have an opposite effect. The arteries have 
 three functions. First, by means of their 
 elasticity to store up the energy exerted by the 
 left ventricle during its systole, and to expand 
 this again in keeping up the even flow of 
 blood during the diastole, when, in the healthy 
 heart, the ventricle is completely shut off from 
 the aorta by the sigmoid valves. The second 
 function is to regulate the flow of blood to 
 those parts which need it, by those vessels 
 which supply the active organs dilating, while 
 those of the other parts of the body contract. 
 The third function, which is less generally 
 recognised, is to pass the blood on from the 
 arteries into the veins by peristaltic action, an 
 action which causes the arteries to be empty 
 after death." 
 
 Arterial tension may be briefly described 
 thus : during the resting-time of the heart. 
 
6o ESSAYS ON PRACTICAL MEDICINE 
 
 between each beat, the ckculation of the 
 blood is maintained by the contractile power 
 of the arteries, especially by that of the 
 arterioles, which steadily urges the blood 
 onwards into the capillaries ; this power is 
 known as arterial tension or pressure, and can 
 be estimated fairly accurately by the sphygmo- 
 manometer. A large number of observations 
 have shown what is the average pressure 
 at different ages, and we are thus able to 
 talk of a normal or abnormal pressure or 
 tension. 
 
 The following extract from the Lancet, 
 January 8, 1916, puts the matter in a most 
 conclusive way : 
 
 ** The clinical value of observations on blood- 
 pressure is doubted only by those who have 
 never made them. It is true that the finger 
 can detect some difference in pulse tension, 
 but it is often entirely at fault, since it can 
 only estimate total pressure, thus missing a high 
 pressure if the volume be small. In the same 
 way, although the hand can detect differences 
 of temperature, it cannot replace the thermo- 
 meter. The sphygmomanometer has enlarged 
 our ideas, cleared up difficulties in diagnosis, 
 and helped in prognosis. 
 
ARTERIOSCLEROSIS 6l 
 
 * * This has naturally reacted on treatment ; it 
 has enlarged our ideas on ' heart failure.' The 
 heart is adjusted to work at certain pressures, 
 and though within considerable limits it can 
 adjust itself to variations, those limits may be 
 exceeded. 
 
 " In an acute infection blood- pressure may 
 fall dangerously low, and sensory stimuli do 
 not produce the usual pressor result, though 
 abdominal massage is still effective. It is the 
 vaso-motor system that is poisoned, rather than 
 the heart that is damaged. Recognition of 
 these facts has led to the problem being attacked 
 through the vaso-motor system by means which 
 act peripherally, thus protecting the heart from 
 secondary damage and needless or harmful 
 stimulation. There is the opposite condition 
 in which the heart fails, while the pressure is 
 very high. In some cases where the pressure 
 has been unduly high, perhaps for years, the 
 heart fails because it can no longer work against 
 an excessive resistance. But in others it is 
 probable that the rise of pressure is compensa- 
 tory. With diminishing output vaso- constric- 
 tion is necessary to lessen the size of the arterial 
 bed. But this vaso-constriction would only 
 raise the blood-pressure to its normal level 
 
62 ESS AY SI ON PRACTICAL MEDICINE 
 
 again ; it would not force it higher. Yet it is 
 often a surprise to find with a feebly beating 
 heart a pressure of 200 mm. or more. The 
 recent work of StarUng throws fresh light on 
 this apparent paradox. The contractile force 
 of a muscle depends upon and is proportional 
 to its previous stretching, so that in its inception 
 even cardiac dilatation is compensatory, and 
 a rise of blood-pressure will increase the stretch- 
 ing of the cardiac muscle. But it is a desperate 
 expedient, for with over- stretching complete 
 failure may ensue." 
 
 Writing ten years later than the foregoing 
 extract, I grieve to say that I still find doctors 
 attempting to estimate blood-pressure by their 
 finger, and to found their treatment on that 
 estimate. I can only say that the results are 
 equally disastrous to their patients and to the 
 reputation of their profession. 
 
 The left ventricle is of course the chief agent 
 that maintains the blood-pressure in the arte- 
 ries, but the height to which that pressure rises 
 largely depends on the resistance met with in 
 the arterioles and capillaries, on what is known 
 as peripheral resistance, but also on the re- 
 sponse that the ventricle is able to make to 
 that resistance. Ower says : " Given a normal 
 
ARTERIOSCLEROSIS 63 
 
 ventricle, the arterial tonus largely determines 
 the ventricular response and the level of the 
 arterial blood-pressure : and there is the key- 
 note of the physiological and pathological 
 variations of pressure." 
 
 A slight increase of blood-pressure and re- 
 sistance as life advances seems to be the rule, 
 and to meet this the heart slowly and steadily 
 increases in size and weight, this increase being 
 chiefly in the left ventricle. In some cases 
 where people live to great old age, this rule 
 perhaps does not hold good, for I have fre- 
 quently observed in such cases no increase of 
 blood-pressure during the last fifteen or twenty 
 years of life, and as far as one can judge no 
 increase in the size of the heart. In some of 
 these cases the blood-pressure is continually 
 below the normal ; that is to say, 130-135 mm. 
 
 Increased arterial resistance soon causes 
 increase of the size of the ventricle, and 
 lengthens the duration of the systole and 
 lessens that of the diastole (thus reducing the 
 resting time of the heart), and if this resistance 
 persists hypertrophy must ensue. 
 
 This hypertrophy is of course a conservative 
 effort which may hold the field for a long time, 
 but eventually degeneration must follow, and 
 
64 ESSAYS ON PRACTICAL MEDICINE 
 
 then dilatation, which, unless cerebral haemor- 
 rhage occurs, is the end of all these cases. 
 
 With this knowledge before us it must be 
 evident that the perfection of physical life 
 depends on the anatomical perfection and on 
 the physiological well-being of the heart and 
 the blood-vessels. The blood is not the Hfe 
 and the heart is not the life — ^the secret of this 
 mystery lies far deeper — ^but both are life's 
 indispensable ministers. 
 
 It would be a very good institution for all 
 persons of middle life to have their hearts 
 and arteries tested occasionally. A wise phy- 
 sician would be able to assure them that all 
 was well, or he would be able to correct slight 
 divergences from health, and to advise as to 
 the mode of life and the amount of work that 
 might be safely done. 
 
 If we find a man to be in the pre-sclerotic 
 stage, what can we do ? Firstly, much can be 
 done by comparative rest, by early hours and 
 long nights (the arterial pressure after a long 
 night's rest is often lo mm. below the average 
 day pressure), by cutting down extremes of 
 work or of social pleasures, and by the avoid- 
 ance of excitement and over-stimulation — in 
 short, by resting the heart and by lessening 
 
ARTERIOSCLEROSIS 65 
 
 peripheral resistance. The diet should be 
 plain and simplified ; red meat should be eaten 
 in great moderation and not more than once a 
 day. There is no need for an absolute purin- 
 free diet, but it should be in that direction. 
 Perhaps the chief thing is to avoid the flesh 
 extracts, such as strong meat soups and rich 
 gravies ; for this reason boiled or stewed meats 
 are better than fried or roast ; this applies to 
 fish and chicken also ; a plain grill is good, but 
 the frying-pan is a danger. Vegetable soups 
 made with a bone stock may be taken. Cheese, 
 eggs and milk should supply the greater part 
 of the nitrogen food. 
 
 In cases, even early ones, when there is 
 very high pressure, and especially when the 
 cerebral symptoms are prominent, such as per- 
 sistent occipital headache, vertigo on stooping, 
 insomnia and tinnitus, a purin-free diet is 
 advisable for a time at any rate. It may be 
 useful as a reminder to give the following 
 extract from Dr. Cautley's paper on " Diet 
 and Dietetics " : 
 
 "A purin-free diet can be devised from a 
 
 combination of the various purin-free foods. 
 
 Nuts are the most nutritious and contain 
 
 much fat, chestnuts being the most digest- 
 
 5 
 
66 ESSAYS ON PRACTICAL MEDICINE 
 
 ible. Macaroni, dates, raisins and cheese are 
 all purin free and are in order of nutritive 
 value. White bread, potato and milk contain 
 minute traces, but so minute that they may 
 be considered as purin free. Cream, butter, 
 fats, eggs, apples, grapes, figs and honey are 
 also purin free. 
 
 " The following table shows what foods are 
 rich in purin. The purin contents of food in 
 grains per pound, pint or teacup : 
 
 Sweetbread 
 
 . 70-43 
 
 Beans 
 
 . 4-16 
 
 Liver 
 
 19-26 
 
 Lentils . 
 
 . 4'i6 
 
 Beefsteak 
 
 14-45 
 
 Oatmeal 
 
 . 3-45 
 
 Sirloin . 
 
 . 9-13 
 
 Asparagus 
 
 . 1-50 
 
 Chicken 
 
 9'06 
 
 Onion 
 
 . o-o6 
 
 Loin of pork 
 
 . . 8-48 
 
 
 
 Veal 
 
 . 8-13 
 
 Porter . 
 
 . 1-35 
 
 Ham 
 
 8.08 
 
 Ale 
 
 1*27 
 
 Mutton 
 
 • 6-75 
 
 T,a.ger beer 
 
 i'09 
 
 Salmon 
 
 . 8.15 
 
 Coffee . 
 
 . 170 
 
 Halibut 
 
 . 7-14 
 
 Ceylon tea 
 
 , I'2I 
 
 Plaice . 
 
 . 5-56 
 
 India tea 
 
 . 1-05 
 
 Cod . . , 
 
 4.07 
 
 China tea 
 
 . 0-75 
 
 With regard to alcohol, one must say that 
 the majority of such patients are better with- 
 out it, but when a person has been accus- 
 tomed to a moderate amount taken with his 
 food it does not always do to suddenly stop 
 it. The digestion may suffer and the general 
 body tone be depressed. Alcohol is not a 
 
ARTERIOSCLEROSIS 67 
 
 pressure elevator, rather the opposite. So 
 
 many of these patients are inclined to have 
 
 gouty tendencies that strong wines and malt 
 
 liquors are certainly unsuitable. A little light 
 
 wine, such as claret, still moselle or grave, may 
 
 do no harm if taken with the meals only, and 
 
 the same rule applies to small quantities of old 
 
 matured spirits. Alcohol, wisely chosen, and 
 
 only used as a digestive tonic, may help, but 
 
 when used as a frequent stimulant to enable 
 
 the body or mind to do more work or to 
 
 increase endurance for pleasurable excitement, 
 
 it certainly does harm. Brunton says : ** All 
 
 the alcohols tend to dilate vessels, to lessen 
 
 blood-pressure and ultimately to diminish 
 
 activity of the nervous tissues, although at 
 
 first they may seem to have a stimulant 
 
 action." In another place he says : " Alcohol 
 
 produces dilatation of the peripheral vessels, 
 
 and tends to lower the blood-pressure, while at 
 
 the same time it stimulates the heart." Alcohol 
 
 contains so little nutritive value (with the 
 
 exception of the sugars and extractives of 
 
 wines and beers) that in itself it may be said 
 
 to give nothing to the body ; it only enables 
 
 a man to draw on his reserves. This may be 
 
 useful in emergencies, or when used in great 
 
68 ESSAYS ON PRACTICAL MEDICINE 
 
 moderation, but unless so used, its inevitable 
 tendency must be to exhaust the reservoirs 
 of nervous energy. This question of alcohol 
 must be handled by physicians on a thor- 
 oughly scientific basis. We shall do more for 
 the cause of temperance by sober judgment 
 and advice, founded on scientific facts, than 
 by hot-headed, unprovable generalisations. 
 
 Strong coffee, especially black coffee, taken 
 after meals is certainly a stimulant, but is a 
 raiser of tension ; it has its good effects as 
 well as its bad. Many folks are much the 
 better for a good cup of cafe au lait in the 
 morning. Tea probably does not raise ten- 
 sion to any extent, but taken in excess may 
 easily produce tachycardia and irregularity of 
 the heart's action, especially if the heart is 
 working under difficulties. Good China tea 
 seems to have less bad effects than the other 
 growths, but it is not quite such a good 
 stimulant. 
 
 The question of tobacco is very frequently 
 presented to us, and it is not always an easy 
 one to answer. Nicotine, no doubt, is one of 
 the most powerful raisers of tension known, 
 but in ordinary forms of smoking not very 
 much gets into the system. Chewing tobacco 
 
ARTERIOSCLEROSIS 69 
 
 and snuff-taking, which are nearly extinct, 
 probably introduce more nicotine into the 
 body than any form of smoking. With cigars 
 the combustion is so complete that very little 
 of the poison remains. There is rather more 
 in pipe smoking. In cigarette smoking the 
 combustion is nearly as complete as in cigar 
 smoking, but the cigarette smoker probably 
 smokes much more tobacco in the course of 
 the day than a cigar smoker, for he is never 
 satisfied. The habit of inhaling the smoke of 
 cigarettes is, however, the real danger ; the 
 absorption of nicotine from the bronchial 
 mucous membrane is very rapid, and much 
 more is absorbed in this way than by smoking 
 through the mouth alone. The other chemical 
 products of tobacco combustion, pyridine 
 and the picoline bases, have probably their 
 effects on the vaso-motor nerves also, but 
 their evil influence is chiefly shown by irri- 
 tation of the pharyngeal mucous membrane. 
 Oliver in his experiments has found that in 
 ordinary people, not excessive smokers, tobacco 
 raises the systolic pressure from 10 to 15 mm., 
 but does not raise the diastolic, so that the 
 variation between the two becomes abnormal ; 
 this effect soon subsides after smoking is 
 
70 ESSAYS ON PRACTICAL MEDICINE 
 
 finished — in a quarter of an hour or so. We 
 all know, of course, from experience that 
 excessive smoking often produces tachycardia 
 and other rhythmical disturbances, and even 
 pretty severe cardiac pain ; the ultimate effect 
 of really excessive smoking is great feebleness 
 of heart and a very low tension. It will 
 readily be seen that a drug which affects the 
 circulation so strongly should, in cases where 
 the arteries are diseased or in an abnorm.al 
 state, be used with great caution and in great 
 moderation. Tobacco, no doubt, has a quiet- 
 ing and soothing effect on many people with 
 irritable nerves, and to this extent may be 
 useful, but one cannot help coming to the 
 conclusion that the average man who shows a 
 tendency towards arterio-sclerosis had better 
 give it up entirely ; this applies especially 
 to men who lead indoor lives. The man 
 threatened with this disease has to face a very 
 serious position, and should take no chances. 
 When we have removed, as far as possible, 
 all deleterious external influences, we can do 
 much to help our patients by medicinal treat- 
 ment. The old routine of giving iodide of 
 potassium in the pre-sclerotic stage is, I think, 
 a mistake ; it often upsets the digestion and 
 
ARTERIOSCLEROSIS 71 
 
 depresses without doing any real good. The 
 vaso-dilators or depressors that we should rely 
 on in this state are the nitrites, the hippurates 
 or the benzoates. The first are rapid depres- 
 sors, but the effect is rather short-lived ; but 
 the two latter will generally do all we want, 
 and their action is more sustained. They 
 cause no headache, and unless given in un- 
 necessarily large doses produce no feeling of 
 depression— indeed, most patients feel much 
 the better for them. The head symptoms, the 
 vertigo, the noises and the sense of brain 
 fatigue soon disappear. In this pre-sclerotic 
 stage there is very often some dilatation of 
 the heart, as one would naturally expect, and 
 sometimes an irregularity of beat ; this con- 
 dition is soon improved by full doses of 
 strophanthus or sulphate of spartein ; in most 
 cases these drugs are to be preferred to digi- 
 talis, and though not so powerful in their 
 action on the heart muscle, are well able to 
 cure the dilatation, if the tension be reduced 
 simultaneously. In laboratory experiments, 
 strophanthin in poisonous doses increases, 
 arterial pressure, but I think that all clinical 
 experience shows that in ordinary medicinal 
 doses of the_ tincture of the seeds, this drug, 
 
72 ESSAYS ON PRACTICAL MEDICINE 
 
 while strengthening the heart-beat, has Httle 
 or no action in contracting the arterioles. It 
 will readily be seen how important a point 
 this is. 
 
 Mackenzie, as the result of experiments on 
 patients at the Mount Vernon Hospital, has 
 come to the conclusion that digitalis does not 
 often raise arterial pressure, but that in some 
 cases it even lowers it. These observations 
 were, in his hands, made with the extreme 
 care that we should expect from him, but 
 I cannot help feeling that there is a partial 
 error somewhere. His patients were at rest 
 and otherwise placed in favourable conditions, 
 but I think strongly that clinical observations 
 of patients leading ordinary lives would give 
 different results. It is a question that ought 
 to be settled as far as possible, for digitalis is, 
 without doubt, the most useful and powerful 
 heart tonic of vegetable origin that we possess, 
 and if there are dangers in its use we should 
 have clear signals to warn us. Dr. F. W. 
 Price confirms Mackenzie's views on its pro- 
 ducing no rise of tension. On the other side 
 Lauder Brunton says : *' It is now generally 
 recognised that digitalis has (i) the power of 
 slowing the heart ; (2) of making it stronger ; 
 
A R TERIO-SCLEROSIS 73 
 
 (3) of contracting the vessels." In his resume 
 at the end of the chapter, he says : " DigitaHs 
 acts on the cardiac muscle, the intrinsic cardiac 
 nerve, and the vagus centre in the medulla. 
 It also affects the arterioles, causing them to 
 contract ; and probably it has upon them also 
 a twofold action, as on the heart, stimulating 
 both the contractile muscular walls and the 
 nerves which go with them." 
 
 Sir William Whitla, a very careful clinical 
 observer, says : "Its action upon the arterioles 
 must always be remembered, for by increasing 
 peripheral resistance it raises the renal and 
 general blood-pressure, and to this is attri- 
 buted its striking value when dropsy has 
 occurred." When the arterial tension is al- 
 ready high, as in valvular disease or Bright's 
 disease, it may be necessary to administer a 
 vaso-dilator in combination with it. Clifford 
 Allbutt in his fifth volume of his Dictionary of 
 Medicine, p. 961, says : '* Tone we may define 
 as that property in heart, artery or other 
 hollow viscus which preserves the mean 
 diameter of the part ; contraction as that 
 which enables the organ, nevertheless, to obey 
 stimulus and to perform particular acts. The 
 vermicular movements of the bowel and of an 
 
74 ESSAYS ON PRACTICAL MEDICINE 
 
 arteriole are due to the quality of contracti- 
 bility ; their tone preserves their mean dia- 
 meters in spite of distension or contraction. 
 Were it not for tone a hollow organ, often 
 subject to extravagant demands, would be 
 strained, and perhaps ruptured. In the heart 
 it is tone which does much, if not all, to pre- 
 vent loss of form under the great variations 
 of internal pressure/' Farther on he says, 
 as the result of his experiments, " that digi- 
 talis produces a distinct increase of tone, 
 which may be pushed to a degree inconsistent 
 with normal function/ ' Again he says : ' ' Tone, 
 then, is the quality to be watched and sup- 
 ported, and in digitalis we have a means 
 of intensifying tone and of moderating dis- 
 tensibility. Now tone, like any other quality 
 in excess, may be injurious, and the output 
 of the constringed ventricle may fall short of 
 the demands of the system. Again, when the 
 muscle falls into degeneration digitalis seems 
 to have other injurious actions, the nature of 
 which is obscure." May we not extend this 
 argument from the ventricular muscle to the 
 arterial muscular coats ? And will not obser- 
 vation of arterial pressure be the guide to the 
 use of this powerful, remedy ? If we giv^ 
 
ARTERIOSCLEROSIS 75 
 
 enough digitalis to render perfect the tone of 
 the ventricle and not to pass beyond that 
 point, we shall probably be doing the same for 
 the musculature of the arterioles, and thereby 
 improve the general condition of the circula- 
 tion and also the nutrition of the arterial coats 
 themselves. But if we press beyond this 
 normal tone point, it is easily seen that we 
 increase peripheral resistance, and so embarrass 
 and add to the work of the heart. In arterio- 
 sclerosis, I think, we often get signs of arterial 
 degeneration before those of cardiac degenera- 
 tion, and in such circumstances it may be that 
 digitalis is especially harmful. The lesson, 
 then, to learn is that when using digitalis 
 as a heart tonic in arterio-sclerosis, we must 
 carefully and frequently watch the tension, 
 and we must stop the drug for a time if there 
 be any marked increase, and especially if there 
 be a marked diminution of urine. 
 
 The following is an attempt to formulate, 
 for practical purposes, our present knowledge 
 of the action of digitalis and of its sphere of 
 usefulness. By its action on the vagus and 
 the intrinsic nerves of the heart, it improves 
 stimulus, it soothes and lessens excitability, 
 and by so doing improves and regulates cou- 
 
76 ESSAYS ON PRACTICAL MEDICINE 
 
 ductivity and rhythm. It decidedly increases 
 contractility — so much so that a poisonous 
 dose may cause the heart to stop in a state 
 of systole ; it increases also tonicity and so 
 prevents the tendency to dilatation from in- 
 ternal pressure ; but under excessive doses 
 this tonicity may be so augmented that the 
 ventricle, not dilating sufficiently, is unable to 
 receive and consequently to discharge the 
 normal quantity of blood into the arteries. 
 Its general effect, under wise dosage, is to 
 improve the power and the nutrition of the 
 heart muscle, and this result is not a mere 
 passing thing. Its sphere of usefulness is 
 chiefly in cases of commencing or partial failure 
 of heart power and tone, and it may be given, 
 with watchfulness, in any such case, whatever 
 the valvular defects may be, though it will be 
 better borne in some valvular diseases than in 
 others. In disorders of cardiac rhythm, such as 
 auricular fibrillation and flutter, it is especially 
 indicated ; in most cases of dropsy, resulting 
 from circulatory failure, it is invaluable. 
 
 It should not be used in conditions of acute 
 myocarditis, which so often occur in the in- 
 fective fevers, and after this condition has 
 passed away it should not be given if the 
 
ARTERIOSCLEROSIS 77 
 
 heart muscle is producing good compensation 
 by itself — first let the natural powers of re- 
 cuperation have their chance. It should be 
 given with great caution where there is much 
 peripheral obstruction in the arterioles, as in 
 advanced sclerosis and in Bright's disease 
 where there is high tension, but even in such 
 cases it may be most useful if combined 
 with vaso-dilators. In cases of extreme myo- 
 cardiac degeneration, where there is no healthy 
 muscle to respond, it will probably do harm, 
 and cannot do good. 
 
 We have, then, in our hands a very powerful 
 and useful weapon, but we must see that we 
 do not draw it in a wrong cause. 
 
 To return to the treatment of the arteries 
 in the pre-sclerotic stage ; when the heart 
 dilatation is cured by this combined treatment 
 of tonics and vaso-dilators, it should not be 
 difficult to keep the tension at the normal 
 point, but thesp cases will, for some time, need 
 careful watching and guiding ; there is always 
 a tendency for both the patient and his 
 arteries to relapse. The hippurates should be 
 given steadily for some months, but in dimin- 
 ishing doses. The salts in use are the sodium, 
 the lithium and the ammonium hippurate — 
 
78 ESSAYS ON PRACTICAL MEDICINE 
 
 of which, I think, the lithium is rather the 
 strongest. From five to ten grains daily are 
 generally sufficient, but the dose may be 
 pushed further if the patient is under observa- 
 tion. I have not so much experience of the 
 benzoates, but here we should have to use 
 larger doses — thirty grains a day or more. 
 The benzoates are not so well borne by the 
 stomach as the hippurates. The nitrite group 
 is represented by sodium nitrite, mannitol 
 nitrate, erythrol tetranitrate, and liquor 
 trinitrin, the dose of the three former being 
 about one to two grains three times a day, 
 and of the liquor trinitrin one or two minims 
 three times a day. The effect of the mannitol 
 and erythrol is probably more sustained. All 
 these may cause headache, which the hippu- 
 rates do not. When these simple remedies 
 fail to materially reduce tension and to give 
 relief to the subjective symptoms, we may feel 
 almost sure that the disease has gone beyond 
 the pre-sclerotic stage, and that we have to 
 deal with actually thickened arteries. We 
 may have to deal also with a hypertrophied 
 heart and with commencing cardio-sclerosis ; 
 the problem thus becomes more compli- 
 cated. 
 
ARTERIOSCLEROSIS 79 
 
 A most important point now is the state of 
 the kidneys ; if there is no albuminuria we 
 may do much to alleviate symptoms and to 
 prevent further progress of the disease. After 
 careful ordering of the patient's life, we should 
 steadily try to reduce the tension and to 
 strengthen the heart's action, as in the early 
 stage, but it will need much care. Where 
 there is confirmed sclerosis, the point of 
 normal tension, as concerns each individual, 
 is no longer constant. One must try to find 
 that point in each case, by watching and by 
 the patient's own sense of well-being. In 
 some cases you can get tension down to 
 140 mm. and they feel much the better for it ; 
 others would get irregular heart action and 
 be miserable. The extreme degrees of tension 
 such as 200 mm. and over should certainly, 
 I think, be attacked, but there are very many 
 cases who do well and lead fairly comfortable 
 lives by the tension point being reduced to 
 160 or 170 mm. These patients, if the kidneys 
 are fairly sound and if they lead careful 
 abstemious lives, may live to real old age, 
 but they should be often under supervision ; 
 till they are well on to eighty they will often 
 need medicinal help ; after eighty generally 
 
8o ESSAYS ON PRACTICAL MEDICINE 
 
 the tendency to progressive sclerosis ceases, 
 the arteries become softer, and the general 
 circulatory stress becomes less. The same 
 drugs will help much in all these cases. An 
 uncertain proportion of sclerotic cases will 
 develop atheroma of the arteries ; the serious- 
 ness of this varies much with the site of the 
 affection. One often detects marked atheroma 
 in the radial, brachial or temporal arteries 
 without any special symptoms being produced. 
 The danger point is in the aorta and cerebral 
 arteries ; cerebral haemorrhage is of course the 
 danger here. In atheromatous conditions the 
 tension varies much, at any rate as measured 
 by our present instruments ; it is some- 
 times normal or below normal. When it is 
 high it should be reduced with extreme cau- 
 tion. In many such cases nature has estab- 
 lished a working equilibrium or compromise 
 that is better left alone ; all we can do is to 
 help the heart and blood-vessels to carry on 
 with the smallest amount of strain. Attention 
 to the action of the liver and bowels will be 
 very important and regulation of bodily work. 
 In the cases of sclerosis at any stage, where 
 there are clear signs of kidney disease, the 
 outlook is, of course, not so good, but still 
 
ARTERIOSCLEROSIS 
 
 much can be done to help. The reduction of 
 tension in the general arterial system will 
 affect the kidney vessels also, and lessen con- 
 gestion ; it will probably help also towards 
 better elimination. The action of over-dosage 
 of digitalis in causing contraction of the 
 kidney arteries, and so in producing suppres- 
 sion of the urinary excretions, shows how 
 important the question of vaso-dilation be- 
 comes to a diseased kidney. The old woman's 
 remedy, broom tea, represented now by 
 sulphate of spartein, was undoubtedly a 
 good diuretic, but better in cardiac dropsy 
 than in that of Bright's disease probably. 
 This effect was produced apparently by the 
 drug's action on the heart muscle, with- 
 out its producing any contraction of the 
 muscular coats of the arteries. It would be 
 outside the scope of this essay to deal at 
 greater length with the kidney side of the 
 question. 
 
 In some sclerotic cases, especially where 
 there is a tendency to obesity, thyroid feeding 
 may be of great use, and will in the future, 
 perhaps to a great extent, supersede other 
 medicinal treatment. Though laboratory ex- 
 periments show some divergence of results, I 
 6 
 
82 ESSAYS ON PRACTICAL MEDICINE 
 
 think we must regard it as an established fact 
 that thyroid extract is a tension depressor. 
 The original experiments by OHver and 
 Schafer seem conclusive, and Biedl in his work 
 on the internal secretory organs corroborates 
 these conclusions. Brunton says : " Thyroid 
 gland, when taken by the mouth, dilates the 
 peripheral vessels, makes the skin warm and 
 moist, and quickens the pulse. In this respect 
 it antagonises the suprarenal secretion. Be- 
 sides this effect on the blood-pressure it has 
 other effects on metabolism which are im- 
 portant." Biedl says : ''If thyroid extract or 
 iodothyrin are given continuously for two or 
 three weeks, the amount of COg excretion will 
 be increased by 15 to 25 per cent. The 
 nitrogenous interchanges are invariably dis- 
 turbed by th3n:oid extract ; the increased 
 decomposition of albumen is expressed by an 
 increased excretion of nitrogen. By increasing 
 the caloric food supply, the nitrogen losses may 
 be avoided. In obesity, owing to the large 
 reserve of fat, the loss of albumen is not as 
 great as in the normal subject. Thjnroidism 
 also brings about a considerable increase in the 
 amount of calcium excreted in the faeces, the 
 calcium carrying off with it a large proportion 
 
ARTERIOSCLEROSIS 83 
 
 of phosphorus. Scholz had before shown that 
 thyroid extract produces in man an increased 
 excretion of phosphorus." It is very evident 
 that we have in thyroid medication something 
 much more than a mere tension depressor. 
 Its other properties, influencing the excretions, 
 explain to some extent its sphere of usefuhiess 
 and its drawbacks. The increased excretion 
 of calcium may be very beneficial in sclerosis, 
 especially perhaps when there is atheroma ; 
 the loss of phosphorus accounts in some 
 measure for the debility and for the nervous 
 symptoms that often follow its use. The in- 
 creased output of CO, and N is probably all 
 helpful, but all these by-effects should be pro- 
 duced slowly and cautiously. I have thought 
 that thyroid treatment in sclerosis is more 
 satisfactory in cases where there is no kidney 
 complication ; this is not unlikely, as in 
 Bright's disease the kidneys would only im- 
 perfectly carry off the results of increased 
 nitrogen metabolism, and this failure of ex- 
 cretion would leave the blood overcharged 
 with these products. An Eastern proverb 
 says, " Don't stir up sleeping dogs if you 
 can't kick them off the premises," the moral 
 of which is not difficult to see. The loss of 
 
84 ESSAYS ON PRACTICAL MEDICINE 
 
 phosphorus can be well remedied by giving 
 lecithin. We should bear in mind that thyroid 
 extract and parathyroid extract are in some 
 measure antagonistic ; thyroid contains, in 
 Schafer's language; an autacoid or stimulator 
 of nervous energy and of some other excretory 
 glands, as the suprarenal ; parathyroid ex- 
 tract contains a chalone and has the reverse 
 effect. I cannot help thinking that some of 
 our therapeutic experiments are brought to 
 naught by preparations carelessly made and 
 containing the extracts of both glands. In 
 thyroid treatment we must stop short, if 
 we can, of producing its disagreeable effects, 
 palpitation of the heart and giddiness ; the 
 sphygmo-manometer is generally a good guide, 
 but if these symptoms come on, they are 
 generally relieved most effectually by supra- 
 renal extract, a 5-grain tablet once or twice 
 daily : this sounds like an illogical proceeding, 
 where you are trying to lower pressure, but in 
 practice it succeeds well. It is well known 
 that thyroid exhibition in health increases the 
 amount of adrenine in the blood ; this is prob- 
 ably a wise compensation, and one can readily 
 understand how in disease this compensation 
 may fail to take place. Though in obesity 
 
ARTERIOSCLEROSIS 85 
 
 thyroid often causes loss of weight, in thin 
 people who are suffering from hypo-thyxoidism 
 it often has the opposite effect. In thyroid 
 treatment, especially as old age draws near, 
 and quite apart from myxoedema, we have 
 before us a most interesting field of study, full 
 of possibilities and of hope. 
 
 The addition of other gland extracts to thy- 
 roid are extremely useful ; they counteract the 
 lowering effects and enable us to greatly prolong 
 its use. 
 
 In arterial sclerosis I nearly always use 
 testicular, ovarian and anterior pituitary 
 (pitglandin) with th37roid. The anterior pitui- 
 tary of these three is far the most important in 
 my opinion, for it is a real tonic as well as a 
 tension depressor. This I shall discuss in the 
 next chapter ; but in passing I should like to say 
 that the ovarian and testicular extracts seem 
 to act with greater effect on the opposite sex. 
 In Russia caviare, the roe of the female fish, 
 is universally regarded as an aphrodisiac for 
 men. In women about the climacteric, when 
 there is depression with some high tension, 
 testicular extract in the form of Burroughs & 
 Wellcome's didymin often gives a new mental 
 outlook. 
 
86 ESSAYS ON PRACTICAL MEDICINE 
 The formula I use is as follows : 
 
 Thyroid dried extract . . . grain J 
 
 Ovarian „ ,, • . • ,, J 
 
 Testicular ,, ,, . . . ,, ^ 
 
 Anterior pituitary (pitglandin) . • „ i 
 
 in tablets i ter die ant. cib. 
 
 With my present knowledge and experience 
 this is generally the most satisfactory and 
 efficient direct depressor of tension that I know. 
 It acts better, I think, in the later stages and in 
 old age than the hippurates, but may be com- 
 bined with them. The thyroid proportion can 
 be safely increased, if the pressure do not fall, 
 and either the ovarian or testicular extract can 
 be left out. 
 
 Still, I have seen many cases in which hip- 
 purate alone has kept high pressures at a safe 
 level through many years, and in real old age 
 cases in which the gland extracts have not 
 apparently been of help. I still feel unable 
 to say positively which line of treatment will 
 succeed the better in any individual case. E.g. 
 I have one lady (ninety-six), whose brain gets 
 clouded and who, to use her own expression, 
 sees visions, when her pressure rises above 
 155°^. In this case hippurate acts like a 
 charm, and she calls it her vision medicine. 
 
ARTERIOSCLEROSIS 87 
 
 Whatever its mode of action may be, we must 
 not forget that it is just as much a native 
 organic medicine as the gland extracts. 
 
 For many years iodide of potassium has had 
 a great reputation in the treatment of arterio- 
 sclerosis, and it apparently does do good in 
 certain cases ; but, as far as experiments show, 
 it has no direct effect in lowering blood- 
 pressure ; it is quite hkely that it acts, as all 
 preparations of iodine do, by stimulating and 
 increasing the output of the thyroid secretion. 
 It is a disagreeable drug to take, depressing, 
 and not always easily digested ; and thyroid 
 itself should, in my opinion, be tried first. 
 The new coUosol iodine may give more constant 
 results. Rendle Short says : " An increased 
 th3n:oid secretion may be obtained by giving 
 iodides. Here we find the explanation, so long 
 sought in vain, of the effects of iodides on 
 gummata, arterio-sclerosis and aneurism. The 
 beneficial agent is really the increased internal 
 secretion of the th3nroid gland. Two im- 
 portant results of observation and experiment 
 confirm this theory. 
 
 " In the first place, in cases of myxcedema, 
 arterio-sclerosis is early and intense. The 
 same is true in animals after removal of the 
 
88 ESSAYS ON PRACTICAL MEDICINE 
 
 thyroid. Eiselsberg gives a number of very 
 convincing photographs of intense atheroma 
 of the aorta in his cretin lambs from which 
 the thyroid had been removed. In the second 
 place, thyroid extract has a wonderful power 
 over young connective tissue, as is seen by 
 the way in which it absorbs the subcuta- 
 neous thickening of myxcedema and cretinism. 
 It is not surprising, therefore, that it should 
 be able to deal also with gummata and 
 atheroma." 
 
 With these facts before us, is it unreasonable 
 to think that the subthyroidism which is so 
 common as old age approaches is one, if not 
 the chief, cause of atheroma ? And is it not 
 reasonable to expect that in such cases thyroid 
 feeding will prevent the extension of the 
 disease and will very possibly cause absorption 
 of the morbid deposits already present ? 
 
 In the general management of sclerotic 
 patients, plenty of fresh air is necessary, and 
 steady, moderate exercise ; their inclination 
 is to lead a sedentary, indoor life, but this is 
 distinctly bad for them. Physical exercise 
 must be of a nature that puts no great strain 
 on the heart and lungs, and to ensure this 
 hurry must be avoided : not hurry alone, but 
 
ARTERIOSCLEROSIS 89 
 
 even the feeling of being hurried or rushed, 
 raises the arterial pressure, before any move- 
 ment has begun. Horace's advice, '* sequam 
 memento rebus in arduis servare mentem," 
 applies with double force to such folk. 
 
 The best exercise is probably walking, on 
 the flat at first, and subsequently, as improve- 
 ment takes place, up graduated inclines. 
 Cycling or^ better still, tricycling when roads 
 and winds are not unfavourable, is good, and 
 not so monotonous. Horseback exercise, on a 
 horse that is not a puller, is perhaps the best 
 of all. Sculling, again, in a light river boat is 
 very good work, and, if not hurried, puts very 
 little strain on the heart, and quietly exercises 
 most of the body muscles. Well-regulated 
 exercise spreads the circulation of the blood 
 over a much larger area ; in rest the blood, to 
 a great extent, collects in our internal reser- 
 voirs, but exercise sends it coursing through 
 aU the arterioles and capillaries of the muscles 
 of our limbs ; thus internal congestion and 
 pressure is reheved. Probably with a seden- 
 tary indoor life the viscosity of the blood is 
 increased — this is a problem that needs working 
 out. It must be evident that an increase of 
 viscosity of any circulating fluid must demand 
 
go ESSAYS ON PRACTICAL MEDICINE 
 
 increased force from the central driving power. 
 Oxygen, without doubt, lessens the viscosity 
 of the blood, and so reduces the heart's 
 work. 
 
 Sir Lauder Brunton, at a meeting of the 
 Medical Society of London a year ago, related 
 a very instructive case. A patient with ad- 
 vanced kidney disease was at death's door, 
 and it was thought necessary to bleed her, but 
 the blood could not be got to flow from the 
 vein on account of its viscosity ; a cylinder of 
 oxygen was in the room, and the happy thought 
 came to him to use it as an inhalant : in a few 
 minutes the blood began to flow, and in a few 
 minutes more there was a full stream. This 
 all emphasises the need and advantage of 
 open air. 
 
 Here I must draw attention to the great 
 value of bleeding in cases of extreme high 
 tension, and especially when there are sjnmp- 
 toms of threatening apoplexy. Bleeding from 
 the arm is the quickest method, but if there 
 are objections to this, a leech or two over each 
 temple and two or more at the back of the 
 neck will answer well ; the leech bites should, 
 of course, be kept running by warm fomenta- 
 tions for some time. But here also we must 
 
ARTERIOSCLEROSIS 91 
 
 not cast back to the old error that blood- pressure 
 is the result of increased blood-mass, for the 
 venous system has plenty of stowage room 
 available as reservoirs, and we must have seen 
 many cases of high blood-pressure in thin 
 people with no sign of plethora ; still judicious 
 bleeding may, I think, relieve local plethora, 
 especially perhaps in the head, a method which 
 Nature follows in epistaxis. The good that 
 results is no doubt due not to the mere empty- 
 ing of the blood-vessels, but to the alteration of 
 the quality of the blood ; as soon as the vessels 
 are partially emptied of the blood, they fill 
 up again, by extracting the watery constituents 
 of the tissues, and thus the viscosity of the 
 blood is reduced. In this state of blood 
 arsenic seems to be beneficial. There remains 
 the important question of balneology and 
 electricity in the treatment of this disease. 
 The Nauheim treatment, as carried out at 
 Nauheim especially, acts perhaps as much in 
 reducing arterial tension and peripheral resist- 
 ance as in causing contraction of the dilated 
 heart ; the immediate effect of the bath is to 
 produce great dilatation of the surface arteri- 
 oles and capillaries of the skin, in fact cutaneous 
 hyperaemia of an active kind ; this naturally 
 
92 ESSAYS ON PRACTICAL MEDICINE 
 
 lessens the amount of blood in the important 
 splanchnic area, and so relieves the work of 
 the heart. This treatment can be well imitated 
 at home. In the Practitioner of August 1912 
 is a clear and instructive article by Dr. Thorne 
 on the good effect of the Nauheim treatment 
 on arterio-sclerosis as carried out in England. 
 Other waters have a somewhat similar action — 
 for instance, Gastein and Llangammarch Wells 
 in Wales ; it is probable that the radio-active 
 character of some of these waters adds to 
 their usefulness. 
 
 Electrical treatment, where obtainable, may 
 be a great help. In the early stages, I think, 
 high frequency is of some considerable help in 
 reducing blood-pressure, and its action is more 
 than a passing one ; it also acts as a general 
 tonic to the vaso-motor nerves and increases 
 metabolism probably ; in the later or con- 
 firmed stages of sclerosis it is not of much use, 
 I think, but here the Bergonie-faradic method 
 seems to have a marked effect and a lasting 
 one. It is perhaps hardly necessary to say 
 that these treatments must be carried out by 
 physicians who have made a special study of 
 electricity and who know its limitations and 
 its risks. 
 
ARTERIOSCLEROSIS 93 
 
 When all has been said about the treatment 
 of this morbid condition we call arterio-sclero- 
 sis, we are sure to be faced with a somewhat 
 sceptical criticism ; one will ask, '* Is not this 
 thickening of the arterial coats and its in- 
 crease of tension Nature's method of keeping 
 up a failing circulation ? " One must honestly 
 answer, " Yes, to a certain extent " : the same 
 criticism would apply equally to the case of 
 hypertrophy of the ventricle, which grows 
 stronger and bigger only to meet an increased 
 demand. The sclerosis is a fault to compen- 
 sate in a measure for another fault ; but if one 
 can remove or partialty cure the originating 
 and causative fault one may and should surely 
 treat and cure, if possible, the resulting fault ; 
 it cannot be our duty to stand by and see the 
 vicious circle of disease go on to its end un- 
 broken. The original causes of the disease, 
 except in those sad cases where the tendency 
 is strongly inherited, are largely removable, 
 for mostly they arise from physiological law 
 breaking and from mental overstrain. Let 
 us then throw aside this weight of paralysing 
 hyper criticism, a sin that doth so easily beset 
 us, and march boldly but cautiously on in the 
 path of restoration and of healing. 
 
94 ESSAYS ON PRACTICAL MEDICINE 
 
 Sir Clifford AUbutt, in his inimitable way, 
 settles, I think, this question as follows: 
 
 *' In entering upon the discussion of vaso- 
 dilatation, as contrasted with agents which 
 bring about this change indirectly by modifying 
 the causes of morbid constriction, we have to 
 consider how far mere dilatation — ^brought 
 about, that is to say, immediately and singly — 
 serves any good purpose. 
 
 " We are told that to act thus directly upon 
 the vessels is but to treat a symptom, and 
 is therefore absurd. But whatsoever be our 
 judgment on this or any such particular effect, 
 the common denunciation of treating symp- 
 toms, which sounds very philosophical, is surely 
 but a parrot phrase. Why should we not treat 
 a symptom ? If in granular kidney by mere 
 pressure reduction the grievous headache be 
 abated, or in angina pectoris the pain be thus 
 charmed away, we have so far at any rate a 
 substantial gain. 
 
 " In renal diseases it is generally agreed that 
 on the whole, with due caution, to lower pressure 
 is helpful. Moreover, if by mitigation of his 
 suffering, the patient gets a chance of picking 
 up in many other ways, are we not more than 
 justified in our interference, narrow as it may 
 
A RTERIO-SCLEROSIS 95 
 
 seem ? We never know what interference may 
 cut a link in a vicious circle. If we cannot 
 stop the crack in the water-pipe, we need not 
 throw away the mop. 
 
 *' The warning should run not against the 
 treatment of a ' mere symptom,' but lest, 
 while giving our attention to the symptom 
 and snatching at an immediate advantage, we 
 lose our grip of the case as a whole." 
 
 After all our theories and speculations, the 
 high court that has to pronounce judgment is 
 formed by our patients themselves. Ask any 
 man or woman who has suffered from the 
 miseries and discomforts of arterio-sclerosis, 
 when accompanied by high blood-pressure, 
 how they feel, after that pressure has been 
 carefully and judiciously reduced, and you will 
 get no uncertain answer. They can work and 
 think far better ; their breathing is much 
 easier, and they lose the cardiac and the 
 cerebral discomforts that made their lives so 
 miserable. Their sleep becomes again quiet 
 and refreshing ; and beyond the improvement 
 in these subjective symptoms, there is a con- 
 dition of far better general health and, what 
 is perhaps more important, of greater safety. 
 It must be evident that any one attempting to 
 
96 ESSAYS ON PRACTICAL MEDICINE 
 
 lead a strenuous, active life, either in mental 
 or bodily work, with a tension much above 
 the normal, is in daily danger of a bad 
 break-down, of one that will practically end 
 his working days. It should be, therefore, our 
 manifest duty to bring all such to the know- 
 ledge of their danger, to persuade them to 
 lead a new life, and to grasp the means of 
 safety that we can offer them. 
 
 During the last few years, it has been the 
 fortunate lot of many of us to be able, with our 
 sclerotic patients, to steer them safely through 
 the dangerous storms and shoals of later middle 
 age into the quiet and restful harbour of real 
 old age, free from paralysis and with mind 
 unclouded. 
 
Ill 
 
 THERAPEUTIC SPECULATIONS AND 
 DOUBTS 
 
 The truest courage lies, 
 
 Not in unseeing eyes, 
 Owning no danger, blindly rushing on ; 
 
 But in the eye that sees 
 
 To grasp the golden keys 
 Of power and circumstance, and make them one. 
 
 When we, in all honesty and out of our 
 patients' hearing, take stock of our therapeutic 
 experiences, we must, I think, allow that our 
 expectations have oftentimes been unfulfilled, 
 or that the results, at any rate, have not been 
 commensurate with our hopes. That this 
 should be so is no cause for wonder and cer- 
 tainly no cause for despair. Till quite recently 
 we were most of us brought up in a school of 
 almost pure empiricism, of traditions, and often 
 of illogical conclusions. It is only in the last 
 twenty or thirty years that either the plant 
 remedies or the chemical ones have been 
 studied at all accurately from the physiological 
 7 97 
 
98 ESSAYS ON PRACTICAL MEDICINE 
 
 point of view, and the results tested by scien- 
 tific methods and instruments. Many of us 
 can remember the wave of pure scepticism 
 that passed over the medical world in the times 
 of Gull, who had the courage to treat seventy 
 cases of acute rheumatism with the old alkahne 
 potash treatment, another seventy cases with 
 peppermint water, and to pubUsh his results. 
 This scepticism and honest criticism undoubt- 
 edly did good — it cleared our minds of a 
 certain amount of cant and of ignorant pre- 
 judice — -but in itself it led nowhere. 
 
 If in therapeutics we lose faith and hope, 
 we become in a measure paralysed, and, what 
 is perhaps worse, we develop an underlying 
 feeling that we are saiHng under false colours 
 and are not giving a quid pro quo, or as Good- 
 hart puts it, a quo pro quid. To-day surely 
 there is no room for faithlessness nor for hope- 
 lessness ; our knowledge is infinitely wider and 
 surer ; it still is very necessary to keep the 
 judicious and critical mind, but our power 
 over disease is daily increasing. The effects 
 of the plant remedies are still often a matter of 
 doubt, though the standardisation of tinctures 
 and the extraction of alkaloids have put things 
 on much surer ground ; these remedies, though 
 
SPECULATIONS AND DOUBTS 99 
 
 very often useful — some of them, indeed, being 
 seemingly indispensable — ^will eventually, I 
 think, lose much of their prominent position, 
 for the reason that they are foreign to the 
 animal system. The inorganic remedies come 
 under rather a different heading ; many of 
 them, like iron, arsenic, iodine, potash and 
 soda, are already constituents of the flesh and 
 blood, and in a measure they can be regarded 
 as body foods ; but the great future, I venture 
 to think, belongs to the organic animal reme- 
 dies, to the ductless gland extracts, and to 
 organic chemistry. 
 
 Still lest we be led astray, we must walk 
 warily and diHgently sift the many observa- 
 tions and theories that are brought before 
 us : the old difficult fences of fost hoc and 
 propter hoc may easily give us a nasty fall. 
 The unreflecting mind will look on a truth 
 that is only half a truth as much the same 
 thing as a lie that is only half a lie ; the 
 immediate present result may be the same, 
 but the difference lies in the intent. If the in- 
 vestigator be honest and has an open mind, the 
 half-tiuth will probably become a whole truth, 
 though perhaps not in his time : it may be for 
 others to enter into his labours, to complete 
 
lOo ESSAYS ON PRACTICAL MEDICINE }^ 
 
 them and to reap the reward (Tulii alter 
 honores applies to us as to others) ; but the 
 true physician seeks not his own glory or 
 honour. A man, on the contrary, who starts 
 with a half-lie, whether intentionally, selfishly 
 or with a scarcely recognised, half- unconscious 
 bias, will most likely complete his lie. His 
 labour will be in vain and the truth still farther 
 from the light. 
 
 Very few of us have the true Darwinian 
 intellect, the calmly calculating mind that is 
 never in a hurry and that accurately weighs 
 both failure and success. How few of us have 
 the moral courage to retrace our steps and to 
 own that we have been marching down a blind 
 alley ! So in much patience we must possess 
 our souls. 
 
 On the other hand, we must not forget that 
 half-truths have an almost fatal fascination 
 for small minds, and sometimes, alas ! for big 
 ones. Professor Macphail says : '* A lie which 
 is only half a lie is far less deadly than a partial 
 truth which is believed to be the whole truth." 
 Partial truths, cherished and worshipped by 
 narrow minds as whole truths, have been 
 the teterrimae causce of wars, burnings and 
 persecutions in religious history and in the 
 
SPECULATIONS AND DOUBTS loi 
 
 march of science almost insurmountable bar- 
 ricades. The truth, the whole truth and 
 nothing but the truth in many things on this 
 side of the grave may be an unattainable ideal, 
 but still should be our standard — our grail. 
 In the search for the inner secrets of life, of 
 which endocrinology is a most important, even 
 fundamental part, can we hope in our short time 
 to find the whole truth ? We may establish 
 the truth of separate facts as we go along, and 
 we may build reasonable theories on them, but 
 the whole, the ultimate truth must still be a 
 far-away goal. Meanwhile, we are surely justi- 
 fied in using the knowledge we have gained for 
 our bodies' weal. 
 
 So that we may get a clear understanding 
 of the nomenclature of this subject, I propose 
 to adopt the terms and definitions that Sir 
 Edward Schafer has used in his lectures. 
 
 1. Material which passes into the blood or 
 lymph from any tissue or cell of the body is 
 termed its internal secretion. 
 
 2. Organs which, so far as is known, possess 
 no other function than this, are called inter- 
 nally secreting or endocrine organs {evBov, 
 within, and Kplvco, to separate). 
 
 3. This term, as at present understood, com- 
 
I02 ESSAYS ON PRACTICAL MEDICINE 
 
 prises the thyroid, the parathyroid, the supra- 
 renal, the pituitary and the pineal glands. 
 (Other glands, like the pancreas, the ovary 
 and the testis, have properties to some extent 
 similar to these glands, but they do not come 
 so definitely under the head of internally 
 secreting organs, as they have in a sense both 
 internal and external secretions.) 
 
 Schafer's definition, then, is "an organ 
 which is known to form some specific chemical 
 substance within its cells and which passes 
 this directly or indirectly into the blood 
 stream. The substance thus formed is the 
 active material of its secretion, just as ptyalin 
 is the active agent of the salivary secretion ; but 
 while the salivary secretion is conveyed by a 
 duct to the exterior, in the case of the ductless 
 glands the secretion remains within the body 
 and circulates with the blood." 
 
 The active agents of the external secretory 
 organs differ from those of the internal secre- 
 tory organs, in that they belong to the class 
 called enzymes, and that they are of the nature 
 of a ferment and are destroyed by heat. The 
 active agents of the internal secretory organs 
 are not so complex, and are not destroyed 
 by boiling ; they are dialysable, and some of 
 
SPECULATIONS AND DOUBTS 103 
 
 them can be isolated in a crystalline form ; 
 the active principle of the adrenals has even 
 been made synthetically. They act quickly 
 on the cells which they influence, and when 
 injected into the blood stream have an im- 
 mediate effect, whereas an enzyme acts more 
 gradually. The action of these principles is 
 not unlike those produced by the active 
 principles of drugs, especially by those of 
 vegetable origin. They also operate by im- 
 mediate chemical action, being conveyed to 
 their special parts by the circulating blood. 
 Like drugs, some of the principles contained 
 in these extracts act by exciting or stimulat- 
 ing cell functions, others by depressing such 
 functions ; the former are called " hormones " 
 {op/jLacD, to stir up), and the latter " chalones " 
 (xaXdco, to make slack). The expression 
 "hormone" has now got such a widely 
 extended meaning that Schafer has coined a 
 new expressive word, ''autacoid" (avT09, self, 
 a/co9, a remedy), which he defines thus : "An 
 autacoid is a specific organic substance formed 
 by the cells of one organ and passed from them 
 into the circulating fluid to produce effects 
 upon other organs similar to those produced by 
 drugs. Such effects are either in the direction 
 
I04 ESSAYS ON PRACTICAL MEDICINE 
 
 of excitation, in which case the endocrine sub- 
 stances producing them may be termed excita- 
 tory autacoids and so would come under the 
 expression * hormones/ or in the direction of 
 restraint or inhibition, in which case they may 
 be termed restraining or inhibiting autacoids 
 and be classed as * chalones/ The action 
 of an autacoid may be termed hormonic or 
 chalonic according to the kind of effect it 
 produces. 
 
 " Some autacoids appear to produce opposite 
 results in different parts of the body : thus 
 adrenine causes contraction of the plain muscles 
 of the blood-vessels and inhibition of that of the 
 intestines. In both cases the action may be 
 regarded as that of a hormone, for both effects 
 are produced by stimulation of the end sub- 
 stance of the sympathetic nerves. The possi- 
 bility of the same autacoid acting under some 
 circumstances as a hormone or excitant and 
 under others as a chalone or depressant must 
 be borne in mind. This illustrates the drug-Hke 
 nature of these principles, for such inversion of 
 action under different circumstances is known 
 to occur with some alkaloids." 
 
 For a more scientific and complete description 
 of this most interesting subject I would refer 
 
SPECULATIONS AND DOUBTS 105 
 
 my readers to " An Introduction to the Study 
 of the Endocrine Glands and Internal Secre- 
 tions," by Sir Edward Schafer, published by 
 Stanford University, California, 19 14, 75 c, 
 and to " The Internal Secretions," by Gley 
 and Fishberg (Heinemann). 
 
 What a field for study, for observation and 
 for successful practice these discoveries open 
 up for us, one must at once perceive. We 
 begin to get a glimpse of the innermost secrets 
 of life — -of those marvellous agencies which 
 maintain the physiological equilibrium of our 
 bodies, and which under ever-varying circum- 
 stances enable us to fight this good fight of 
 vitality versus decay. The I knowledge we 
 have already obtained has produced most 
 important results, but we are not yet with- 
 in sight of the horizon of the therapeutic 
 possibilities. 
 
 These ductless glands, by their secretions, 
 control and activate not only each other but 
 the great sympathetic nervous system and all 
 the vital processes of the body. The secre- 
 tions of most of these glands, from some 
 points of view, appear to be antagonistic to 
 one another, but from other points of view 
 helpful and compensatory. In their totality 
 
io6 ESSAYS ON PRACTICAL MEDICINE 
 
 they are the essence of Hfe itself. Our aim 
 and hope must be, by patient study and 
 by experiment, to bring these powerful and 
 apparently divergent remedies into such use 
 and combination that they will make harmony 
 again out of the discord we call disease. 
 
 Dr. Gley has introduced another word, which 
 perhaps fills a gap, harmozone (from the Greek 
 dpfjbdco, I rule or direct). Physiological experi- 
 ments on all these secretions are as yet, 
 in many cases, inconclusive. One observer is 
 frequently disproving his own theories or those 
 of another, or else methods of investigation 
 are proved to produce compHcations which do 
 not occur in life or health. Still, there is much 
 solid groundwork — enough, I think, for practical 
 physicians to proceed actively and without 
 fear on empiric lines ; in fact, empiric medicine 
 will oftentimes prove or disprove physiological 
 theories, and will guide and direct the thera- 
 peutical applications of the work of the labora- 
 tory. It must be remembered also that this 
 clinical experiment can be carried on quite 
 safely, for none of these gland extracts are 
 poisonous, and any disturbances of function 
 they may cause soon passes away or can be 
 corrected by other means, 
 
SPECULATIONS AND DOUBTS 107 
 
 It would be dif&cult to say which of these 
 glands is the most important, but the thyroid, 
 I think, must come first, as its errors appar- 
 ently are concerned more than those of others 
 with the ordinary morbid conditions of life. 
 Without going into the anatomy, the histology, 
 or the development of the thyroid apparatus, 
 we must bear in mind that it consists in 
 man of two lobes united by an isthmus, and 
 of four parathyroids. It is found in all the 
 vertebrates. It is a very vascular organ and 
 contains many lymphatics. The nerve supply 
 is from the sympathetic and from the vagus, 
 and is distributed both to the blood-vessels 
 and to the secreting epithelium. Its vesicles 
 contain the " colloid," which almost for certain 
 contains the active principle of the gland ; 
 this colloid is insoluble in ether, alcohol or 
 water, and contains iodine. The parathyroids 
 are, in man, closely attached to the thyroid, 
 but are physiologically distinct ; vesicles con- 
 taining colloid material similar to that of the 
 thyroid are often found in them, but the 
 similarity of the chemical nature of the two 
 colloids is not proved. If the thyroid be 
 completely removed and one or more para- 
 thyroids be left, the colloid-containing vesicles 
 
io8 ESSAYS ON PRACTICAL MEDICINE 
 
 of the remaining ones increase in number and 
 size. 
 
 The normal functions of the thyroid appara- 
 tus can be best arrived at in the first place by 
 noting the effects of removal. 
 
 If the parathyroids be completely removed, 
 most animals die within a few days or weeks ; 
 the carnivora are the more rapidly affected. 
 The symptoms belong chiefly to the nervous 
 system, and show generally exaggeration of 
 reflexes, passing on into clonic muscular con- 
 tractions and then into convulsions ; the 
 symptoms closely resemble those of the disease 
 called " tetany." This disease has frequently 
 occurred in man, after a complete removal of 
 the whole thyroid and parathyroid apparatus, 
 and can only be cured by a successful graft 
 of a human parathyroid. In operations for 
 removal of thyroid tumours it is necessary, in 
 order to prevent these dangerous symptoms, 
 to leave two of the four parathyroids. The 
 most satisfactory explanation of " tetany " 
 coming after parathyroid removal is the as- 
 sumption that they give to the blood an 
 autacoid which has an inhibiting or chalonic 
 effect on over-excitation of nerve cells. The 
 removal of parathyroids in growing animals 
 
SPECULATIONS AND DOUBTS 109 
 
 probably causes delay in the growth and 
 development of bones and teeth. The effects 
 of removal of parathyroids have been relieved 
 by the injection of extract of parath5n:oid ; 
 pituitary extract is reported to have a like 
 effect. Schafer concludes by saying that no 
 other substance appears to exhibit the specific 
 action on the nervous system of this para- 
 thyroid autacoid. 
 
 Ott says that intravenous injections of para- 
 thyroid extract have quite a different effect 
 from those of thyroid. The blood-pressure is 
 first raised, then depressed ; there is an in- 
 creased respiratory rate ; they are diuretic, 
 acting directly on the renal epithelium ; and in 
 large doses they lower the body temperature. 
 Applied locally they increase contraction of 
 intestine and uterus and dilate the pupil. 
 
 If the th3n:oid be removed or become atro- 
 phied (two or more parathyroids remaining), 
 the following are the chief symptoms, these 
 being more marked in the young than in 
 the mature : arrest of growth, especially of the 
 skeleton, and delay in the development of the 
 generative organs ; the skin is swollen and 
 dry, the hair thin, the face pale and puffy, 
 the abdomen swollen, the nose depressed, the 
 
no ESSAYS ON PRACTICAL MEDICINE 
 
 hands and feet podgy. The fontanelles remain 
 open, the muscles are weak, and the higher 
 functions of the nervous system remain un- 
 developed, this being due to arrested develop- 
 ment of the cortex cerebri. In short, we have 
 the condition called '' cretinism." This con- 
 dition may be sporadic or endemic, the former 
 being caused by early atrophy or by absence 
 of the th57roid, the latter by goitrous degenera- 
 tion. McGarrison says that in India there 
 are two types, the myxoedematous and the 
 nervous, the latter presumably being associated 
 with parathyroid deficiency. The first type 
 is the more common in Europe. These symp- 
 toms rarely are seen till some little time after 
 birth, the theory being that the th5^oid in- 
 sufficiency is compensated for a time by the 
 autacoids conveyed from the mother, before 
 birth by the placenta and afterwards by the 
 milk. If thyroid atrophy comes on in adult 
 age, the condition called myxoedema comes 
 on. This also frequently supervenes on com- 
 plete surgical removal of the gland. Kocher 
 says : '' If about a quarter of the gland is left, 
 the symptoms of thyroid insufficiency do not 
 appear." This is Schafer's description : "It 
 is characterised by the thickening and swelling 
 
SPECULATIONS AND DOUBTS iii 
 
 of the skin, which pits on pressure, the pitting 
 disappearing on relaxing the pressure ; by the 
 skin becoming dry and the hairs faUing out ; 
 by a low body temperature, by mental dull- 
 ness, and by general impairment of sensi- 
 bility." Metabolism is lessened, so that body 
 weight may increase in spite of a smaller in- 
 take of food ; there is often a considerable 
 deposition of fat, especially under the skin, 
 and there is a diminished amount of oxygen 
 consumed and of nitrogen excreted. There is 
 a diminished excretion of calcium salts — ^after 
 parath5n:oid removal only, an increase of this 
 excretion has been observed — ^and there is an 
 increased tolerance for sugar ; in th5n:oidecto- 
 mised animals a full injection of adrenalin, 
 which in ordinary circumstances would pro- 
 duce glycosuria, fails to do so ; in this respect 
 also the thyroids and parathyroids seem to 
 have opposite action. The skin of the face 
 is often affected more than in other parts, 
 especially under the eyes, and gives the peculiar 
 expressionless, masklike appearance which we 
 associate with myxoedema. The general con- 
 clusions arrived at by Biedl, Eppinger and 
 others seem to be these : " that the thyroid 
 and the chroma ffine system, together with the 
 
112 ESSAYS ON PRACTICAL MEDICINE 
 
 infundibular portion of the hypophysis, con- 
 stitute a group of vascular glands which 
 augment and accelerate the processes of meta- 
 bolism. The balance is maintained by the 
 antagonistic activity of those other vascular 
 glands like the pancreas and the parathyroids 
 which exercise a restraining influence upon 
 metaboHsm. These two groups of internal 
 secretory glands possess physiological inter- 
 relationships with one another ; the extirpa- 
 tion of a vascular gland is followed by differing 
 sets of phenomena. Firstly, there are the 
 direct results, due to suppression of the specific 
 secretion ; secondly, there are the indirect 
 results, due to derangement of other glands, 
 the functions of which, under normal condi- 
 tions, were either stimulated or inhibited by 
 the secretion of the suppressed gland. The 
 thyroid is believed to promote the activity of 
 the chromafiine system and to inhibit that of 
 the pancreas. The direct results of removal 
 of the thyroid consist in reduction of the 
 metaboHsm of albumin, fat and salts ; the in- 
 direct results are on the one hand the absence 
 of stimulation of the chromafhne system, and 
 on the other a hyper-activity of the pancreas 
 due to the removal of the inhibitory agent. It 
 
SPECULATIONS AND DOUBTS 113 
 
 is believed that the nervous system is the 
 agent by which the inter-activities of these 
 vascular glands are affected. That group of 
 them which promotes metabolism has a sym- 
 pathetic innervation and stimulates the sym- 
 pathetic nerves, at the same time exercising 
 an inhibitory effect upon the autonomous 
 nerves. The group which retards metabolism, 
 on the other hand, possesses an autonomous 
 innervation, and while stimulating the auto- 
 nomous nerves, inhibits the sympathetic. 
 The thyroid possesses a double function, being 
 furnished with both classes of nerves, and is 
 thus able to affect both divisions of the vege- 
 tative nervous system." It will thus be seen 
 what an important and central position the 
 thyroid holds in our economy, and what 
 numerous hints for treatment of morbid con- 
 ditions and for the explanation of them the 
 study of the subject suggests. The great ab- 
 dominal sympathetic ganglion has been called 
 the Clapham Junction of the nervous system. 
 In like manner the thjnroid seems to be the 
 principal centre of the system, that receives 
 and transmits the hormonic and chalonic 
 messages which pass from gland to gland, 
 and which to such a large extent govern 
 8 
 
114 ESSAYS ON PRACTICAL MEDICINE 
 
 the processes of growth and nutrition in our 
 bodies. 
 
 For practical reasons I think it will be better 
 to consider thyroid insufficiency or hypo- 
 thyroidism first. The external objective symp- 
 toms of myxoedema are so marked that one 
 would think the correct diagnosis would rarely 
 be missed, but in my experience this disease 
 is often passed over or mistaken for Bright's 
 disease ; if there be any doubt as to the nature 
 of the oedema, the examination of the urine will 
 clear it up. It is not my intention to discuss 
 the symptoms and treatment of complete 
 myxoedema, for they are so well known, but I 
 wish to draw attention to the very numerous 
 cases of hypothyroidism in which the objective 
 symptoms are not clearly marked. These 
 cases occur chiefly in late middle life and in 
 old age. Hertoghe calls the condition " Hypo- 
 th37roidie benigne chronique.'' There can be 
 no doubt, I think, that this arises from partial 
 degeneration of the thyroid and from a lessen- 
 ing of its colloid output. The symptoms are 
 chiefly as follows, and show, I think, isolated 
 symptoms of full myxoedema. These may 
 last for years, and may never pass on, even if 
 untreated, into the complete disease. Shght 
 
SPECULATIONS AND DOUBTS 115 
 
 and sometimes transitory infiltration of the skin 
 in certain parts of the body and in the lower 
 eyelids especially ; a common instance of this 
 infiltration, often unobserved, is in the lower 
 part of the leg just above the ankles, and not 
 affecting the foot. This, if it does not remain 
 pitted on pressure and if it be not caused by 
 varicose veins, is almost a conclusive symp- 
 tom. The hair becomes thin and brittle and 
 loses its gloss and colour ; the skin is generally 
 dry and harsh and the scalp shiny ; the tem- 
 perature is subnormal ; the hands and feet 
 are generally cold ; there is a troublesome 
 sense of chilliness over the loins and upper 
 part of the thighs, which causes these persons 
 to be very sensitive to draughts of air, and they 
 often get catarrhs. Muscular pains about the 
 back and even fibrositis are common and not 
 easily cured by the ordinary rheumatic remedies. 
 The genera] result is low vitality, mental and 
 physical, a sense of chronic fatigue, and a feel- 
 ing of inability to face the work of life. In 
 most cases the arterial tension is above nor- 
 mal, and there are often present the cerebral 
 symptoms that go with raised tension, vertigo 
 and tinnitus. Women are undoubtedly affected 
 more than men, and if the disease occur in them 
 
ii6 ESSAYS ON PRACTICAL MEDICINE 
 
 before fifty, menorrhagia will be common. If 
 there be any doubt as to the nature of these 
 cases, the judicious use of thyroid feeding 
 will soon clear it up. This, if done without 
 good results, involves no risk. The disturbed 
 rhythm and weakness of the heart caused by 
 thjnroid should not be a bar to its use in any 
 suitable case. It is only a question of dose 
 or of a counteraction. Speaking generally, 
 all these troubles can be much relieved and 
 can often be cured by th57roid feeding, but the 
 treatment in most cases will have to be con- 
 tinued for the rest of life. After the symptoms 
 have mostly passed away, five grains of the 
 fresh gland twice a week is often sufficient to 
 maintain a fair degree of health. Not infre- 
 quently we are brought to what appears to be 
 a deadlock, by the action of this remedy on the 
 heart. A certain number of patients will get 
 cardiac pain, an irregular pulse, and perhaps 
 giddiness ; often they have insomnia. They 
 think they cannot go on with the treatment. 
 In such cases, I believe, a low arterial tension 
 will be found, and if so, suprarenal extract 
 given at the same time will remove these dis- 
 comforts. Ten grains of suprarenal and five 
 grains of thyroid daily will act well together. 
 
SPECULATIONS AND DOUBTS 117 
 
 The following is a case in point. A lady, 
 aged fifty-eight, showed many of the minor 
 symptoms of hypothyroidism ; and was put- 
 ting on weight so fast that her breathing 
 became much embarrassed. On five grains of 
 thyroid extract daily, she rapidly lost weight, 
 and at first felt better. The puffiness of the 
 lower eyelids passed away, and her hair, which 
 originally had been a bright auburn, and had 
 become dull and rusty, regained all its gloss 
 and colour. After three weeks' treatment she 
 developed all the cardiac symptoms I have 
 enumerated, and insomnia. I found her ten- 
 sion 120 mm. only. She took ten grains of 
 suprarenal extract daily with the thyroid, and 
 all the disagreeable symptoms passed away. 
 
 In all cases of thyroid treatment, the 
 arterial tension should be watched, and should 
 be the guide to the increase or decrease of 
 the dose. When once one's eyes are opened, it 
 will be surprising to find how much hypothy- 
 roidism enters into the maladies of middle age. 
 Besides the symptoms described, there are also 
 occasionally symptoms of profound nervous 
 disorder. The following is an instructive case. 
 A lady, aged fifty-six, whom I had not seen 
 for some years, but who, I think, had been 
 
ii8 ESSAYS ON PRACTICAL MEDICINE 
 
 inclined to myxoedema all her life, collapsed 
 suddenly ; she lost nearly all power over her 
 limbs, so that she could not stand ; the reflexes 
 were, perhaps, slightly exaggerated, but her 
 sphincters were for a time quite paralysed. 
 Swallowing was not affected. She developed 
 very soon a bed-sore, and appeared to be 
 dying from prostration ; arterial tension was 
 165 mm. After trying strychnine for a few 
 days without result, I put her on to thyroid 
 feeding only. In a few days her sphincters 
 had recovered, the bed-sore healed, and she 
 has made a good recovery. Her friends say 
 that her mental condition is better than before 
 her illness. In this case moderate thyroid 
 feeding will probably have to go on for years. 
 In women it is especially about the meno- 
 pause that we shall find the minor symptoms 
 of hypothyioidism ; at the same time often 
 we shall find early symptoms of arterio- 
 sclerosis and of high blood-pressure. With 
 this knowledge in our minds, we ought to be 
 able to steer many a dehcate woman safely 
 through these troublesome years. The in- 
 judicious use of strong nerve tonics and of 
 nerve sedatives in these cases often does more 
 harm than good. Before using them the state 
 
SPECULATIONS AND DOUBTS 119 
 
 of the thyroid and of the arteries should be 
 tested. In those cases of hypothyroidism 
 where there is subnormal blood-pressure, we 
 often find a very poor state of venous circula- 
 tion, as evidenced by cold feet and hands, with 
 the fingers and toes blue, and with chilblains 
 often. The vitality is generally low. Here 
 much benefit is obtained from the addition of 
 suprarenal extract to that of the thyroid, and 
 by giving freely calcium salts. With regard 
 to these calcium salts Rendle Short says : "It 
 has long been recognised that they are essen- 
 tial to the continued success of perfusion 
 fluids, and now we know that they control 
 the coagulation and viscosity of the blood and 
 probably the functions of the ovary and para- 
 thyroid glands also." 
 
 Remarkable results have been obtained in 
 many cases by giving calcium lactate in 15- 
 grain doses three times a day (on an empty 
 stomach) for three days only in the following 
 conditions : transient or functional albuminuria, 
 lymphatic headache occurring in anaemic girls, 
 in urticaria, in chilblains and in all varieties of 
 tetany. The symptoms of the menopause are 
 sometimes greatly relieved by this salt. 
 
 When one considers how much the thj^roid 
 
I20 ESSAYS ON PRACTICAL MEDICINE 
 
 and parathyroid glands are concerned with 
 calcium metabolism, we must realise how much 
 assistance they may give in the circulatory 
 troubles of thyroid disturbance. 
 
 As we pass on to real old age we often find 
 the symptoms of hypoth3^oidism more marked 
 and of graver import. We are only beginning 
 to realise how much senility depends on in- 
 ternal gland insufficiency. Biedl says : "A 
 special pathogenetic significance is ascribed 
 to thyroid insufficiency in the changes which 
 occur in later life, and which are included in 
 the term senile degeneration. The founda- 
 tion for the theory that old age results from 
 changes in the thyroid gland lies in the fact 
 that in old age the thyroid becomes atrophied, 
 its follicles shrink, and retrogressive changes 
 take place in the epithelial cells. This is re- 
 inforced by the fact that there is a profound 
 analogy between the signs of advanced old age 
 and those of myxoedema. The falling of the 
 hair and the dropping out of the teeth, the 
 dry and wrinkled skin, the lowered body tem- 
 perature, the diminished perspiration, the in- 
 dolent digestion and consequent emaciation, 
 the reduced metabolism, the atrophy of the 
 sexual organs, the decrease of mental power. 
 
SPECULATIONS AND DOUBTS 121 
 
 and the diminution of the activity of the 
 whole nervous system — ^these are all symptoms 
 which characterise chronic myxcedema. Hors- 
 ley holds the view that senility is due, at any 
 rate in part, to th5n:oid degeneration, while 
 myxcedema may be described as a condition 
 of premature senility/' Biedl concludes by 
 saying : " We have not sufficient grounds for 
 the assumption that senile decay results from 
 the suppression of function of internal secre- 
 tory organs other than the thyroid. The 
 pathogenesis of this condition offers a wide 
 field for investigation." With this clue to 
 guide our researches and observations it ought 
 surely to turn out a most fruitful field. The 
 mere prolongation of life were an object 
 scarcely worth the seeking if we could not at 
 the same time hope to preserve the strength of 
 body and mind. There is no pleasanter sight 
 than old age free from bodily suffering and 
 with mind serene and mature ; and there is 
 no more distressing sight than old age borne 
 down with infirmity and with the mind clouded 
 and unhappy. 
 
 By nature an incurable optimist, I cannot 
 help thinking that these investigations and 
 discoveries will result in great amelioration of 
 
122 ESSAYS ON PRACTICAL MEDICINE 
 
 the troubles of senility, and in the prolonga- 
 tion of healthy life. As an example I give 
 the following case. *' A man aged eighty-five, 
 who for some time had shown early symptoms 
 of brain degeneration, suddenly, after a tiring 
 day, collapsed. He was almost unconscious, 
 and lay prostrate on his back. For days he 
 could hardly swallow, the power over both 
 sphincters was completely in abeyance ; bed- 
 sore commenced, and he looked a hopeless, 
 dying case. Yet there was no true paralysis, 
 no hemiplegia, no absolute aphasia ; he could 
 just move every limb if pressed to do so. 
 Reflexes were present, but feeble. Arterial 
 tension was 165 mm. As a forlorn hope I 
 gave him thyroid extract, 5 grains daily. 
 He at once began to improve ; in a fortnight 
 all incontinence was gone, he could swallow 
 well, and the bed-sores promptly healed. 
 After three months' continuous thj^roid treat- 
 ment he could walk two miles daily, his 
 tension was down to 140 mm. and his mental 
 condition was improved also. No other medi- 
 cinal treatment was given, and I think thyroid 
 may fairly claim the honour of the results. In 
 many cases of bladder weakness in old age, 
 where there is partial incontinency, thyroid 
 
SPECULATIONS AND DOUBTS 123 
 
 gives much help, especially perhaps after 
 paralytic strokes. In old men with enlarged 
 prostate we see no rapid effects, but there is 
 evidence to show that thyroid feeding controls 
 and lessens the growth of the gland itself, and 
 so in time relief may come ; where there is no 
 prostatic enlargement and where good results, 
 it must affect, I think, the innervation of the 
 bladder. When we learn to use this remedy 
 more scientifically and in fitting doses, I feel 
 sure that we shall have far more control over 
 the maladies of old age, and over some of their 
 mental disabilities also. 
 
 In childhood there is also a large field for its 
 
 use. In the enuresis of children and young 
 
 adults thyroid rarely fails to cure, but in some 
 
 cases enuresis is caused by it or increased. 
 
 It is well borne in youth, and seldom produces 
 
 the distressing cardiac symptoms that we find 
 
 later in life ; even in infants it can be given 
 
 safely and with good results — -for instance, in 
 
 some cases of infantile eczema. There is a great 
 
 opportunity for its use, I feel sure, in cases of 
 
 arrested development both of mind and body. 
 
 In childhood we occasionally see two types of 
 
 myxoedema ; one congenital, showing itself in 
 
 infancy, and not due to disease, but to entire 
 
124 ESSAYS ON PRACTICAL MEDICINE 
 
 absence of the thyroid. These cases resemble 
 in their symptoms those in which the thyroid 
 has been entirely removed ; they are very 
 severe, and are accompanied always by dwarf- 
 ism and idiocy ; in these little but temporary 
 good can be expected. The other type — 
 called not very happily infantile myxoedema — 
 shows itself about the fifth year. It is much 
 like adult myxoedema, and is clearly due to 
 atrophy of a thyroid gland that has been 
 present. Here thyroid treatment may do 
 much good and even wake up the atrophied 
 gland to new life. 
 
 Hypothyroidism is probably the foundation 
 of the condition known as infantilism, the chief 
 features of which are the persistence of infantile 
 characteristics in mind and body. The above 
 three morbid conditions show the extreme 
 results of athyroidism and of hypothyroidism, 
 but there are innumerable cases, most of them 
 unrecognised, in which partial and often tem- 
 porary arrest of mental and bodily develop- 
 ment is caused by thyroid deficiency. There 
 can be no doubt that the healthy state of this 
 gland, in conjunction with the pituitary, is 
 very largely responsible for normal growth 
 and development. In watching the growth of 
 
SPECULATIONS AND DOUBTS 125 
 
 a young animal, a colt, for instance, we see him 
 at one time — -to use a slang expression — all legs 
 and no head, in another month or so he is all 
 head and no legs. Growth and development, 
 mental and bodily, even in healthy children, 
 seem often to progress in jerks. It is in these 
 cases that the judicious use of thyroid and 
 sometimes of pituitary extract will often tide 
 over difficulties. A wise schoolmaster or mis- 
 tress should, if the circumstances and theories 
 be explained to them, be a very good judge of 
 the need of thyroid and of its value. Many an 
 apparently hopeless child will wake up into 
 mental activity under its use. 
 
 In young girls at the age of puberty or soon 
 after, in whom there is amenorrhoea or dysmen- 
 orrhoea (not due to some mechanical cause) 
 it will often put everything right. It will 
 be no exaggeration, I think, to say that in 
 amenorrhoea, not obviously due to chlorosis, 
 thyroid is the most successful remedy. Further 
 — -which is a very important matter for the 
 future of every woman — -it promotes complete 
 and healthy development of the whole sexual 
 apparatus. In mental disease, especially in 
 asylum practice, where the symptoms can be 
 carefully watched, I feel sure that internal 
 
126 ESSAYS ON PRACTICAL MEDICINE 
 
 gland remedies will show very happy results. 
 The variations of arterial tension from the 
 normal that occur in melancholia, where the 
 tension is often very high, and in acute 
 maniacal conditions, where after the attack it 
 is very low, can often be corrected by the care- 
 ful use of thyroid, suprarenal or other gland 
 extracts. 
 
 Another use of thyroid which holds out great 
 promise of success is in albuminuria and threat- 
 ening eclampsia of pregnancy. 
 
 In this morbid state we see constantly raised 
 blood- pressure, albumin and diminished secre- 
 tion of urea. The secretion of urine, in a bad 
 case, almost entirely ceases, and if any is passed 
 it boils almost solid. The more threatening 
 the symptoms, the higher the blood-pressure 
 rises. If the patient is put to rest in bed and 
 a careful diet of milk and farinas only given, 
 thyroid will generally ward off the danger of 
 eclampsia ; but full doses must be given — a 
 5-grain tablet of fresh extract every three or 
 four hours. This in twenty-four hours will 
 produce a free flow of urine, with increased urea 
 and lessened albumin. As the symptoms im- 
 prove the doses must be lessened, but thyroid 
 treatment should be continued till delivery 
 
SPECULATIONS AND DOUBTS 127 
 
 takes place and for a time afterwards. This 
 treatment was first suggested by Dr. Oliphant 
 Nicholson of Edinburgh in 1901. The follow- 
 ing interesting cases have occurred lately in the 
 practice of my son, Dr. Arthur Scott : 
 
 (i) A woman aged twenty-six became 
 albuminuric, with marked oedema, when be- 
 tween five and six months pregnant; about 
 the thirtieth week fits started, recurring every 
 few minutes : labour had not started. She was 
 given 10 grains of the fresh thyroid three times 
 a day, and was put into hot packs. After eight 
 hours fits ceased, and the urine became copious, 
 though before only a few ounces had been 
 secreted in the twenty-four hours. Labour 
 was induced two days later ; the child died 
 two days after birth in convulsions. 
 
 (2) A woman aged thirty-four started oedema 
 and albuminuria about the eighth month. 
 Urine passed in twenty-four hours was 6 ozs. 
 only, and boiled solid with albumin. (Edema 
 became general : 8 grains of fresh thyroid were 
 given three times daily and a daily hot pack. 
 Urine at once became plentiful and oedema 
 lessened. She went her full time, taking 17 
 grains a day : parturition was normal without 
 eclampsia. The child died in convulsions three 
 
128 ESSAYS ON PRACTICAL MEDICINE 
 
 days later, though apparently healthy at 
 birth. 
 
 (3) Woman aged twenty-eight. Albuminuria 
 and oedema came on suddenly when about a 
 fortnight from full time. Urine passed in 
 twenty-four hours only 4 ozs. (Edema great, 
 with much dyspnoea. Patient was seen at 
 night, and 30 grains of fresh gland was given 
 in the first twelve hours, and then reduced to 
 20 grains in twenty-four hours. Under this 
 thyroid treatment and without any hot packs 
 improvement at once set in, oedema and 
 dyspnoea diminished, and the urine, though still 
 loaded with albumin, increased to 30 ozs. 
 Parturition was normal and the child survived. 
 In this case thyroid was given to the child 
 at once, and there were no convulsions. 
 
 This remedial effect is not easy to explain. 
 The thyroid, no doubt, in these large doses 
 lowers the blood-pressure considerably, but 
 that will hardly explain its diuretic action. 
 It must act, I think, favourably on the ovaries 
 and possibly on the suprarenals. The occur- 
 rence of fits in the new-born infants seems 
 more than a coincidence. 
 
 Not unfrequently in girls from twelve to 
 eighteen years of age we see an enlargement of 
 
SPECULATIONS AND DOUBTS 129 
 
 the thyroid, which comes on rather suddenly. 
 The gland feels pulpy and as a rule is not 
 painful, but it often interferes with swallowing 
 by its backward growth. There is no marked 
 pulsation and no tachycardia. This enlarge- 
 ment soon subsides with thjnroid feeding and 
 can be cured, but if the cause be not recog- 
 nised a permanent enlargement and deformity 
 remains. After twenty the symptoms of sub- 
 th5n:oidism usually disappear. 
 
 There has been some confusion and doubt 
 as to dosage of gland extracts, some physi- 
 cians and writers working with fresh-gland 
 tablets and some with dried powders. It will, 
 I think, be a help if I give the following rela- 
 tions, which are approximately correct : 
 
 British Pharmacopceia 
 I grain of dried thyroid = 3 1 grains of fresh gland. 
 
 Dried Powders of Various Makers 
 I grain dried orchilic = 7 grains fresh gland. 
 I grain dried whole pituitary = 4 grains fresh gland, 
 I grain dried ovarian = 7 grains fresh gland. 
 I grain dried suprarenal = 6 grains fresh gland. 
 I grain dried pitglandin or ant. pituitary = 4 grains of 
 fresh gland. 
 
 The following is an extract from Dr. Ken- 
 dall's article in Endocrinology : 
 
 " Plummer has been making a very detailed 
 
 9 
 
130 ESSAYS ON PRACTICAL MEDICINE 
 
 study of the function of the thj^oid, and he 
 has been led to believe that the location of 
 the active constituent of the thjnroid, when it 
 functions, is within the cells, not of any par- 
 ticular set of organs or portion of the body, 
 but that it is a constituent of cellular life and 
 activity. He says that this active constituent 
 of the thyroid determines the rate at which any 
 particular cell can produce energy — that is, it 
 establishes the quantum of energy which any 
 cell can produce when it is stimulated either 
 from within itself or from without — so that the 
 thyroid is directly related to the production of 
 energy within the body. He has found that 
 one-third of one milligram of the active con- 
 stituent increases the basal metabolic rate 
 I per cent, in an adult 150 lbs. in weight. 
 
 *' When the active constituent, thyroxin, 
 is given to a myxoedematous patient, all the 
 sjnuptoms are promptly reheved ; when it is 
 given in too large a dose, hyperthyroid symp- 
 toms are produced. The moment we know that 
 in a myxoedematous patient the administration 
 of 10 mg. of thyroxin increases the basal meta- 
 boHc rate 30 per cent., we have the key to the 
 explanation of the relief of a very complicated 
 clinical syndrome. 
 
SPECULATIONS AND DOUBTS 131 
 
 " The oedema is relieved, the sluggish 
 mentality is relieved, and all the symptoms 
 disappear. In short, every cell in the body 
 responds with its own expression of activity." 
 
 This increased cellular and metabolic activity 
 suggests many uses of thyroid in other con- 
 ditions than of pure myxoedema and gives a 
 scientific basis and direction for its use in 
 disease. 
 
 Graves' disease is of all the endocrine dis- 
 turbances the most puzzling, and in consequence 
 perhaps the most interesting. I prefer to still 
 use the name of the great physician who first 
 described it, for the modern title Exophthalmic 
 Goitre is neither accurate nor inclusive of all 
 the symptoms. On this subject I am quoting 
 largely from an article of mine in the Practi- 
 tioner of May 1 918, which its Editor has most 
 kindly given me leave to use. 
 
 The cardinal symptoms of Graves' disease 
 are thyroid enlargement, exophthalmos, tachy- 
 cardia and nervous tremor ; but the first two 
 may be entirely absent, while the last two 
 are always present. In this disease, perhaps, 
 more than in most, the prominent symptoms 
 are generally so striking that the unscientific 
 mind sees the superficial picture only, the 
 
132 ESSAYS ON PRACTICAL MEDICINE 
 
 visible morbid signs, and contentedly sees no 
 more. 
 
 In reality this syndrome displays a wonder- 
 ful example of deep-seated, widely- distributed 
 functional disturbance, that, if unchecked, ends 
 in organic structural disease. The cause is 
 neither in the thyroid nor in the eye. When 
 one studies the early history of these cases 
 and their premonitory signs, one is inevitably 
 led back to the nervous system, and especially 
 to the sympathetic branch of that system. 
 The tremor and the tachycardia, which, as I 
 have said, are always present, precede the 
 thjnroid enlargement and the exophthalmos. 
 This, I think, proves that the nervous system 
 is the functional disturbance that comes before 
 the more visible signs ; but we must go still 
 deeper and search for the causa causans. 
 In some cases, especially in women, but not 
 exclusively, there is a clear account of nervous 
 shock, of great grief or anxiety sufficient 
 perhaps to be called a cause, but in some 
 cases the oncoming is insidious, and there is a 
 period when there is no th5Toid enlargement, 
 and only occasional tachycardia and tremor; 
 and even in the shock cases careful inquiry 
 will often reveal pre-existing disorder. 
 
SPECULATIONS AND DOUBTS 133 
 
 McGarrison's definition is this : 
 
 " A disease characterised by heightened ex- 
 citability of the whole sympathetic nervous 
 system, greatly increased metabolism, abnormal 
 action of the heart and of the thyroid gland, 
 and disordered states of other hormone pro- 
 ducing organs." 
 
 It is very rare before the age of puberty. It 
 occurs in women much more frequently than 
 in men, and in them is almost entirely confined 
 to the years of their sexual activity. In men it 
 not infrequently occurs in later life. It ter- 
 minates in recovery, death or myxcedema. 
 
 I cannot, for my purpose, do better than 
 quote Major McGarrison's exhaustive descrip- 
 tion. He says : 
 
 ** The setiological factors which favour the 
 onset of Graves' disease are those which we 
 have seen determine all departures of the 
 thyro-parathyroid glands from the normal 
 state ; these are nutritional, psychic and 
 infectious. 
 
 " Briefly recapitulated, these factors are : 
 (i) insufficient food or over-indulgence in food, 
 and the disorders of nutrition to which these 
 and chronic debilitating diseases give rise. 
 Amongst the most important of such diseases 
 
134 ESSAYS ON PRACTICAL MEDICINE 
 
 are chronic constipation, intestinal disorders 
 generally, and chiefly intestinal stasis. (2) 
 Fright, mental distress and worry, business or 
 social cares, unfortunate love-affairs, violent 
 emotion, and mental and physical exhaustion, 
 with loss of sleep, such as occurs amongst 
 soldiers in the trenches. (3) Attacks of acute 
 infectious diseases, notably influenza, tonsilitis, 
 rheumatic fever, typhoid fever, tuberculosis, 
 secondary or hereditary syphilis; naso-pha- 
 ryngeal and uro-genital disorders, pyorrhoea 
 alveolaris and helminthiasis. 
 
 " As in myxoedema, so in Graves' disease, the 
 onset of a proportion of cases may be precipi- 
 tated by some accidental occurrence, such as 
 a train disaster, a fall from a horse, or by the 
 excitement and strain of war. 
 
 '* The ideal conditions for the development 
 of the disease are provided when all three classes 
 of factors — nutritional, psychic and infectious 
 — operate on the individual at the same time, 
 or where two of them do so. They a e pre- 
 disposing causes only, which favour the action 
 of the underlying causal agency. 
 
 " This agency is one which gives rise to 
 continuous excitation of the sympathetic 
 nervous system. That symptoms similar to 
 
SPECULATIONS AND DOUBTS 135 
 
 those of exophthalmic goitre can be induced 
 by the continuous excitation of this system 
 is shown by the experiment of Cannon, where 
 the phrenic nerve was joined to the peripheral 
 portion of the cut cervical sympathetic in the 
 cat (Cannon, W. B., Boston Medical Journal, 
 1916, clxxv. 16, p. 564). The operation 
 resulted in tachycardia, increased excitability, 
 loose motions, exophthalmos, on the operated 
 side, and increase of the body metabolism, as 
 well as in an increase in the size of the adrenals. 
 In seeking for the source of the excitant of these 
 symptoms in Graves' disease, one is reminded 
 that effects similar to those caused by stimula- 
 tion of the sympathetic nervous system are 
 produced by certain amines, resulting from 
 the putrefactive decomposition of proteins or 
 amino-acids in consequence of bacterial action 
 (Barger, G., * The Simpler Natural Bases,' 
 London, 1914). The most common source of 
 these amines is the gastro-intestinal tract. 
 
 " The extraordinary influence of the gastro- 
 intestinal toxaemia in the genesis of Graves* 
 disease is exemplified by a case recently ad- 
 mitted under the care of Sir Arbuthnot Lane 
 at Guy's Hospital. 
 
 " The subject was a girl of ig^- years of age^ 
 
136 ESSAYS ON PRACTICAL MEDICINE 
 
 who developed, in South Africa, Graves' disease 
 of very severe type. The condition was of some 
 eighteen months' standing. She had a marked 
 rheumatic history, having had chorea at nine 
 years, and ' nervous debiUty ' for six months 
 at thirteen years. She had suffered from 
 palpitation from the age of eleven. On ad- 
 mission to hospital she presented the following 
 sjmiptoms : great emaciation, dull abdominal 
 pain, recurring attacks of nausea and vomiting, 
 goitre of small size, prominent exophthalmos, 
 tachycardia, severe palpitation and a heart's 
 action so violent as to shake the bed, great 
 pulsation of the carotids, abdominal and iliac 
 arteries, great muscular weakness, pronounced 
 tremor with a tendency to drop things, great 
 nervousness, dizziness, severe headache, flush- 
 ings, subjective sensations of heat, suppressed 
 menses, loss of and greying of the hair, vora- 
 cious appetite, and albumen and sugar in 
 the urine ; in short, a case so typical and so 
 severe as to leave no room for doubt as to 
 its nature. 
 
 '' Rontgen-ray examination by Dr. Jordan 
 revealed the presence of a greatly dilated 
 stomach with pyloric spasm, an elongated 
 duodenum, and a state of chronic irritation of 
 
SPECULATIONS AND DOUBTS 137 
 
 the colon, resulting in unduly rapid emptying 
 of the contents. 
 
 ** Sir Arbuthnot Lane performed gastro- 
 jejunostomy, and removed an anchored appen- 
 dix, which exerted a most marked control upon 
 the ileal effluent, and freed a very tight ter- 
 minal kink at the junction of the ileac and 
 pelvic colon. The operation was performed 
 on January 21, 1916, and was followed by two 
 weeks' considerable pyrexia. At this time 
 the patient's weight was only 4 st. 10 lbs., but, 
 following the return of the temperature to 
 normal, she began to put on weight and to 
 improve in the most remarkable way. Seen 
 on October 20, 1916, her weight had increased 
 to 8 St. 5 lbs., the exophthalmos had totally 
 disappeared, the palpitation was completely 
 gone and the tachycardia was greatly lessened, 
 menstruation had returned, the muscular weak- 
 ness, headache, vomiting and all the other 
 symptoms, with the exception of the small 
 goitre, had disappeared. The goitre was but 
 little altered in size, and persisted, doubtless, 
 owing to fibrotic changes. The patient felt 
 and looked a different being, and could walk 
 for a considerable distance without fatigue, 
 while the greyness of the hair had disappeared 
 
138 ESSAYS ON PRACTICAL MEDICINE 
 
 and its scantiness was replaced by luxuriant 
 growth. 
 
 " Here, then, is a case of surpassing interest, 
 in which the symptoms of Graves' disease are 
 definitely shown to have resulted from alimen- 
 tary toxaemia." 
 
 There are many other cases reported in 
 which intestinal stasis, gastro-enteroptosis and 
 chronic colitis have for a long time preceded 
 true Graves' disease, and in which all s^^mptoms, 
 except thyroid enlargement, have passed off 
 after cure of the abdominal fault. 
 
 Skilled X-ray examination of the abdomen 
 will often reveal a removable cause of septic 
 absorption. 
 
 McGarrison says further on : " The thyroid 
 gland has for so long played the star part 
 in the drama of Graves' disease, that too 
 little attention has been paid to less promi- 
 nent performers, and its author's identity 
 has for this reason been to a great extent 
 obscured." 
 
 Other sources of microbic infection may be 
 found in the gums, tonsils or nose (pyorrhoea 
 alveolaris is common in this state), and finally 
 a microscopic examination of the faeces may 
 show an abdoniinal bacterial content, to which 
 
SPECULATIONS AND DOUBTS 139 
 
 the patient's resistance is low, and which might 
 possibly form a curative vaccine. 
 
 The anatomical alterations found in many 
 organs would take too long to describe in a 
 book of this description ; for these I must refer 
 to text-books, and especially to McGarrison's 
 great work on the Thyroid Gland. 
 
 From the general practitioner's point of view, 
 which is also mine, in all the academic text- 
 book descriptions of disease there is something 
 lacking. It is, no doubt, interesting, and to a 
 certain extent satisfactory, to find a diagnosis 
 confirmed in the post-mortem room, but 
 nevertheless that room remains the grave of 
 our hopes, the mausoleum of our failures. In 
 the words of "The Biglow Papers*' : 
 
 " Sermon through and come to do — 
 Why, there's the old J. B. 
 A-crowdin' you and me." 
 
 John Bull and his daughters have, in their 
 blind, rather selfish way, no altruistic ambitions 
 to become pathological specimens ; they want 
 to be cured, and it is we general practitioners 
 that have to do it. ^Etiology, morbid anatomy, 
 family histories and predisposing causes are 
 all very valuable in their way, but the study of 
 disease is too apt to end here ; they are all 
 
I40 ESSAYS ON PRACTICAL MEDICINE 
 
 useless, unless they are made the sure and 
 stable foundations for building thereon the 
 temple of health. 
 
 Graves' disease in a hospital ward is a very 
 interesting study, but in domestic life it is 
 almost a tragedy ; the nervous restlessness, 
 irritability and unreasoning temper become 
 a scourge both to the patient and to the family. 
 One cannot help feeling that up to recent times 
 the treatment of this disease has been almost 
 a failure. About half the number recovered 
 more or less spontaneously, more or less com- 
 pletely, and the other half went down the hill 
 and died. 
 
 The greatly increased metaboHsm leads to 
 emaciation, dilatation of the heart and valvular 
 insufficiency. The treatment to-day, with our 
 new and rapidly increasing knowledge of the 
 endocrine glands, is much more hopeful and 
 already more successful. Briefly, not wishing 
 to be dogmatic, but only suggestive, this, I 
 think, should be the scheme. First, rest, as 
 complete as circumstances and the tempera- 
 ment of the patient will allow — it will never 
 be more than partial ; secondly, find out by 
 all the means in our power the initial error, 
 the source of microbic infection, if such there 
 
SPECULATIONS AND DOUBTS 141 
 
 be, intestinal, uterine, oral, nasal; then 
 medically or surgically treat them as they need, 
 and finally treat the resulting symptoms by 
 our modern glandular extracts. 
 
 In practice, all these methods will have to 
 be carried out together. The first error to be 
 attacked in the majority of cases will be in the 
 digestive tract ; frequently there will be found 
 gastric or intestinal dyspepsia, and the intes- 
 tinal is the more important ; signs of coHtis 
 are often present. These faults are best 
 attacked by intestinal antiseptics, such as 
 beta-naphthal and saHcylate of bismuth. In 
 addition to these duodenal extract is a great 
 help. 
 
 This formula I have found work well : 
 
 Duodenal Extract .... grs. 2 
 
 Ext, Cannabis Ind. . . • • gr. | 
 
 In tablets : one, three times a day, an hour after food. 
 
 This acts often like a charm on duodenal 
 catarrh and on colitis that has not gone too far. 
 Carnrick's new Kinazyme acts very favourably 
 in the same way. Constipation can generally 
 be avoided by giving paraffin daily. The diet 
 should be simple, not rich, and should not 
 include much meat. Milk better than any other 
 food supplies the waste of lime salts. 
 
142 ESSAYS ON PRACTICAL MEDICINE 
 
 The persistent diarrhoea which one sees in 
 a few cases will nearly always yield to the 
 following : 
 
 Bism 
 
 uth. Salicylat. . 
 
 . 
 
 
 grs. 
 
 12 
 
 Liq. 
 
 Hyd. Perchlor. . 
 
 . 
 
 
 ni3 
 
 
 Pulv 
 
 Trag. Co, 
 
 . 
 
 
 q.s. 
 
 
 Tine. 
 
 Chloroform. Co. 
 
 c, Morph. 
 
 (P.B. 
 
 
 
 1885) . 
 
 . 
 
 
 11^12 
 
 ter die 
 
 The small dose of the perchloride with the 
 salicylate acts well as a bactericide. 
 
 There is one gland which is grossly affected 
 in the disease besides the thyroid, and that is 
 the thymus. In about 75 per cent, of cases 
 this has been found much enlarged. It would 
 seem that the enlargement does not mean 
 increase of function, but the opposite, for in 
 some few cases thymus feeding has had very 
 good results. It fails in the majority, I think, 
 and how to select the likely cases I know not. 
 
 When we come to the special symptoms of 
 Graves' disease, we must decide whether to 
 attack the cardiac or the nerve symptoms 
 chiefly, though both may be treated to a 
 certain extent together. 
 
 The original cause acts probably as a dis- 
 turber of all internal glands, but the three 
 chiefly affected are the suprarenal, the thyroid 
 
SPECULATIONS AND DOUBTS 143 
 
 and the parathyroid. The suprarenal is sup- 
 posed to be over-stimulated by the excess of 
 thyrine poured into the blood, which is known 
 to be a hormone to that organ, but it may be 
 affected primarily by the same poison. In 
 most cases, then, we get evidence of thyroid 
 and suprarenal excess. The exophthalmos is 
 due to excessive action of the suprarenals, as 
 has been shown by Maurice of Lyons. The 
 tachycardia is generally the earliest symptom 
 that we can estimate, and is due to irritation of 
 the sympathetic nerves supplying the heart. 
 
 McGarrison says, p. 213 : 
 
 ** It does not appear from evidence at present 
 available that the explanation of the cardiac 
 activity is so superficial or simple as either a 
 thyroid hypersecretion or hyposecretion would 
 indicate, but both the cardiac activity and the 
 thyroid reaction are parallel manifestations, 
 consequent on some more general and remote 
 disturbances. 
 
 " Not only does the thyroid hyperplasia bear 
 no direct relationship to the pulse-rate, but the 
 excess of a-iodine (thyroid hormone) in the 
 blood-stream, which results from it, appears to 
 be only indirectly responsible for the tachy- 
 cardia. Experiment has shown that after the 
 
144 ESSAYS ON PRACTICAL MEDICINE 
 
 administration of this substance there is no 
 apparent effect for many hours. There is no 
 increased pulse-rate or drop in the blood- 
 pressure. If, however, amino-acids are injected 
 simultaneously the pulse-rate is enormously 
 increased (Kendal, E. C, Boston Medical and 
 Scientific Journal, 1 916) . These findings appear 
 to me to provide a further clue to the nature of 
 the substances responsible for the heightened 
 cardiac action in Graves' disease. They are, 
 I beheve, the poisonous decomposition product 
 of amino-acids — 'monamines and diamines — 
 which may be formed in the organism wherever 
 proteins or amino-acids are exposed to the 
 action of bacteria, and especially to the action 
 of anaerobic bacteria in the gastro-intestinal 
 tract (Barger, G., ** The Simpler Natural 
 Bases,'' London, 1914). These highly virulent 
 poisons may not only initiate the histological 
 changes in the thyroid gland, but, by their 
 direct action on the adrenal sympathetic system 
 or by their chemical interaction with the 
 gland's secretion and the disturbance of its 
 normal balance, they may give rise at the same 
 time to the tachycardia." 
 
 Man is much more susceptible to large doses 
 of thyroid than animals, but although some of 
 
SPECULATIONS AND DOUBTS 145 
 
 the symptoms of Graves' disease are produced 
 by these doses the whole picture or syndrome 
 is iar from complete. 
 
 We must, I think, conclude that hypersecre- 
 tion of the thyroid is only one of the causes of 
 the cardiac affection. 
 
 There arises now the question : How much 
 is the parathyroid involved ? The nerve 
 tremors point to parathyroid deficiency. Does 
 the cause that stimulates the suprarenal and 
 the thyroid depress parathyroid action ? Or is 
 the balance of power so disturbed that the 
 excess of thyrine overwhelms the parathyroid ? 
 I think the latter is probably the case. The 
 nervous symptoms point, as I have said, to 
 parathyroid deficiency, but this may be only 
 relative ; the natural antagonism between the 
 two glands is always present, but the hyper- 
 thyroidism wins the day. It will be found, I 
 think, that parathyroid treatment by the mouth 
 controls and helps much to cure the tremors and 
 other nerve troubles of this disease. I have 
 seen this case lately : 
 
 A lady, thirty-two years of age, had had 
 colitis and leucorrhoea for some time, and latter- 
 ly an ulcerated condition of tongue and mouth ; 
 she had lost flesh, and become very weak and 
 10 
 
146 ESSAYS ON PRACTICAL MEDICINE 
 
 short of breath. She had tachycardia, varying 
 in intensity, and characteristic tremors of the 
 hands. The th3n:oid was sHghtly enlarged and 
 pulsating — no exophthalmos; the stethoscope 
 revealed a slight systolic murmur over the 
 gland. She was given Izal perles and para- 
 thyroid (dried) in J-grain doses three times a 
 day. 
 
 This is a typical case of Graves' disease with 
 the common intestinal causation. Four weeks 
 of this treatment has removed all the symp- 
 toms, with the exception of the colitis, which is 
 not quite cured. 
 
 Another type of case of early Graves', the 
 
 most acute I have ever seen, has been published 
 
 in the Practitioner, but will, I think, bear 
 
 repeating. It was reported by Dr. Norman of 
 
 Broadstone. 
 A young woman miscarried at four months 
 
 on May 3, 1915 — no abnormal hsemorrhage. 
 
 At the same time she complained of such 
 
 intense headache that all other pains were 
 
 masked. 
 
 May 6. — 'Slight dyspnoea, temp. 100. Has 
 
 not slept since her illness began ; headache 
 
 still very bad, pulse no. 
 
 May 14. — I saw the case with Dr. Norman. 
 
SPECULATIONS AND DOUBTS 147 
 
 Pulse 130. Systolic pressure 100 mm., with 
 large pulsating thyroid, heart dilated, great 
 dyspnoea, tremor of hands, but no exoph- 
 thalmos. She was quite unable to lie down, 
 and looked as if she had only a day or two to 
 live. Diagnosis, acute Graves' disease. That 
 night she slept after scopolamine and morphia. 
 Parath5^oid, |~gr. doses, was given frequently, 
 and in four days all symptoms rapidly abated. 
 On the 25th — ^eleven days after parathyroid 
 was begun — -she was able to be about, the 
 thyroid enlargement had almost disappeared, 
 and she has continued quite well ever since, 
 more than a year having elapsed. 
 
 In this case, there was no evident sepsis in 
 the mother, and the cause was possibly in the 
 dead foetus. 
 
 The only exogenous drug that seems to me 
 to be of use is strophanthus ; this may be given 
 in large doses when the heart is much dilated. 
 
 I have seen a case lately in which removal of 
 three-quarters of the thyroid had little or no 
 effect on the symptoms, and in which para- 
 thyroid and intestinal antiseptics have nearly 
 cured all the symptoms. 
 
 My contention is that we have in this disease 
 a pluriglandular disturbance, not only as to 
 
148 ESSAYS ON PRACTICAL MEDICINE 
 
 quantity of secretion, but as to quality also, 
 and that this disturbance is in the great 
 majority of cases caused by bacterial poisons 
 from within. Shock, grief and fright are, I 
 think, only emergencies stirring up partly latent 
 trouble. These glandular disturbances act 
 partly by direct action on certain organs, such as 
 the heart and sympathetic ganglia, but chiefly, 
 perhaps, by producing discord in the glandular 
 system of the whole body. The newer phy- 
 siology has given us a glimpse of the wonderful 
 perfection and delicacy of that vital machinery ; 
 surely, then, it should point the way to a return 
 from these jangling discords to the oldharmonies 
 of health. The first two cases I have quoted 
 were brought under treatment in the early 
 stages ; mostly, we have not the chance of 
 seeing them till the symptoms have been going 
 on for some time, and when secondary damage 
 has been done. We have then to call other 
 glands to our aid. Thyroid, we know, in the 
 active onset of the disease, does harm and 
 increases the tachycardia. 
 
 For many years, the action of suprarenal in 
 this disease has been advocated. Some phy- 
 sicians, hke the late Sir Lauder Brunton, have 
 succeeded with it, while others have failed. 
 
SPECULATIONS AND DOUBTS 149 
 
 I think the error has arisen in the choice of 
 cases, though in most it is of some help. 
 
 Schafer says on this point, referring to the 
 sympathetic excitability seen in this disease : 
 " Here the question arises, Is this a direct 
 effect on the sympathetic system ? Or is it 
 indirect through the adrenals, which are stimu- 
 lated to increased activity by the excess of 
 thj^ine in the blood ? The answer is not easy ; 
 but it may be stated that although certain 
 symptoms of hyperthyroidism are similar to 
 those produced by excess of adrenine in the 
 blood, others are not so — ^this is the case with 
 flushing of the skin, which is due to vascular 
 dilatation, whereas adrenine ordinarily produces 
 vaso-contraction ; moreover, it is undoubtedly 
 the case that the administration of adrenine 
 exercises a markedly beneficial effect in some 
 cases of the disease — a fact which would be 
 inexplicable on the theory that the results of 
 hyperthyroidism are simply due to excitation 
 of the suprarenals and to the production of an 
 excess of adrenine." 
 
 Systematic observation of the blood-pressure 
 shows daily and hourly variations ; mostly 
 it is sKghtly raised, but it is often much below 
 the normal (Dr. Norman's case). 
 
I50 ESSAYS ON PRACTICAL MEDICINE 
 
 The sphygmomanometer should be our guide 
 to the use and dosage of suprarenal extract ; 
 the flushed, hypersemic, perspiring skin would 
 point also to its beneficial use, and any exces- 
 sive rise of blood-pressure can be met by 
 hippurates or nitrites. 
 
 In nearly all cases we have in the circulation 
 a plus condition of thyrine and probably a 
 perverted condition as well ; we have also a 
 plus condition of adrenine. May not this be 
 an effort of nature not only to balance the 
 depressor effect of thyrine, but to correct its 
 quality also ? The cases which show an 
 habitual low blood-pressure are, in my opinion, 
 more severe and more Hkely to develop the 
 later serious cardiac symptoms. It may be 
 these cases that benefit so much from suprarenal 
 treatment. The combination in these cases of 
 suprarenal and parathyroid treatment is very 
 effectual. 
 
 In acute febrile diseases, as pneumonia and 
 diphtheria, when the blood-pressure falls very 
 low, suprarenal will soon raise the pressure to 
 the patient's great advantage. Pituitrin and 
 thymus have been used, but there is no great 
 weight of testimony in their favour. 
 
 The critic will say, perhaps, " Is not this 
 
SPECULATIONS AND DOUBTS 151 
 
 therapeusis as speculative as its physiology ? 
 If it is, where is the danger ? " We are not 
 dealing with dangerous, exogenous poisons. 
 How many of our successful remedies have 
 come from pure empiricism ? Here we are, 
 doubtless, empirics, but working on and from 
 physiological data. The investigation and 
 discoveries of endocrinology point in Graves' 
 disease to a pluriglandular disturbance, and it 
 must be met and conquered by pluriglandular 
 aids. 
 
 Biedl, after all his years of patient, brilliant 
 work, sums up the subject in this impotent 
 manner : 
 
 *' The results of organotherapy in Graves' 
 disease are interesting only in so far as they 
 furnish direct evidence against the assumption 
 of a hypothyroidism in this condition. The 
 effect produced by thyroid extract is universally 
 the exaggeration of the disease. Attempts to 
 treat Graves' disease with extracts of thymus 
 ovary and suprarenal have a certain theoretic 
 interest, but are of no practical significance." 
 
 This is a typical example of the limitations 
 of the scientific mind. He brings one within 
 sight of the promised land, and then throws 
 doubts on its very existence. 
 
152 ESSAYS ON PRACTICAL MEDICINE 
 
 It is only exceptional minds, like Lord 
 Kelvin's and Lauder Brunton's, that can trans- 
 late their deep knowledge into beneficial action. 
 On the other side, Rudinger says (to go back 
 to parathyroid) : 
 
 " We have to suppose that, under normal 
 conditions, the function of the one gland (thy- 
 roid and parathyroid) is controlled by the other, 
 and that when the balance is disturbed by 
 the extirpation of one, the remaining organ 
 becomes functionally and later organically 
 hyper trophied/' 
 
 He brings the following as evidence in 
 support : 
 
 " Moussa and Channin found that the ex- 
 hibition of the parathyroid gland of horses 
 was followed by unfavourable symptoms in 
 myxoedema, but that in Graves' disease it 
 had a very beneficial effect. Rudinger believes 
 that the hyperf unction of the thyroid in Graves' 
 disease is restored by the exhibition of para- 
 thyroid, while in myxoedema the hypofunction 
 is intensified. He also is inclined to attribute 
 the favourable action of Moebius' serum and 
 of rhodagen to the presence of a large propor- 
 tion of parathyroid secretion. The removal of 
 the thyroid permits of an increased activity on 
 
SPECULATIONS AND DOUBTS 153 
 
 the part of the parathyroids ; thus, the serum 
 and the milk contain substances which, being 
 stronger than those in normal serum and milk, 
 are better able to counteract the activity of the 
 thyroid gland. Rudinger, as the result of his 
 investigations with Eppinger and Falta on the 
 action of adrenaUn in thjnroidectomised animals 
 (with regard to the ensuing glycosuria), infers 
 that thyroid secretion stimulates the sympa- 
 thetic nerve, while that of the parathjo-oids 
 has an inhibitory effect on it. Stimulation and 
 inhibition are so balanced by the activity of 
 the two glands that, under normal conditions, 
 oscillation is possible within a very small range 
 only. 
 
 "The suppression of the thyroid secretion 
 reduces the irritability of the sympathetic 
 nerve, not only by robbing it of its stimulating 
 agent, but by releasing the inhibitory effects 
 of the parathyroid. With the extirpation 
 of the parath5n:oids the inhibitory agent is 
 removed, and this brings in its train a 
 condition of hypersensibility of the sympa- 
 thetic. '^ 
 
 In paralysis agitans and tetany, which bear 
 many points of relation to Graves' disease, there 
 is almost certainly parathyroid deficiency ; at 
 
154 ESSAYS ON PRACTICAL MEDICINE 
 
 any rate, they are much benefited by para- 
 thyroid feeding. 
 
 Schafer, on this point, says: ** The most 
 satisfactory explanation of the nervous results 
 of the removal of the parathyroids is the 
 assumption that they yield to the blood a 
 special autacoid— presumably of a chalonic or 
 restraining nature — ^which tends to prevent 
 over-excitation of nerve cells. This hypo- 
 thetical autacoid — ^which has not yet been 
 isolated — ^may provisionally be termed para- 
 thyrine. We shall see that there is reason to 
 beHeve that the thyroid produces an autacoid 
 with an opposite tendency/' 
 
 Halpenny and Thompson, as a result of 
 observations on dogs after parathyroidectomy, 
 see good reason to believe that the parathyroid 
 exercises an inhibitory influence upon the 
 thyroid itself, as well as on the sympathetic 
 system. 
 
 In the clinical study of all diseases of the 
 thyroid apparatus, we see compHcations arising 
 that are more or less absent in the laboratory. 
 It is rare, I think, to get disease of the thyroid 
 or parathyroids pure and simple ; that is to 
 say, without the involvement of the other to 
 some extent. This makes the treatment of 
 
SPECULATIONS AND DOUBTS 155 
 
 either Graves' disease or myxoedema a more 
 subtle but more interesting study. 
 
 When one reads Kocher's well-known list 
 of symptoms of the two diseases in parallel 
 columns, one's first thought is, that never were 
 two diseases with such complete contrasts, but 
 his description of the symptoms is at the 
 acme of their activity, and the later study of 
 individual cases will often show a slow merging 
 of one into the other or at any rate of Graves' 
 into myxoedema. Hyper function, if long-con- 
 tinued, must lead to hypertrophy and ulti- 
 mately to atrophy. We see this hypofunction 
 ending in a form of myxoedema at the end of 
 a fair number of Graves' diseases. This fact 
 should make us pause and very carefully con- 
 sider before we sanction the operation of 
 thyroidectomy. The complete removal of the 
 gland is, as we know, disastrous, and in the 
 partial removal, which has often shown at first 
 brilliant results, we know little of the after- 
 history. 
 
 How do such cases fare in real old age, when 
 we want all the thyroid we can get, and most 
 of us a bit more ? 
 
 With a noisy, turbulent crowd in a music- 
 hall, the chucker-out is a necessary bit of 
 
156 ESSAYS ON PRACTICAL MEDICINE 
 
 brutality ; but all our endocrine glands, even 
 when quarrelsome, are essential to our well- 
 being, and so the chucker-out, in the form 
 of the surgeon, should be the last court of 
 appeal. 
 
 There are some cases that have become so 
 severe that his help is necessary, but his 
 appearance on the stage is a great reflection on 
 our therapeutic weapons and skill. 
 
 Wendell Holmes has somewhat sarcastically 
 called the profession of undertaker the post- 
 medical profession. In Graves' disease, we 
 should not allow the surgeon to earn and 
 assume this honourable title. That brilliant 
 craftsman, the thyroidectomist, should become 
 an anachronism, a tradition only of the dark 
 days that are gone ; and medicine, strong 
 in physiological faith, should resume her 
 peaceful sway. Midway between medicine 
 and surgery comes the X-ray treatment. This 
 method has been so improved of late by the 
 combination of the sinusoidal current with 
 X-rays that experts feel confident that they 
 can avoid permanent injury to the gland (see 
 Dr. Hernaman Johnson's wise and temperate 
 letter in the Lancet of December 29, 1917), but 
 one cannot help feeling that, in any but the 
 
SPECULATIONS AND DOUBTS 157 
 
 most skilled hands, there must be some risk of 
 injury which may only show itself in the far 
 future. 
 
 The treatment by the judicious combina- 
 tion of X-rays with the internal glands holds 
 out, I feel sure, a most hopeful prospect. In 
 medicine, then, we must be boldly radical, but 
 in surgery wisely conservative, for 
 
 " The mill will never grind again 
 With the water that has passed." 
 
 Since writing the above, Dr. Hertz of Guy's 
 has published a most interesting case of para- 
 thyroid insufficiency in " Endocrinology,'' 1918. 
 This, I think, corroborates fully my views on 
 connection between Graves' disease and para- 
 thyroid insufficiency, and also explains the 
 success of parathyroid feeding. 
 
 In the suprarenal gland we have another 
 most interesting field of study. As we all 
 know, this gland is composed of two portions, 
 the cortex and the medulla. Physiologists are 
 still in doubt as to the properties of the former, 
 though their speculations are full of interest. 
 In the medulla, from which we get our supra- 
 renal extract, the cells peculiar to it are 
 derived from the same tissue, morphologically, 
 
158 ESSAYS ON PRACTICAL MEDICINE 
 
 as the ganglion cells of the sympathetic. 
 Elliott graphically says : *' The adrenine cells 
 and the ganglion cells are closely related 
 stations on the great sympathetic highway that 
 reaches from the central nervous system to the 
 blood-vessels. The adrenine cell is essentially 
 a part of the nervous system, and in reality not 
 a peripheral cell at all." But apart from its 
 nerve connection and influence this gland 
 has a chemical action which seems to be inde- 
 pendent of its nerve action ; this exists in its 
 chromaffin tissue, which Noel Paton describes 
 thus : *' The chromaffin tissue may be defined as 
 a tissue composed of cells derived from the nerve 
 cells of the abdomino-thoracic sympathetic 
 system, which stain a brown colour with chrome 
 salts and which produce a physiologically 
 active substance called adrenine." This sub- 
 stance can be produced synthetically. When 
 injected into the blood-vessels it stimulates the 
 terminations of the true sympathetic in visceral 
 muscle and in glands, and it acts on these ter- 
 minations alone. That adrenine has a double 
 way of action is proved by the fact that all the 
 nerves of the sympathetic group may be re- 
 moved and yet the animal will live ; but if 
 the glands themselves are removed the animal 
 
SPECULATIONS AND DOUBTS 159 
 
 inevitably dies, showing that the passage of 
 adrenine into the blood stream is necessary to 
 life. It is important, in investigating the range 
 of action of this internal secretion, to remember 
 this. Elliott says again : *' Adrenine has the 
 remarkable power of stimulating only that 
 plain muscle in the body which is supplied 
 by the sympathetic nerves, and the action 
 produced by it is always identical with that 
 caused by electrical stimulation of the nerves. 
 The chemical substance circulating in the blood 
 evokes exactly the same response as does the 
 nervous impulse — each reinforces the other." 
 To use a homely simile, this front- and back- 
 stairs passage for its influence shows its great 
 importance in the animal economy. 
 
 The suprarenal glands are very richly sup- 
 plied with nerves from the splanchnic direct, 
 and from the suprarenal plexus. It is probably 
 with one exception the most vascular organ 
 in the body. The following is a short extract 
 from Schafer's lecture : *' If an extract of 
 suprarenal capsule be injected into the vein of 
 an animal, the first effect is an immediate and 
 marked rise of blood-pressure ; this can be 
 shown to be caused by contraction of the 
 peripheral arteries. Along with this contrac- 
 
i6o ESSAYS ON PRACTICAL MEDICINE 
 
 tion a slowing of the heart's action may occur, 
 due to an effect on the cardio-inhibitory centre, 
 and this may hmit somewhat the rise of blood- 
 pressure. But if the vagi are cut or paralysed 
 by atropine, the heart's action becomes very 
 accelerated, and also augmented in force (pri- 
 marily by the action of the autacoid on the 
 auricles but also somewhat on the ventricles), 
 and this greatly increases the rise of blood- 
 pressure. The effect on the vessels lasts a few 
 minutes, passing off gradually ; afterwards 
 the blood-pressure is usually a little lower than 
 before. The arteries which are most affected 
 are those of the splanchnic area ; those of 
 the limbs and trunk rather less, although the 
 cutaneous vessels are often strongly contracted ; 
 those of the pulmonary system and of the 
 brain only very sHghtly, if at all, and those 
 of the coronary circulation not at all. It is 
 always the smaller vessels that are most 
 affected, and in consequence of the great rise 
 of pressure which their contraction produces, 
 the larger arteries tend to become passively 
 dilated ; this dilatation may be very great. 
 The effect upon the vessels is seen after com- 
 plete destruction of the central nervous system, 
 and after severance of nerves to the part. It 
 
SPECULATIONS AND DOUBTS i6f 
 
 is, therefore, due to a direct action of the 
 autacoid principle of the gland on the con- 
 tractile tissue of the heart and vessels ; never- 
 theless such action only occurs in tissues which 
 are supplied by the sympathetic system, and 
 severance of the nerves, so far from stopping 
 the action, tends to make the tissues supplied 
 by the severed nerve more easily excited by 
 the autacoid. Gunn and Chavasse have shown 
 that adrenine has also an action upon the 
 muscular coat of veins, causing tonic contrac- 
 tion in peripheral veins and rhythmic con- 
 traction of the superior vena cava near the 
 heart." 
 
 To arrive at the wonderful and beneficial 
 results that may be obtained clinically from 
 this powerful extract, one must think very 
 deeply over all these physiological experiments 
 and results. We have evidently a weapon that 
 may be powerful for good or for evil, and 
 one that must be used in accordance with our 
 reasoning powers and our knowledge. Elliott 
 says in his eloquent way : " The adrenal 
 glands, whether medulla alone or cortex and 
 medulla, are concerned in maintaining the 
 steady tone of all muscles innervated by the 
 sympathetic nerves. They are responsible day 
 II 
 
i62 ESSAYS ON PRACTICAL MEDICINE 
 
 by day for the upholding touch that maintains 
 the driving power of the pulsating current of 
 blood by which we live. The nervous im- 
 pulses, which play upon these muscles, merely 
 serve to change the tension up and down, here 
 and there, where special circumstances require 
 more delicate adjustment to local and peculiar 
 needs of the body." 
 
 We have, then, before us the power which 
 by way of the blood and by way of the sym- 
 pathetic activates and controls the energy of 
 the heart muscle and the force of its contrac- 
 tions, and which also controls that most im- 
 portant property, the tonicity of the muscles 
 of the heart and of the arteries. When we 
 learn how to use this power wisely and in ac- 
 cordance with physiological laws, we shall have 
 probably the most effective heart tonic in our 
 repertoire. To compare it accurately with 
 digitalis takes a better pen and mind than 
 mine, but one may briefly say, I think, that 
 digitalis acts firstly as a tonic on the vagus 
 roots, and so on the inhibition of the heart, 
 and that adrenalin acts chiefly and firstly on 
 the sympathetic system and so on the stimula- 
 tion of the heart ; the one on the vegetative 
 nervous system, the other on the autonomous. 
 
SPECULATIONS AND DOUBTS 163 
 
 Both remedies, if pushed too far, extend their 
 action to the other division of the nervous 
 system, and in poisonous doses produce results 
 quite opposite to their primary ones. If we 
 have an open choice of remedies, I think we 
 should choose the ones that already belong to 
 the animal system. Just now we are perhaps 
 unduly prejudiced against aliens. They have 
 been yery useful in the past, but I think the 
 time has now come for the use and protection 
 of native goods and industries. One cannot 
 help feeling that the foreigner has something 
 harmful up his sleeve. In ordinary practice 
 intravenous injections are not possible, so we 
 must consider only the hypodermic and the 
 oral method of administration. Some authori- 
 ties say that adrenalin given hypodermically 
 takes a long time to get into the circulation, 
 but if one has watched the rapid relief 
 that it gives to spasmodic asthma one can 
 hardly accept this statement. No doubt the 
 local astringent action delays its absorption 
 somewhat, but I think this may be got over by 
 combining with it 2 minims of liq. trinitrin, 
 and by further dilution. One may make an 
 interesting speculative study of the effects of 
 adrenalin and of chloroform narcosis on the 
 
164 ESSAYS ON PRACTICAL MEDICINE 
 
 heart. If adrenalin be given in too concen- 
 trated a form there is often a period of half a 
 minute or more when the heart's action, in- 
 stead of being strengthened, wobbles and has 
 a halting gait, and the patient becomes pale 
 and faint ; in the same way there is often such 
 a period of uncertainty at the commencement 
 of chloroform narcosis. Can these effects be 
 accounted for thus ? Under chloroform the 
 chief control of the heart, in French I'ordre 
 superieur, passes from the vagus, the servant 
 of the vegetative nervous system, and is taken 
 up by the sympathetic, the servant of the 
 autonomous system. The same happens, I 
 think, when we give a full dose of adrenahn. 
 It is in this transition period, when the gears 
 are being changed, that danger is present. 
 This has been overcome to some extent of late 
 years, in anaesthetic work, by giving an injec- 
 tion of morphia and scopolamine or of morphia 
 and atropine shortly before the chloroform. 
 The effect of this is partly to paralyse the 
 vagus and so to put it out of action. This 
 makes the change of gears more rapid and 
 easy. In the same way, I believe, the addi- 
 tion of atropine or scopolamine to adrenalin 
 would produce a safer and more rapid effect. 
 
SPECULATIONS AND DOUBTS 165 
 
 My physiology may be wrong, but I think 
 my facts are right. 
 
 To return to the practical point of adrenalin 
 dilution. This case illustrates my point. A 
 clever, observant woman, who has spasmodic 
 asthma very severely, finds her only relief from 
 hypodermic injections of adrenahn. She was 
 at first told to use eight to ten minims neat ; 
 each time she felt very faint, and became so 
 pale that her relations begged her to give it 
 up. By diluting eight minims with twelve of 
 sterilised water these bad effects never occurred 
 and the good effects were continued. 
 
 To show the far-reaching effects of the supra- 
 renal secretion, and as an incentive to the 
 deeper study of its possibilities, I give Dr. 
 George Murray's words from his article in the 
 Practitioner of February 1915 : "It has been 
 shown clearly by the investigations of Elliott, 
 Cannon, and others that under the influence of 
 a strong stimulus, such as fright, adrenine is 
 rapidly discharged into the adrenal veins and 
 so into the general circulation. It is interesting 
 to follow up the effects of this condition of 
 adrenalsemia and to see how useful they may 
 be to an animal either in contending with or 
 escaping from the cause of fear. The excess 
 
i66 ESSAYS ON PRACTICAL MEDICINE 
 
 of adrenine dilates the coronary arteries, 
 giving the heart a larger supply of blood, in- 
 creases the strength of the cardiac contractions, 
 and raises the blood-pressure. It tends to 
 divert the chief flow of blood from the ab- 
 dominal vessels to those of the central nervous 
 system, heart, lungs, and muscles. The adre- 
 nine thus stimulates just those activities which 
 an animal employs either in fighting a foe or 
 in escaping from an enemy. In addition to 
 this, the adrenine mobihses the store of glyco- 
 gen in the Hver, thus increasing the amount 
 of sugar in the blood and rendering it avail- 
 able for use in the muscular action entailed 
 by the effort.*' 
 
 Transferring the consideration of these facts 
 to our own more placid lives, may we not 
 discover many analogies and aids to help us 
 in the fight against disease, and methods of 
 escape also from the attacks of our microbic 
 and other enemies ? This force is ever quietly 
 working to maintain and protect us ; it must 
 be our aim to support this friendly power, 
 and to supplement it if need arise. We 
 see in Addison's disease how the destruction 
 of this organ and the consequent absence of 
 its secretion soon ends in progressive debihty 
 
SPECULATIONS AND DOUBTS 167 
 
 and death, but also we see that from the same 
 cause our defences are broken down and the 
 body hes open to any attack. In not a few 
 other acute diseases, such as diphtheria and 
 cholera, the suprarenal secretion is partly or 
 entirely suppressed, and this is probably one 
 of the chief causes of the muscular and cardiac 
 weakness, and of the loss of arterial tone that 
 so often seems to be the cause of death. In all 
 these diseases suprarenal extract or adrenalin 
 injections have already proved very useful. 
 In pneumonia especially, a falling blood-pres- 
 sure should be the sign for the use of this 
 remedy, and it should be given freely and con- 
 tinuously. In addition to its good effect on 
 contractility and tonicity, it is in many cases 
 a good timer of the heart. I have seen cases 
 of auricular fibrillation yield to it when digi- 
 talis has failed. Its rather unexpected action 
 on spasmodic asthma is not easy to explain, 
 but it is probably due chiefly to its stimulating 
 effect on the sympathetic nerve endings and 
 ' by this effect overcoming the muscular spasm, 
 arising from over-action of the vagus. Its 
 power of dilating the coronary arteries may 
 also be a factor. The local action of adrenalin 
 is so well known that I need not tpuci on it,. 
 
i68 ESSAYS ON PRACTICAL MEDICINE 
 
 There remains the question of the mode of 
 internal administration. To give the Hquor 
 adrenalin would at first sight seem to be the 
 easier and the more scientific way, but as a 
 matter of experience it is found that it has in 
 most cases but little general effect when given 
 by the stomach. Grunbaum says that even 
 in doses of 60 minims it fails to raise the blood- 
 pressure. The explanation probably is that it 
 has such an astringent or blanching effect on 
 the gastric mucous membrane that absorp- 
 tion is very slow. This local effect is very 
 valuable in cases of hsematemesis. At present 
 we can best get the effects we aim at by giving 
 extract of the gland, and this is best given 
 in the tablet form — 5-grain tablets may be 
 given every two hours in emergencies. The 
 manometer will always show when enough has 
 been given. Some writers say that this 
 method is ineffectual, but that is quite con- 
 trary to my experience, and we must remem- 
 ber that Oliver and Schafer's original experi- 
 ments, which have so largely led to our present 
 knowledge, were made, as Dr. Oliver has him- 
 self told me, with teaspoonful doses of a strong 
 glycerine extract or emulsion of the supra- 
 jenals of the sheep ; it therefore seems prob- 
 
SPECULATIONS AND DOUBTS 169 
 
 able that large doses are required to produce 
 their physiological results, and here, as so often 
 happens, want of courage leads to want of 
 faith. The ideal method, of course, in emer- 
 gencies especially, is by intravenous injection, 
 but, except in hospital practice, that is rarely 
 possible. 
 
 One more gland remains for special notice — 
 the pituitary. In recent years the powers 
 of this gland have been recognised as very 
 remarkable, and apparently neither life nor 
 health can exist for any length of time when 
 it is destroyed. The anatomy, position and 
 histology it is needless for me to describe, but a 
 careful study of its structure will help towards 
 a grasp of its physiological properties and 
 possibilities. To make a brief summary, ap- 
 parently as far as our present knowledge goes, 
 the anterior or glandular portion is the part 
 essential to life. It is this portion also which 
 governs the growth of the body, and particularly 
 of the skeleton. The abnormal conditions of 
 gigantism, infantilism and acromegaly belong, 
 it is thought, to faulty conditions of this part. 
 The pars intermedia secretes one or more 
 hormones that affect the heart and circulation 
 in the manner describecj below. They also 
 
I70 ESSAYS ON PRACTICAL MEDICINE- 
 
 increase the activity of smooth muscle and 
 cause an increase of gastric, renal and mam- 
 mary secretion. The active principles that 
 affect the circulation are found more in the pars 
 posterior, but it is beheved that they are only 
 passing through, from the intermedia, where 
 they arise, to the third ventricle, and subse- 
 quently by that route into the cerebro-spinal 
 fluid. Experimentally the effect of these ex- 
 tracts upon the heart and blood-vessels is a 
 direct one, and is not due, as in the suprarenal 
 autacoid, to its stimulant action on the sym- 
 pathetic nerve endings. The effect on the 
 heart is also different ; for whereas — ^with 
 the vagi cut or paralysed — adrenine causes a 
 marked acceleration of the heart (sympathetic 
 stimulation), the pituitary causes a slowing 
 of the heart's action along with increased 
 force. Moreover, while adrenine produces 
 dilatation of the coronary vessels the auta- 
 coid of the pituitary constricts them, as it 
 does other systemic arterioles, and the same is 
 the case with the pulmonary vessels. 
 
 The interrelationship of this gland with the 
 other internal secretory glands is very intimate 
 and important, and is well worth study. The 
 practical applications of pituitary extract that 
 
SPECULATIONS AND DOUBTS 171 
 
 interest us are firstly its effect on the heart and 
 circulation, as described above, in which it has 
 proved to be a very valuable ally to adrenine 
 and to the digitalis group. Secondly, its 
 action on the uterus. Here in obstetric prac- 
 tice it is most effectual. Schafer says : " The 
 uterus under its influence is rendered more 
 excitable to influences reaching it through its 
 nerves. Pituitary extract probably acts on 
 plain muscle more by increasing its sensitive- 
 ness to normal stimuli, than by acting as a 
 direct excitant. Thus, when given in preg- 
 nancy before the commencement of parturition 
 it produced no effect, but its action during 
 parturition is well marked." In cases of 
 uterine inertia before and after birth it is 
 probably the most rapid and powerful remedy 
 that we have. Thirdly, in intestinal inertia 
 and meteorism, that so often occur after 
 abdominal operations, this remedy will often 
 restore the muscular tone, and will help much 
 towards the expulsion of the bowel contents. 
 Fourthly, its very valuable action on the 
 kidneys as a diuretic ; this has not been as yet 
 fully worked out from the clinical side, but 
 probably it will be of most use in the renal 
 inadequacy of heart disease and in most forms 
 
172 ESSAYS ON PRACTICAL MEDICINE 
 
 of dropsy. Fifthly, it is a very powerful 
 restorative in all forms of shock. Its good 
 action on arterial tension is not repeated by a 
 second dose, at any rate if given within a few 
 hours ; but on the heart muscle, the uterus, 
 the intestine and the kidney it can be given 
 frequently with good effect. Some writers 
 claim that it has a good effect in Graves' disease, 
 and its similarity in some respects to adrenine 
 would certainly suggest its use. The oral use 
 of pituitary extract has so far proved to be un- 
 satisfactory. The active principle of the pars 
 posterior seems to be destroyed by the gastric 
 juice and to be inert. 
 
 The action of pitglandin (the American name 
 for the extract of the pars anterior of the 
 pituitary) has only come into scientific notice 
 the last two years. Its influence on growth 
 and development is known to be so important 
 that one is convinced that there must be some 
 valuable therapeutic use for it. About two 
 years ago. Dr. Robertson and his colleagues in 
 the CaHf ornia University succeeded in isolating 
 from the pars anterior a chemical substance, 
 which they named tetheHn ; this when available 
 may help us to get better and more reliable 
 results than the dry glajid e^ctjract itself gives. 
 
SPECULATIONS AND DOUBTS 173 
 
 The powerful and almost poisonous effects of 
 the whole gland, which included of course the 
 pars posterior, have hitherto prevented con- 
 clusive trials, but it is now found that the 
 anterior lobe extract can be used in very 
 large doses, and that small doses produce but 
 little effect ; indeed, we may almost say that 
 there is nothing toxic in pitglandin. The 
 well-known connection between the pars 
 anterior and the process of growth points to 
 its use in delayed or defective development, 
 and the results are already more than encourag- 
 ing, but the most striking results are perhaps 
 on the nervous system. Dr. Harrower, the 
 first editor of " Endocrinology," says, " This re- 
 medy has undoubted virtue in Graves' disease." 
 Richter (Medical Herald, Kansas City) says: 
 ** Four cases of ambulatory Graves' disease have 
 been materially benefited by the administra- 
 tion for several weeks of pitglandin. All cases 
 showed well-marked symptoms, and all, because 
 of their circumstances, were forced to forgo 
 the advantages of rest and suitable hygienic 
 treatment. Despite this, remarkable improve- 
 ment was obtained. The dosage recommended 
 is 15 to 40 grains daily of fresh gland extract 
 in 5-grain tablets." Since this was published 
 
174 ESSAYS ON PRACTICAL MEDICINE 
 
 I have not used this treatment in Graves' 
 disease, as I have had such good results from 
 parathyroid, but with such testimony it is 
 clearly a weapon in reserve. 
 
 Another nervous defect successfully treated 
 by it is impotence in the male. Several cases 
 of complete cure have been reported by 
 Stalwagen in the New York Medical Journal, 
 1 916. There are also favourable reports of its 
 use in epilepsy. From my own observation 
 on others and on myself, I think we shall find 
 pitglandin a valuable restorer of power both 
 physical and mental in the feebleness of old age. 
 From its intimate connection in early life with 
 the process of growth, and especially perhaps 
 with the development of the gonads, one 
 would expect to find some stimulating, renew- 
 ing effect on the nervous system all through 
 life, and apparently such is the case. As 
 Brown-Sequard found new energy from testi- 
 cular extract, so I think we shall get similar 
 and more extended effects from this. 
 
 There are many polyglandular preparations 
 of value on the market, Carnrick of New York 
 with his very valuable hormotones leading the 
 way. 
 
 The early preparations of most makers con- 
 
SPECULATIONS AND DOUBTS 175 
 
 tained whole pituitary, and were very useful 
 as nerve tonics in neurasthenic states. They 
 were found, however, in elderly people to ra,ise 
 blood-pressure unduly, and so others have 
 been issued without the pituitary ; a still later 
 and more valuable issue is a polyglandular 
 tablet containing thyroid, ovary, testis and 
 pitglandin alone. 
 
 Dr. Leonard Williams, who has done such 
 good work as an apostle of endocrine treatment 
 in this country, says that whole pituitary extract 
 does not raise blood-pressure when given by the 
 mouth. I hesitate much to differ with him, 
 but my experience has led me into the opposite 
 opinion. My working rule is to give the com- 
 bination with whole pituitary when the blood- 
 pressure is normal or below, and to substitute 
 half or a quarter of a grain of pitglandin when 
 the pressure is above ; the pitglandin, I feel 
 sure, helps the thyroid to lower pressure, and 
 acts at the same time as a general nerve tonic 
 or stimulant. There are very few men or women 
 above fifty who are not the better for a little 
 thyroid, and the older one grows the more one 
 wants it, and pitglandin more than counteracts 
 its slightly depressing effect. I should like to 
 ask my medical confreres, who are ageing and 
 
176 ESSAYS ON PRACTICAL MEDICINE 
 
 who are feeling the burden of their years and of 
 their toil, to try it on themselves. I feel sure 
 they will find their capacity for work increase, 
 its quahty improved, and that their labours 
 will become again a pleasure instead of a 
 drudgery. 
 
 Of the things, then, that we have spoken this 
 is the sum. The old Romans in their deep 
 wisdom and insight recognised an unseen force 
 that in our bodies was ever fighting the battle 
 of health versus disease, of life versus death. 
 This they called the " Vis medicatrix naturse." 
 Of this power till now we have known but Httle 
 more than this happy name. Harvey's dis- 
 covery of the circulation of the blood was an 
 enormous advance, but was no solution of 
 the mystery. But when we ponder on these 
 internal glands, their secretions, which are 
 essential to life itself, their intimate correla- 
 tions and their extraordinary powers, we are 
 tempted in the first flush of our enthusiasm to 
 cry out, like St. Paul to the Athenians, " That 
 power, that vim, which ye ignorantly worship, 
 that declare we unto you." And yet, on deeper 
 reflection, we come to feel that it is still not 
 the power that we see, but only the Great 
 Architect's marvellous mechanism : and so 
 
SPECULATIONS AND MVBTS \^1 
 
 we become humble again, Our knowledge has 
 grown immeasurably, our usefulness has grown, 
 and with them our wonder and our worship, 
 In scientific language, Biedl sums up the 
 present position of our knowledge thus : " Two 
 agents are concerned in ordering and main- 
 taining the complex activity of the animal 
 organism ; in addition to the nervous com- 
 munication, which admittedly is the agent in 
 effecting rapid readjustments, there is also a 
 chemical correlation of the different organs ; 
 in accordance with the latter, each organ, each 
 tissue, and even each cell by means of its specific 
 secretory products, acting through the agency 
 of the blood-stream, is enabled to exert a 
 specific influence upon other parts of the body. 
 In this manner the equilibrium of the various 
 parts is maintained." 
 
 In simpler but more poetical language St. 
 Paul expresses the same truth : * ' And whether 
 one member suffer, all the members suffer with 
 it, or one member be honoured, all the members 
 rejoice with it." The condition, then, that we 
 call perfect health implies a perfect balancing 
 or equilibrium of all our organs and powers. 
 To maintain this balance, or to regain it, if 
 it be for a time lost, is mercifully the Divine 
 
 12 
 
17^ ESSAYS ON PRACTICAL MED t CINE 
 
 order, the implanted tendency in all. We may 
 so fight against or ignore the laws of Nature 
 that this balance is never perfect, and it is 
 thus that chronic disease arises and gains the 
 mastery. 
 
 The strange and unexpected results that we 
 sometimes see arise from so-called faith healing 
 and Christian Science can, I think, be thus 
 scientifically explained. Under the influence 
 of great emotions, of joy or hope, and also of 
 religious fervour, some of us seem to have the 
 power of caUing on our dormant reserves and 
 of increasing the output into the blood of all 
 our home-made autacoids ; this often results 
 in improvement of health, and in some cases 
 even of cure. It is surely not for us to throw 
 on poor struggling mortals the cold douche of 
 C5niical semi-scientific scepticism, but rather 
 to encourage them in their spontaneous efforts, 
 and to let them see that we can supplement 
 their own natural powers from outside. 
 
 With this new knowledge of the " Vis medi- 
 catrix," of its mechanism and of its chemistry, 
 we must realise that our control over disease 
 is enormously increased, and that there is a 
 far brighter and less suffering future for the 
 sons of men. 
 
SPECULATIONS AND DOUBTS 179 
 
 Whether this essay will have on the minds 
 of my readers a hormonic or a chalonic effect 
 I know not, but I venture to hope that the 
 absorbing interest of the subject will cause 
 them to forget or at any rate to forgive the 
 shortcomings of the writer. 
 
IV 
 
 CHRONIC BRONCHITIS AND BRONCHIAL 
 ASTHMA 
 
 The Microbe. — "Apologia pro Vita Mea." 
 
 Blindly we seem to labour. 
 
 Whether for good or for ill ; 
 But God, all-seeing, who made us. 
 
 Knows we are working His will. 
 
 Patient unceasing toilers, 
 
 In the welter of growth and decay 
 
 We further the infinite purpose 
 Of His wondrous alchemy. 
 
 In this essay I propose to deal with chronic 
 bronchitis and its frequent sequel, which is 
 generally called bronchial asthma. The disease 
 called pure spasmodic asthma, which may begin 
 at any rate without bronchitis, I shall only 
 mention incidentally. Especially in the large 
 cities with impure, smoky atmospheres, this 
 disease, as we all know, gives us a large part of 
 our work, and often gives as much worry and 
 discontent, but that is of little consequence 
 compared with the wretched health and the 
 
 i8o 
 
BRONCHITIS A ND BRONCHIA L A STHMA 1 8 1 
 
 crippling of work and energy that it causes in 
 our patients. It leads also, without saying, to 
 shortening of life. The original causes are not 
 always the same. It may begin by frequent 
 attacks of simple catarrh, it may begin from 
 influenza, from slight attacks of pneumonia 
 or bronchitis, or it may be caused by continued 
 inhalation of irritant particles or gases. Among 
 men and women who have to live and work in 
 unhealthy surroundings, we have to fight this 
 disease chiefly in its own lair — change of air 
 and work are rarely possible — and this is a 
 fight which needs all the weapons that modern 
 science can give us, all our patience and all our 
 skill ; but when one considers the results, it is 
 a fight worth the fighting. 
 
 Whatever the original cause of this con- 
 dition may be, we find that in almost every case 
 we have a microbic infection to deal with. 
 It is very rarely indeed that one finds the 
 sputum sterile. The microbes that we find 
 are chiefly — and I am trying to give them in 
 the order of their frequency — M. catarrhalis> 
 pneumococcus, and one or other variety of 
 staphylococcus or of streptococcus ; the Fried- 
 lander is also occasionally found. When one 
 has treated these microbes with autogenous 
 
1 82 ESSAYS ON PRACTICAL MEDICINE 
 
 vaccines, and has watched and weighed the 
 results, one must, I think, arrive at the conclu- 
 sion that they are the chief causes that main- 
 tain and perpetuate the chronic disease. I am 
 by no means claiming that we always get good 
 effects from this treatment, but the number 
 of cases that are either cured or much relieved 
 is so great and so far in excess of the failures 
 that I can come to no other conclusion. In 
 fact, I have almost come to the further conclu- 
 sion that failure is the result of some error 
 either in selection of the microbes or in the 
 technique of the preparations. The number- 
 less cases that have been cured by this method 
 during the last few years should encourage 
 us to further scientific investigation, and the 
 failures should only serve to show us our 
 defects. 
 
 There is one point that I must emphasise 
 in this place — that is, the importance of 
 a good, careful bacteriologist. The prepara- 
 tion of these vaccines, if done in a careless, 
 haphazard way, will only lead to failure and 
 disappointment ; and, what is perhaps worse, 
 will cast a stigma on us and on that subject of 
 pride, our medical science. I am not speak- 
 ing like this without reason, for even in large. 
 
BRONCHITIS AND BRONCHIAL ASTHMA 183 
 
 well-known bacterial laboratories I have known 
 very poor work done. I am inclined to think 
 that private workers, and if possible qualified 
 medical men, will oftentimes make better 
 vaccines than institutions, where individual 
 watching is often impossible. As an example, 
 we who have any considerable experience of 
 these methods must have come across cases 
 which have been cured by one man's vaccine 
 when another man's has totally failed. It is 
 perhaps hardly necessary to say that all vac- 
 cines for this disease should be autogenous, 
 and yet I have known stock vaccines to be 
 sent out and recommended as equally good. 
 
 Hitherto I have been looking at this disease 
 from the point of view only of the invader, and 
 I have been considering only the destruction 
 of the enemy by our artillery. The wise 
 physician will soon see that this is only part 
 of the problem. The patient who has un- 
 luckily got the disease is really the man who 
 has to do the fighting ; we can help him much 
 by attacking the enemy from without, but we 
 must also teach him and help him to put his 
 natural defences in order. Strictly speaking, 
 we must look on these poisonous bacteria as 
 foreigners, but as a matter of fact they are 
 
1 84 ESSAYS ON PRACTICAL MEDICINE 
 
 almost always with us. Very rarely does a 
 microscopical examination of the mucus of the 
 nose or mouth fail to show the presence of one 
 or other of them, even in health. Our natural 
 powers of resistance, our internal secretions 
 and our phagocytes are generally able to deal 
 with them effectually, and to ward off their 
 importunities ; but it is when these poweis fail 
 or are caught napping, when the bacteria 
 multiply by millions and there is nothing to 
 destroy them, when they pass out of their 
 place and invade the internal organs, that 
 disease is established. The prevention of this 
 failure of resisting power must be our first 
 aim. Overwork, intemperance, improper feed- 
 ing, exposure to damp and chill, all tend to lower 
 the vitality and to expose us to attack. These 
 we must fight as best we can and as circum- 
 stances allow. The enemy is always round the 
 corner waiting for his chance. It is to our 
 frontiers that we must always be looking. 
 
 Our most vulnerable points are probably the 
 nose and mouth. The nose in health should act 
 as a dust and germ filter so effectually that no 
 live germ should gain entrance into our system, 
 but the mucous membrane of the nose, espe- 
 cially in impure atmospheres, often becomes 
 
BRONCHITIS A ND BRONCHIA L A STHMA 1 85 
 
 irritated and thickened, and proper nose breath- 
 ing becomes a difficult thing ; then mouth 
 breathing becomes more or less a habit. This, 
 though a natural passage for air, is not an effec- 
 tive filter. One sees how very liable children 
 with adenoids are to bronchitis and bronchial 
 asthma. The nose, then, is the first point to 
 attend to. The physicians and surgeons who 
 have devoted themselves to this branch of work 
 can often give us great help, by restoring a 
 proper nasal passage and by attention to the 
 tonsils. There is often a congested tender spot 
 in one or both nostrils, which seems to act as 
 a centre from which proceed the nerve storms 
 that cause spasmodic asthma. Here, also, hay 
 fever seems to originate. This spot needs great 
 care in treatment, and harm can easily be 
 done ; but some of our chief specialists, by 
 their skill, produce in these cases something 
 like a miraculous revolution. Our largest 
 frontier, of course, is the skin, and this many 
 working folk habitually neglect. Their work 
 often causes sweating, and the skin that sweats 
 needs careful washing and protection. They 
 often wear clothes that do not absorb the 
 moisture, and so, when work ceases, their skin 
 is in contact with a damp, chilly material. 
 
i86 ESSAYS ON PRACTICAL MEDICINE 
 
 Much may be done by bathing and after-rubbing 
 with a rough towel to keep the circulation of 
 the skin in a healthy resisting state. Bron- 
 chial folk, as a rule, cannot stand a cold bath, 
 and a hot bath often relaxes the pores and 
 leaves them Hable to chill. The best plan is 
 to thoroughly wash and soap in hot water, 
 and then, standing up with the feet still in the 
 hot water, to have two or three good sponges 
 down with cold water, beginning at the head. 
 This produces a good reaction of the circulation 
 and is a pleasant stimulant. The clothing 
 should be not too light, nor so heavy as to 
 produce perspiration when not at work. Light 
 woollen materials are, I think, the best, but 
 some of the modern cellular makes of cotton 
 seem to answer well. 
 
 It is clear, then, that any one with a tendency 
 to bronchial catarrh or asthma needs to lead 
 a most careful and watchful life ; he is inces- 
 santly almost open to attack from hostile 
 germs, and every chill weakens his defences. 
 We, on our part, can do much to help these 
 cases by looking to the heart and blood-vessels, 
 the digestion and the kidneys. Many of these 
 patients, especially in middle Hfe, have over- 
 strained, dilated hearts, and often some degree 
 
BRONCHITIS AND BRONCHIAL ASTHMA 187 
 
 of arterio-sclerosis, and there may be early 
 kidney trouble. The action of the liver often 
 is sluggish and the organ may be congested ; 
 this, of course, causes indigestion and the flatu- 
 lence which bothers many of them so much. 
 Careful attention to all these points will help 
 much towards cure, especially in conjunction 
 with the vaccine treatment. To gain real 
 success the old therapeutics and the new must 
 go hand in hand. 
 
 There is a distinctly gouty form of chronic 
 bronchitis which often alternates with true 
 gout and eczema. This, in the first instance, 
 will only yield to appropriate gouty treatment : 
 alkalies, sulphur, etc. ; but even this form 
 becomes bacterial in the end, and the sputum 
 should always be examined. Most of the 
 remedies (and they are almost innumerable) 
 that we have used empirically in the past have 
 acted chiefly as bactericides — for example, the 
 tars, turpentine, terebene, the balsams, the 
 benzoates ; the great favourite, iodide of 
 potassium, acts probably in this way directly 
 by its iodine and indirectly by stimulating 
 the output of thyroid secretion. Chloride of 
 ammonium, again, probably acts in the same 
 way. Antimony, which in the acute early 
 
i88 ESSAYS ON PRACTICAL MEDICINE 
 
 stages of bronchitis was our forefathers' sheet- 
 anchor, and which has fallen out of use far 
 too much, is probably a bactericide [vide its 
 action on trypanosomes). While carrying out 
 the vaccine treatment, even if there be no 
 cardiac complication, the patient will need 
 helping in every possible way. Arsenic and 
 iron are often very useful. The judicious use 
 of internal secretion preparations will often 
 help wonderfully. In cases with high tension 
 and threatening arterio-sclerosis, thyroid will 
 often bring about a better state of general 
 health and help to reduce abnormal deposits 
 of fat about the heart. In others suprarenal 
 extract will do good, especially if arterial ten- 
 sion be low ; in others one of the polyglandular 
 preparations will raise the general tone and 
 resisting power. 
 
 When we come to the practical use of vac- 
 cines, we have first to find out what the sputum 
 contains — for there will rarely be only one 
 enemy — and then to decide on a single or 
 multiple vaccine. I think we must give 
 pneumococcus the place of honour. He is as 
 common as any and perhaps the most easily 
 cured. It is very surprising how many cases 
 of chronic bronchitis, with or without asthma. 
 
BRONCHITIS A ND BRONCHIA L A STHMA 1 89 
 
 have pneumococci, even when there is no history 
 of any attack that one can suspect of being 
 true pneumonia. One must, I think, come 
 to the conclusion that many attacks of acute 
 bronchitis are pneumococcic in origin, even 
 when there have been no signs of lung con- 
 solidation or of rusty sputum. In the British 
 Medical Journal of June 14, 1913, Dr. Pirie, 
 in an article that is very instructive both to 
 the physician and to the bacteriologist, gives 
 the following statistics. 
 
 Bacteriology of sixteen cases of chronip 
 bronchitis without asthma : 
 
 Pneumococci . 
 
 . 12 cases 
 
 M. catarrhalis 
 
 . 12 „ 
 
 Staphylococci . 
 
 • 5 » 
 
 Streptococci 
 
 . 6 „ 
 
 Friedlander 
 
 . 5 „ 
 
 In sixteen cases of chronic bronchial asthma 
 he found : 
 
 Pneumococci . 
 
 . 16 cases 
 
 M. catarrhalis . 
 
 . 16 „ 
 
 Staphylococci . 
 
 . 8 „ 
 
 Streptococci . 
 
 . 6 „ 
 
 Friedlander 
 
 . 6 „ 
 
rgo ESSAYS ON PRACTICAL MEDICINE 
 
 The almost universal absence or non-dis- 
 covery of the influenza bacillus, even with a 
 clear history of a recent attack, is remarkable. 
 The selection will, to a certain extent, depend 
 on the predominance of one or other bacillus 
 in the culture, and generally speaking a mul- 
 tiple vaccine, with the possible exception of 
 pneumococcus, is more likely to be effectual 
 than a single one. The following is the ex- 
 perience of my son, Dr. Arthur Scott, who has 
 for the last five years made most of my 
 vaccines : 
 
 " Much disappointment and doubt as to the 
 value of vaccines in chronic chest complaints 
 is, I beHeve, prevalent among the medical pro- 
 fession. Yet I think that those medical men 
 who have given them, in chronic cases, frequent 
 and prolonged trial become more and more 
 convinced of their general value ; I say gene- 
 ral value, for one meets with many failures in 
 cases which one thinks would promise well. 
 Granted a definite curative value in vaccines, 
 it becomes difficult to explain their complete 
 failure in certain cases. Making an attempt 
 to group these causes of failure, there is in 
 the first place the unknown condition in some 
 patients that negatives immunity : for ex- 
 
BRONCHITIS AND BRONCHIAL A STHMA igi 
 
 ample, from an attack of measles one person 
 becomes immune for life, another may get it 
 again in a few months. It seems that there 
 is a failure on the part of some patients to 
 retain their anti-bodies in the system. 
 
 " In a second group, and it is a large one, 
 the vaccine is at fault. In nearly all bronchial 
 cases there is a mixed infection, and the diffi- 
 culty in choosing from which bacteria to 
 make the vaccine arises. Make a separate 
 vaccine of all the likely bacteria present and 
 mix them together is the apparent solution 
 of the problem, but this entails making sub- 
 cultures into several generations, and vaccines 
 from subcultures have very Httle power of 
 conferring immunity. Probably the most 
 efficient way is to make a solution from the 
 primary culture, then estimate the relative 
 proportions of the varieties of bacteria to 
 each other, by naked-eye examination of the 
 cultures (this is rather guess-work), or where 
 possible by examining a prepared slide of the 
 solution. The predominating variety is then 
 not subcultured, but the varieties occurring in 
 small numbers are subcultured and added to 
 the original solution in proportion to the dose 
 required for administration. This method is 
 
1^2 ESSAYS ON PRACTICAL MEDICIN:^ 
 
 necessarily faulty, but not more so than the 
 use of impure subcultures of all the varieties. 
 Subcultures can only be obtained pure after 
 several generations have been made. 
 
 " Often the method of sterilisation of the 
 vaccine destroys its value : for example, a 
 pneumococcal vaccine begins to lose its virtue 
 when heated to 55° C, whereas a staphylo- 
 coccal vaccine may not be killed at 60° C. 
 This explanation shows that it is not neces- 
 sarily the principle of vaccination that is the 
 cause of failure, but often the so far insuperable 
 difficulties of the bacteriologist. It is possible 
 that in the future the X-rays may help to 
 solve some of these difficulties. 
 
 " In a third group error in administration 
 is the cause of failure. The size of the doses 
 and the intervals between them can only be 
 determined by the patient's symptoms. The 
 opsonic index will not help, as in bronchial 
 cases it is a question of local or tissue immunity 
 rather than of general immunity. Of more 
 importance than all is the duration of the 
 treatment. Most patients are not kept under 
 treatment nearly long enough. It is to be 
 remembered that the bacteria present are 
 probably leading a saprophytic as well as a 
 
BRONCHITIS AND BRONCHIAL ASTHMA 193 
 
 parasitic existence. This I personally believe 
 to be always the case in chronic bronchitis. 
 Thus the organisms present are living not 
 only on the bronchial epithelium but also on 
 the bronchial secretions ; these are, in the first 
 place, set up by repeated bacterial attacks on 
 the epithelial cells, which are then kept actively 
 secreting by the irritation of the toxins, a 
 vicious circle being thus formed. Hence, if 
 both general and local immunity are obtained, 
 it will not follow that the symptoms of bron- 
 chitis will at once disappear, for the sapro- 
 phytic existence of the bacteria is not only 
 active, but is waiting for lowering of immunity 
 to attack again. For these reasons I think 
 that vaccine treatment of chronic chest 
 catarrhs, etc., should be continued for very 
 much longer periods of time than is now 
 usually done, so as to allow the bronchial 
 epithelium to regain a normal, healthy con- 
 dition. I believe that in old-standing cases of 
 bronchial asthma treatment of less than two 
 years' duration is of little use. The vaccines 
 will not need to be given very frequently after 
 the first six months : once a fortnight, or once 
 in three weeks, is generally sufiicient." 
 
 From my own experience I would further 
 
 13 
 
194 ESSAYS ON PRACTICAL MEDICINE 
 
 say that in these long-standing cases it is good 
 policy to have a fresh bacterial examination 
 made every six months or so, and if the bac- 
 terial conditions have altered, to have a fresh 
 vaccine made. One of the most successful 
 cases I have ever seen is an old lady, now 
 eighty-three years of age, who lived out of 
 England for many years in the hope of getting 
 rid of persistent bronchial asthma. She finally 
 came to Bournemouth to end her days as a 
 hopeless case. She has been under treatment 
 now for five years, having a vaccine, which is 
 changed from time to time, every fortnight. 
 tJnder this she has regained a very fair degree 
 of health, and the bronchial asthma is almost 
 cured. Age is no bar to this treatment. Quite 
 old people of seventy-five to eighty-five do 
 very well and get no alarming symptoms. 
 Children also of two or three years old re- 
 spond equally well. The most disappointing 
 cases, perhaps, are in overworked, anxious, 
 neurotic, middle-aged folk. Confirmed em- 
 physema has, by some, been thought to be 
 unsuitable for vaccines, but that is not at 
 all my experience. On the contrary, I have 
 seen bad cases of emphysema very much im- 
 proved, and surely it is only what one would 
 
BRONCHITIS AND BRONCHI AL ASTHMA 195 
 
 expect ; if catarrh, cough, and expectoration 
 are lessened or cured, the lung substance has 
 again a chance to recover its elasticity. As I 
 have said before, pneumococci cases often 
 respond quickly and well. Catarrhalis cases 
 vary, but are generally rather obstinate, and 
 it is not always easy to find the suitable dose 
 to begin with. Too big a dose will sometimes 
 increase dyspnoea. Staphylo cases are gener- 
 ally in conjunction with pneumococci or more 
 often with catarrhalis, and a double vaccine 
 often answers well. Streptococci cases will 
 often need a long course, but do very well in 
 the end. This microbe will not seldom be 
 found with pneumococci. It is well to begin 
 with a small dose, ten or fifteen millions, and 
 to watch for symptoms of irritation such as 
 increased cough or dyspnoea ; a rise of tem- 
 perature is very rare, and if it occur should 
 cause no alarm. The smaller doses should be 
 given every four or five days. When one has 
 found the dose that does good, it is better, I 
 think, to stick to it and to give it every ten 
 days or so, till one has got the symptoms well 
 under control, and then to carry it on at inter- 
 vals of every two or three weeks for a year 
 or more. 
 
196 ESSAYS ON PRACTICAL MEDICINE 
 
 It is hardly necessary for me to say that all 
 vaccine treatment should be carried through 
 with strict antiseptic precautions. I find that 
 washing the syringe and needle inside and out 
 with a weak lysol solution is a quick and safe 
 plan ; the patient's skin should be cleaned 
 with the same solution or with iodine. If 
 lysol is left in the syringe more pain is caused 
 than is necessary ; so I wash it out, before 
 drawing in the vaccine, with boiled water. 
 The collection of sputum should be done in 
 the morning, if possible, before food is taken, 
 and the mouth should be washed out pre- 
 viously with hot water, not with any antiseptic 
 wash. The sputum should be expectorated 
 straight into a wide-mouthed bottle with 
 glass stopper that has been sterihsed by boil- 
 ing the previous night, and should be sent 
 with little delay to the examiner. 
 
 In many of these cases one will find high 
 tension and early symptoms of arterio-sclero- 
 sis ; this has been thought by some to contra- 
 indicate vaccine, but my experience has, with 
 these cases, been very favourable. The high 
 tension, etc., has been to a large extent 
 brought about by the continual strain of 
 coughing and dyspnoea and by broken rest. 
 
BRONCHITIS AND BRONCHIAL ASTHMA 197 
 
 and the relief of these will alone lower tension. 
 It is very common for old people who have 
 had a chronic cough to die of a sudden un- 
 explainable pneumonia, without any chill 
 or exposure to infection : these cases are 
 all latent pneumococcic affections. For some 
 reason the resisting power has given way, and 
 the invasion has taken place. Such cases 
 could be easily prevented by the occasional 
 use of pneumococcus vaccine, for the microbe 
 could have been detected in the sputum of 
 the chronic state. 
 
 Further, arterio-sclerosis is thought by many 
 to be caused in some cases by auto-intoxica- 
 tion from the abnormal bacteria of the diges- 
 tive tract : is it not reasonable to think that 
 it may be caused also by auto-intoxication 
 from the abnormal bacteria of the respiratory 
 tract ? Whatever the cause may be, you will 
 generally have the satisfaction of seeing the 
 high tension satisfactorily subside, with all its 
 accompanying symptoms, and this will take 
 place without using any depressor remedies. 
 
 With such a varied pathological cause for 
 the group of morbid symptoms that we call 
 bronchial asthma, is it reasonable to expect 
 that any medicinal course of treatment, either 
 
198 ESSAYS ON PRACTICAL MEDICINE 
 
 by the stomach or by inhalation, can ever 
 effect a radical cure, or have any but a passing 
 action ? A symptom here and there can be 
 relieved and the patient made more comfort- 
 able {vide the endless list of patent and pro- 
 prietary cures that are no cures). As scientific 
 men we should go, if possible, to the lOots of 
 the disease, and the modern science of bacteri- 
 ology is helping us to do this most effectually. 
 We have much to learn, and something to 
 unlearn, but patience and honest work will 
 produce undreamt-of results. Finally, I look 
 on this treatment as a true and logical ex- 
 tension of my dream — organic therapeutics. 
 
 l^ONDON : H. K. I/EWIS & Co. I,TD., 136 GOWER STREET, W.Q.l 
 
 PrinUd by Htucll, Watson & Viney, Ld., London and Aylesbury 
 
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