Columbia ®[nibergitj> m tfje Citj) of ^efco |9orfe COLLEGE OF PHYSICIANS AND SURGEONS Reference Library Given by Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/fieldofdiseaseboOOrich THE FIELD OF DISEASE. THE FIELD OF DISEASE A BOOK OF PREVENTIVE MEDICINE BEXJAMm WAKD EICHAKDSON, M.D., LL.D., F.R.S FELLOW OF THE EOYAL COLLEGE OF PHYSICIANS, AND HONOKA-KY PHYSICIAN TO THE KOYAL LITEKAKY FUND. Homines ad deos nulla re pj'opius accedunt quani salutem hominibus da7ido." Cicero. PHILADELPHIA HENRY C. LEA'S SON & CO, 1884 TBOW'8 PRINTING AND BOOKBINDING COMPANY, NEW YORK. TO RICHARD OWEN, C.B., D.C.L., RR.S., IN HOMAGE TO GENIUS, IN ADMIRATION OF INDUSTKY, IN REMEMBRANCE OF LONG FRIENDSHIP, THIS BOOK IS INSCRIBED. AMERICAN PUBLISHERS' NOTICE. The prevention, no less than the cure o£ disease, is now under- stood to belong to the function of the physician, to whom alone the public can look for protection as well as for rescue. As the author very truly says : " The conception that these atilictions can be prevented is of modern times, and indeed we may say practi- cally of the present century, or even of the later two-thii-ds of the present century ; " and it would seem that the time had now come in which the r.esults of the investigations and experience as to the relations between health and disease should be summed up, not only for present use but as a starting-point for fm'ther acqui- sitions in this supremely important field of knowledge. Although Dr. Richardson assumes that the i)resent volume is intended primarily for the public, the publishers have, for the reason just stated, no hesitation in laying it before the profession, being advised that it contains much with which every physician should be familiar, while there is no work in the language in which the information here presented can be sought, systemati- cally arranged, and intelligibly presented. Philadelphia, November, 1883. PREFACE. I HAVE written this work for those members of the intelli- gent reading public who, without desiring to ti-ench on the prov- ince of the Physician and Surgeon, or to dabble in the science and art of medical treatment of disease, wish to know the leading facts about the diseases of the human family, their causes and prevention. Any one, therefore, who opens this book with the expectation of iinding in it receipts and nostrums will not have that expectation fulfilled, and will discover i-eference to no remedies except such as are purely preventive in chai'acter. To adapt the book to the general reader I have carefully avoid- ed most of the new names and terms which have recently stolen their way, at a rapid rate, into the literature of medicine. This was a necessity which I do not regret, because the old historical terms with which the people have become familiar are, as a rule, far more correct and classical than the new terms which have been introduced by modern caprice and love of change rather than by learning and judgment. For the same reason I have kept pretty closely to that classifi- cation of diseases which has descended from the best scholars in medical science and art, and M'hich, through their labors, is best known to the people at large. For the objects and intentions of the book I respectfully refer the reader to the first or introductory chapter, in which all that is desired to be achieved is fully expressed. 25 MANCHESxr.R Square, London, W. CONTENTS. Book I. — Diseases. DISEASE AS UNITY WITH VARIETY OF PHENOMENA. CHAP. PAGE The Preventive Scheme of Medicine 19 PART THE FIRST. GENEEAL DISEASES AFFECTING MANKIND. I. Outlines of General Disease 25 n. Conditions of Disease 28 III. General Diseases Running a Definite Course 44 rV. General Diseases of Constitutional Type.' 59 PART THE SECOND. LOCAL DISEASES. I. The Seats of Local Diseases. A Physiological Outline 71 II. Diseases of the Digestive System 104 in. Diseases of the Heart, Circulatory Apparatus, and Blood 129 rV. Local Diseases of the Breathing or Respiratoiy System 153 V. Local Diseases of the Nervous System 167 VI. Diseases of the Organs of the Senses 185 VII. Diseases of the Absorbent and Glandular Systems 202 Vni. Diseases of the Muscular System, Tendons, and Appendages., 231 IX. Diseases of the Osseous System or Skeleton, including the Teeth 238 X. Diseases of the Skin and Membranous System 250 Xii CONTENTS. PART THE THIRD. DISEASES FEOM NATUEAL ACCIDENTS. CHAP. PAGE I. Diseases from Natural Accidents 273 II. Diseases from Natural Poisonings and from Accumulations of Poisonous Excretions Within the Body 280 III. Diseases from Venomous Organic Substances 287 IV. Diseases from Animal and Vegetable Poisons Taken as Food. 293 V. Diseases and Accidents connected with Pregnancy and Child- bii-th 297 Book II.— Acquired Diseases. DISEASES OF ARTIFICIAL OEIGIN. PHENOMENA AND COUESE. Induced or Acquired Diseases 311 PART THE FIRST ACQUIEED DISEASES FEOM INOEGANIC AND OEGANIG POISONS. I. Acquired Diseases from Inorganic Poisons 315 II. Acquired Diseases from Inorganic Gases and Vapors 331 in. Acquired Diseases from Organic Poisons 343 PART THE SECOND. ACQUIEED DISEASES FEOM PHYSICAL AGENCIES, JMECHAN- ICAL AND GENEEAL. I. Acquired Diseases from Dusts 377 II. Acquired Diseases from Mechanical Pressui-e on the Lungs . . 390 ITT, Acquired Diseases from Mechanical Concussions and Shocks . 395 IV. Acquired Diseases from Muscular Overwork and Strain 400 V. Acquired Deformities and Defects of Body 410 VI. Acquired Diseases from Physical Injuries 416 Vn. Surgical Operations 425 CONTENTS. xiii PART THE THIRD. ACQUIEED DISEASES FEOM MENTAL AGENCIES, MOEAL, EMOTIONAL, AND HABITUAL. CHAP. PAGE I. Acquired Disease from Mental Agencies , 443 n. Acquired Disease from Moral Agencies 448 m. Acquired Disease from Mental Shock 453 IV. Acquired Disease from Imitation or Moral Contagion 458 V. Acquired Disease from Hysterical Emotion 465 VI. Acquired Disease from the Common Emotions or Passions . . 470 Vn. Acquired Disease from Habits of Life 480 Book III.— A Practical Summary of the Origins, Causes, and Preventions of Disease. Origins, Causes, and Preventions of Disease 499 PART THE FIRST OEIGINS AND CAUSES OF DISEASE. I. Varieties of Origins and Causes of Disease 505 n. Congenital and Hereditary, or Constitutional Causes of Dis- ease 508 III. Atmospherical, Meteorological, and Climatic Causes of Dis- ease 524 rv. On Weather and Season as Causes of Disease 530 " V. Atmosjiherical, Meteorological, and Climatic Causes Consid- ered in Detail 546 VI. On Parasites in connection with Disease 559 VII. On Parasites as Causes of Disease 566 VIII. Zymosis, or Ferment, as a Cause of Disease 588 IX. Industrial and Accidental Causes and Origins of Disease 621 X. Social and Psychical Origins and Causes of Disease 628 XI. Senile Degenerative Causes of Disease 636 XII. Deaths and Chief Causes of Death in England and Wales in 1880 639 XIV PEEFACE. PART THE SECOND. PRACTICAL SUMMARY OF PEEVENTIONS OF DISEASE. CHAP. PAGE I. Intro diictoiy Notes 645 H. Prevention of Hereditary Constitiitional Diseases 648 1 1 1 - Preventions of Atmospherical, Meteorological, and Climatic Disease 659 rV. Preventions of Parasitical Disease 668 V. Preventions of Zymotic Disease 673 YI. Preventions of Accidental and Industrial Diseases 692 Vli. Preventions of Social and Psychical Disease 701 "Viii. Preventions of Senile Disease 712 BOOK THE FIRST. DISEASES. DISEASE AS UNITY WITH VARIETY OF PHENOMENA. THE PREYENTIYE SCHEME OE MEDICmE. In this work we have to study first the nature, secondly the causes, and afterwards the prevention of those calamities which afflict mankind, and which have received the title of diseases. The conception that these afflictions can he prevented is of mod- ern times, and indeed we may say practically of the present cen- tury, or even of the hitter two-thirds of the present century. The idea which came down almost to us who now live was that diseases of every kind were a portion of the necessary sufferings of human existence, sufferings which might by some art, or conjuration or divination, be removed, but which could not be avoided or pre- vented. For this reason the so-called curative art, the art of i-e- lieving or removing diseases, took, naturallj^, a first place in the course of human progress. This curative art, brilliant in many of its discoveries, useful in many of its applications, and benefi- cent alike in discovery and application, could not, however, be ex- pected forever to remain the be-all and end-all of human effort against disease. It was wonderful while it combated the unknown and the invisible. But in course of natural development of knowledge the unknown and the invisible passed away, in so far as belief in them was concerned, and there was left on the mind, in place of that belief, the fact that not one of the diseases long thought to be supernatural and out of the range of inquiry as to first causes, w^as supernatural at all. Each was traceable, by the acquirement of correct knowledge, and, when traceable, was largely and effectively preventible by a further extension of the same acquirement. In this manner has arisen the science and art of preventive medicine. It is not a science, it is not an art separated neces- sarily or properly from so-called curative medicine. On the con- trary, the study of prevention and cure proceed well together, 20 THE PREVENTIVE SCHEME OF MEDICIXE. and lie is the most perfect sanitarian, and lie is the most accom- plished and useful physician, who knows most both of the pre- vention of disease and of the nature and treatment of disease ; he who knows, in fact, the before and the after of each striking phe- nomenon of disease that is presented for his observation. If I were to speak of the progress that has been made in the past thirty years, I should be obliged, in candor, to confess that great losses of time and great injaries to advancement have been caused by the circumstance that the unity of the two labors has not been duly recognized. A few enthusiastic men. devoted al- most exclusively to the grand and new instauration of medicine in its preventive character, have, if I may so say, made war on the curative system which has held such long, such undisputed, and such classical sway. They have consequently often been led to speak and write about diseases without any accurate knowledge of the natural history of disease after its birth, and so have in- flicted harm on the principles of preventive art. To use an ap- propriate simile, they have reasoned on diseases as another school of philosophers might reason on the antecedents of unborn indi- viduals without knowing anything whatever of the natural history, or the natural life, or the natural peculiarity, or the natural ter- mination of the lives of those individuals after they had come into existence. All this has led to unnecessary and often to enthusiastic and extravagant warfare ; and it has had the effect of interrupting the order of reformation of thought amongst the representatives of the curative school, who by inheritance have held the study of disease in their hands. These having few treatises of the past, or little wisdom of the past, descending from great and acknowl- edged masters, to guide them on the subject of the prevention of first or antecedent causes of disease, have held obstinately by their own principles, and have sometimes stoutly resisted Avliat they have conceived to be an igTiorant encroachment on their rightful domain. I confess, for my own part, I have had great sympathy with the curative school, in which I was bred, and with which I remain associated too closely ever to be disconnected from it. At the same time the truth must now be candidly admitted, that the sys- tem of relieving mankind of its misery and load of disease can no longer ]'est alone on what is called curative skill. We have en- THE PEEVEXTIVE SCHEME OF MEDICINE. 21 tered an era in wliicli the steady effort must be, not only to cure disease, but to cui-e cure. The men who have prochiimed the art of prevention, based upon the art of learning tlie antecedents of the phenomena of disease and the reasons why diseases are devel- oped at all, are right in principle however widely they may some- times have erred in details of facts and in endeavors after practi- cal attainments for the realizations of which they were not ready, and for many a long day will not be ready. The grand work of this era is to reconcile the two different schools ; to systematize the preventive part of medical science, so far as that is now know'n ; to bring the preventive part into en- the accord with the remedial ; to let the world at large under- stand the interrelationships which exist between the two parts ; and, by a sympathy of action, based on knowledge, to enable every man and woman to assist in tliat part which tends towards prevention. With the objects here expressed I write this present volume. I have nothing to say in it that has any relation to the cure of diseases. I base it nevertheless on the curative side of medical learnino-. In other words, I strive to trace the diseases from their actual representation, as they exist before us, in their natural progress after their birth, back to their origin, and, as far as I am able, I try to seek the conditions out of which they spring. Thereupon I endeavor, further, to investigate the conditions, to see how far they are 2-emovable, and how far they are avoidable. The success of my effort will turn on the success with which I am able to carry out this analytical and practical design. I may say at once that I know the effort, though it be ever so laborious, cannot be perfect. The wisest of us who look at disease are still like persons M-atching the progress of a dramatic representation. We see the various characters, we hear them speak, we observe the scenic conditions, we understand the plot and its develop- ment ; but as yet we are not acquainted with the players, Ave arc not behind the scenes nor conversant with the very simple means by which the most startling effects are often produced. It is ray wisli to get at all the truth, as far as is possible, in the study of the phenomena of tlie great tragic drama of disease which is ever being enacted before us. I ask no pardon for apparent or ronl failure wherever it occurs, because I am sure tliat frequent fail- ure in this stage of human knowledge is inevitable. At the same 22 THE PREVENTIVE SCHEME OF MEDICINE. time I know, at the outset, that the attempt cannot be laboriously m.ade bj any one without securing some success, since by such an attempt the general reader may be led to learn certain facts which will be useful to him as facts, though he cast all generalizations to the winds as learned dust. By such an attempt the critical reader also may be led to go deeper than he has gone, perchance, into a subject worthy of his criticism, and may thereby have the opportunity of giving to the world a good market of his own founded on my imperfections. Lastly, by such an attempt the candid, thoughtful, and original students of nature in the future, — and they are the men and women I would specially win, — may be induced to follow out, with greater knowledge and wisdom than pertains to me, the height of this argument, and from their more commanding position to recast it perfected. BOOK L PART THE FIRST. GENEEAL DISEASES AFFECTING MANKIND. CHAPTER I. OUTLINES OP GENERAL DISEASE. Let us before we proceed further glance in a preliminary way at some of the evils which, under a correct system of preventive medicine, have to be removed from mankind. Let us, in other words, glance at those phenomena of nature which in their variety constitute what is called disease. Disease is unity with a variety of phenomena. Disease is a departure from a certain assumed standard of health either in the individual as a whole living body physically and mentally exist- ing, or of a part of that body ; and, without any error, I may say a part of that mind. For this reason the phenomena of disease have, from very early times, been divided into the general and the local. This division has in late days been re-affirmed by no less an authority than a Committee of the Koyal College of Physi- cians, which has reported on the " nonhenclatwre of diseased The College defines general diseases to be such " as affect the whole frame rather tlian any special part of it," and local diseases to be such " as occupy special parts of the body." Under tlie head of general diseases the same authority enu- merates Jiftij-eight forms. Under the head of local diseases it enumerates eight hundred and forty-three .v?iY\ei\es>. To tliese it adds ninety-one of " other conditions of disease " which are not necessarily associated with general or local diseases, and which include premature birth ; old age ; debility or " uniform exliaus- tion of all the organs of the body without specific disease ; " tlie affections arising from the action of the various animal, vegetable, and mineral poisons ; and the affections arising from wounds in- flicted by poisonous animals. Li conclusion it also adds one hun- dred and fftg-Jive forms of injuries, {a) general, such as burns and scalds; {h) local, such as fractures and other mechanical inju- ries of parts of the body. 26 GENERAL DISEASES AFFECTING MANKIND. The result of this calculation gives us a grand total of one thousand one hundred and forty-six variations from health as making up the conditions and the phenomena of disease to which the human family, at this period of its civilization, maj be sub- jected. A pliilosophical friend who has no practical knowledge of dis- ease, tells me he is surprised to learn that the number of diseases is so small. It is in truth very much smaller than above stated. The learned men who with infinite labor have drawn up this latest record of diseases, a record historical in its character and singularly practical, were bound, by the nature of their task, to retain much that they might have thrown aside, and which they doubtless would have thrown aside had they been classifying dis- eases on any philosophical system that might lead to condensation. This was not their duty. They were compelled to' simplify names and classifications in such a manner and to such an extent as to keep their record in harmony with current knowledge and method of description, and to adapt it, without too rapid transition of thought or practice, to the requirements of medical men every- where, to the million of physic, throughout the world. And so we may start with the great fact in our minds, a fact we may afterwards use for whatever necessary purpose we may be at in illustrating prevention, that there are, in detail, before the scholar of the preventive art one thousand one hundred and forty- six diseases affecting mankind which he has to study with a view to their abatement or removal. In the classification of diseases which the most recent authori- tative effort at classification has supplied, the difficulty of estab- lishing a sound and simple mode of classification is set forth with all candor. Diseases, say the College reporters, might be classi- fied according to their symptoms; their causes, their intimate nature ; the tissues or the systems of the body that are affected ; or the parts of the body as they lie anatomically. After due con- sideration the reporters determined to follow the anatomical plan, and to base their classification upon anatomical considerations. Thus, after dividing the fifty-eight general diseases into two classes, a class {a) of thirty-three diseases, including all that are infectious and contagions, and a class (b) of twenty-five diseases, including the great constitutional maladies, such as gout, cancer, scrofula, they pass afterwards to the classification of one thousand and OUTLINES OF GENERAL DISEASE. 27 eighty-eight local diseases, — diseases having a localized seat in some organ or part rather than in the body altogether, — and thus they complete their laborious and important undertaking. Taking the work of the Koyal College as a general basis and direction, I would now proceed to place before the reader the descriptive list of the general diseases affecting mankind. Before passing to this task it will, however, be necessary to render famil- iar certain terms, which are in common use amongst the learned for expressing what may be called attendant conditions of disease; conditions which may be present in the course of different dis- eases, and common to them in various stages, but which are not strictly diseases themselves, though much may depend on their presence or their absence. The facts relating to these conditions apply to the part of this book which treats of general diseases. They apply also to the part which treats of local diseases. In fact they cover the whole field of disease. We will consider them in a special chapter. CHAPTER n. CONDITIONS OF DISEASE. The conditions of disease referred to in the last chapter and now inviting definition and brief exposition inaj be classified under fifteen heads. 1, Fever. It is customary to say of persons suffering from various acute diseases and from some slow or lingering diseases, that they have fever ; that the fever runs high ; that the fever is reduced ; that the fever is intermittent, and so on. Under this term fever, the older writers sometimes meant one special disease, which they defined no further. Afterwards fever began to be considered under two heads, according as it was or was not communicable. Thus there were contagious fevers, or such as were communicable by touch and could be conveyed by something that was capable of being carried from the affected to the healthy ; and there were infectious fevers, or such as could be contracted by coming into immediate contact with the poison that was emanating from the affected. Again, there were fevers which were neither contagious nor infectious — sinvple fevers ; or which ran a continued course, conthvuecl fevers. By another change of expression fever was connected with diseases of particular organs, as with the brain, hrahifever, or with particular functions or states, by which method of expression we got such terms as milk- fever and chilcl-hed fever. Once more fever was connected M'ith another general term, inflammation, so giving rise to the term in- flammatory fever • or it was considered to be the result of some irritation, from which view was derived the expression ii^rltative fever. In these days we have not lost these expressions, but we use them, when we are speaking correctly, with more precision. AV^e CONDITIOXS OF DISEASE. 29 liave now learned to take with the tliermometer the temperature of the human body, and we accept the natural temperature to be 98.4° Falu-enheit in temperate climates, with a range of two- tenths on either side, below for arctic, and above for tropical con- ditions. It is the fact even in what may be considered health that these ranges may be extended on either side for short periods of time, but practically the figures are sufficiently correct. When therefore the temperature of the body is shown by an accurate thermometer to be 98.4° Fahrenheit, we consider there is a natu- ral temperature. When the temperature is above 98.4° in any marked degree we say there is, fever. We must not boast that by this definition we have added much to human knowledge, for the most ancient physicians and scholars gave us a similar, if less precise, statement, and went so far as to discuss whether fever could exist of itself without any preceding change in the bod}^, such as inflanmiation. But we have gained, by the labors of many hard- workers, by those of the late Dr. Wunderlich especially, a correctness in the reading and the detection of the range of fever that was never before attain- able. From its intensity we now measure fever and its dangers with almost exact detail : so much fever, so much or so little danger, so much probability of recovery, so much probability of death. By the term fever in these daj's we mean an elevation of ani^ mal temperature varying in degree, and when the word is used alone we mean nothing else. If the fever is one, two, or three degrees above the natural, we look upon it as mild in form. If it runs up to four and five degrees above the natural, we say it in- dicates danger ; if it rises over six degrees, the danger is immi- nent ; when it passes seven, the chance of continued life is very small ; and, at eight degrees, if the condition continue very long, death is all but certain. At an increment of eleven degrees of heat above the natural, on Fahrenheit'^ scale, continuance of life is, with the rarest of exceptions, impossible. Before that stage is reached the minute blood-vessels have undergone contraction ; the muscles of the body, generally, have shown a tendency to spas- modic contraction which may pass into tetanus ; and the blood has, in some instances, commenced to separate into two parts, or, as it is commonly said, it has commenced to set, or coagulate. Fever thus viewed becomes a condition of disease running 30 GENERAL DISEASES ArFECTIN"G MA]S"KIND. with other conditions wliicli mar, locally, be more apparent, but which in a general sense cannot be more definite. It is not a basic condition, for it is a result of something that preceded it. But it determines the after results so decidedly that to retain it as if it were basic, and to speak of irritative fever, inflammatory fever, contagious fever, intermittent fever, hectic fever, tetanoid fever, scarlet fever, spotted fever, malarial fever, and the lilce, is quite correct if vre only keep in mind the simple truth that the added words merely express either the origin, or the course, or the phenomena of the febrile state. A good simile is given to us of this in the example of a com- mon fire. Fire is not a base ; it is a result ; and yet it determines consequences so decidedly that it very soon becomes the one domi- nant fact. Fire may be sharp, slow, bright, smouldering, acci- dental ; it may be a coal fire, a wood fire, a peat fire ; it may be continued, intermittent, subdued, wild ; and by all such terms we may distinguish its character. Instead of serving its intended purpose in the house or manufactory, it may be playing the part of a destroyer. Fever is the counterpart of this in the house of life ; it is the animal fire burning beyond what is natural, excited to that burning by something that was, in a basic sense, the prime cause of the condition of disease. The influences which set up fever in the aninial body are many. If sensitive nervous surfaces be rubbed or irritated so that pain results there is an increase of temperatui'e, irritative fever^ a fever probably of short duration and harmless in kind, lasting only so long as the irritation lasts and dependent on the disturbed nervous balance, but still present. If, from local causes, an organ of the body becomes inflamed, there is soon some increase of temperature, or fever, hiflammatory fever, which will vary in intensity with the extent of the inflammation, and will probably subside with the inflammation, but will not fail to be present. If some foreign substances, minute particles of matter, — fever-poisons, — be introduced into the body, they may modify the animal chemistry, so as to increase the animal com- bustion and produce fever, contagious or infectious fever, -which will last so long as the cause of the disturbance remains in opera- tion. Such fever may, in some instances, subside from reduction of the cause, and then break out again as the cause is reproduced, or it may by its violence, either before or after the cause has CONDITION'S OF DISEASE. 31 ceased to operate, give rise to a destruction which renders death inevitable. If the body be exposed to agents which modify the vascular tension so that through the vessels the blood shall pass with undue friction, there may be an increase of fever which might be c-aWedif riot tonal fever. Or, if the tension of the vessels be suddenly reduced by some agent, say alcohol, or cold, so that the heart shall intensely inject the minute vessels with blood, there may again be, from the reaction, an increase of tempera- ture, /dyer of reaction or congestive fever. Lastly, if the body be subjected to the influence of some agent which, interfering for a time with the animal chemistry, causes a development of fever, then ceases to act, as if it were itself destroyed, but after a time is reproduced and sets up once more the increase of temperature, there is excited what is known as recurrent., reUipsing, intermit- tent, or hectic fever. Thus it will be seen that the word fever indicates a condition of the widest significance, while in itself it is not strictly speaking a disease. It is an exalted state of that natural function by which all the flexibility of life, the chemistry of life, the construction of matter into living form, the destruction and removal of matter in dead form, is regularly carried on. In fever, the body is, in short, living out of its compass, and wherever in these pages the term fever is used, let it be remembered as meaning fire, — over- action, — expenditure beyond the natural capacity of vital process. Irritation. The term irritation is applied to express a condition in which some sensitive surface richly supplied with nerves is subjected to mechanical cr chemical injury. The effect produced on the sur- face of the eye by the introduction of some small foreign body, like a grain of sand between the lids and the eyeball, is a familiar illustration of irritation. "We may say, as a general rule, that the effects of irritation are always confined to membranous surfaces ; as to the skin or cutaneous membrane ; to the nuicous membranes of the eye, the alimentary canal, the bladder and its passages ; to the serous membranes enveloping the heart, the lungs, the intes- tines ; to the membranes enveloping the brain and nerves; to the membrane which covers the bones, the periosteum ; to the ner- vous membranous expanses like the retina or receptive surface of the eyeball. 32 GENERAL DISEASES AFFECTIISTG MANKIND. When a membrane is irritated, in addition to the pain which is produced, there is an effect also on the blood-vessels. The ves- sels, seeming to lose control over the current of blood that should be passing through them in measured and self -adjusted quantity, become overcharged with blood, or, as it is said, congested and dilated. If the part affected be in nervous communication with a secreting gland, the gland is influenced, and pours forth a too abundant secretion. And, finally, in regard to local effects, if the irritation be continued, changes take place which are usually in- flammatory in character. Irritation, as a local condition, is therefore attended with many inconveniences and dangei's, but the mischief does not always stop at what is local. Owing to the intimate intercommu- nications between one part of the body and other parts, by means of nervous fibres, and owing to the fact that vibrations communi- cated to irritated parts may easily be conveyed along nervous fibres, from the circumference to the nervous centres themselves, it constantly happens that by irritation in one part of the body a disturbance of action communicated to a nervous centre is reflected from that centre, through other nervous fibres that are directly or indirectly connected with it, to some remote part which is thereby affected. An illustration of this is offered in the case of convul- sions from an irritation in the intestinal canal. It happens fre- quently in infancy, and occasionally in later life, that a foreign substance in the stomach is a cause of convulsions of a general character. Here the irritation communicated to the nerves of the stomach is carried to the motor part of the spinal cord, and fi'om thence is reflected along the motor tract of nerves to the muscles which they supply with the stimulus to excite contraction, and with the result of exciting uncontrolled convulsive movements in the muscular organs. Irritation may therefore produce four distinct phenomena. {a) Pain ; (h) congestion of blood-vessels, leading towards inflam- mation ; (c) over-secretion ; and, (d) convulsive muscular move- ment. Further, it may produce a general febrile condition, and as a producer of one or more, or all of these changes, it deserves to be remembered and understood whenever it is named in rela- tion to disease. Agencies producing irritation are called irritants. They may be purely mechanical, like a grain of sand, or chemical, like the CONDITIONS OF DISEASE. 33 vapors of ammonia or turpentine. Their mode of action is not so clearly understood as their course of action, but it is probably by the setting-up of vibration in nervous matter, through an ethereal medium or nervous atmosphere. Cataeeh. When under irritation there is an excessive flux or discharge from any secreting or excreting surface of the bodj'', the term catarrh is employed to express the fact. This term indicates that the natural secretion or excretion is being thrown off in excess. In common cold there is an excessive secretion from the nostrils, and what is called oiasal catarrh is presented. "When there is discharge of mucous fluid from the bladder vesical catarrh is said to be present. When there is free secretion and expectoration of phlegm from the bronchial tubes, without inflammation, hronchial catarrh is said to be present. The condition is what the word de- scribes ; it is an outpouring or defluxion. Inflammation. Inflammation is one of the most common conditions of dis- ease, and from oldest times the term, like the term fever, has been in common use. The question whether there can be fever without inflammation is, in fact, one of the oldest problems in medicine, dating even from Erasistratus. Inflammation is under- stood to mean a change in an organ or part, attended with four distinct phenomena, " rubor et tumor, cum calore, et dolore " : redness and swelling, with heat and pain. As a picture of phe- nomena nothing more accurate has ever been given. When any part is red and sioollen, with heat and j^ain, it is inflamed. The condition leading to this state is one of preceding irritation, and the phenomena observed are all indications of a derangement be- tween the nerves and blood-vessels. The vessels are dilated with blood, and the surrounding loose tissues swollen ; the nerves are painfully compressed ; the whole of the affected part is raised in temperature, — it may be above the temperature of the rest of the body ; — and, the injected parts are red. All portions of the body that are supplied with blood-vessels and nerves are subject to inflammation, so that there is an im- mense number of inflammations, as many, in fact, as there are organs, or even of parts of some of the more complicated organs. 8 34 GENERAL DISEASES AFFECTING MANKIND. To give one example : the eyeball alone is subject^ in its various parts, to six distinct acute inflammations. Inflammation, besides being considered in respect to local structures and organs, lias also to be considered in regard to cer- tain characters of the condition itself. If the inflammation of a part be connected with some particular state or condition of body by which its own phenomena are modified, the particular constitutional state is described, adjectively, to express the con- nection that has occurred. In this manner peculiar forms of in- flammation are quoted, of which the following are specially given in the scientific nomenclature, PycB7niG Inflainniation. — An inflammation occurring during the existence of the diseased state called pysemia or pysemic fever. In pyaemia, which follows often on a wound or after an operation, there is a state of the blood inclining it to coagulate within the body, and to arrest its circulation in the visceral organs, by the clot which is formed from the coagulation. The presence of the obstructing clot causes irritation and inflammation, which is then called pysemic inflammation. RlieimiatiG Inflammation. — Inflammation connected with the rheumatic condition, and sometimes of a flying character during the attack of disease. The inflammation affects different organs of the body, or one or other of the joints, or the coverings of the heart, or the valvular structures of the heart. Gouty Inflammation. — Inflammation connected with a gouty condition of body and developed in some local parts during the gouty state, and especially in some particular part, as the great toe. This inflammation, like the rheumatic, is often transitory in character, and moves from one organ of the body to another, by what the older writers designated, metastasis, or transference of disease. SyphilitiG Inflamm,ation,.- — Inflammation associated with and taking its inclination from the specific contagious disease known as syphilis. Scrofulous Inflammation. — Inflammation connected with the general condition and feebleness of body recognized, commonly, as struma, scrofula, or, — once on a time, — king's evil. The in- flammatory state in persons of scrofulous taint is easily excited, is often of a low, or " asthenic " type, and is prone to invade the glands of the body, and especially the glands of the neck. CONDITIONS OF DISEASE. 35 Gonorrficaal Infiammation. — Inflammation connected with the contagions disease, gonorrhoea. Inflammation finally gives origin to certain clianges in the parts to which it has been confined, whicli changes have received also particnlar names. To three of these, owing to their fre- cpency, special reference must be made. Ulceration. — When from acute or slow inflammation a struct- ure, such as the skin or a mucous membrane of the body, is locally destroyed on the surface, so that there is left an open sore which will only heal by contraction of its edges and formation of raised points or granules, the part is said to have ulcerated, and an ulcer is said to have been formed. If the tendency of an in- flammation is towards this state, %dcerative inflammation is the term used to define the condition of disease. tSupjyuration and Abscess. — If the result of inflammation be the formation in the inflamed part of the white, creamy-like fluid called "matter," or "pus," the terms suppuration and abscess are used to explain what has occurred, and the inflammation is said to be suppurative. When the formation of matter is circum- scribed and is confined to a small spot, with a tendency to break through and escape at some point where there is least resistance, the term hoil is ordinarily used to describe the change. When the accumulation of matter is large, an abscess is said to have been formed. Plastic Exudation. — Wlien in the course of an inflammation there is thrown out of the blood-vessels, frozn the blood, a portion of the fibrinous, sizy, or plastic part of the blood, and when that plastic fluid, in the course of after changes, instead of being re- absorl)ed into the blood, is solidified and causes adjacent parts to be held together or condensed, plastic exudation is said to have occurred, and the term plastic is used to define the inflammatory condition. In the membranous. cavities, such as the pleural cav- ity of the chest, plastic exudation ma}'" bind the pleural surfaces together. In the cavity of the abdomen plastic exudation may form bands around the intestines. In the structure of organs, such as the lungs, plastic exudation may infiltrate into the loose connecting tissue, and may even become the basis of new growths. In all these cases, and in others of a similar kind, in different parts of the body, the inflammation is said to be plastic in its character. 36 GEjS^EEAL diseases AFFECTIISTG MAISTKIISTD. Gaxgeene, Moettfication. When an organ or structure ceases to live, either from defi- ciency in its supply of blood or from deficiency of its nervous supply, and when, so changed, it begins to darken and to give off offensive gases, the term gangrene, or mortification, is used to ex- press the diseased condition. COKGESTIOJI'. "When in an organ or part richly supplied with blood, — such as the lung, the brain, the liver, the kidney, a serous membrane, a mucous membrane, or the skin, — the blood, flowing through the organ or part, stagnates and accumulates, the organ or part is then said to be suffering from congestion. The congestion may- be active or passive. EXTEAVASATIOX. When in an organ or part there is poured, into its structure, a quantity of blood which has escaped from the blood-vessels that naturally supply it ; and when the blood, — instead of flowing on in due course, yielding to each part the material necessary for its sustainment, and taking up the used materials, — is mechanically diffused in the structure of the part, the structure is then said to be subjected to extravasation ofhlood. Hemokehage. When the blood having escaped from its vessels, flows away from them, hemorrhage is said to have occurred. If the blood is slowly oozing away the hemorrhage is said to be passive. If the blood flows in a steady stream, or if it spurts out in a jet, the hemorrhage is said to be active. Deopst. When the watery part of the blood exudes too freely into a cavity of tlie body, — such as the pleural cavity of the chest, the pericardial cavity of the heart, or the peritoneal cavity of the ab- domen, — and when the fluid accumulates in such cavities, the term dropsy is employed to designate the condition. When the watery fluid accumulates in the celhdar or connecting tissue of the body so as to cause the skin to be raised and tense, and the feet CONDITIONS OF DISEASE. 37 or other parts to be swollen, the same tenn, dropsij, is ' still em- ployed to express the condition. The word anasm'ca is also used to express this iast-uamed dropsy. FiBKiNOUS Deposition. Dm-ing life the healthy blood contains 2.50 in the 1000 parts of a substance called fibrine. This substance is the plastic part of the blood, and in the blood stream it is in the fluid state. Drawn from the body it coagulates and becomes solid, forming the blood clot. In some conditions of disease this fibrine sepa- rates, within the body, during life. It may separate as a coagu- lum or clot in the heart or blood-vessels, portions of wliich clot may be carried into the circulation and may close up the smaller vessels. It may separate in the structure of very vascular organs. "When such separations occur the term fibrinous s¶tion or deposition is applied to express the diseased state. Dilatation and Contkaction. When different organs or parts of the body are subjected to strain or to irregular work they change in their dimensions, and to these changes different terms are applied. "When a hollow structure, — such as the heart, or an artery, or a vein, — is dis- tended without being enlarged in its own structure, it is said to be suffering from dilatation. When, on the other hand, it is re- duced in calibre, it is said to be suffering from contraction. Htpektrophy ok Enlargement. Sometimes it happens that an organ or part is increased in size, throughout its entire substance, beyond what is natural. A common illustration of this state is shown in the muscles of the working, or hammer-arm of the blacksmith. To this condition of enlargement the term hypertrophy is applied. Ateophy or Wasting. An organ or part of the body may undergo just the opposite change from that described under the head hypertrophy. It may become smaller, from having wasted, under which circumstances the word atrophy is used to express the change that has been produced. The words, dilatation, contraction, hypertrophy, atrophy, are 38 GENEEAL DISEASES AFFECTING MANKIND. of common use in the literature of disease, and tlieir general meaning should be carefully remembered. The terms may be applied to any organ. Thus in diseased conditions of the heart, to cite a common example, the heart may be dilated, contracted, hypertrophied, or atrophied. Degenekations of Organs ajstd Paets. The organs of the body, the more active especially,— though none are actually exempt, — are apt to undergo actual change of structure, so as to have their minute and elementary structure transformed into new and unnatural structure, the function of the organ being thereby deranged. When these changes occur the word degeneration is generally employed to express the change. The degenerations are rather numerous, and they are very im- portant in relation to life. Without being detected or known by the person subjected to them, they are often in progress until they have so far advanced that life is reduced in value, or is even sud- denly cut off, in the midst of apparent health. The principal de- generative changes are as follow : — Fatty and Calcareous. Atheroma. — A change of structure most commonly occurring in the heart and arteries, and consist- ing of a degeneration of the structures into a peculiar fatty and calcareous, or petrifactive, condition. To this the term atheroma, or atheromatous condition, is technically applied. The structures aifected are rendered very brittle and are easily ruptured. Apo- plexy, from the rupture of a vessel, is often due to atheroma. Ossification. — A change developed in the arterial vessels, but not specially confined to them, and consisting of a transformation of active or even elastic structure into inactive bony substance. This change may extend to other parts than the blood-vessels. It may affect the membranes and the muscular structures. Fibroid Degeneration. — In certain structures of the body, the lungs particularly, the elastic connective tissue becomes firm, hardened, and fibrous, causing condensation of structure, and, it may be, compression of neighboring tissues. To this change the 'wovdi fibroid degeneration is applied. Lardaceous Amyloid or Waxy Degeneration. — A change in which the structure of important organs, — such as the liver, — un- dergoes a transformation into a lardaceous waxy condition. This is called the lardaceous amyloid or waxy condition of disease. CONDITIONS OF DISEASE. 39 Fatty and Granular Degenerations. — Sometimes active organs, — sucli as the lieai't and other muscles of the body, the brain, liver, or kidney, — undergo a fatty transformation w^hich renders them liable to tear or rupture, and which greatly impairs their active power. These degenerations are of two kinds, one fatty, in which the elementary parts of the muscle or the cells gf the affected organs Or centres are transformed into fatty elements ; the other granular, in which the natural elements are changed into a granular fatty state, and lose their ordinary functional capa- city. These changes become most important when they affect the heart, the liver, or the brain and other portions of the ner- vous system. Tliey invariably lead to failure of action on the part of these vital organs, and, as affecting the heart, are frequent causes of sudden suspension of function, of faintness, and even of death. CirrJiosis. — Under various influences, — the influence of alco- holic drinks particularly, — in addition to many of the above- named induced changes of structure, there is one particular change of condition to which the liver is especially liable. The connective tissue of the organ is hypertrophied and hardened, and the compressed secreting cells are charged with a yellow coloring stuff or pigment. To this condition the term cirrhosis is applied. Pigmentation. — A degeneration is occasionally met with in which the minute elementary cells of parts or organs are charged with dark pigment. This change has been known to commence on one place in the skin and to extend over the whole of its sur- face, producing an actual dark or black skin. The phenomenon is extremely rare. Specific Degenerations. — The different organs and tissues of the body are sometimes affected with special constitutional changes which mark off forms of local disease, also called degenerative. Changes from syphilitic diseases, from cancer, and from colloid, i.e., gelatinous growth, are of this kind. Scrofulous degenera- tions, — with and without the specific condition of true phthisical or consumptive affections, tubercle, — come under this head. TuMOES AND Cysts. The organs and parts of the body are liable to become the seats of growths which are not necessarily malignant or fatal in character, though they may give rise to inconvenience, and, iudi- 40 GEJfEEAL DISEASES AFFECTIXG MANKIJSTD. recti J, to serious or fatal obstructions or pressures. Such growths are called non-malignant tumors. Analogous, in some respects to them, are other growths which contain fluid or cheesy-like mate- rial within them, and which are called hollow or encysted tumors, or cysts. The growths which are often seen on the exterior of the body, which occasionally grow to a large size, and are vulgarly called " wens," are of this encysted or cystic character. Calculus. In some of the open cavities of the body, as in the gall blad- der, in the urinary bladder, and in the intestinal canal, there are formed, in some persons, hard, separate, loose masses, which, taking somewhat the character of stones or pebbles, are called calculi — calculus, a pebble. In the gall bladder they usually con- sist of a fatty substance, — cholesterine. In the urinary bladder they consist of earthy bases combined with an animal acid, or of an insoluble animal acid itself, condensed on a foreign body which acts as a nucleus. In the intestine they consist generally of some foreign substance which has been swallowed in large quantities, such as magnesia, and which, failing to pass along the intestine, has entered into a concrete or solid mass. Malfoematio:?^. Amongst the local diseases affecting particular organs and parts of the body, is included, in scientific nomenclature, what is called malformation of organs, some error of natural construction by which the proper working of the organic structure is imj^eded or perverted. A good illustration of this is supplied in those who are born with a defect in the partition wall which separates the right from the left side of the heart in the auricular ca^'ities of the heart. When this malformation occurs, the venous blood on the right side of the heart, which, naturally, should all pass over the lungs to be oxidized, is allowed, before it reaches the left side, to pass, in part, directly from the venous into the arterial side of the circulation, and so to circulate over the body as a blood im- perfectly arterialized. The blood in this state is of a dark or venous color, and the blue condition of body which is present gives origin to the term cyanosis as descriptive of tlie condition. This is only one malformation, but it is perhaps the best that could be offered for the purposes of practical illustration. CONDITIONS OF DISEASE. 41 PaUASITIC CoNDITIOiSrS. There is another state of the coi-poreal organs or structures in which the change which constitutes the condition of disease is due to the introduction of new forms of animal life which multiply, and by their presence and multiplication create local, and, from the local, general, derangement of the body. To these manifes- tations of disease the term j)arasitic is applied. One common illustration of parasitic aifection is offered in those who are suffer- ing from intestinal worms ; another is supplied in those who are suffering from scabies, vulgarly, itch, in whom an insect, the Sar- coptes scahiei, burrows under the skin and keeps up a constant eruption and irritation. Cachexia. Literally a bad state of body. The term is used to describe, without any particular definition of disease, a condition of feeble- ness, a depression of a physical, or, of a physical and mental char- acter. The term is often applied to people of scrofulous consti- tution. It is applied also to persons who have become reduced in health from confinement in close air, from overwork, or from indifferent diet. It is applied again to those who have long been subject to slow and exhausting diseases. It is sometimes used to define the bloodless condition more correctly expressed as anaemia. Collapse and Syncope. The word collapse is applied to a condition in which the pow- ers of life are rapidly sinking, the body prostrate, the abdomen shrunken, the limbs helpless, the face contracted, the expression vacant, the mind listless or unconscious, the external surface cold, and the respiratory muscles and heart failing in their action. When the bodily and mental powers suddenly collapse, faint- ness or syncope is said to have taken place. Functional Derangement. An expression employed to define a class of disorders, as yet very obscure in their nature, in which the organs of the body are moved to manifestations of disease without being themselves actually changed in structure. The affected organs may seem, to all appearances and to all present modes of physical investigation, 42 GENERAL DISEASES AFFECTING MANKIND. to be healthy, but may, nevertheless, be performing their duties in an imperfect or irregular manner. They often, under these circumstances, regain their natural powers altogether. When an organ itself seemingly perfect and capable of regaining its orderly life and action is under this irregular action, it is said to be func- tionally disturbed, and the phenomena of disease caused by its aberrations are held to be functional disorders, as distinct from positive organic diseases. The distinction is, as a rule, vital in its meaning, inasmuch as the most alarming symptoms of a func- tional character may be of lesser moment than a comparatively light series of symptoms springing from actual organic change. The skilful physician is, therefore, ever on the watch to detect the difference between symptoms dependent on functional aber- rations and symptoms dependent on organic changes. Tlie func- tional disorders are, generally, of nervous origin, and are depen- dent on a disturbance of the nervous atmosphere or nervous function of the organ affected, not on structural disease of the organ itself. The derangement is as from a storm passing through the structure and temporarily modifying its action, not from phys- ical change of the structure. Debility. The College authorities define the technical application of the term debility as intending to express an " uniform exhaustion of all the organs of the body without specific disease." The defini- tion is, perhaps, as complete as can be supplied in our present state of knowledge, and many deaths are registered every year in this and other countries as from debility. The term is more commonly used to express the intermediate condition between an attack of acute or exhausting disease and the return to the natural state. Debility is sometimes defined as asthenia. Coma. Literally a profound or deep sleep. A condition of disease in which the body lies unconscious, insensible to all external impres- sions, and incapable of being roused from the torpor. Asphyxia. Suffocation. A condition in which the respiration is checked, — as during strangulation, — and the body is rendered cold and CONDITIONS OF DISEASE. 43 dark from obstructed aeration of the blood. By asphyxia, coma, asthenia, or syncope, death ordinarily supervenes. ll^ATURAL OR SeNILE DeCAY. Natural or senile decay is that condition in which the bodil}^ powers pass into helplessness and the mental powers into second childishness and mere oblivion. The condition is one in which the elastic structures of all the organs of the body have lost much of their resilience ; the muscular structures have shrunken ; the cartilao;es have been transformed into bone : the bones have be- come condensed ; the skin has shrivelled and become dry ; the hair has become gray or has fallen off ; the gums have atrophied ; the teeth have fallen out or decayed ; and the cells of the nervous system, locked up, as it were, in the now firm connective tissue, or nerve cement, are all but dead to motion. In this state death at last takes place as in a sleep, the one only natural mode of dis- solution. CHAPTER III. GENERAL DISEASES RUimiNG A DEFINITE COURSE. 1. THE GREAT PLAGUES. In the nomenclature of tlie Royal College of Physicians, on the lines of which, with few exceptions, I, as a rule, proceed, the general diseases that affect mankind, as apart from the local con- ditions of disease, are divided into two grand classes : namely, into diseases which run a definite course, and take, some of them, an epidemic or spreading character : and into diseases which are not spreading, but are of a constitutional and often of an heredi- tary nature. I propose in the present chapter to state the diseases of the first of these classes, the epidemics or great plagues. They are defined, authoritatively, as follows : — - Diseases " which appear to involve a morbid condition of the blood ; which, for the most part, but not all of them, run a definite course ; are attended with fever, and frequently with eruptions on the skin ; are more oi- less readily communicable from person to person ; and possess the singular and important property of generally protecting those who suffer them from a second attack." These diseases have each a period, between the time when they are first contracted and the first appearance of eruption or other symptom, which is called the period of incuba- tion. Some of these diseases have also what is called a critical day or crisis, upon which the patient either begins to succumb or commences to recover. The diseases of this class are thirty-seven in number. They are, emphatically, the great plagues. They are all dependent for their development on some particular poisonous agent which is generally communicable from the affected to other susceptible persons. DISEASES RUNNHSTG A DEFINITE COURSE. 45 SlVIALL-POX. YaEIOLA. An extremely contagions affection, marked by an ernption over the body containing matter or pus, and called pustules. The period of incubation is twelve days. The crisis is about the eighth day of eruption, but is not very definite. Varieties. Distinct. — Each pustule of the eruption distinct. Co7ifl2ient.— Pustules very numerous and running together over the surface of the body. 8emi-confiue7it. — Pustules running together in parts. Abortive, varicelloid. — Minor small-pox. Few pustules, and those little more than vesicles, — little bladders, — containing wa- tery fluid. Petechial. — Called, vulgarly, black or putrid small-pox, dark blood being effused into the pustules. Ileinorr'hagic. — Small-pox with blood in the pustules, with a tendency to bleeding from the mucous membrane of the intes- tinal canal. Corymbose. — The disease with the pustules running in clusters like bunches of grapes. Cow-pox. Yaccina. A disease induced in the human subject by the process of vac- cination. A modified form of small-pox, in which a cow-pox vesicle on the udder of a cow or heifer is the common original source of the infecting matter. A disease attended, as a rule, with no further eruption than the vesicle or pustule at the points where the matter is inoculated ; communicable hj inoculation, but not otherwise ; mild in its course, and yet, generally speaking, protective against small-pox. The period of incubation is from two to three days. The crisis is about the eighth day. Chicken-pox. Yaricella. A disease attended, like the small-pox, with a vesicular erup- tion, which may become pustular. The spots of the eruption usually lie far apart, and are confined to the trunk of the body. In bad forms varicella so closely resembles small-pox as to re- quire skilled medical knowledge to distinguish it. The disease is 46 GENEEAIi DISEASES AFFECTING MANKIND. attended with some fever, but is hardly ever fatal, and rarelv leaves pits or marks on the body. It is not prevented by vaccina- tion, and it is not protective against small-pox. It is also doubt- ful whether small-pox is protective against it. It is not com- municable by inoculation. The period of incubation is from ten to twelve days. The crisis is about the fifth day of the eruption. Measles. Mojrbilli. A common and well-known eruptive contagious affection com- mon to the young, and occurring in all parts of the world into which it may be imported. The disease is attended with a gen- eral red measly eruption and fever, preceded by symptoms of catarrh or cold in the eyes and nose. Under conditions favorable for recovery it is not generally fatal, but it becomes very fatal under unfavorable conditions. The period of incubation is from ten to fourteen days. The crisis, — not very definite, — is about the fourth day of the eruption. German ■ Measles. Rotiieln. Rubeola. A contagious mild disease, attended with slight fever, sore throat and measly oval-shaped red eruption. The affection, which usually commences with catarrh of the nose and eyes, pre- sents mixed symptoms of measles and of scarlatina. Tlie period of incubation is from four to six days. The crisis is on the second or third day of the eruption. Scarlet Fevek. Febris rubra. A very contagious and often fatal disease, marked by a uni- versal red rash over the body with high fever, strawberry tongue, and with redness and, sometimes, ulceration of the throat. The period of incubation is usually considered six to eight days, but may be not moi-e than as many hours. Tlie natural crisis is about the fifth day of the eruption, but is often prolonged by complications. Varieties. Sim/pie Scarlet Fever. — Commonly called Scarlatina. The rash on the body is well marked, and the throat is very red but is not ulcerated. Anginose Scai^let Fever'. — A more severe type ; the throat is DISEASES RUJSTJSriNG A DEFINITE COURSE. 47 red, swollen, and ulcerated, with formation, sometimes, of abscess in the neck. Malignant Scarlet Fever. — Scarlet fever in its most rapid and fatal form. In this variety the throat becomes covered with a slough from quick decomposition of the mucous membrane ; the eruption on the skin is dark; the fever intense; the external glands of the throat are much enlarged ; and, the prostration, sudden and severe, is attended often with convulsive movements of the limbs, with insensibility, coma and death. As a general rule the malignant form of scarlet fever is developed from the onset, and it may be said, generally, of each variety that, with rare exceptions, each maintains its own character and runs its own course. This is true of epidemics as of individual instances of the disease. At the same time all the varieties are contagious, and one may be caught from the other, the severe form from the milder form, the milder form from the severe, or the like from the like. Constitutional 23eculiarity seems to determine the type which the disease will assume. Sub-Varieties. Doitbtftd Scarlet Fever. Rosalia Idiojoathica. — A disease described originally in my Clinical Essays, in whicli a scarlatmal eruption occurs with some fever, soreness of the throat, and strawberry-like tongue. The disease is transient in character, does not spread, and apparently is not contagious. The period of incubation is probably from one to two days. The crisis is on the second day of the eruption. The disease is not known to l)e fatal. Rheumatic Scarlet Fever. — A mixed condition of rheumatic and scarlet fevers, — also defined in the Clinical Essays, — in whicli, with the symptoms either of simple or of anginose scarlet fever, there is acute rheumatism of the joints. The scarlatinal element of the disease is contagious. The period of incubation is the same as of scarlet fever. The crisis is rendered indefinite by the frequent recurrence of rheumatic complications. Dengue. Dandy Fever. A febrile contagious disease, attended witli rheumatic symp- toms and with an eruption resembling measles. It occurs in tlie West Indies and in some other hot or tropical climates. The 48 GEISTEEAL DISEASES AFFECTIISTG MAK-KIISTD. period of incubation is short, probably not more than three days. The crisis is rendered indefinite by tlie recurrence of rlieumatic symptoms. CEEEBEO-SPrNTAL OR TETANOID FeVEE. Cerebro-spinal fever is sometimes called malignant purpuric fever; or epidemic cerebro-spinal meningitis. More recently it has been named by Dr. Rosenstein, and as I venture to think most correctly, tetanoid fever. It has been known to occur in England. It is marked by a dark eruption, intense fever, deli- rium, and tetanic spasms. It is very fatal. The periods of in- cubation and of crisis are not determined. It is probably not contagious. Typhus Fevee. A continued fever attended with a dark mottled rash on the body, great nervous prostration and delirium, but without any specific affection of the bowels. The disease is very contagious, and very fatal. The period of incubation is, in most cases, from ten to twelve days. The crisis is about the fourteenth day after the eruption. Typhoid oe Enteeic Fevee. Typhoid or enteric fever, called also gastro-enteric, — owing to the circumstance that in it the stomach and intestines are seats of disease, — is marked by a rose-colored rash on the skin, high fever, delirium, and much disturbance of the bowels. Until com- paratively modern days typhus and typhoid fevers were con- founded together as one disease, in the same way as measles and scarlet fever once were. Typhoid is now known as a distinct af- fection, and is distinguished from typhus by the occurrence of special intestinal derangement as well as by the eruption. It is not so readily contagious as typhus. The period of incubation ranges from six to fourteen days. The crisis is about the four- teenth day after the eruption. Typhoid, owing to its common connection with bad drainage, has received the vulgar but expres- sive name of " drain or cesspool fever." Relapsing oe Famine Fevee. A fever which breaks out in ill-fed, badly-housed, or rather closely-housed communities. In some respects it resembles ty- DISEASES RUNNING A DEFINITE COURSE. 49 plius, but differs in the absence of an eruption and in the circum- stance that the onset is direct, i.e., without preliminary signs, and that the febrile attacks, usually of short though severe duration, pass away leaving the person comparatively well. After an in- terval of about seven days the attacks recur, the relapse taking place, it may be, four and even five times. The disease is less fatal than typhus fever, but recovery from it is often much more prolonged. It is extremely communicable, and attacks those who are well fed if they be exposed to its influence. It is connected with famine in its origin, but seems also to require impure air for its development. The period of incubation is from five to seven days. The period of crisis is indefinite. Febeicula. A minor fever, in which the person affected is for three or four days feverish without showing any signs of eruption on the skin or any indications of inflammatory disease, recovery being rapid and complete. The disease can hardly be called communi- cable, though it may be epidemic. The periods of incubation and of crisis are indefinite. Continued Fever. Simple fever, without eruption, inflammation, or other specific sign that would link it with any of the specifically contagious fe- brile diseases. It differs from simple febricula by its longer con- tinuance. In past days physicians included many of the now well-defined fevers under the term continued fever, making it almost a general term to describe a fever that was of lonac dura- tion. The periods of incubation and of crisis are undefined. Yellow Fever. "A malignant epidemic fever, usually continued, — but some- times assuming a paroxj'smal type, — characterized by yellowness of tlie skin, and accompanied, in the severest cases, by black vomit, hemorrhage from the stomach, nose and mouth." This is the terse description of the disease by the Royal College. It is peculiar to tropical climates, and does not spread in a tempera- ture below 72° F. It is extremely fatal, perhaps communicable, and decidedly epidemic. The period of incubation is indefinite, 4 50 GENERAL DISEASES AFFECTING MANKIND. but probably not more than four days. The period of crisis is from six to eight days. Plague. Plague is defined as "a specific fever, attended with bubo, 'boil,' of the inguinal glands of the groin," and other glands, and "occasionally with carbuncles." It is the pest or pestilentia, black death, of the old writers, and at one period it invaded this country, though it has always been chiefly confined to Eastern countries. It is easily communicable and extremely fatal. The periods of incubation and of crisis are very short, two to eight days, but have not been definitely assigned. Ague. Intermittent Fevek. A disease attended with paroxysms of severe fever, followed by intermissions of the febrile condition during which the suf- ferer, though he may be enfeebled, is comparatively well. The paroxysms are signalized by three stages, called respectively the hot stage, in which the fever may rise to 105° F. ; the sweating stage, in the course of Mdiich, owing to the profuse loss of water from the body, the fever is reduced and the temperature brought down ; the cold stage, in which the body is reduced in temperature to the natural 98.4°, and sometimes to a little below what is nat- ural. The paroxysms thus developed recur with considerable regularity, not in all cases in the same order of time, but in the same case after the same order. Thus, in one case the paroxysm will recur daily, in another every third day, in another every fourth day, — in regular order. This has led to the enumeration of sev- eral varieties of the disease. Quotidian, where the fit occurs every twenty-four liours while the disease lasts. Tertian, where the fit occurs every forty-eight hours while the disease lasts. Quartan, where the fit occurs every seventy-two hours while the disease lasts. Irregular, in which the paroxysms are not distinctly periodi- cal. Under this head the College includes the periodical neural- gia which is called brow ague. In quotidian ague, the fit is most prolonged ; it may last for sixteen hours during the three stages. In the tertian variety the DISEASES EUNNIISTG A DEEHSTITE COURSE. 51 fit is of shorter dnration, ten hours. In the quartan tlie fit is of shorter duration still, namely, six hours. Ague was once a com- mon disease in England, and even in London. The great Lord Protector, Oliver Cromwell, succumbed to it, and in the time of His Higlmess and long afterwards the physicians had much practice from it. It declined in this country from two causes, from the drainage of fenny and marshy districts, and from the introduction of Jesuit's bark, — cinchona, — for its treatment. The disease seems to be entirely due to some miasmatic marshy poison which, disposed of lai'gely during the paroxysm, re-forms in the bod}'' in the course of the interval of remission and reproduces the attack. The period of incubation is from one to fourteen days. The crisis in each fit is defined above. The general crisis is un- determined. Remittent Fever. A fever occurring occasionally in this country, but more fre- quently in warmer climates, in which, with paroxysmal attacks of high fever, as in ague, — but at less regular intervals, — there is a yellowness of the skin something like that which characterizes yellow fever. The disease in temperate climates is sometimes called " bilious remittent," and in tropical climates malignant re- mittent fever. It is rarely fatal in the milder forms of it, and is of local or endemic character, depending upon some malarious cause. It was remarked to me thirty years ago by an old prac- titioner, who in the fen districts had, in his early life, seen much of ague, that on cessation of that disease bilious remittent fever, which had also been common, remained much longer as a local disease. There are no definite periods of incubation nor of crisis. Simple Cholera. Cholera, or relaxation of the boAvels, with or without vomit- ing. Tlie disease occurs in this and in other countries with a cer- tain degree of seasonal regularity, and is marked by a copious loss of fluid from the intestinal canal, with, in bad cases, cramps in the bowels and limbs and coldness of the body, followed, during recovery, by reactive fever. The affection, which is not conta- gious, occurs at times epidemically, and -is not infrequently fatal. From its common appearance in the autumn, it is sometimes called autumnal cholera. It is usually excited by indulgence in 52 GENERAL DISEASES AFFECTING MANKIND. some form of indigestible foods, siicli as unripe fruits, but there is, at the same time, a presiding influence promoting the tendency, which is probably atmospheric, but which is not as yet defined by scientific research. The period of incubation is usually short, not more than a few hours. There is no defined period of crisis. Malignant Cholera. Specifically, the cholera. Called also Asiatic cholera, serous cholera, spasmodic cholera, and defined, graphically, by the Koyal College as '' an epidemic disease, characterized by vomiting and purging, with evacuations like rice water, accompanied by cramps, and resulting in suppression of urine and collapse." The disease is of Eastern origin, but has travelled over the temperate, and to some extent into the arctic zone. It is apparently communicable, seems to follow the courses of great rivers, and, according to the modern view, first advanced by the late Dr. Snow, the poison of it is conveyed mainly by water. It is extremely fatal, and at- tacks people of all ages, but men more frequently than women. Occasionally, it takes a sporadic form, breaking out, that is to say, in scattered places and then ceasing, without pursuing a def- inite course. The period of incubation is short, often not exceed- ing five or six hours. The crisis is indefinite. DiPHTHEEIA. A disease which in many respects is allied to croup, but which differs from that affection in that it is of contagious character. It is attended with fever, which usually appears to arise from cold and sore throat, but which ends in a specific aifection of the throat. In bad cases the windpipe and air-passages become cov- ered with a tough membranous exudation, which may separate like a piece of leather from the mucous surface. Diphtheria is most frequent and fatal in children, but it attacks persons of adolescent and middle life, and it is extremely fatal. There are some persons who seem more susceptible than others to its influ- ence, and there can be no doubt that the tendency to it runs in particular families. Although manifesting itself by the most marked local signs in the throat, it is a general disease in Avhich there is a tendency to separation and coagulation of the fibrinous part of the blood. It is often rendered rapidly fatal by the sepa- ration and coagulation of the fibrine of the blood within the heart. DISEASES EUNNING A DEFINITE COUKSE. 53 The period of incubation, according to my observation, is from three to six days. The crisis is about the iif tli day. Dirplitheritic Paralysis. — Diphtheria is sometimes followed by paralysis of some of the muscles of the body. The palsy affects mostly the muscles used in swallowing, but it sometimes extends to the muscles of the neck, and even to those of the limbs. I have seen it once extend so as to include the whole of the mus- cles of the riglit side of the body. It is, I believe, due to a pro- cess of coagulation in the nervous fibres. As a rule persons of fair general health recover from it under conditions favorable for recovery. WlIOOPING-COUGH OR PeKTUSSIS. A disease beginning as a cold and attended with spasmodic cough coming on in paroxysms and often, by the violence of the cough, causing disease of the lungs. It is attended at first with some febrile disturbance, and in all stages it is communicable. At the onset it is apparently confined to irritation in or near the glottis,^ — the opening into the windpipe. The period of incubation is from four to six days. The crisis is indefinite, but the disease rarely lasts less than five weeks. Mumps. An epidemic and probably a communicable disease, affecting the salivary glands. The glands are much swollen and inflamed, and there is a general feverish condition. It is rarely a fatal disease, but is often severely painful. The period of incubation is about fourteen days ; that of crisis about four days. Influp:kza. A suddenly developed and intensely sevei*e cold or catarrh, hence sometimes called " lightning catarrh," attended with an extreme nervous depression and violent cough. It is often epi- demic or spreading, but is not proved to be contagious. Some- times it suddenly affects a whole community, and in many epidemic visitations has been extremely fatal. The period of incubation is a few hours. The crisis is indefinite. 54 GENEEAL DISEASES AFFECTING MANKIND. Glandebs. A contagious disease commencing as a specific inflammation usually of the mucous membrane of tlie nose and throat, and originating in contagion derived from a glandered horse. In the horse the poisonous matter comes from the mucous secretion of the nostrils, but it may enter the human subject by a wound. The disease is contagious from one affected person to another. The period of incubation is short, from two to four days. The crisis is also short, from four to seven days. Faect. A form of disease affecting man, caused by contagious mate- rial passing from a horse, either under glanders or farc}^, to man. It is a specific inflammation of the skin and absorbent vessels and glands. The disease is sometimes accompanied by swellings called either farcy buds or farcy buttons. It is communicable from the matter secreted from the sores. The period of incuba- tion is about four days. The crisis is indefinite. Gkease. Equinia mitis. A form of local pustular disease produced by communication of contagious matter from a horse suffering from what is called " grease," — inflammation of the sebaceous or grease glands, — to man. The period of incubation is four days, and of crisis or maturation of pustules, eight days. IVEalignant Pustule. Chaebon. Another serioiTS form of disease communicated by the trans- mission of contagion derived from cattle suffering from malignant pustule. The disease commences as a small bladder or vesicle on the skin, and spreads as a gangrenous inflammation which becomes hard and extremely offensive. It is exceedingly fatal. The period of incubation is limited from ten to twenty hom-s. The crisis is indefinite. Phagedena. Phagedena is a condition of wounds in which a slough, — a decomposing or putrefactive surface, — attacks wounds or ulcers and spreads from them. The disease is usually produced in DISEASES RUNNING A DEFINITE COURSE. 55 wounds affecting persons in a bad atmosphere. The periods of incubation and of crisis are indefinite. Sloughing Phagedena. A more severe form of phagedena, in the progress of which the putrefactive destructive change not only extends on the surface of the body, but goes deep into the tissues, involving the cellular or connective tissue beneath the skin. The periods of incubation and of crisis is indefinite. Hospital Gangrene. A form of " sloughing phagedena occurring endemically, i.e., locally, in hospitals." The disease is developed in hospitals charged with impure air. The periods of incubation and of cri- sis are indefinite. Erysipelas. St. Anthony's Tire, A specific inflammation of the skin, of a contagious character and tending to spread over the surface of the skin. The inflam- mation sometimes springs up spontaneously, affecting the head and face more frequently than other parts of the body. It is apt to occur from wounds and after surgical operations. It may become epidemic. The period of incubation is about four days ; that of crisis is indefinite. Varieties. SiTuple. — In which the inflammation is entirely superficial or confined to the surface of the skin. PJdegmonous. — In which the inflammation extends below the skin into the cellular or connective structure. Diffuse. — In which the inflammation, extending into the cel- lular tissue beneath the skin, diffuses through the cellular tissue. Pyemia. Suppurative Fever. x\n acute febrile affection resulting in formation of purulent matter and of abscess in the viscera and other parts of the body. Pyaemia follows on wounds, surgical operations, and childbirtli. Tlie period of incubation is from four to eight days. The crisis is indefinite. 56 GENEEAL DISEASES AFFECTING MANKIND. PUERPEKAL FeVEK. ChILDBED FeVEE. An acute form of contagious fever occurring in women dur- ing or after childbirth, usually a few days after childbirth. The poison of this fever may be conmiunicated by those who attend her to the childbed woman, and it is so conveyed in many instances. But the disease may probably originate from other poisonous secretions than the secretion derived from a previous specific case. Thus it may occur from contagion of scarlet fever or erysipelas. The periods of incubation and of crisis are un- certain. PuERPEEAii Ephemera. "Weed. A fever, sometimes called milk-fever, usually occurring in women after childbirth. It is probably not contagious, but may be of malarious origin. The secretion of milk is suppressed, and fever of a short remittent kind follows. The period of incuba- tion is from three to seven days. The crisis is uncertain. Syphilis. A contagious disease called sometimes speciJiG disease, affect- ing both sexes, and produced by the inoculation of a poison known as a " venereal " poison. The period of incubation is variable, forty days being the most common period. The crisis is indefinite. Varieties. Primary syphilis. — In which the disease is limited, in effect, to the part inoculated with the poison and to the lymphatic ves- sels and glands, — glands of the groin, — connected with it. Sub-varieties of primary syphilis : — • (1) Where the part inoculated is swollen and hard, and the glands affected are swollen and indurated ; indurated boil, or bubo. (2) Where the part inoculated is swollen and soft, and the glands swollen and suppurating ; suppurating boil, or bubo. (3) Where the part inoculated is a spreading sore ; phagedenic sore. (4) Where the part inoculated is sloughing or superficially mortifying ; sloughing sore. DISEASES BUNKING A DEFINITE COURSE. 57 Secondary syphilis. — In which the disease extending beyond the part inocuhxted affects the system generally, causing soreness of the throat, neuralgic and rheumatic pains in the limbs, copper- colored eruption on the skin, and general cachexia. Tertiary syjjhilis. — In which the disease, without new inocu- lation, and after apparent recovery from secondary symptoms, recurs in the secondary form. Hereditary syj)kilis. — In which the disease appears in the child in tlie constitutional form, from taint communicated by its parent ; one or other of its parents having been affected with the disease or having inherited it. GONOKEHCEA. A contagious disease affecting both sexes, and consisting of a suppurative inflammation, yielding a specific poisonous secretion, and sometimes accompanied with swelling in the groin. The disease has an acute and chronic stage, the chronic or prolonged stage being commonly called gleet. The period of incubation varies from three to nine days. The crisis is indefinite. Gonor.rhoeal inflammation, when it is present, is apt to produce three specific mflammations, designated respectively : Gonorrheal Ojyhtkalmia, a specific inflammation of the con- junctiva or mucous covering of the eyeball. Gonorrhtjial Iritis, a specific inflammation of the iris or cur- tain of the eyeball. Gonorrhmal Hheumatism, a specific rheumatic fever occurring during the presence of gonorrhoea. Hydkophobia. Literally a disease marked by fear of water, hudor, water, and jphohos, fear. Actually, one of the communicable diseases depend- ing upon a specific poison secreted by certain animals, the dog particularly, while in a state of rabies, fury. Both terms, hydro- phobia and rabies, are unfortunate. As a rule the disease is com- municated by the bite of the rabid animal, the poison being in the saliva of the animal, and the wound made in the person bitten being the receiving surface. The symptoms are those of painful dread on hearing the motion of water and otlier similar sounds ; frenzied terror ; difficulty of swallowing ; convulsions 58 GENERAL DISEASES AFFECTING MANKIND. proceeding to tetanus ; copious secretions of saliva ; and, death from exhaustion or from spasmodic seizure of the muscles of respiration. The period of incubation varies. The symptoms may appear within a few days or even a few hours after the inoc- ulation, but the time is varied from those short intervals to the longer one of weeks and months, and in rare instances of two and even three years. The crisis is from the thu'd to the fourth day after the first appearance of the symptoms. CHAPTEE IV. GENERAL DISEASES OF CONSTITUTIONAL TYPE. The diseases enumerated in the nomenclature of disease, under the second section or division of General Diseases, are dis- tinguished from those of the first division bj their longer per- sistence, their possible recurrence in the same person, and their constitutional and hereditary character. These types of disease are defined in the nomenclature of the Koyal College as : — " Diseases for the most part which are apt to invade different parts of the same l)ody simultaneously or in succession. They are sometimes spoken of as constitutional diseases, and they often manifest a tendency to transmission by inheritance." The diseases may be described in the following order. Acute Rheumatism. A specific disease, attended with fever and characterized by inflammation of the fibrous tissues surrounding the joints, but M'ithout tendency to the formation of matter. Many joints may be affected in the course of an attack at the same time or in suc- cession. Acute rheumatism is attended with a free secretion of acid fluid from the skin, the acid being of the kind known as lactic. In my experimental researches I have shown that this acid has the power of producing the symptoms of the disease. Rheu- matic disease of the heart is a common result of acute rheumatic fever. The affection is hereditary. Varieties of Rheumatism. Suhacute Rlieuniatism. — A less acute form of the disease, but attended usually with some fever and much pain. Gonorrhoaal Eheumatism. — A specific form of acute rheuma- 60 GENERAL DISEASES AEEECTING MANKIND, tism, often very severe, and attended with severe febrile disturb- ance and with pain and swelling in the joints. A disease con- nected with and probably dependent on the specific disease which precedes its occurrence. Synovial Mheumatism. — Rheumatism of the joints with ac- cumulation of serous or watery fluid in the synovial sacs or in- vesting membranous pouches of the joints in which the lubricat- ing synovial fluid is secreted. The disease is attended with much local swelling of the joints and pain, but with less inflammation and fever than occurs in acute rheumatism. Muscular Rheumatism. — A form of rheumatism affecting the sheaths, or fibrous coverings of muscles, and giving rise to pain, increased greatly by motion, throughout the muscular structures. There are two sub-varieties of muscular rheumatism : — Lumbago, or rheumatism of the muscles of the back. Stiff neck, or rheumatism of the muscles of the neck. Chronic lihetmiatism. — Kheumatism in which the pain is con- tinued chiefly in joints, and attended with " stiffness and swelling of the various affected joints," and with little or no fever. Gout. Acute Gout. "A specific febrile disorder, characterized by inflammation without suppuration " — in other words, without the formation in the part affected of matter or pus — " but with considerable red- ness of the affected joints, chiefly of the hands and feet, and especially of the great toe. The disease is attended with excess of uric acid in the blood." Varieties of Gout. Chronic Gout. — A disease marked by a persistent gouty con- dition, with the joints often permanently enlarged from deposit of the urate of soda. Goutij Synovitis. — Gout attacking the synovial, or lining mem- brane of the joints. Chronic Rheumatic Arthritis. — "An affection characterized by pain, stiffness, and deformity of one or more of the joints, as- sociated with deposition of new bone around them." This affec- tion is sometimes confounded with pure chronic gouty disease. DISEASES OF CONSTITUTIONAL TYPE. 61 Cancer. Malignant Disease. " A deposit or growth that tends to spread indefinitely into the surronnding structures, and in the course of the lymphatics in the part of the body affected, and to reproduce itself in remote parts of the body." Yarieties of Cancel'. Schirrus. — Hard cancer. A cancerous swelling, hard at first and then ulcerating. Schirrus often affects the breast in the female. Medullary. — Soft cancer. A cancerous tumor, frequently of rapid growth. It often becomes fungoid and easily bleeds. Epithelial. Caiicroid. — Surface cancer. A cancer occurring superficially, and ulcerating over a large surface from the point where it commences. Melanotic Cancer. Melanosis. — Dark cancer. A cancerous growth with deposition in it of black pigment. Osteoid. — Cancer commencing in bone, and followed, as a rule, by similar development in other organs of tlie body. Villous. — Cancer of mucous membrane covered by villi or fine projecting mucous filaments. Colloid. " A new growth, a great part of which is formed of trans- parent gelatinous substance," often attaining a large size. Colloid is doubtfully ranked as malignant. Tdmoks. Simple Tumors or Swelllngs. The term tumor or simple tumor is applied to a swelling caused by a growth which is not cancerous or malignant. Such growth is sometimes called " benign," or non-malignant. Varieties of Tumors. Fihrous tumor. — A circumscribed growth of fibrous tissue, usually firm and of slow development. Fihro-cellular. — A circumscribed growth of mixed fibrous and cellular tissue. Fihro-nucleated. — A growth of fibrous tissue containing elon- gated nuclei. 62 GENEEAL DISEASES AFFECTIJSTG MANKIND. Fihro-plastic. — A rapidlj-growing nucleated cellular growth, the cells being fusiform, spindle shaped. Myeloid. — A growth of red tint, containing many nucleated cells, and commencing, generally, in the ends of bones. Fatty. — Sometimes called Lipoma. — A growth composed of adipose or fatty tissue. Osseous. — A growth of bone called sometimes exostosis, and presenting several sub-varieties, as ivory, or hard and smooth ; — cancellated or porous ; and diffused or spreading. Cartilaginous, sometimes called JEnchondroma. — A growth affecting cartilage or cartilaginous structure. Fihro-cartila-ginous. — A growth composed of fibrous and car- tilaginous elements. Glandular. — A growth occurring near to a gland and, to some extent, resembling a gland in structure. Sometimes called Ade- nocele. Vascular. — A growth composed lai'gely of blood-vessels, but increasing slowly. Nc&dus. — A vascular growth developing upon or below the skin, and when upon the skin assuming a round or strawberry- like character. Diffused over a considerable surface of the skin, a nsevus is called, vulgarly, " port- wine mark " or " mother's mark." Sebaceous. — A gi'owth containing a fatty suet-like material, and often called a wen. Cholesteatoma. — A growth containing a fatty substance re- sembling cholesterine. Molluscum. — A firm dermoid growth connected with the hair follicles and resembling somewhat the bodies of molluscs. The growths attain sometimes a large size and have a pedicle or stalk. Warts. — The hard, rough, vegetative-like structures occurring on the skin. Cheloid. — A hard growth on the skin. Is often developed on a cicatrix or healed wound or sore. Moles. — Irregular raised spots on the skin containing black pigment. Cysts. Cysts, — often also called wens, — are hollow growths, more or less firm, containing some substance within them. The contained DISEASES OF CONSTITUTIOlSrAL TYPE. 63 substance varies, and so gives rise to modifications of cj-sts. Se- rous cjsts contain watery or serous fluid. Synovial cysts, situated near joints, contain synovial fluid. JSwsm are the little swellings which occur near to joints, as at the back of the wrist. In addi- tion to these there are also muGous cysts ; supjyurating cysts ; sanguineous cysts, — called by the vulgar blood-warts ; — hemor- rhagic i aneurismal ; oily; gelatinous; convpound ov prolifer- ous / complex / cretaceous or dermoid ; and dentigerous cysts. Lupus. 'Eoia me Tangere. " A spreading tuberculous inflammation of the skin, usually of the face, tending to destructive ulceration." There are two varie- ties : — Chronic lupus ; fixed, or not spreading. Lupus excedens / extending or spreading lupus. Rodent Ulcer. A gnawing ulcer, or destructive ulceration going very deeply into the tissues without previous hardness, ulceration, or constitu- tional affection. The appearance is as if the tissues had been bitten or nibbled out from the surface. Leprosy. The Elephantiasis of the Greeks. A disease of the skin, con- sisting of dark-red swellings or tubercles, with a rougli and raised state of the skin generally. The affection is attended with hoarse- ness of the voice ; with a foetid discharge from the nose; andM'ith ulcerations on the surface of the body. Scrofula. A common constitutional disease, showing itself, general!}^, in symptoms of physical weakness of the body, with external swell- ings of the glands which often end in suppuration, — formation of matter. In some instances there is a deposit of tuberculous mat- ter in different structures or organs of the body, especially in the lungs and in the mesenteric glands. To this condition or ten- dency of the body, the term scrofulous diathesis has been applied. There are two varieties of scrofula. Scrofula with tuhercle. Scrofula without tubercle. 64 GEIfEEAL DISEASES AFFECTINa MANKIND. There are also several forms of scrofulous affection character- ized bj their position in relation to the organs of the body that are attacked bj the disease. TVhen tubercular deposit, the result of the scrofulous diathesis or constitution, is on the coverings or meninges of the brain, with inflammation, tubercular meningitis is said to be present ; when on the bag or covering of the heart, tuhercular jjei'icarditis is the name applied ; when the deposit is in the lungs, consunvption, ov j)ht?dsis j^ulmonalis, is the disease; when deposit occurs of a miliary or millet-seed character on the surfaces of the body, acute miliary tuberculosis is the name adopted; when the deposit is in the mesenteric glands, — the glands of the mesentery, or fold of membrane which connects the small intestine with the posterior wail of the abdomen, — memn- terio disease, or Tabes mesenterica {tahes, wasting), is the name of the disease ; when the deposit is on the peritoneum, with inflam- mation, tuhercular ijeritonitis is the local affection. KlCKETS. A disease briefly and sharply defined by the College, as — " A constitutional disease of early childhood, manifested by curvature of the shafts of the long bones and enlargement of their cancel- lous extremities." The disease arises fi-om a deficiency of earthy- matter in the bones. Ceetikism. A disease equally well epitomized as — "A condition of im- perfect development and deformity of the whole body, especially of the head, occurring in the valleys of certain mountainous dis- tricts, and attended by feebleness or absence of the mental quali- ties and special senses, and often accompanied M'ith goitre." There are two varieties of cretinism. Complete cretinism : — " Characterized by idiocy, deaf dumb- ness, deficiency of general sensibility, and absence of reproductive power." iTWomplete cretinism : — Or '* curable cretinism ; a degree of cretinism in which the mental faculties, though limited, are capa- ble of development ; the head is well formed and erect ; and the special senses, the faculty of speech, and the reproductive powers are present." DISEASES OF CONSTITUTIOIS^AL TYPE. 65 Diabetes. Diabetes Mellitus. A disease in wliicli there is excessive discharge of fluid from the kidneys, and in whicli ghicose, or grape-sngar, is produced in the body in large quantity, and to whicli the profuse eliniination is due. The urine contains grape-sugar in excess. The exhaus- tion which follows the loss of fluid is often accompanied by other systemic changes, due to the presence of sugar in the other secre- tions and in the blood, and to the modifications of nutrition which thereby are effected. Opacity of the crystalline lens, — diabetic cataract, — is, occasionally, one of these modifications of structure ; shrinking of the structure of the brain is another ; a peculiar type of pneuniouia is a third. Diabetes commonly proves fatal. It is primarily due to changes commencing in the nervous system. Yariety. Diabetes Insij)idus : — A form of disease resembling diabetes mellitus in one symptom, viz., the excessive excretion of fluid by the kidney. There is, however, no sugar excreted in this variety of the disease. The affection is more frequent amongst members of the n;ale than of the female sex, and it is less fatal, as it is also less common, than diabetes mellitus. The stage of adoles- cence, and a few years afterwards, are the periods in which the disease is most apt to occnr. The nature, causes, and seats of this malady are indifferently understood. Purpura. Land- Scurvy. A disease in which the surfaces of the body are affected with small purple spots or blotches of effused blood, but without fever. The blood is exceedingly fluid, with a tendency to tlie separation of its fibrine. There are two varieties of purpura. Simple : — In which there is no acute loss or discharge of blood from the body. JTemorrhagic : — In which the mucous surfaces of the body bleed or give out blood. ScuRwv'. SEA-ScuR^^^ A disease allied to purpura, but attended with a spongy con- dition of the jaws and witli " livid patches undej- the skin of con- siderable extent, which are generally harder to the touch than 5 66 GETiEEAL DISEASES AFFECTIXG 3IAXKIXD. the sniTOimding tissues." The disease is common at sea in those who have been long kept on salted provisions and exposed to much hardship. It has been stigmatized as the " great plao'ne of the sea." It is sometimes called " sea-scurvj," as purpura is called " laud-scurvj." Al^JEMIA. A disease attended with paleness of the surface of the body and deficiency of the red corpuscles of the blood. A common disease amongst women and amongst the ill-fed and badly nour- ished of both sexes, in crowded and close localities. Chlorosis. Geeex Sickstess. Another form of ansemia peculiar to women and attended with paleness, tending to a green tint, of the surface of the body. The disease occurs after puberty, but rarely after twenty-five or twenty-six years of age. Beri-beri. Acute Ax^isnc Dropsy. A very serious disease peculiar or endemic to Cej'lon, part of Madras, the Mauritius, and the coast of Malabar. The disease begins with anaemia or bloodlessness, and terminates in general dropsy. It attacks natives and Europeans, but the latter rarely until after nine or ten months' residence in the affected district. It is often very fatal, destroying one in three or four of those attacked by it. It attacks most severely those who indulge in alcoholic drinks, and men more than women. SIJMMABT. The reader, if he shall have followed these pages carefully, has now a concise, but fairly complete view of the general diseases which in this day afflict humanity in civilized communities. He will, I doubt not, wonder with my friend of whom I have before spoken, that the diseases should be so limited in number, and he will expect to be prepared for entirely new phases of diseased action when he comes to the next part of this work, which treats of local diseases, injuries, and poisonings. In this expectation, however, he will be largely deceived. The list of local affections and injuries will, it is true, be a long one ; but it will be found to be made uj), in great part, of repetitions of one or other of the DISEASES OF CONSTITUTIONAL TYPE. 67 several conditions of disease, applied, over and over again, to particular organs and structures ; of repetitions or references to certain of the general diseases which run a regular course ; and of repetitions of some of the diseases which have been classified as of constltutloncd type. In a word, essential as it is to become acquainted with the local diseases and injuries, the reader will iind the fact remaining that, if by preventive art we could con- trol the comparatively small number of conditions and affections which have been detailed in the last three chapters, we could control the local diseases as well as the general, and could prevent the whole, with the exception, always, of that final process of decay which forms the prelude to natural death from ripe old age. BOOK L PART THE SECOND, LOCAL DISEASES. CHAPTER I. THE SEATS OP LOCAL DISEASES. A PHYSIOLOGICAL OUTLINE. In the preceding four chapters we have studied the subject of human diseases as divided into those which are general and those which are local, and in the last two of these chapters we have taken a brief analytical review of the general diseases as a whole. To take into similar review the local diseases is our next task. For the purpose of this book it will be convenient to depart a lit- tle from the plan of the Royal College of Physicians in specify- ing the local affections, in order to condense the narrative and bring the facts of it into close compass. With this intent I shall place the local diseases under nine heads, corresponding to the systems of organs of the body ; — the digestive, circulatory, respiratory, nervous, sensory, glandular and absorbent, muscular, osseous, and membranous. Let me, however, in a brief preliminary manner, first describe these systems. If we could by some sleight of science look physically through a living man and see how all his vital organs work, as we can look into the mechanism of a watch or a timepiece, Ave should discover in the nine grand systems of working organs, some active in their uses, some passive, but all playing important parts in the duties of maintaining or utilizing life. AVe should also discover them to be all bound together for a common object, that of bring- ing the various organs and systems of organs into one organic frame or whole; so that while each system and each organ is to some extent independent of the others, such intimate ties hold them all together, that it is difficult, if not impossible, for one alone to suffer and for the rest to be unaffected. 72 THE SEATS OF LOCAL DISEASES. The Digestive System. In the trunk of the body, we should first observe a tube which the ancients very correctly called the prinice vice, the first ways, and which we moderns call the digestive, or alimentary tube. The tube is truly the first way. It is the canal which receives the aliment out of which itself and the whole of the body is built up. It is the centre from which the body that is to be proceeds, in crude form it is true, but prepared for elaboration. Into this long canal, which, laid out and measured, would, in the adult, be found to be not less than thirty-two feet in length, and which is composed of many divisions, each playing, as we shall see, its own part in digestiv-e work, the food and drink enter. Received here, the drink, if it be solnble, if it be water or a flnid miscible with water, is at once taken up by membranous and vascular ab- sorption into the blood. The food, solid or semi-solid as it enters the mouth, is ground there or masticated, mixed with saliva which helps to fluidify its starchy and fatty parts, and is then swallowed into the stomach. In the stomach this food is digested and churned until its albuminous or flesh-forming structures ai'e brought into solution, and this eft'ected, the prepared fluid is passed into the first part of the intestine below the stomach, the duodenum, where, meeting with the secretions from the liver and pancreas, — the bile and pancreatic juice, — the starchy and fattj^, or heat-producing, portions of it are emulsified, liquefied, and made ready also to be absorbed and further utilized. Thence the prepared nutriment, passing into a longer line of intestinal canal, the jejunum, and ileum, is further digested, and at last is, directly or indirectly, conveyed by two classes of vessels into the circulating blood, and through the blood into all other structures, to become for a time the vei'itable body of the man, — bone, mus- cle, sinew, nerve, eye, ear, heart, vessel, membrane, — everything there is of body. Finally, from that long absorbing portion of the alimentary tube sundry parts of the food that have been taken and are not wanted are passed into the large intestines, — the crecum, colon, and I'ectum, — with gases generated in the process of digestion, and debris of food that could not be digested or applied to the purposes of life. These are all passed on into the larger recepta- A PHYSIOLOGICAL OUTLINE. 73 cle of the intestine to be expelled, as the ejected results of the digestive process. In observing the parts of the digestive system we shonld note various structures and organs, beginning at the lips and extending to the lowest part of the intestinal tube. The canal is lined with the red mucous membrane which we see at the lips, and which, throughout its entire length, is surrounded by two layers of mus- cular fibres, one longitudinal or long, the other circular. These are all enclosed, in some parts, in a strong investing sheath, the stomach and intestines being further invested, in great part, with a delicate serous membi'ane called the peritoneum. The parts of the alimentary system to be observed would be : — {a) the mouth, — into which the saliva is poured, — the tongue, the fauces or back of the throat, the palate, the tivula and tonsils, (b) The pharynx, or dilated poucli at the back of the throat, end- ing in (c) the msoj)hagus or gullet, — the tube extending from the pharynx to the stomach. {(!) The stomach, or first true digesting receptacle, in which the albuminous or flesh-forming foods are transformed during primary digestion into chyme, which is passed through the pylorus, or exit gate of the stomach, into the duode- num, {e) The duodenum, or first portion of the small intestine, into which the liver pours its bile and the pancreas its emulsify- ing juice, and in which the fatty and starchy portions of the food are digested, — secondary digestion, — before being carried into the next small intestines. {/) The small intestmes,, jejumcm and ileum-, in which digestion is completed, and from which the pre- pared food is absorbed into the blood, partly by the veins, — direct absorption, — and partly by the villi or absorbents which line the intestinal surface, and which convey the fluid to the glands of the mesentery, from whence, after elaboration, it may pass into the thoracic duct, and by that cliannel find its way into the veins, and so into the circulating blood, (g) The large intestine, called the colon, for receiving the dehris, the undigested or useless part of food substances, and the gases arising from digestion. The colon springing from a pouch, the ccecuni, situated at the end of the small intestine on the right side, first ascends, and tlien ex- tending across the al)doniinal cavity from right to left, next descends, and at last terminates on the left side in the straight intestine. (A) The straight intestine, the rectum, with the outlet of which the canal is terminated, {i) The peritoneum 74 THE SEATS OF LOCAL DISEASES. or serous membrane of tlie abdominal cavity, in which the stomach, the intestines, and other abdominal organs are in great part infolded, and which lines also the walls of the abdominal cavity. AVithin the canal on the mucous surface at various points we should discover glands or secreting organs. Gastric glands in the stomach, for secreting the gastric juice ; two large external glands, the liver and the pancreas, pouring bile from the liver and pan- creatic juice from the pancreas, into the first part of the small in- testine, or duodenum ; and other smaller glands along the mucous surface of the small intestines. Shall anj local disease, functional or structural, visit this sys- tem of organs, indications of general and local disorder must needs ensue. The old fable of the belly and the members is re- told. Let the alimentary canal fail in any of its duties ; let its salivary juices be inactive ; let its stomachic digestive juices be deficient or inactive ; let its intestinal juices be deficient or inac- tive ; and the balance of supply to the organism will be disturbed. Or let the tube be obstructed, so that food cannot enter the diges- tive apparatus freely ; oi-, entering and being digested, cannot pass on for absorption ; or, passing the absorbing surface, cannot discharge itself ; then, the balance of supply to all parts must be disturbed. Or let the mechanical part of the digestive system fail ; let the mastication be imperfect : let the swallowing be dif- ficult ; let the churning movements of the stomach be enfeebled ; let the transmitting power or motion of the lower parts of the canal be irregular; then the balance of supply of food to all parts must be disturbed. Once more. Let the absorbing portion of this system be in any way impeded, and the balance of supply in all parts must be disturbed. Lastly, let the digestive system, perfect in itself, be overloaded or overcharged, or undercharged, or improperly charged M'ith foods and drinks, and the balance of supply to all parts must be disturbed. If to these facts we attach one more, namely, that by nervous communication the intestinal canal is brought into coranmnion with all the nervous centres in which vital acts, automatic and voluntary, have their seat, we discover how the digestive system, as a system exposed to local diseases, holds a first place for our consideration. It has been called the jprimce vice, the first ways ; it might with almost equal truth be called the first ways of dis- A PHYSIOLOGICAL OUTLINE. 75 ease. Indeed the most learned have not as yet discovered how many diseases take tlieir origin there. The Cieculatoky System. Keeping our minds still intent on studying the construction of tlie body during life, — looking through the man, — we should observe that the fluids prepared by the process of digestion find tlieir entrance into another tubular system by which they are car- ried round the body in two circuits, one large, including all the bodj', the other small, and including only a part. We should see that the fluid which leaves the alimentary organs, white or milky in color, is, in this next system of tubes, of red, or bluish red, color, and that it has become a red, tenacious, and coagulable or clotting fluid which flows from a wound in the body directly a wound is made, and which is called blood. The new supply of this blood, received from the digestive parts, Avould be seen borne along by a series of tubes of a darkish blue color, which, from all parts, head, limbs, trunk, are making for one point, like a river which, springing from several sources, is making for a lake into which it will finally discharge itself. These tubes, as an anatomist would explain them to us, are called veins ; and the point they are making for, in order to give up their currents, is tlie pulsating organ on the left side of the body, lying in the cav- ity of the chest above the stomach, and separated from the cavity holding the stomach by a partly fleshy, partly tendinous parti- tion, the diaphragm or midriff. The beating or pulsating organ disclosed to us we should be told to recognize as the heart. The heart, we should discover, to be formed of four hollow structures, each structure expanding and contracting in perfect rhythmical order. The veins carrying their blood would be observed to pour the blood into the upper small dark cavity on the right side, called the right auricle of the heart. There, being compressed by the contraction of that cavit}', the blood would be seen to be driven into a cavity immediately below it, through a valve, the tricuspid, which placed in the intervening opening would allow it to pass downwards, but would not let it pass back again. Here arrived we should see this lower cavity, called the right ventricle, contract ; the valve, consisting of three segments, rise and close up with a dull sound, so as to let no blood get back into the auri- cle from whence it came ; and the blood itself make its way to 76 THE SEATS OF LOCAL DISEASES. a large vessel springing out of the lower eavity and then move towards two spongj-looking organs, lying ahove the heart, named the lungs. As it passed into this vessel the blood would be seen to push np before it three little flaps of valves, shaped like cres- cents, — the semilunar valves, — and as it filled the vessel the ves- sel would expand for a moment, and afterwards contract, like an india-rubber tube expanding and contracting from fluid pumped through it. The contraction of the vessel on its contained blood would drive down, with a sharp click, the three little crescent- shaped or semilunar valves ; and as by their closure the blood would be prevented getting back into the heart, it would be driven up into the two spongy lungs above. It would enter the lungs dark in color, but, as they moved in breathing, as they ex- panded, the color of the blood would be found to change, and to become of very bright red. Thus changed the blood would be detected leaving the lungs, and by four small vessels going back again to the heart. The four vessels would be found directing their course to another small cavity of the heart at the top of the organ, a cavity lying on the left side, on a level with that cavity on the right side which took in the blood from the veins, and which we understood was the right auricle. This second small cavity, also called an auricle, — the left auricle, — would be seen to be the i-eceptacle of the blood from the lungs. It would be dis- covered filling with I'ed blood from the lungs as its fellow filled with dark blood from the body. It would contract after it had filled, in the same way as its fellow, and at the same moment, but in contracting it would drive its charge into another cavity of the heart Iving beneath it, called the left ventricle. The blood, pass- ino- throuijh the opening from the left auricle to the left ventri- cle, would force open a valve, — the mitral, — composed of two cur- tains which woukl let it enter and fill the left ventricle. Xext, the ventricle would be seen to contract, the curtains of its valves to rise, then close with a dull sound, and the blood, unable to go back into the auricle, would be observed to ascend towards another large tube, which, springing from the ventricle, makes a beautiful arch that stretches three to four inches over the heart from right to left. The blood moved, by tlie contraction beneath, towards tliis vessel, called technically the great aorta or great arterial ves- sel, would be discovered, as before, to lift up three little crescent- shaped valves, — aortic semilunar valves, — as it passed into the A PHYSIOLOGICAL OUTLIJ^E. 77 vessel. Under tlie pressure we slionld now behold the big elastic aortic vessel expand, so that its whole bow or arch is included in the expansion. In an instant its expansion would, however, be followed bj its contraction, the little crescent valves would go down with a short sharp click or sound, and the column of blood, unable to get past the little valves back into the heart, would be carried in the direction of the aorta into the vessels that branch .off from the aorta, in its course over the whole of the vascular system. And now, if we continued to follow that column of blood tlms ejected from the beating heart through the great arterial vessel, we should have to look for it at every portion of the body from head to foot ; for wherever there is a living part of the body the arterial blood will permeate. The great vessel dividing into smaller vessels, penetrates, it will be noted, every limb and every organ, not excepting the hard skeleton itself. The vessels beat with the heart and giva iis the pulses we feel in the wrist, the temple, and other portions of the body. The small vessels sub- divide into smaller still, and by continuance of subdivision the whole system of vessels passes into one vast hair-like, — capillary, — web of tubes expanding out in all structures, looking like the ulti- mate branches and foliage of a tree, and forming, in fact, the whole organic outline of the corporeal frame. I have elsewhere called this fine net-work of ultimate vessels the minute circulation. It is in fact the organism, as we look at it, spread out in proper form. We see in it the features and out- lines of every structure and organ. It is, as it were, the living- canvas on which the organism is constructed. Here the blood yields np its constituent portions to make organs, bone stuff for bone, muscle for muscle, nerve for nerve. Here the animal fire glows, the blood from the lungs breathing into it its vital air. We nuiy, as we look at it, almost see it as a slow but steady animal fire. At the same time we are led to observe that the blood, carried into this vital arena, does not rest there. AVc detect that by an infinite number of minute vessels, springing from the vital arena, it returns back, after making its extended circuit, to the heart. It returns now dark in color. It collects in small veins. Tlie veins by tributaries become larger and larger, and so the whole volume of blood, from the great minute circulation, goes back again 78 THE SEATS OF LOCAL DISEASES. throTigli the venous trunks to the right side of the heart from whence we behold it start, to repeat its round on its greater and lesser circulations. In the construction of this vital system of organs, — as will already be gathered from the above, — is included the blood itself ; the heart or propelling organ ; the arteries ; the minute circula- tion ; and the veins. The hlood, arterial and red on the one side of the system, venous and dark on the other, is a fluid having a specific weight of 1055, compared with water as 1000. It has an alkaline reaction. In the body it flows along the vessels in a thin liquid state, although a part of it is in the solid form. It consists of corpuscles or globules, which float in a saline albuminous fluid, and which are so small that they pass through the minutest ves- sels. The globules are of two kinds, red and white. The red globules, each about the three-thousandth of an inch in diameter and the ten-thousandth in thickness, are four-hundred times more abundant than the white. In the lungs they receive oxygen from the air, carbonic acid being given off as oxygen is taken in. In the extremities of the circulation they give up oxygen, and, as I have elsewhere shown, assist in condensing the carbonic acid formed during the animal combustion. The fluid in which the corpuscles float, — liquor sanguinis,— is composed of water, albu- men, fibrine, and saline matter. The proportion of the parts of the blood in the thousand is :^water, seven hundred and eighty- four parts ; blood corpuscles, one hundred and thirty ; albumen, seventy ; fibrine, two and a half ; fatty substances, one and a half ; chloride of sodium, — common salt, — three ; other inorganic salts, two ; extracts of grape sugar, coloring substances, and organic salts, six. Iron is one of the inorganic constituents of the blood ; it exists in the red blood corpuscles. While the blood is circulating in the body the whole mass seems fluid, the red corpuscles being afloat in the stream, and so mobile as to convey the idea even of their fluidity. But when blood is drawn the fibrine separates and coagulates, or sets, enclos- ing the blood corpuscles in its setting, and forming that red blood clot by which wounded vessels are plugged up and closed. The arterial, red, or out-going blood contains the oxygen ; the venous, dark, or returning blood contains the carbonic acid. The temper- ature of the blood is 99° Fahrenheit. The arterial blood goes forth in jets from the heart ; the blood in the minute vessels flows A PHySIOLOGICx\L OUTLINE. 79 as tlirougli a sponge ; the venous blood flows in steady circuit towards the lieart. The hearty the central driving organ of the circulation, we should find to be, — if Ave cai'ried our inquiry so far, — made up of muscular fibres, in fact, a strong muscular organ. AYe should discover that it possesses an independent arterial and venous cir- culation of blood, and that it is fed by the first supply of blood which it, itself, pours forth. "We should learn that it has two lines of nervous supply, one stimulating it to motion, the other control- ling its motion. On its outside, the heart would be disclosed as coated with a strong fibrous membrane which can be stripped off its surface, and this membrane, reflected on and over the heart, would be observed as enclosing the organ in a membranous bag, — the pericardium, — containing a small quantity of serous or pericardial fluid. Inside the muscular organ we should find another fine strong serous membrane lining the walls and the four sets of valves of both cavities of the heart, — the endocardium. The arteries, if we looked into their structure, Avould exhibit a smooth internal lining or coat, — epithelial, — surrounded by a coat of elastic fibres. Next to the elastic fibres w^ould be detected a middle coat of circular musculai- fibres with some interwoven elastic tissue ; and outside all a firm strong coat, made up of con- nective tissue containing some more elastic fibres. Thus an artery is elastic under internal pressure or dilatation ; contractile by its own muscular power ; and strong and resistant by its external investment. If, following up the arteries, we paused to consider next the Tnimute circulating or cajpillary system, we should come upon a sim- pler but much more extended vascular ai'rangement. We should find a web or net-work of vessels, springing fi-om divisions of the arteries, and themselves now of neai'ly equal dimensions, one- three-thousandtli of an inch, throughout. A lining and surround- ing nicml)rane is all that would be found in the finer structure of these vessels ; l)ut there would be exposed a free supply of nerves, under the influence of whicli the small vessels would either con- tract or dilate, as directed by the nervous current. The contents would still be the blood, the corpuscles of which would be seen to pass in single file, through the capillaries. The inner lining of the capillaries, derived or continuous from the arteries, would be traceable into the veins. 80 THE SEATS OF LOCAL DISEASES. The veins rising, as it would appear, from the capillaries and passing on towards the heart, increasing in size as they progress, would be disclosed to us next as a series of tubes closeW resem- bling the arteries but less strong in structure. Internally we should detect in them a similar epithelial coat or lining ; around that a lining or coat of circular muscular fibres with some elastic fibres ; and outside all a covering or coat of connective tissue. In addition, the veins would present interiorly a series of small valves, derived from their inner coat, which open upwards and direct the blood onwards in its course to the heart. Shall any local disease visit this circulating system the result must be some disturbance of the balance of life. Let the blood be changed in physical property ; let the heart overact or fail in its beat ; let the valves of the heart get wrong ; let the arteries or veins give way ; let the vital arena of the minute circulation be the seat of change, let its minute vessels distend or break, its fire glow too fiercely, or its fire die out in whole or in part ; and the result must be disturbance of the balance of life. The Eespiratoey System. From the circulation and the parts of which it is, as a sys- tem, composed, we would next, naturally, turn to the respiratory system at which we did already briefly glance when our attention was directed to the course of the blood from the right to the left side of the heart. In the respiratory mechanism we should ob- serve the mode in which the blood is changed from the dark venous to the red or arterial hue. We should see in the two spongy organs, the lungs, one on the right, the other on the left side of the chest, the vessel which comes into them from the right ventricle of the heart dividing into two large branches, a branch for each lung. We should observe, further, that the vessel belonging to each lung divides again into smaller branches, and that these smaller branches, after numerous divisions and subdivisions, become, at length, a vast web of very fine vessels, like to the minute circulation of the body at large. We should, in this instance, however, detect a difi'erence, owing to the in- troduction of a new element into the refined circulation of the luno-. We should discover that in the net-work of the minute vessels of the lung as the vessels pass on in their course to form the commencement of veins, there are interposed mill- A niYSIOLOGICAL OUTLIIN^E. 81 ions of little vesicles or bladders, over the outer surfaces of which the web of vessels spreads. We should find that with each breath drawn the little vesicles expand, wdiile w'ith each expiration of breath thej contract, so that the whole mass of the lung expands and contracts by the expansion and contrac- tion of the whole mass of the vesicles. Tracing out the meaning of this we should learn that the tiny vesicles are the terminal pouches or cysts of small tubes from which they cluster, some- thing like as grapes cluster from their stems. Following the tubes from the vesicles we should trace them becoming larger and firmer, until at last they became large strong tubes lined with mucous membrane, coated with mucous secretion, and filled M'ith air. Finally we should see that the tubes, as they increase, be- come firmer still, — constructed now of rings of cartilage, — and that at last they emerge, by a single tube, from the right lung and the left, to form one common large tube which runs up to the throat, and opens into the throat by a chink from which the sound issues wdien the voice is heard. The anatomist would tell us that the tubes springing from the little vesicles are the minute ramifications of what he calls the bronchial tubes ; that the lai-ger tubes are the bronchial tubes themselves ; and that the final large tube, ending in the larynx or voice-box, is the trachea or windpipe. The anatomist would also explain to us that all the parts named as belonging to the lungs, the large blood-vessels, the minute blood-vessels, the air vesicles, the bronchial ramifications, and the bronchial tubes, are united together, in each lung, by connective tissue and by abundance of elastic tissue ; and that each lung, made up of a great number of little lobules, all con- structed on the one plan, is finally included in a delicate, semi- transparent sensitive membrane. This memlu-ane surrounding the whole spongy mass, is reflected over the walls of the chest, enclosing the lung in a double bag, — the j^^cural luemhrane, or jpleura^ — the bag or space of which is thej^/^^i^/'^Z ccmiUj. If, now, knowing these general facts of construction, we looked at the intention of so much fine and beautiful mechanism, we should detect that in each act of breathing the chest, by its expansion, draws, like a bellows that is being expanded, a quan- tity of air, from three to four cubic inches by volume, into tlie lungs through the windpipe ; that under this the small air vesicles are filled with air ; that during the expansion of the vesicles the 6 82 THE SEATS OF LOCAL DISEASES. blood, wliich courses over them in the minute circulation of the lung, changes in color from dark to red. We should further de- tect that, in expiration, or emptying of the chest, the vesicles contract, and give back into the bronchial tubes and into the windpipe, and so into the outer air, the same or nearly the same quantity of air as that which they took in during inspiration. One change more would demand our attention. The air which the tiny vesicles receive in the act of drawing in the breath is common atmospheric air. It is a mixture of two gases in un- equal quantities, Is early four parts out of five are made up of a gas called nitrogen ; rather more than one part is made up of a gas called oxygen, in which gas substances capable of going into flame or of being more slowly consumed by slow combustion, burn, with evolution of heat. From this atmospheric air then we should see, as it passes over into the air vesicles, a certain portion of oxygen extracted by the blood. The myriads of small disks of red color floating in the blood stream Nvould be observed to seize upon the oxygen till saturated with it, while the blood would give up, in return, into the bronchial tubes, the windpipe, the mouth and nostrils, and the outer air another gas, a mixture of oxygen and carbon, — carbonic acid, — with some returned nitrogen, and with some unused oxygen. Presuming that we were not acquainted with the nature of this curious process, we might think that by these interchanges of air and blood some heat was produced in the lung when the dark blood began to glow. The industrious scholars who first noticed these changes thought so, naturally enough. We know better now. The process is all for this primary end, that the blood may be charged with oxygen and may carry oxygen into that minute circulation of the body at large which we have already seen to be the vital arena. There the oxygen is to be given up ; there the animal fire is to burn ; there the carbon supplied by the food is to consume; and there the blood, losing its oxygen, is to exchange it for the newly-formed carbonic acid, and to convey that product of combustion to the lungs, to be cast off by them. To render the physical mechanism of the lungs more perfect, there is planted, — as the microscope would next reveal to us, — all along the mucous membrane covering the bronchial surface, not only bronchial glands to afford secretion, but an exquisite ap- paratus called the ciliary. This, if we got to view it, would be A PHYSIOLOGICAL OUTLINE. 83 found to consist of an immense nnmber of fine processes, — cilia, — wliich pave the mucous membrane round the tubes and keep ever in motion, like the waving motion of corn in the breeze, to- wards the outlets of the tubes. Thus fine particles of offending dust drawn into the depths of the lungs, in inspiration, are wafted back bj the cilia, and brought into the throat by the windpipe, are removed from the lungs by being expectorated or swallowed. Shall any local disease visit this respiratory sj-stem, the result must be some disturbance of the body at large. Let the bronchial channels be obstructed, then the animal fire, unfed by vital air, must decline in proportion to the obstruction, even to the extent of going out altogether. Let the air contain some gas or vapor that modifies the character of the respiratory act or carries new matter into the blood, and the whole body must suffer. Let the minute air vesicles be charged with fluid, or be congested with blood, or be dilated, or broken, and the whole body must feel the disturbance. Let the structure of the lungs be the seat of a new growth, and the whole body must suffer something from the mis- chief. Let the heart fail to send arterialized blood to the minute circulation, or blood that cannot sustain combustion, and the whole body must needs collapse. Let the sensitive pleural mem- brane be injected with blood, or rendered dry and inflamed so that its surfaces rub one against the other, and pain will follow, from the lowering effects of which all the body will sympathize. Let the surfaces of the pleural membrane be fixed by adhering one to the other, or be compressed by an excess of fluid secreted between them, and so much breathing power must be lost, to the comparative detriment of all the organism. Lastly, let the elas- ticity of the elastic fibre of the lung tissue become impaired, and the vital capacity, as a whole, nrmst suffer relative impairment. The Keevous Systems. Keeping our attention still directed on the construction of the living man, looking through him still, we should remark that in parts of his organism, on the terminals of liis vascular system, there are certain solid organs from which spring an infinite num- ber of cords and threads, to traverse the body in as many direc- tions as the blood-vessels themselves, and to enter freely into the fleshy structures, to which, at times, they seem to impart motion. At the uppermost part of the body, crowning the wiiole, and 84 THE SEATS OF LOCAL DISEASES. occupying the cavitj wliicli we call the skull, the largest of these organs, — the brain, — will lie before ns. It fills the cavity of the skull. It is divided into two parts, one part large in front and above, the other small and concealed behind the larger, and both divided by a vertical or perpendicular separation into two sections or halves. From the back of these structures we should also see a cord of the same kind of substance extending along the central opening in the long column of bone known as the spinal column, —the sjjinal cord. From these great centres in the cavity of tlie skull and in the cavity of the spine, we should next see a series of small white cords, proceeding to their various destinations. The anatomist would tell us that the large mass in the fore part of the skull is known as the cerebrum, or larger brain, and that each half of it is called a hemisphere ; that the smaller lower mass,- — seven times smaller than the larger, — is known as the cerebellum, or smaller brain, the two halves into which it is also divided being its hemispheres ; and that the long cord passing along the spinal canal is the sjjinal cord, the first part, a little more than an inch, proceeding from the two brains, — for he would show us that it does proceed from both, — being particularly defined as the medulla oblongata. The smaller cords that come off from the brain and from the spinal cord he would designate as nerves. He would explain to us that all these parts, large brain, small brain, spinal cord, and nerves, form one great system, of which he would speak as the cereljro-sjdnal system / and he would demonstrate that the centres of this system are not merely covered by bone, but by membranes also, three in number. Upon the actual sur- face of the brain and spinal cord he would show a fine web of blood-vessels, a nutrient membrane, i\\e jnct 'inater {goodi mother); above that, and coequal with it, a delicate serous membrane, so delicate that he calls it the arachnoid, spider-web-like membrane, yet active enough to secrete a layer of fluid to interpose between the brain and the firm over surrounding parts ; while enveloping the whole, he would exhibit to us a strong, liard, fibrous, white membrane, inelastic and smooth, lying between the delicate arach- noid and the inside of the bony cavity, M'liich firm membrane he would call the dura mater (hard mother). Turning then to the brain and spinal cord enveloped in tlie three membranes, — pia mater, arachnoid, and dura mater, — he would describe to us that they are each made up of two kinds of nervous matter, one dis- A PHYSIOLOGICAL OUTLINE. 85 tinctlj white, the other as distinctly gray. In the brain he would bid us observe that the gray matter is all on the outside and gath- ered lip into folds, or convolutions, the white matter being en- closed within it ; wliile in the spinal cord the gray is in the centre and the white on the outside, lie wonld show, too, that the gray matter, very rich in blood supply, is composed of an infinite number of minute cells, held together by a soft nervous coimec- tive substance, nerve cement ; and that the white matter, more clearly linear, and made up of fibres similarly connected, is the apparent origin of the nerves which are passing from the centres to deploy over the body at large. In relation to the nerves he would indicate that some go from the brain to special structures, the eye, the nose, the ear, — nerves of special sense ; and that the nerves which issue from the spinal cord pass off from it in pairs on each side the cord. He would trace out thirty-one pairs of spinal nerves, each nerve having two origins or roots, one from a back segment, the other from a front segment of the cord, which is in fact built up of four columns, two on each side, as if for this special purpose of dividing the nerves into pairs on each side. Of the nerves themselves he would give us a ready demonstra- tion. He would show us that the nerves going from the brain to the organs of the senses spread out, at their terminations, into a sheet or screen, endowed with active cells like a small spread-out brain, at the far end of the connecting nerve. He would show that the nerves which go off from the spinal cord, divided into two roots at their start, soon unite into common or compound nerves, and that these combined nerves, with others from the brain not destined to go to the organs of the senses, are distrib- uted either to the fleshy parts or muscles, or to membranes and skin. Here, in their infinitely fine terminations, they would be found making a surface or net-work equivalent to tlie vascular net-work we have already surveyed, and probably equivalent in material quantity to the nervous centres from which they spring. And now if, turning to the meaning of this elaborate con- struction, we could mentally realize what was effected by it, the lesson would indeed be curious. "We should see that M-henever an external vibrating impression, — a picture to the eye, a sound to the ear, a friction on the skin, — is made on a part of the great terminal nervous surface, the vilu-ation is conveyed directly away to the communicating centre, telling it, as it were, what has 86 THE SEATS OF LOCAL DISEASES. occurred. Or we should see some indication of will made in a centre, and conveyed from thence to the nervous termination, bid- ding that to set in motion muscular fibre, and creating, for a time, motion of body or limb. We should notice that all kinds of motor connections from the centre pass through the front columns of the spinal cord ; while all counter impressions, from the ex- tremities of the nerves to the commanding centres, pass through the columns that are at the back of the spinal cord. Thus in the cerebro-spinal system we should witness the connections between will and actions of will ; the mode by which the physical impres- sions of the outer world are poured into the inner man to inspire him, while he lives, with the life of the outer Avorld ; and the mode by which he responds to, or reflects back, those inspirations. But another survey of the nervous microcosm would be neces- sary. The cerebro-spinal is one nervous system. There is a second. Our anatomist, ready to instruct us here also, would dis- close for us the centres of this second nervous system, not in the bony cavities of the skull and spinal column, but in the trunk of the body itself, in the great cavities where lie the lungs, heart, stomach, and intestinal canal. Behind these organs and running in front of the spinal column, on both sides of it, he would point out a double line of small masses of nervous matter, — ganglia. These, he would indicate, extend, on each side, through the neck, np to a point inside the skull a little above the eyeball. Of these masses, the largest not much larger than an almond, he would count for us twenty-eight in each chain. He would demonstrate, springing from these centres, sets- of nerves which pass off from each centre in four directions, and often closely communicate in their course with the nerves of the cerebro-spinal system. He would tell us, that in addition to this chain of ganglia there are other distinctive ganglia and plexuses of sympathetic nerves con- nected Math the heart and all the vital organs ; and one great gan- glion, the semilunar, near to the stomach, Mdiich receives branches from the cerebro-spinal system, and which sends off radiating fibres to so many organs,— stomach, diaphragm, liver, kidneys, and intestines, — that it was called, by the oldest physicians, the great solar or radiating plexus. But chiefly would the anatomist interest us by pointing out the leading course of the sympathetic nerves from their chain of ganglionic centres, in the direction of the lines of the arterial A PHYSIOLOGICAL OUTLINE. 87 blood-vessels. He would expound forcibly and do all in his power to fix on our memories the fact that wherever arterial blood-vessels are distributed, whether they go to muscles, or glands, or nervous masses, or membranes, or skin, or to tlieir finest terminations in the vital arena, they are attended, to their idtimate branches, by a fibre from this system of organic nerves. "\Ye look, naturally enough, as we witness this demonstration, for an explanation of its meaning. We gather on inquiry that if we could see the mechanism, it is this. The nervous masses oi the chain are the centres of what is known as the sympathetic, organic, vegetative, or ganglionic system, and they are called, as we know, ganglia. In them, from the blood which supplies them, nervous force or stimulus is always being produced. From them the nervous influence is at all times passing, independently of will, automatically that is to say, through the nervous cords to the arterial tubes and to their terminals. Over these fine blood- vessels, at their extremities, the nervous influence so supplied exerts a perfect control as long as the action is steadily main- tained, and by that control the vessels of the minute circulation are regulated. Each vessel, fine as it is, being thus obedient to nervous direction, is so governed that, under the stroke of the heart, it shall admit the right quantity of blood, and distribute the proper supply to the vital arena with as much order and rhythm as the pulsating heart shall deliver the supply. These are some of the phenomena derivable from our survey of the nervous sj^stems. The knowledge is a treasury as applied to the diseases of human-kind. Shall the great centres of the cerebro-spinal system be injured, how can they receive external impressions, how can they deliver commands in response, or reflect back what they have received, in due time and order ? Shall the nerves conveying sensible impressions to a part be interrupted in their work, then the part, cut off from its nervous centre, must be rendered senseless. Shall the nerves conveying motion from a centre to a part be interrupted in their function, the part nuist be rendered motionless, — paralyzed. Shall a portion of nerve in the nervous circuit be excited, or irritated, tlie irritation, reflected by intercommunicating fibres to many centres, may produce various movements or sensations which may be quite remote from the original direction, as well as in it. Shall the expanse of an organ of sense be over-excited, the effect may tell, perchance, on all 88 THE SEATS OF LOCAL DISEASES. centres. Shall an interruption occur between an organ of sense and its centre, the sense will fail in proportion to the interruption. Shall the centres, the masses of gray matter of brain and spinal cord cease to act ; shall the active cells which move in the con- necting substance or nerve cement die out ; or, shall their sur- rounding substance become, as it is apt to become, too solid and firm ; then all parts supplied from cerebro-spinal tracts thus in- jured will, virtually, live a vegetative life, receive no impression, deliver no impulse nor command. The most striking piece of learning of all, would, however, be gleaned from the study of the automatic nervous regulating pro- cess carried out by the second nervous system, the organic, sym- pathetic, vegetative, or ganglionic nervous chain, the nerves of which follow the arteries throughout their coiu'se. Shall this nervous system be subject to disease, functional or actual, then instantly the tale is told. By a sudden blow or mental impulse of surprise or emotion the centres of this system being for a mo- ment overpowered, the blush of red blood on the cheeks and over the surface of the body will declare that the control over vessels has been checked as far as the termination of the nervous fibre ; while the glands that may be involved in the same shock, and for the same reason left uncontrolled, will weep and pour out their secretions in copious streams. Shall the shock be so extreme as to communicate a vibration from the centres, the nervous fibres will be irritated so decisively as to close the arterial terminals and shut off the blood stream in the vital arena. Then sudden and death-like pallor will seize the surface of the body ; the brain- cells, unsupplied, will fail to yield consciousness ; a load of blood cast on the struggling heart?, itself the first organ to be robbed, by the shock, of its arterial supply, the heart will sink in its beat, and all the powers prostrate, there will be primary death, syncope or faint, an apparent prelude to that which shall close all access to impression and all impulse of will, death. Again, shall these organic nervous centres be injured in parts so that local supply from them is impeded, then the structures they quicken will suffer in proportion to the injury. The vessels will be congested of blood or surrounded by effused fluid derived from blood which may undergo a false organization, and all the natural functions become dei-anged. Lastly, if the extremities of the nerves of this organic system A PHYSIOLOGICAL OUTLINE. 89 be afPected, as tliey are constantly, by various changes, of heat, or cold, or mechanical motions acting upon them, thereby interrupt- ing the cun-ent supplied to them from their centres, the effect on their function is instantaneous. The part or organ to which they minister is made red, or pale, is heated or cooled, as if by the mere motion of the agent itself that exerted the change. Thus the skin held before the fire glows ; the skin held in the cold grows white ; thfe skin recovering from exposure to cold gi-ows red and feels hot ; the hand covered with turpentine or mustard reddens and burns ; the eye irritated, the lachrymal gland M-eeps ; the membrane of the nostrils excited, is first made dry and then pours forth a secretion, — catarrh; the limgs taking in first a warm and then suddenly a cold air, become congested with blood ; the lungs inhaling a gas which excites them, the whole body is rendered red or pale, is convulsed or collapsed. In each and all of these disturbances it is the organic nervous chain or its fibres that have experienced the shock or communicated the results. The Sensory System. "While yet our minds were occupied with the task of observing the construction of the nervous organization we should see con- nected with certain parts of it a special adaptation for bringing it into communication with the motions of the external world. We should discover in connection with it two organs of purely optical character, for condensing and focussing light, for receiving a pict- ure on a nervous screen, and for letting that picture pass to the brain. These are the organs of sight. "We should see two other organs for collecting the atmospheric waves which cause sound, for receiving the impressions so collected on a nervous expanse, and for transmitting the impressions to the brain. These are the organs of heai-ing. "We should discover, in a third part, a ner- vous surface supplied with a much simpler plan of condensation, for receiving the impulses, in this case perhaps purely mechanical, which odorous particles impart to the nervous sense. Tliis is the organ of smell. "We should discover in another portion, at the tips of the fingers, a small nervous body containing a little gray matter and surmounting a filament of a nerve for receiving the special impressions conveyed by delicate pressure on an external object. This is the organ of touch. Lastly, in a less perfected and certain form, we should discover a nervous expanse in a por- 90 THE SEATS OF LOCAL DISEASES. tion of the tongue and palate, for the reception of impressions conveyed by foods, drinks, and other substances which may enter the mouth. This is the organ of taste. Our anatomist would describe to us in respect to these organs that in every instance the design is carried out on the same prin- ciple, though the details vary considerably in each case. He would show to us that there is, in all instances : {a) a collecting part of the organs for bringing together the vibrations that have to be absorbed ; ih) a receiving nervous surface for taking up the im- pression ; (c) a special nerve, originating in the nervous receiving surface and going to the brain, for conveying the impression ; {d) a receiving part within the brain itself, by which the impression is finally brought into the physical domain of thought and con- sciousness. Defining these general facts by and from the special organs, the anatomist would show to us that in the organ of vision the condensing part consists of three duly adjusted lenses: of the cornea, or concavo-convex lens in front of the eye, fixed into the hard sclerotic white coat which forms the outer part of the ball of the eye ; of double convex lens situated further back within the globe of the eye, and called the crystalline lens / and of a third fluid transparent structure, concave in front, convex behind, made up of many segments in membranous divisions, and filling the greater part of the globe, the vitreous humor or lens. He would show also that between the first and second of these lenses there is a perforated curtain which, responsive to the stimulus of light, closes or opens automatically, so as to exclude light or admit it freely according to circumstance, the iris. He would explain that the inner surface of the globe of the eye behind the curtain is clothed with an absorbing dark coat, the choroid; and that on the choroid is spread the nervous expanse, the retina, for receiv- ing the picture or impression of the objects Mdiich gave or reflected the waves of light. He would show us the nerve, the 02)tiG nerve, which proceeds from the retina of each eye to the brain; he would trace that nerve in its course, and point out how on each side at a certain point within the skull it meets and conjoins Avith its fellow from the opposite side, and then passes on in separate or amalgamated tracts to the brain to be lost in the matter of the cerebrum. Lastly he would describe how the eye is moved in the orbit by six muscles, and how it is lubricated by a fluid, secreted A PHYSIOLOGICAL OUTLINE. 91 fi'om a gland lying above it in the outer corner of eacli eye, the lachrymal gland, the Huid from which, after it has flowed over ,the eyeball, escapes by a minute opening, the lachryinal duct, and, finding a ready passage uito the nasal cavity, on each side, is disposed of there by evaporation. From the eye, as the organ of sight, our guide would lead ns to the organ of hearing, the ear. He would show us a tube on each side of the skull, for the collection of sound, leading inwards the distance of three-quarters of an inch, the meatus auditorius exter- nus. He would show us a membrane stretched across the bottom of the tube, like the head of a drum, the tyr/vpanum. Beyond this he would lead us into the middle ear, a cavity into which he would show us an opening from the throat by a tube, called after its discoverer, Eustachius, the Eustachian tube. In this cavity he would indicate four minute muscles for the regulation of the tym- panum and thi'ee small bones, the mcdleus, incus, and stapes, the hammer, anvil, and stirrup, — so named from likenesses to those in- struments, — stretching across in a connected line from the inner surface of the tympanum to an opposite surface in which are two small openings each covered with a membrane, and on one of which membranes the foot of the stirrup is planted. This middle ear, he would tell us, is the tym.jpaniG cavity, the opening into it from the throat being intended to keep up a balance of air on both sides of the tympanum, so that the tympanum may vibrate freely, without pressure from within the cavity. IS^ext he would take us into a third and innermost recess of the ear, the part which the older anatomists, in their admiring wonder, called the lahyrlnth, and which is indeed to this day a labyrinthine mystery. He would point out to us in this internal ear two nervous surfaces ; one spread out on membranous tubes filled with fiuid, endolymph, en- closed in three semicircular canals ; the other spread out on a fine membrane laid on a spiral layer of bone, the cochlea or shell. From these nervous expanses, so singularly formed, he would show us the origin of another nerve of sense, the auditory nerve. He would trace this nerve for us out of the temporal bone, through an opening in its hard, or petrous part,- the meatus auditorius in- ternus, into tlie cavity of the skull ; and, he would finally trace .the nerve, which he would tell us is like a nervous trunk of the great sympathetic chain in its consistency and construction, first by an obvious tract into the substance of the brain, and after- 93 THE SEATS OF LOCAL DISEASES. wards, as some suppose, into the organic chain of nerves. This mechanism we should perceive is all for condensation and trans- mission of sound. Under the vibration of the external air the tympanum vibrates. The vibration of the tympanum is comnm- nicated through the middle ear and the membranes at the back of it to the nervous expanses in the labyrinth. The nervous ex- panses receive the vibrations, and through the auditory nerve transmit them to the sensorium. Membranes, muscles, bones, fluids, nerves, all play their parts in this exquisite physical mech- anism. These parts, again, are fed from blood passing into them by minute blood-vessels ; and these blood-vessels are regulated and governed by nervous force. Passing from the ear to the sense of smell, our anatomist would show to us, within the cavity of tlie nostril, an elaborate surface of nervous membrane laid out to receive the ultimate fila- ments of another pair of nerves of special sense, the olfactory nerves. He would trace up these nerves, one on each side, into the cavity of the skull. Here he would expose for us two enlarge- ments of these nerves in their course, the olfactory bulbs, from which the nervous filaments descend to the nostril ; and he would follow the nerves back in their tract until they are lost in the sub- stance of the brain. In this mechanism we should see a simpler means for obtain- ing an impression than was presented in the two other senses. If we passed to the organ of touch we should find that simpler still, for there we should discover an ordinary nerve endowed, at its termination, with a minute ganglionic structure for receipt of im- pressions ; while in the sense of taste even this modification is absent, — a common sensitive nerve, spread out on the nmcous sur- face of the tongue and palate, doing the special work. But in every instance, simple or elaborate, we should find the principle to be the same. ■ "We become conscious, at once, as we learn these various parts of the different organs that very slight changes in them are suf- ficient to make varieties of disease. If the collecting surfaces be injured the function of the organ must be perverted or destroyed. If the receiving surface of the organ be damaged or made imper- fect for reception in any way, the function of the organ must be deranged. If the transmitting nerves between the receiving sur- face and the brain be interrupted or obstructed, the function of A PHYSIOLOGICAL OUTLIN'E. 93 the organ mnst be disturbed or suspended. If the brain at the point of reception be affected, however perfect all the other parts may be np to that point, the impression from the senses mnst be imperfectly appreciated. Injury to an organ of sense may more- over be indirectly injurious to other organs or pai'ts. One eye is easily affected, sympathetically, from injury to or disease of the other eye. But of all organs the ear is that which excites the widest range of physical sympathy. Derangement in the ear may be communicated, by sympathetic nervous agitation, to all the bod3% The body may be actually stunned by sound. Every vi- bration of a harsh and shrill nature " goes through the body," as it is said, with pain and suffering ; while pleasant sounds, sounds of beautiful music, thrill every nerve and make the body dance with pleasure and delight. The Absorbent and Glandular System. The absorbent and glandular system is made up of a series of tubes and of masses of fleshy-looking matter which are called glands, and which are dispersed over various parts of the body. If we continued our plan of looking through the man we should see glands in every cavity of the body, and beneath the skin in many of the external parts, as in the arm-pits, groin, and neck. In the structure of the skin itself we should discover, deep down in it, many thousands of small sweat glands. In this display of structure we should be first impressed by the fact that there are various kinds of glandular systems in the body. "VVe should see one system, {juite distinct in itself, pos- sessing its own proper vessels or tubes connected with its glands, and charged with a fluid either of a limpid or of milky charactei". This our anatomical teacher would tell ns is the al)8orhent or hjm- 2')liatiG glandular system. We should discover next a series of glands connected with the vascular system and seeming to be made up of arterial vessels from which they derive all their fluids, and this system we should be told is the vascular glandu- lar system. Looking still closer at the vascular glands we should see that they are of various kinds. In some we should find an artery entering and a vein coming out of the gland, but no otiier tube. These are called ductless glands. In others we should sec an artery entering the gland, a small vein coming out of it, and, 94 THE SEATS OF LOCAL DISEASES. in addition to the vein, a new tube wliicli is called a duct. These are duct glands. Analyzing the facts further, we should detect that the duct glands do not return all tlie blood they receive from their arteries by veins, but yield by their ducts a new fluid, which, like the fluid that flows from the duct of the gland called the liver, — the bile, — may be going forth to be partly taken up again into the blood, — a secretion : or like the fluid from the kidney, — the urine, — may be entirely an excrementitious fluid going out of the body, an excretion. Thus we should see in the glandular system absorbent glands and vascular glands. Of the vascular glands we should see duct- less glands, and glands with a duct. Of the duct glands we should see some which are secreting fluids that are about to be applied to the purposes of the economy ; others which are excret- ing fluids that are no longer of use in the economy, but require to be voided. Tracing out the absorbent glands, we should find them to be connected with a series of vessels called the lymphatic, or lymph- collecting vessels. In the body these vessels would be seen to rise independently of the vascular system, and after coursing a dis- tance along a limb or part, in the connective tissue beneath the skin, conveying a white lymphy fluid, into a gland ; from whence, by a new tube, the course, perhaps through other glands in line, would be towards the heart. Finally the system of absorbent tubes from all parts, gathering together near the heart, would be seen to pour their fluid or lynijjh into one of tlie large veins close to the heart itself, where the lymph mingling with the blood en- ters the circulation by the right auricle. In the intestinal canal the absorbent vessels would be seen to rise from what are called the villi of the small intestine. Here, rising by an immense number of radicles, they would be observed to form into tubes, lacteals^ which convey a milky fluid derived from the digested food, and, running along the folds of the mes- entery, to enter a series of glandular masses called the mesenteric glands. Elaborated in these glands, and transformed into chyle, a fluid now containing white cells, we should see this fluid passing out of the glands by an exit tube, and through other tubes on towards a point a little below the middle half of the spinal col- umn. At this point the tubes from the mesenteric glands all col- A PHYSIOLOGICAL OUTLHSTE. 95 lecting into a small receptacle, the rec&ptctculum cJiyli, become one tube, the thoracic duct, which makes its way, as we shonld discover, in the line of the spinal column, towards the heart, to enter with the other lymphatic currents into the venous system and into the circulation, by the right auricle. Turning from the absorbent glands to the vascular, we should be puzzled about the ductless glands. We should find four of these deserving our special notice. One in the front of the neck, called the thyroid, the gland that is enlarged in cases of "full neck," or " goitre." Anothei^, very large, in the cavity of the abdomen, the spleen, the gland that is enlarged to form what is called " Ague cake ; " and two others, one on the upper part of each kidney but separate from it, the siqyrarenal capsules. Our anatomist would tell us that as the blood courses through these ductless glands it is changed for some important purpose, the precise nature of which change he cannot define. Turning, lastly, to the vascular glands with ducts we should find, in each case, a vascular and tubular system, with a secerning or separating cellular arrangement, and with a rich nervous supply for regulating the amount of secretion or excretion. The salivary glands we should see secreting saliva ; the stomach glands gastric juice; the pancreas pancreatic juice; the liver bile; the lachry- mal gland excreting tears ; the skin glands sweat ; the kidneys urine ; the glands of the mucous surfaces the fluid excretions of the bronchial passages and of the intestinal canal. Shall any derangement take place in these systems of glands the effect on the body is, of necessity, marked in various ways and forms of disease. If the absorbent glands fail to act, there is loss of supply to the blood, and therewith exhaustion and wasting. If they absorb what is foreign to them, there is poisoning by the ab- sorption. If the ductless glands are pervei-'ted in action, there is set up several kinds of obscure, but serious diseases : goitre ; white blood cell disease ; bronzed skin disease, — xVddison's disease. If the secreting glands either fail or overwork there is direct irregu- larity of their physiological function and power. If the excreting glands fail, there is retention in the body of water and of various excrementitious, or, it may be, poisonous products; while if they overact, there is catarrh or flux, and exhaustion from that cause. Finally the condition of the glandular system is of special im- portance, from the circumstance that the secretions derived from 96 THE SEATS OF LOCAL DISEASES. the secreting glands are apt, under some conditions, to become themselves poisonous, and in this manner to be the promoters of diseases that are communicable. Thus the saliva of the rabid dog is a virulent poison ; the secretion which produces the specific dis- ease syphilis is a virulent poison ; the nasal secretion of a glan- dered animal is a virulent poison ; and, the same may be said of other glandular fluids, as we shall ultimately discover. The Mtjsculae System. Keeping our minds still on the living man, we should see in him a set of organs that, under various impulses, are excited to movements by which parts of the body, as the limbs, or the whole of .the body, may be moved. These the anatomist would tell us are the muscles or muscular organs, the engines of the organism. He would explain that in the body there are three classes of mus- cles. One class made up of the ordinary red muscles of the limbs and trunk, which we can order to work when we like, — the volun- tary muscles, A second class composed of muscles of similar con- struction, but only partially or indirectly under our will, the heart and the muscles used in breathing, — the semi-voluntary muscles. A third class composed of white muscular fibres, delicate in struct- ure, which surround the intestinal tube, the stomach, the bladder, and the arterial blood-vessels, wliich do not act under the direc- tion of the will, but which keep the vegetative life going, inde- pendently of ourselves, our business, or it may be our inclinations, — the involuntary muscles. The anatomist would show us that the voluntary and semi- voluntary muscles are composed of bun- dles within bundles of fieshy fibres surrounded by membranous sheaths, which fibres are ultimately made up of disks that lie upon each other in lines or striae. He would exhibit to us a beautiful net-work of blood-vessels in the muscular structure, and an equally fine distribution of nervous filaments. He would show how when a nerve current, directed by the will from a nervous centre, enters the voluntary muscle, the organ is at once contracted or shortened, producing motion ; and he would define, as the difference between this form of muscle and the involuntary muscular fibres around the visceral organs and the arteries, that the organic muscles have no true muscular striated elements, and that the nervous supply which moves them is not from the will but is rhythmical and automatic. Again, he would show this difference between the A PHYSIOLOGICAL OUTLINE. 97 voluntary and semi-voluntary muscles, that although both are nearly alike in structural character, the nervous direction, in the semi-voluntary muscles, as in the involuntary, is mainly rhythmi- cal and automatic. Shall any change in function occur in the muscular action, the derangement in the system at large must needs be marked. If a voluntary muscle ceases to obey the will, if it contracts with- out the direction of the will, then it is convulsed or tetanized / if it will not contract, but remains quiescent when the will bids it move, then it is paralyzed. If the involuntary muscles respond to an unnatural stimulus, so as to become convulsed or tetanic, the parts they surround are contracted. By such contraction the blood in the arteries may be obstructed or cut off ; the intestinal canal may be thrown into the painful spasm called colic ; the pu- pil of the eye may be contracted. If the involuntary muscular fibres fail to respond to their natural stimulus, if they are relaxed by the action of some agent, such as alcohol, or extreme cold, or physical injury, then the parts they surroimd may be paralyzed, and the blood-vessels injected with blood until the surfaces they supply are intensely reddened, congested and inflamed. The Osseous, or Bony System. We should observe as we kept up our observations of the liv- ing man that all the parts of him which we have had before us up to the present time, — digestive organs, circulatory organs, breathing organs, nervous system, — organs of sense, absorbent vessels, glands, muscles, — are placed upon, or are enclosed in, a passive system of organs, which, combined into one great system, is denominated the osseous, or the skeleton. The anatomical teacher, wonderfully at home in this system, will declare it to be the groundwork of the body. He will de- scribe it as divided into the skull, the trunk, and the limbs. He will divide the skull into the head and face ; the trunk into the spinal column, thorax, and pelvis ; the upper limbs into the clavi- cle or collar-bone, the scapula or shoulder-blade, the humerus or arm-bone, the ulna and radius or fore-arm, the carpus, metacarpus and phalanges, — finger-bones, — or the hand ; the lower limbs into the femur or thigh-bone, the patella or knee-pan, the tibia and fibula or leg-bones, and the tarsus, metatarsus and phalanges, — toe-bones, — or the foot. He will describe the various kinds of 7 98 THE SEATS OF LOCAL DISEASES. joints. He will enter into the subject of structure and explain how the hardest bone is really built on a vascular net-work. He will tear off from the bone a portion of strong membrane, — periosteum, — will tell us that this membrane is supplied with nerves, by which it is rendered extremely sensitive, and that by it the bony structure is secreted. He will also explain that the structure of bone is made up of earthy and animal matters in such proportion as to give solidity, but with sufficient tenacity to prevent brittleness or easy fracture. Shall these bones be subject to injury or local disease, there will be acute pain, shock, and some inability of movement of the body ; shall there be much exposure of bone to air, there will be decomposition ; shall the parts which make up the bone be dis- arranged so that the earthy matter is in excess, the bone will be brittle and will easily break ; shall the organic matter be in ex- cess, the bone will bend or give way so as to produce deformity, and will fail to sustain, naturally, the structures it was intended to support. The Membranous System. Our last survey would extend to those surfaces of the body of the living man which constitute the membranous system. The anatomist would point to the skin as the most obvious of those surfaces. He would tell us that this skin surface consists of twa layers, one of outer or scarf-skin, made up of dead and flattened cells, and forming a negative protecting cover on which corrosive substances have little action, the ejoidermis ; and of another or deeper layer of true skin, the derm or derma. In this true skin he would show to us blood-vessels, nerves, papillae rising up to give the ridges of the skin which are so plainly seen in the hand and other parts, and the open tubes of the perspiratory ducts which, passing in spiral or corkscrew-like fashion from glands beneath, pour out the cutaneous watery excretion called sweat. Beneath the derma he would also show us another membra- nous layer, partly belonging to the skin, a layer of connective tissue, in which we should find embedded the sweat-glands, a number of fat glands, and in many parts a number of small follicles or folds, in each of which a bulb of hair is planted, — hair foUicles ; — and thus he would incidentally teach us the fact that the hair is an A PHYSIOLOGICAL OUTLINE. 99 appendage of the skin. The same fact he would afterwards show us to hold good in regard to the nails. We should gather from this demonstration that the skin is more than a protective elastic covering of the body. We should find that it is also a vast excreting surface; that it excretes car- bonic-acid gas and acid fluids, — formic and lactic acids,— that from it an immense quantity of water, taken into or produced in the economy, is disposed of, insensibly, by evaporation ; and that, in truth, the equalization of the temperature of the body is mainly regulated by the excreting action of the cutaneous sheet which envelops the body. From the membranous outer enveloping skin our attention would next be directed to that internal membranous lining which, commencing from the skin and seeming to be, as it really is, a modification and continuation of the skin, is called the red or mw- cous meinhrane. As we looked at the face of the man before us we should be informed that where the skin terminates on the eye- lids the mucous membrane begins, and that the outer part of the ball of the eye, all of the ball that is visible, is covered with a layer of mucous membrane called, technicallj'', the conjunctiva. It would be demonstrated that the inner margin of the mucous membrane, continuous from a series of glands situated under the delicate cartilages of the eyelids and receiving watery secretion from them, is continuous also with the little duct, — the lachrymal duct, — which runs down from the inner angle or corner of each eye, into the nasal cavity, to convey away the tears. If we turned from the eye to the ear, we should find that at the point entering the ear, at the point where the skin ends, tlie nnicous membrane begins, and that extending into the ear it lines the external mea- tus or passage and the outer side of the drum. Here, too, we should find the membrane supplied with minute glands for pro- ducing secretion. The most extensive tracts of mucous membrane would be de- scribed to us, however, when we came to look at the tract which commences where the skin terminates in the lines of red mem- brane at the margins of the nostrils and the lips. In those red lines we should be made to recognize the beginning of the great pulmonary or hronchial, and of the intestinal tracts of mucous membrane. In the nostril the membrane would be observed to 100 THE SEATS OF LOCAL DISEASES. cover the nasal cavity and to become continuous with the con- junctiva through the lachrymal duct. It would also be seen to continue to the back of the throat. In the mouth the membrane would be detected as covering all the inner surface to the throat and as extending at the back, on each side, along the Eustachian tube into the cavity of the internal ear, lining that also. From the throat, the mucous membrane, continuous from the mouth and nose, would be observed as extending in two directions. In one direction it would be seen passing down the chink of the glottis into the windpipe and thence through both lungs, lining the bron- chial tubes throughout all their course and dipping into the struct- ure of the bronchial follicles, or small glandular folds which yield the bronchial secretion, to the bronchial surface. In the other direction it would be seen extending down the pharynx or ex- panded upper part of the alimentary canal ; along the oesophagus or gullet into the stomach ; from the stomach through the duo- denum, jejunum, ileum, csecum, colon, and rectum; and so on quite through the canal to terminate by again joining with the surface of the skin. In this course through the alimentary tract we should learn that the mucous membrane is everywhere in con- tact with glandular structures, dipping into the ducts of those structures and formins; their inner tubular coating. In the throat this glandular plan would be seen to be follicular ; in the stomach, — where the gastric juice is produced, — tubular. In the first part of the small intestine the mucous membrane would be found dipping in so as to line the tubular ducts and passages from the pancreas and liver ; in the other parts it would be observed lining all the small intestinal mucous glands that open into the canal and afford a secretion. !Nor would the course of the mucous membrane end with these views of the pulmonary and the alimentary tracts. We should ob- serve that again from the skin there proceeded a tract of mucous membrane along the passages leading to the bladder ; through and fi'om the bladder to the small tubes, the ureters, which convey the urine from the kidney to the bladder ; to the kidneys and on through the tubular excretory structure of the kidneys up to the cusps containing the vascular tufts from which the renal fluid is derived. We should thus, in the end, be led to the conclusion that all the parts of the body are enclosed in these two kindred mem- A PHYSIOLOGICAL OUTLINE. lOl branes, the skin and the mucous membrane, and should readily keep in mind their continuous and intimate relationships the one to the other. There would still remain for us to recall this further fact re- lating to the membranous system, that all the organs of the body are individually enveloped in membranes proper to themselves. The brain and spinal cord, we should remember, as being invested with three membranes, ihejna Q/iater, arachnoid, and dura mater : the bones, in their, outer parts, with ^periosteiwi, in their joints with sr/novial niembra.ne: the heart with the pericardium : the lungs with the pleura : the liver, stomach, intestines and bladder, in great part, with the peritoneum : the kidneys with a fine capsule or covering of their own, the renal capside. These membranes would also be found either to be strong and fibrous like the dura mater ; or fibro-serous like the pericardium ; or serous and singu- larly sensitive to pain, like the peritoneum and pleura. Our observations on the membranous surfaces would not be ended until it was demonstrated to us that the whole of the or- gans of the body are knitted together by a thin web of tissue, called the cellular or areolar tissue, which so intimately interposes between each separate structure, that if air be blown into 'it every organ of the body can be separated by a coating of air from every other organ. This tissue, elastic, interweaving, binding, is seen in all parts except in the serous bags and in the mucous canals. It lies between the skin and the muscles ; between the muscles themselves ; surrounding the glandular masses ; filling vacant spaces between organs ; connecting organs ; and in many of the spongy organs making up the chief portion of their structure. Shall anything interfere with the functions of these membra- nous surfaces, disturbance of the bodily functions must result, and that to an extent often little appreciated. Shall the pores of the skin be blocked up by dust and dirt, the evaporation from the body will be reduced, and the limgs, liver, and kidneys will at once have thrown upon them some extra or vicarious labor it was not their duty to perform. Shall the skin be clothed with an impermeable covering so that evaporation be generally checked, the same derangement will be presented in a more marked, nay, even fatal degree. Shall the excretion of free acid by the skin be suspended, there will follow a dyspeptic condition and rheu- 102 , THE SEATS OF LOCAL DISEASFlS. matic tendencj. Shall tlie skin' be subjected to great irritation or injury, the sympathetic shock and reflected nervous agitation will extend through the nervous system in the most decisive manner. Shall the follicles of the hair become tilled with purulent or fatty substance, there will be a destruction which may be as painful to the sufferer as it is offensive to the observer. One more peculi- arity we shall gather in relation to the skin and disease. We shall learn that the skin is the special surface on which many of the specific characters of the epidemic and contagious diseases are so legibly written that these diseases are often named by their mode of eruption upon the skin, and are called eruptive diseases. Lastly, we should learn that the skin is, for many reasons, the fre- quent temporary residence of various parasitic growths, animal and vegetative; that some of these growths destroy the upper or scarf- skin, laying bare the sensitive under-skin ; that others bore beneath the surf ace and while they are present keep up a constant irritation. Shall disease occur in the course of the great tracts of mucous membrane, the disturbance excited will be acutely or slowly de- monstrated. Every condition of disease which we designate by the name of a catarrh or flux, and which is attended with the discharge of phlegm or mucous fluid, is an affection of a mucous membrane. A cold in the eyes, in the throat, in the bronchial tubes, in the stomach, in the intestine, in the bladder, is an affec- tion of mucous membrane. The inflammations that, occur in the same parts and the ulcerations that may succeed, are inflamma- tions and ulcerations of mucous membrane. The irritations that occur from foreign substances lodged in the alimentary canal and which when long continued lead to convulsions, as in the convul- sions so common during childhood, are primarily irritations of mucous membrane reflected from tlie irritated spot, through the nervous system, to the nmscular organs. Shall disease occur in the fibrous or serous membranes, all of which are subject to irritation, inflammation, over-secretion, dry- ness, thickening, and even transformation into new structure such as bone, the evils resultant must, it will easily be conceived, be serious in the extreme, first to the vital organs enveloped by the membranes, and next to the body at large. The dropsies are accumulations of fluid in the membranous pouches. The inflam- mations that are most acutely painful, pleurisy, peritonitis, are inflammations of the delicate and sensitive serous surfaces. A PHYSIOLOGICAL OUTLINE. 103 Lastl}^, if the connective or areolar tissue, that wonderful web which binds together all the organs and parts so intimately, is the seat of disease, the danger may and often does become rapidly universal. Through this web-work gases and fluids diffuse as through a vast sponge. Through the meshes of it poisons can pass, practically, without interruption over all the organic sur- faces. The watery part of the blood accumulating in it produces anasarca, general dropsy, until the pressed skin above indents like dough. Air diffused through it produces the disease called emphysema of the cellular tissue. Pus or matter burrowing through it, produces circumscribed inflammation, — carbuncle, or diffused phlegmonous inflammation, — erysipelas. It is the seat of many tumors and diseased growths, and is perhaps the mother of them all. And now our general survey concluded, we may pass to the study of the local diseases belonging to the great organic systems which have been made the subject of our observations in the pres- ent chapter. CHAPTER 11. DISEASES OF THE DIGESTIVE SYSTEM. In studying the local diseases of mankind we cannot do better than take them in order as affecting the different systems of or- ganic parts we have just considered. The local diseases, the reader may be once more reminded, are, for the most part, but repetitions of the conditions of disease and of the general dis- eases, locally situated. We commence, therefore, following our physiological outline, with the diseases of the alimentary or diges- tive system of organs. The different parts of the alimentary system are, as we have seen, (a) The lips, mouth, tongue, fauces or back of the throat, and palate, with the uvula and tonsils, {h) The pharynx, or dilated pouch at the back of the throat, ending in the oesophagus or gul- let, the tube extending from the pharynx to the stomach, (c) The stomach, or first digesting receptacle, in which the albumi- nous or flesh- forming foods are transformed into chyme, primary digestion, to be passed through the pylorus or exit gate of the stomach, into the duodenum, (d) The duodenum, or first portion of small intestine into which the liver pours its bile and tlie pan- creas its emulsifying juice, under which the fatty and starchy portions of the food are digested, — secondary digestion, — before being carried into the small intestines, {e) The small intestines, jejunum and ileum, in which digestion is completed, and from which the prepared food is absorbed into the blood. (/") The large intestine springing from a pouch, the caecum, for receiving the debris, undigested or useless part of food substances, and the gases arising during digestion, — the colon, (g) The straight in- testine, with the outlet of which the canal is terminated, (h) The 'mucous membrane lining the whole of the canal internally, (i) The peritoneum or serous membrane of the abdominal cavity, in DISEASES OF THE DIGESTIVE SYSTEM. 105 which the intestines and other abdominal organs are in great part enfolded, and which lines also the walls of the cavitj. All these parts are seats of local disease. Diseases of the Lips. Ulcer of the Lvp. — A small round ulcer by which the mucous membrane is destroyed in a circular manner so cleanly that it looks as if a portion had been punched out, the cellular tissue be- neath forming the lower part or base. The ulcer is often exceed- ingly painful, and frequently recurs in those who are liable to it. Fissure. — A cleft in the mucous membrane of the lips running longitudinally, often occurring in the middle of one lip, and most frecpiently in the lower lip. As a rule the fissure is painful, slow to heal, and apt to recur. Cancer.- — Cancer usually of the form called epithelial, occur- ring mostly in the lower lip, and excited in many cases in those who are addicted to smoking by irritation from the stem of the pipe. The disease not unfrequently affects men, but so rarely af- fects women, that in thirty years of medical observation I have not seen one instance of it. Cysts. — Small cystic or hollow tumors attached to the mucous surface of the lips. Harelijy. — A malformation in which the upper lip has not been developed in such way as to unite in the centre previous to birth, so that there is a deep cleft down the lip. The malforma- tion is now remediable by surgical art. Diseases op the Mouth and Tongue. Stomatitis. — A diseased condition of the mouth to which in- fants or young children are most subject, in which the mucous membrane is more or less covered with whitish flaky-looking spots or patches. Follicular Stomatitis. — A catarrhal inflammatory state of the follicles or little sacs of the mucous surface. Ulcerative Stomatitis. — A series of small ulcerations of the mucous surface involving the follicles. Thrush. Vesicular Stomatitis. — Stomatitis in which there is a vesicular eruption of thrush on the mucous surface. Parasitic Thrush. — Thrush in which there is present the par- asite called oidiuni albicans, or thrush fungus. 106 LOCAL DISEASES. Cancrum Oris, Canker of the Mouth. — A form of stomatitis in which there is de^th or mortilication of the mucous membrane. The disease is sometimes called gangrenous stomatitis. In all these local forms of disease there is some pre-existing general disease and weakness of the body, the common cause of which is improper feeding. Thrush most generally precedes death in exhausting diseases, and is, as a rule, a fatal symptom. Ahscess. — A circumscribed accumulation of matter or pus in the structure of the cheek, the result of inflammation. Cyst. — Growth of a hollow or cystic tumor beneath or upon tlie mucous surface of the cheek. Manula. — A cystic tumor beneath the tongue, sometimes, but not always, connected with destruction of one of the ducts which convey the saliva from the salivary gland into the mouth. It is occasionally attended with a deposit of phosphatic concretion or calculus, derived from the saliva. Diseases of the Gums. Injiainination. — Inflammation of the firm structure which, covered with mucous membrane, extends over the alveolar part, — socket part, — of the jawbone up to the commencement of the crowns of the teeth. When the inflammation is caused by a de- cayed tooth, and involves the periosteum of the fang of the tooth, the term gum hoil is employed to express the disease. Ulceration. — A destruction, by ulceration, of the surface of the gum from irritation or inflammation. IIy2)e7'troj>hy. — An excessive growth or thickening of the structure of the gum. Atrophy. — Wasting of the structure, often called, in advanced life, shrinking of the gums. Induration. — Hardness of the structure of the gum ; a condi- tion which, occurring in infancy, causes much pain and difficult}^ in the process of cutting the teeth. Tumors. — Growths, malignant or non-malignant, attached to or springing from the structure of the gum. The cancerous or malignant growths are usually epithelial. The simple or non- malignant are of four kinds, {a) Polypoid. (Ji) Cartilaginous. {c) Vascular, {d) Fibrous, called sometimes epulis. Perforation of the Palate. — The palate, the bony structure forming the roof of the mouth and, iu the natural state, covered DISEASES OF THE DIGESTIVE SYSTEM. 107 with mucous membrane, is said to be cleft or perforated when from irregular development before birth the two parts of which it is composed have not come together. The condition is some- times accompanied with cleft or harelip. Diseases of the Tongue. Glossitis. — Inflammation of the structure of the tongue, an acute disease of rare occurrence. Ulceration. — An ulceration of the mucous surface of the tongue assuming different forms, {a) Small round ulcers like those seen on the lips, or taking the form of a cleft. (Jj) Wider spread, more irregular shaped, deeper ulcers, (a) Aphthous ulcers, ulcers accompanied with aphthse, often of parasitic char- acter. Ahscess. — A circumscribed accumulation of matter or pus in the structure of the tongue, the result of inflammation. A dis- ease of comparatively rare occurrence. Hyjpertrojphy . — A partial or general enlargement of the tongue, the organ sometimes assuming a great size from interstitial de- posit between the muscular fibres of which it is composed. Cancer. — Malignant disease commencing in the tongue, usu- ally in the epithelial form of the malady, but taking, sometimes, the hard or scirrhous type. Vascular Tumors. — Various forms of tumors, made up mainly of arterial and venous vessels, and attached to the tongue from its cellular or connective structure. Cellular Injiltration. — A condition I have observed and de- scribed, in which the whole cellular structure of the tongue has become infiltrated with diseased serous fluid as the result of inoc- ulation, through a wound in the tongue, of decomposing animal substance taken as food. The tongue is greatly enlarged so as to protrude from the mouth, is of soft spongy consistency, and com- pletely infiltrated with a serous, milky-looking decomposing fluid. Paralysis. — The tongue often shares with the lips and other parts of the body in paralysis. In rare instances it is subjected to paralysis of motion independently of the rest of the body. Tongue Tie. — A malformation in which, from prolongation of the little central band called the fraenum, the tongue is tied down to the lower jaAV. 108 LOCAL DISEASES. Exfoliation of the Mucous Membrane. — In some dyspeptics, especially in persons wlio smoke excessively, the tongue is some- times coated with a thick white fur, which peels off, carrying with it the epithelial surface and leaving an irritable red surface beneath. Diseases of the Throat, The part of the mouth called the fauces, the back of the throat, is commonly injected, inflamed, and ulcerated in the course of some acute febrile affections, such as scarlet fever. It is also subject to several purely local affections. The following are the more important : Sore Throat. — A diffuse injection of the mucous membrane of the throat, with raised points, accompanied by a sense of sore- ness, heat, and dryness, but without exudation of any membra- nous substance. The affection is a frequent attendant of a com- mon cold, — cold and sore throat, — and may be associated with some degree of temporary deafness and feeling of pressure on the drum of the ear. The Eustachian tube, which extends from the throat into the middle ear, is then also affected. Relaxed Throat. — A state of the mucous membrane of the fauces in which, with redness and irritation, there is a relaxed condition of the mucous merabi'ane, with j)rojecting folds of membrane which are often, at the same time, large and relaxed. The condition follows usually upon cold and sore throat, but it may be induced by mechanical causes, such as severe hoarse cough, screaming, shouting, frequent reading in one harsh tone, and overstrain in singing. It is induced also, in persons who are susceptible to it, by no means an inconsiderable number, by smok- ing tobacco. It is more frequent in men than in v.'omen, and specially in men who are engaged in occupations in which the voice is employed in one strain. Thus to one chronic form of this affection the term " clergyman's throat " is applied, because it aifects numbers of the clergy who, while in indifferent health, read the services of the Church and preach too frequently. Ulcerated Throat. — A condition in which the nnicous mem- brane of the throat is in parts destroyed so deeply in bad cases, that the connective tissue beneath it may be seen. It is tlie re- sult, as a rule, of inflammation of the mucous membrane or of specific disease. DISEASES OF THE DIGESTIVE SYSTEM. 109 Quinsy. Cynanche. Cynanche Tonsillaris. — An inflamma- tion ending often in formation of matter in one or both tonsils. The disease is usually brought on by cold, and occurs most fre- quently in the young. It is strongly hereditary. Tonsillitis. — Sometimes called follicular tonsillitis. A super- ficial inflammation of the tonsils common in childhood. The tonsils are swollen, but the inflammation is on the surface, and matter does not form in the substance of the tonsil. The disease is apt to assume a chronic form in children who are badly fed, or who are of weakly constitution. Hyj^ertrophy . — Enlargement, or hypertrophy of the tonsils, from repeated or long-continued chronic inflammation. The en- largement may be so marked and persistent that the tonsils may have to be removed altogether by operation. Cynanche Maligna. — Called also sloughing sore throat or pu- trid sore throat. A low and dangerous form of inflammation of the tonsils, attended With death or putrefaction of the mucous membrane and sloughing of the tonsil itself, there being no at- tendant scarlet fever. The disease seems at times to have taken an epidemic character, but has not been shown to be contagious. It is not so common now as it was in past days. Other Affections. — The tonsils, in diphtheria, may be swollen and covered with diphtheritic false membrane or spots of false membrane. The tonsils are occasionally the seats of cancer. Finally the tonsils are often enlarged and irritable in persons of scrofulous taint, so that chronic enlargement is, by some, believed to be an indication of that taint. When connected with scrofulous swellings in other parts of the body, enlargement or abscess of the tonsils is called scrofulous disease of the tonsils. Elongated Uvula. — An enlarged condition of the uvula, with elongation, so that the inverted apex of the structure descends into the throat and is a cause of irritation, with some difficulty of swallowing and occasional sense of choking and cough. Stricture of the Fauces. — Contraction of the back of the throat, sometimes from accident, as from drinking of scalding water ; at other times from severe inflammation ; and again from malignant disease. Tumors of the Fauces. — There are several varieties of tumors affecting the fauces : — Malignant or cancerous growths ; flbro- cellular and fibro-cystic non-malignant growths ; specific growths ; 110 LOCAL DISEASES. the mucous covering of the fauces being the seat of syphilitic ulceration in persons who are under the taint of that specific disease. Diseases of the Pharynx. Pharyngitis. — Infiammation of the mucous membrane of the pharynx or expanded part or pouch lying between the fauces and the commencement of the gullet or oesophagus. Ulcer. — Ulceration of the mucous surface of the pharynx. There are two varieties : — {a) Superficial ; the ulceration being on the surface only, (b) Perforating ; in which the ulceration extends through the mucous membrane or even through the coats of the pharyngeal tube entirely. Ahscess. — A circumscribed accumulation of matter or pus in the structure of the pharynx. Tumors. — Tumors or growths affecting the pharynx ; of which there are the same varieties as above iiamed in respect to the fauces. Other Affections. — The pharynx is subjected to other forms of disease. Sloughing of the mucous surface. Dilatation. Adhe- sion of the soft palate. Injury by scalding and by corrosive sub- stances. Sj'philitic ulceration. Impaction of foreign bodies. Paralysis. Constriction of the pharynx, stricture, is an occasional disease usually the result of accident. Diseases of the CEsophagus or Gullet. (Es(yphagitis. — Inflammation of the mucous membrane of the tube extending from the pharynx to the cardiac end of the stom- ach. The inflammation is generally the result of an accidental swallowing of some irritant ; but it may arise from erysipelas of the throat, or from inflammation extending from the throat or the stomach. The disease is of rare occurrence. Ulceration. — An ulcerated condition, localized in the oesopha- geal tube and involving the mucous surface. The ulceration is of two kinds : — («) Supei-ficial ; involving the mucous surface only, (b) Perforating ; the ulceration extending more deeply, so as to cause, in the extreme form of the affection, perforation through all the coats of the tube. Stricture.— K condition in which the gullet is constricted at one or more points, so that foods and drinks are swallowed with DISEASES OF THE DIGESTIVE SYSTEM. Ill difficulty, or are prevented from being swallowed altogether. Tliere are several varieties of stricture of the oesophagus. Spasmodic Stricture. — Stricture in which the obstruction is due to simple spasm of the oesophageal tube. A condition often connected with hysteria, and, though alarming for a time, recov- erable as a general rule. Traumatic Stricture. — Stricture in which the constriction has been caused by irritation and inflammation due to an injury in- flicted on the oesophageal surface in some part of its course, as by the swallowing of scalding water, or of corrosive substances. A condition in which the act of swallowing may be rendered perma- nently difficult, but in which the mischief need not, necessarily, become fatal. Simple Organic Stricture. — A form of the disease in which there is simple thickening of the tube at some part, without ten- dency to ulceration. Malignant Organic Stricture. — The most common form of stricture of the gullet. The affection comes on in persons subject to the hereditary taint of cancer. It is excited originally, in most instances, by some accidental irritation. The malignant manifes- tation takes at least two distinct forms. It is sometimes of a firm or cartilaginous character ; at other times it is of an ulcerative character. It is most common in the upper third of the tube, but may be developed in two or more points at the same time. I have seen it in three. The tendency is to progress to a fatal issue, either by producing a complete obstruction or by an ulceration extending through the tube, perforation, Dysjyhagia. Difficulty in swallowing. The term is applied generally to indicate difficulty in swallowing from any cause. It is also ap- plied to express difficulty arising from spasm or other mere tem- porary state by which the act of swallowing is impeded. Literally it means swallowing badly, and is rather a definition of a symptom than of any particular disease. Diseases of the Stomach. Gastritis. — Inflammation, acute or chronic, of the lining mem- brane of the stomach. There are several varieties of gastritis. Simple Catarrhal Inflammation. — A temporary and slight in- 112 LOCAL DISEASES. flammation of the gastric mucous surface, attended with pain, thirst, some fever, and sometimes bilious vomiting. Acute Inflammation. — Inflammation occurring without an obvious external cause ; attended with pain, sensation of sinking, vomiting and fever, with tendency to sudden collapse. Traumatic Gastritis. — Acute inflammation of the mucous sur- face, arising from the swallowing of scalding or corrosive sub- stances. Gastro-Enteric Inflammation. — Inflammation of the stomach coincident with inflammation in the intestinal canal. A condi- tion occurring during the existence of intestinal or enteric fever, and adding seriously to the dangers of that complaint. Ulceration. — Ulcerative destruction of the mucous membrane of the stomach and of adjacent structures. There are five varie- ties of this ulceration. Small Defined Gastric Ulcer. — An ulcer of the mucous mem- brane of similar character to the simple circular ulcer of the lip, and productive of much pain, especially after food. Perforating Gastric Ulcer. — An ulcer extending deeply, but often limited and circumscribed. It extends sometimes so deeply as to perforate through the whole of the coats of the stomach and to cause death by allowing the contents of the stomach to enter the abdominal or peritoneal cavity. Traumatic Gastric Ulcer. — An ulcer of the stomach produced by injury to the coats of the stomach, as by the swallowing of heated or corrosive fluids, and, in rare cases, by the swallowing of hard solid substances. Alcoholic Gastric Ulceration, — A diffused ulcerated condition in which, from the long-continued action of strong alcoholic drinks taken in free quantities, the mucous surface becomes studded with small ulcerated points which often give out blood, and which always give rise to extreme dyspepsia, deficiency of appetite, uneasiness, pain, and failure of digestive power. Malignant Gastric Ulcer. — Ulceration of the mucous surface of the stomach, from the development of cancer. Cancer. — The stomach may be the seat of cancerous disease, especially of epithelial or diffuse, and of scirrhus or hai-d cancel-. The cardiac part of the stomach is most frequently the seat of epithelial, the pyloric of scirrhus cancer. Tlie disease, in either case, is, as a rule, developed in those only who are under the DISEASES OF THE DIGESTIVE SYSTEM. 113 taint of the constitutional malady, and both forms are, np to this time, fatal conditions of disease. Hmriatemesis. — Literally vomiting of blood, but a term used to define loss of blood from the stomach only. H^matemesis may occur from extreme congestion of the vessels of the stomach, but it is most frequently a result of rupture of vessels from ulceration. This loss of blood is often extremely profuse from the stomach during the congestion and ulceration produced by the taking of alcoholic drinks. Siirvple Tumors. — The stomach may be the seat of growths or tumors of the non-malignant kind ; fibro-cellular, fibro-cystic, cystic, and gelatinous or colloid. The colloid tumor is by some considered malignant in character. Parasitic Disease. — The stomach may be the seat of various forms of parasitic disease. It may be the seat of aphthous para- sitic affection. It may be a point of attachment for cysts contain- ing the larv83 of parasites. It may hold parasitic growths in its digestive and mucous fluids. Spontaneous Laceration. — The stomach may be spontaneously torn or lacerated during some act of exertion of the body, or even during digestion of food. The accident is usually preceded by degenerative changes, during which the coats of the organ have become so weakened that they are easily ruptured. Injuries of the Stomach. — The stomach is liable to accidental injuries. External blows over the stomach and affecting it are extremely and suddenly dangerous. Wounds penetrating the stomach are causes of great danger, although there have been re- coveries from such wounds. Injuries from swallowing foreign substances of large size and irregular foi-m, are also occasional]}' produced, though here again it is remarkable how much disturb- ance the stomach will sometimes bear. This is well seen in men who, as a feat, pass a blade or cane into the gastric cavity. Dyspe/psia. Literally bad or imperfect digestion. A condition in which the food taken into the stomach is not naturally digested, and in which the stomach becomes either overcharged with food, or subjected to foods that undergo fermentation or other changes M'hich are not according to nature. Pain, distention, oppression, disturbed bowels, and excitement or depression of mind, are the 114 LOCAL DISEASES. leading signs of dyspepsia. Dyspepsia when it is sharp and short is said to be acute ; when it is subdued and continuous, it is said to be chronic. It may be due to one or other of the diseases of the stomach itself, or to entire carelessness in loading a healthy stomach with foods and drinks which it was never intended to receive. The last-named is, by far, the most common cause of dyspepsia. Gastrodynia. Pain in the stomach, or pain referred to the stomach, occur- ring usually after a meal, sometimes periodically and acutely. The periodic form of gastrodynia is often of neuralgic or gouty character, and may alternate with attacks of tic or neuralgia in other parts of the body. It is dependent rather on constitutional than local causes. Gastrodynia occurring after food, and not otherwise periodically, is a common symptom of indigestion. Pyrosis. Commonly called water-brash. A sudden rising into the mouth of a thin fluid, brackish in taste, and now and then acid. The eructation often occurs early in the morning, before break- fast, and in many persons is attended by a singular sensation of exhaustion and feebleness. It is induced by alcoholic drinks, by smoking tobacco, by eating sweets, — especially such nauseous sweets as chocolate cakes, — and by oatmeal porridge. The watery matter thrown up is not always the same. It is in some cases a mere watery fluid containing the seci*etions of the stomach, while in other instances it contains, in addition, forms of organ- ized growths called sarcince ventriculi, which seem to be con- nected with some peculiar fermentative change excited by food through which the organized particles were first introduced, and in which they have continued to be generated. Degenerative Gastric Exhaustion. The stomach in aged people, and in people who are prema- turely aged, undergoes an enfeeblement both in its secreting power and in its muscular tone. Under this condition the func- tions of the stomach become imperfect and its action, at last so indifferent that all desire for food ceases and the body sinks from inanition. DISEASES OF THE DIGESTIVE SYSTEM. 115 Vomiting. Vomiting, though called a disease, is rather a symptom of some derangement that excites the stomach to revulsive action than a disease in itself. It may occur under any of the affections of the stomach which we have seen, as well as in other condi- tions, such as sea-sickness and sickness from fear or mental emo- tion. In the latter case the impression producing the phenome- non is primarily made on the nervous system and is reflected to the stomach. Dilatation. — The stomach may be greatly dilated, and the dilatation may remain permanent. This is often the case in per- sons who for long periods daily over-indulge in eating. It also occurs in dyspeptic persons in whom the stomach is much dis- tended wdth gases. In some kinds of chest disease, phthisis pul- raonalis, chronic bronchitis, asthma, in which the stomach per- forms vicarious work by retaining and ejecting large quantities of gas, distention and dilatation of the stomach is extremely com- mon. The stomach when permanently dilated is feeble in its contraction, and secretes the digestive fluids most imperfectly. Dilatation is a source of persistent indigestion and general de- rangement of the body, and is a more frequent cause of prema- ture vital decay than is usually supposed. /Stricture. — The stomach is occasionally the seat of stricture, the pyloric end or outlet being the part most frequently constrict- ed. The stricture may be spasmodic in character. It may be a simple thickening of the mucous membrane. It is more fre- quently the result of malignant disease. Gastric Fistula. — By gastric fistula is meant a permanent opening, that is not natural, from the stomach to some other part. The stomach in this way has been made, either by acci- dent or by operation, to communicate directly with the outside of the body through the abdotninal wall, and by the opening so pro- duced foods and drinks have been introduced into it. The pro- cess of stomachic digestion has thus been observed from stage to stage. By a gastric fistula the stomach has also been known to communicate with the intestines, and even with the bladder. Gastric Hernia. — An accidental affection, in which the stom- ach protrudes through a!i opening in the abdomen, or through an opening in the mesenteric membrane within the abdominal cavity. 116 LOCAL DISEASES. Refiex Disease froTn Gastric Irritation. The stomach, richly supplied with nervous fibres, derived both from the cerebro-spinal and the sympathetic nervous sys- tems, is a frequent centre of reflected irritation to remote organs. This is shown in the convulsions of infancy arising from stomach derangement ; in that form of epilepsy of the adult called stom- ach epilepsy ; in palpitation of the heart from distention or op- pression of the stomach ; and in vertigo or giddiness and faintness, from the same cause. Diseases of the Intestines. Enteritis. Inflammation of the whole, or of a portion of the mucous tract of the small intestines. In some instances enteritis is a purely local affection, occurring after exposure to cold and priva- tion. In other instances it is the result of injury, or of the pas- sage of irritant substances with food, or of improperly-digested food, into the intestine. In a third class it is induced by sympa- thetic irritation, as in examples where the neighboring mesenteric glands are the seats of acute disease. Lastly, it is an accompani- ment of certain forms of general disease, especially of typhoid or enteric fever. It is, in fact, so regularly a part of this fever that the word "enteric'' is as often used to express the fever as the word "typhoid." In typhoid the lower part of the small intes- tine is the most seriously involved, the groups of mucous glands called Peyer's glands or Peyer's patches being specially affected, swollen and inflamed, or ulcerated. In all its forms, acute and chronic, enteritis is a serious dis- ease. The irritation keeps up a frequent discharge from the bowels, wdiich is most exhausting. The absorption of food is in- terfered with, and the danger is always contingent that ulceration, proceeding to perforation of the intestine into the peritoneal cav- ity, will take place and will lead to an all but certain fatal termi- nation. Enteritis may assume a slow or chronic form, in which case the suffering person is for a long time subject to pain in the bowels, diarrhcea often attended with loss of blood, and exhaustion, ending in death from obstruction or perforation of the intestine. DISEASES OF THE DIGESTIVE SYSTEM. 117 Typlilitis. Under this term the College authorities define a disease which consists of inflammation of the mucous membrane lining the cae- cum or large pouch in the right lower side of the abdomen, the pouch in which the small intestine ends, and from wliicli the colon or large intestine takes its rise. The caecum has been called the second stomach, the idea once being that in it the final pro- cess of intestinal digestion was carried out. It is often the recep- tacle of food that has not been digested, and of substances, such as magnesia, taken as medicine for long periods, which do not admit of being digested, and it is to irritation caused by the pres- ence of such bodies that the inflannnation known as tyjjhlitis is usually due. The most remarkable illustration of the disease I have met wutli was one in which the cause of irritation w'as a large concretion made up of magnesium carbonate, which drug the affected person had in early life been made to take for several months in repeated doses. The disease, acute at first, becomes chi-onic, as a rule, and terminates in various ways. The substance in the caecum, as in the instance just referred to, may break up, and after much suffering be ejected by the bowels ; or it may create abscess or accumulation of matter which may burst into the peri- toneal cavity, or may even escape through an external opening from the body. Dysentery. The term dysentery is most commonly applied to define a severe epidemical, but not contagious, affection of tropical coun- tries. The disease consists of inflammation, principally of the mucous surface of the small intestines and of the solitary glands there, followed by ulceration, and, in very bad cases, by perfora- tion or contraction of the intestinal tube. The disease, in the first instance, is marked by choleraic discharges from the bowels followed by discharges of blood, the latter being the specific symptom. In the epidemic form dysentery is often a very fatal disease. In temperate and cold climates dysentery rarel}' occurs, but persons who have lived in tropical, and have returned to temper- ate, climates, suffer, especially in hot weather, from symptoms of chronic dysenterj'. Occasionally, too, persons permanently 118 LOCAL DISEASES. residing in temperate climes experience dysenteric symptoms, due to extreme irritation in the intestinal canal from the presence there of undigested food or other foreign substances. Chronic Affections of the Intestine. Ulceration. — An ulceration, usually from inflammation, of the lining coat of the intestine, in points, or over an extended surface. The ulceration commences from the mucous coat, and extends more or less deeply towards the external investing mem- branous coat, the peritoneum. Perforation. — An ulceration or injury extending through the intestinal tube into the abdominal or peritoneal cavity. Fecal Abscess and Fistula. — An unnatural opening, perma- nent in character until closed by medical art, from the intestine into some part of the abdominal cavity, or through to the outside of the body. "When the fistula so formed allows the contents of the intestine to escape through it, it is called fecal fistula. Hemorrhage and Melciena. — The intestinal canal may be the seat of hemorrhage, or loss of blood, from ulceration of the mu- cous coat, injury, malignant growths, or undue fluidity of blood. When blood is discharged from the bowel of a dark color or black, the term melsena is sometimes employed to express the condition of disease. Physical Changes of Intestine. The intestine is subject to dilatation in the whole or in parts of its length ; to distention from accumulation of gases within it, tympanitis / and to obstruction from various substances lodged in it that have not been digested. Stricture. — Stricture of the intestine is a constriction of the canal in some particular part. There are several varieties of in- testinal stricture. Spasmodic. — Stricture from a spasm, form usually temporary in character, due to irritation, and often connected with hysteria. Inflammatory. — Stricture fi-om inflammation of the mucous coat, followed by deposition and thickening, or by ulceration and contraction. Mechanical. — ^tvictwve from jyressure on the intestine by some external growth, or by a band of membrane or adhesion surround- ing or enclosing it. DISEASES or THE DIGESTIVE SYSTEM. 119 Malignant. — Stricture from the occurrence of malignant de- posit, cancer, in the intestinal wall. Intussusception. — The involution of a portion of the intestinal tube into another portion, as if a piece of a thin india-rubber tube were pushed, in an involuted or folded manner, into the inner part of the tube. Intussusception as a cause of obstruction in the canal is usually of fatal character. It is, as a rule, the result of some accidental shock or strain. Internal Strangulation. — Internal strangulation of the intes- tines occurs when the intestine is so tightly compressed that the circulation through it is checked and mortification is the threat- ened or actual result. There are two varieties : Mesenteric. — In this form the intestine slips through a small opening in the membranous expansion called the mesentery. Mesocolic. — In this form the intestine slips through an open- ing in the part of the mesentery which hangs like an apron from the transverse part of the colon. In either form the strangula- tion is due to the pressure or tie caused by the opening in the membrane into which the fold of bowel has slipped. The disease is usually the result of accident, and is fatal unless the detection of its nature be speedily discovered, and the resources of operative art be promptly secured and applied. Hernia. Whenever an organ or part of the body protrudes from the cavity containing it, pushing before it the skin of the body, her- nia is said to have taken place. The term comes from hernos, a branch, and implies a branching out of the protruded structure. Thus protrusion of the cerebrum from the cavity of tlie skull is called "hernia cerebri." The. word, however, is most frequently applied to protrusion of the intestines from the abdominal cavity. The intestines are the part most frequently subjected to the acci- dent, a natural sequence from their structure, function, and posi- tion. Hernias are divided, in the first place, according to their characters. If the hernia, or protrusion of intestine through the abdominal wall, can be put back into its cavity by pressure over the skin at the point of protrusion, it is called a rediicihle hernia. If it cannot be put back in this way, it is called an irreducihle her- nia. If it is prevented from returning by some obstacle within it- 120 LOCAL DISEASES. self, it is called an obstructed hernia. If it has become subject to inflammatoiy action, it is called an inflamed hernia. If it is so constricted at the opening from which it has escaped that the circulation through it is prevented, it is called a strangulated hernia. Hernias, again, are named after the parts which they pass through. If the protrusion is through the midriff or diaphragm, it is said to be diaphragmatic • if through the epigastrium, epigastric • if through the umbilicus or navel, umhilical ^ if through the fore part of the abdominal w^alls, ventral ^ if through the back part, lumhar / if in the groin, through the abdominal rings, inguinal • if on to the thigh, below the ligament that crosses obliquely from the crest of the hip to the central pubic bone, femoral y if through the great obdurator ligament in the front of the pelvis, obdurator y if through the ischiatic notch at the back of the pelvis, ischiatic. The most common form of hernia is inguinal. The intestine in inguinal hernia slips through the weakest and one of the most dependent parts of the abdominal cavity. There are six varieties of inguinal hernia : — The Oblique : in which the course of the protruded intestine is, obliquely downwards and inwards in the line of the inguinal canal. The Direct : in Avhich the protrusion is pushed out strongly, forming a direct protrusion from the cavity. The Incomplete: in which the protrusion is not completely into the inguinal 'Canal. The Scrotal : in which the intestine passes quite along the inguinal canal until it enters the pouch called the scrotum. The Congenital : in which the male child is born with the disease. The bowel descending with the testes into the scrotal bag. The Infantile, a variety of the congenital : in which the bowel is enclosed in two adherent folds of membrane. This is also called encysted hernia. Hernia is often produced by very slight causes : by a jerk, as in suddenly pulling open a door that sticks ; by a fall ; by an at- tempt to raise a heavy weight, or any other act M'hich tends to bring a strain upon the intestines that shall make them bear downwards. It is also favored by many causes ; by over-eating ; DISEASES OF THE DIGESTIVE SYSTEM. 121 by over-exhausting exertion ; and, by exertion during times when the body is enfeebled by disease. The affection is hereditary. It is more frequent on the right than on the left side of the body ; and it is so common in civilized communities that in America during the late war one man in every thirteen men was found to be subject to it. Occasionally from strangulation of the intestine hernia proves fatal, but surgical art has reduced the dangers of death fi'om it to a very low figure. Diseases of the Hernial Pouches or Sacs. — When a hernia has existed for a long time it forms for itself a distinct pouch or sac out of the investing peritoneal membrane which the intestine has pushed before it. The sac so formed is, in turn, subject to local diseases, of which the following have been described. Inflamma- tion ; fibrinous exudation, with closure of the sac as a result ; suppuration ; dropsy ; movable bodies within the sac ; tear or laceration of the sac. Tumors of the Intestines. The intestinal canal is sometimes the seat of internal tumors. There are several varieties. Malignant — Cancer in one or other of its forms. Colloid or gelatinous tumor. !Non-malignant tumors and polypus. ParasitiG Disease. The intestinal canal is often the seat of parasites, vulgarly called worms. The three common forms of parasite of this part are the teenia solium, tape-worm ; the ascaris lumbricoides. round- worm ; and the oxyuris verniicularis, or thread-worm. The canal ma}' also be the seat of certain rare forms of developed parasites, and of cysts containing larvae of a parasitic nature. Parasites are always introduced into the canal from without, with foods or drinks. The round-worm and the thread-worm are most frequently present in young persons, the tape-worm in adults. The worms are a source of great irritation so long as they remain, and in childhood are one of the common causes of con- vulsion from reflex irritation. 122 LOCAL DISEASES. Diarrhoea. The word diarrlioea is used to express a looseness or discharge from the canal, in which the action of the bowels is much dis- turbed, and the contents eliminated are fluid and profuse. It may be regarded rather as a symptom of disease than as an actual primary disease ; but custom has made it to be considered as a disease of itself. Diarrhcea is classified, ordinarily, under the fol- lowing heads. Simple Diarrhoea. — A temporary loss or discharge from the bowels of fluid secretion without acute pain. This is called chronic catarrh of the bowels when it is long-continued. Diar- rhcBa is often dependent upon cold, and on changes of season; it is due to congestion of the mucous surface of the intestinal canal, a tendency which in some persons is constitutional. Irritative Diarrhoea. — Diarrhoea accompanied with griping and pain, in w^hich the discharge is induced by some foreign substance in the canal, creating the irritation and exciting the over-secretion. Choleraic Diarrhoea. — A condition of disease in which the dis- charge of fluid from the bowels is very profuse, with pain, ex- haustion, coldness of the body, and, it may be, cramps in , the limbs. This form of diarrhoea is the same as the cholera of the autumn season, generally described and known as autumnal cholera. It is apt to assume an epidemic form, but it is not con- tagious. Paralysis of the Intestines. — The intestines in various parts of their course are subject to paralysis, or palsy, either from muscu- lar wasting or from want of nervous supply. The condition is dependent on some disease pre-existent in the muscular fibre, or in the nervous centres, or in the nerves of the motor parts of the cerebro-spinal system. It is attended with deficiency of propul- sive power in the canal, and, as a result, with imperfect action of the bowels. Colic. An acute spasmodic affection of the intestinal canal, without diarrhoea, but often attended with severe cramps of the abdomi- nal muscles, extending even to the muscles of the extremities. There may be some fever with colic, but severe cases occur in which there is no febrile excitement at all. There are two varieties of colic. DISEASES OF THE DIGESTIVE SYSTEM. 123 Idiopathic Colic. — Colic in which the disease occurs from ordinaiy causes ; usually, from accumulation in the intestines of indio-estible and irritating food. Lead Colic. — Colic in which the disease is caused by taking into the body some preparation of lead, which in its poisonous action specially afPects the nmscular coats of the intestinal tube. Potters, ^v'llo dip the earthen-ware in a solution of lead ; painters, who work in lead paint ; and plumbers, who handle white lead, are very liable to this form of colic, and are sometimes fatally affected by it. Constipation. Constipation is a condition of disease in which the intestinal canal is inactive, and in which, as a result, it becomes loaded with undigested parts or debris of digested food. The large intestine, the colon, is the part usually inactive and loaded in constipation, the signs of the affection being pain and sense of weight in the abdo- men, depression of spirits, biliousness, headache or dull pain in the head, ringing noises in the ears, and bad appetite. Constipation may be due to mechanical obstruction in the canal, or to paralysis. In the large majority of instances it is caused by want of exercise, indulgence in improper food, or inattention to the daily natural action of the bowsls. It is more common in women than in men, and more in men who follow in-door and sedentary pursuits than in those who are engaged in active out-door occupations. It tends to recur more determinately in the aged of both sexes, and it seems to be an hereditary condition in some families. Diseases of the Lowee Bowel or Straight Intestine. The last portion of the intestinal canal, a tube about ten inches long, extending from the end of the colon to the extreme outlet of the canal, and called the straight intestine or rectum, is subject to several forms of local disease. Ulceration. — The mucous surface of this part of the intestinal tube is subject to ulceration as a result of inilammation, and, in exhausting diseases, this is attended with much irritation and discharge from the bowels, giving rise also to paroxysms of ir- ritative fever. The ulcerative surface is usually limited and irregular, Abscess. — A condition in which, subsequent to inflammation, 124 LOCAL DISEASES. there is a circumscribed accumulation of matter or pus m lower part of the straiglit intestine. Fistula. Fistula in Ano. An opening commencing as a result of inflammation and of localized ulceration in the mucous surface of the intestine, low- down in its course, perforating its coats and extending from the lower or straight bowel, into the surrounding cellular tissue, and downwards until it opens through the skin near to the natural outlet of the alimentary canal. Through this fistula the contents of the bowels are apt to pass, unchecked by the volition of the sufferer. This affection, which is called technically "fistula in ano," is a frequent complication of tubercular disease, and particu- larly of tubercular disease of the lungs, pulmonary consumption. It sometimes occurs from the accidental lodgement in tlie lower bowel of some foreign body, as a fish-bone or fruit-stone. Fis- tula is met with in persons of almost all periods of life, and, though painful, is usually amenable to surgical art. The fistulous opening is, in most instances, from the bowel to an outlet through the skin by the side of the intestine. It sometimes opens into the bladder, — recto-vesical fistula^ — in other cases into the urethra, — reGto-urethral fistula, — and in the female, in some instances, into the vagina, — recto-vaginal fistula. These forms of fistula are now also largely amenable to medical and surgical art. Hemorrhoids. Swellings, vulgarly called piles, in the lowest part of the straiglit intestine and consisting of a vas3ular enlargement, or of enlargements, covered by the nmcous membrane, which protrude into the passage, and which often extrude from the outlet of the bowel so as to exist there as small or large painful external tume- factions. There are three varieties of hemorrhoids or piles. Internal. — When the swelling does not descend so as to appear externally, but is a painful internal obstruction, occasionally giving out blood, internal piles are said to be present. External. — When the enlarged tumefactions descend and are detectable externally, external piles are said to be present. They may or may not be returnable. Bleeding. — When either internal or external piles give out blood they are called bleeding hemorrhoids or bleeding piles. DISEASES OF THE DIGESTIVE SYSTEM. 125 Hemorrhoids are caused by indifferent flow of blood through the hemorrhoidal veins, or veins which retm-n the blood from tlie lower bowel into the circulation. These veins empty in great part into the hepatic portal, or venous portal system of the liver, and in almost every case the hemorrhoidal affection is due prima- rily to congestive and temporary inaction of the liver. For this reason the disease is common in persons who lead a sedentary life, and especially in those of sedentary life who indulge in alcoholic drinks. As a rule the first attack of piles is developed after consti- pation. The affection is often excessively painful, is attended with dejection of mind, and where there is much loss of blood, with exhaustion of body. It is amenable to medical and surgical art. He7no7'7'hage. — Hemorrhage, or bleeding from the lower bowel, is usually caused by an enlargement and congestion of the hemorrhoidal veins, but it may also occur from ulceration. In all cases it is secondary to some other local affection. Fissure. — An extremely painful affection, in which the lip or outlet of the lower bowel is fissured, the mucous membrane being divided or cleft transversely down to the circular fibres of tlic sphincter, or muscle which surrounds and closes the outlet. The fissure may be caused originally by tear or accidental cut from the passage of a sharp substance, like a fruit-stone or fish-bone passing from the bowel. It is more frequently the result of deep "ulceration of the mucous membrane. It often attacks those who are subject to hemorrhoids, in whom the mucous membrane is easily congested. It is a remediable affection. Prolajpsus. — A state of local disease in which the intestinal tube, or its mucous membrane at the lowest part, is prolapsed or projected from the outlet of the bowels. The condition is most common in children, but may occur in persons of any time of life. The protrusion may be to the extent of three or four inches, and in the severest forms may be attended with complete strangula- tion of the extruded part. It is caused in most instances by con- stipation, and is generally a recoverable condition, but not always without operation. St/ricture of the Lower Bowel. Internal constriction of the bowel, so that the passage is ob- structed in part or altogether, is called stricture. There are sev- eral varieties of this affection. 126 LOCAL DISEASES. Spasmodic Stricture. — Stricture arising from spasm of the muscular circular fibres, and due to irritation of a nervous centre. This is sometimes an hysterical phenomenon. External Stricture. — Stricture produced by pressure on the tube externally, as by a tumor, an abscess, or a band. Internal Non-malignant Stricture. — Stricture in which the mucous membrane is contracted from thickening or deposition beneath it ; or from ulceration followed by contraction. Malignant Stricture. — Stricture in which the constriction is caused by one or other of the varieties of cancer. In most cases of stricture of the lower bowel the disease be- longs to the cancerous or malignant form. It is more frequently developed in the lower third of the tube than in the other parts. Tumors. — The lower bowel is the local seat of tumors which may be simple or malignant, and of the same types as those al- ready described .as developing in other parts of the intestinal canal. Parasitic Disease. — The lower bowel is the most common seat of the parasite called thread-worm, Oxyuris vermicularis. It may also be the seat of cystic parasitic growths. Sjpasm of the Sphincter. — The circular band of muscular fibres which encircle the lower bowel at its outlet is sometimes subject to spasm and spasmodic closure : this may be of four kinds. Hysterical. — Spasm of the sphincter, developed as the result of hysterical spasmodic excitement. Irritative. — Spasm of the sphincter, excited by irritation in the bowel above, or in some remote nervous surface or centre. Traumatic. — Spasm of the sphincter, the result of some injury inflicted from without. General. — Spasm of the sphincter occurring as a part of a general spasmodic condition, as in tetanus. Tenesmus. — A painful condition of the lower part of the lower bowel, accompanied with straining, desire for action of the bowel, spasm of the sphincter, sense of acidity in the throat by which the teeth are " set on edge," and general irritation, with some irritative fever. The affection is usually due to irritation within the intestinal canal from the presence of a foreign sub- stance. Neuralgia. — Painful neuralgic seizure, affecting the lower bowel, and occurring, as a rule, with more or less of periodic DISEASES OF THE DIGESTIVE SYSTEM. 127 regularity. It is connected nsnally with some other form of neuralgic pain, and especially with sciatica, Pruritis. — An affection of the lower bowel at its outlet, con- sisting of an intolerable itching, and attended often by a slightly raised eruption, which may extend to the adjoining skin. It is caused most frequently by congestion of the vessels of the mucous membrane from disturbance of the action of the liver, and is ac- companied usually by constipation and other signs of dyspepsia. Injuries. — The lower bowel is, lastly, subject to local disease from external wounds and from impaction of foreign bodies within it. Diseases of the Peeitoneuivi. Peritonitis. The peritoneum, or delicate investing serous membrane of the intestines and abdominal cavity, is subject to various local condi- tions of disease. Inflammation of the peritoneal membrane is called peritonitis. It is an inflammatory condition of extreme danger, and is usually attended with high febrile excitement and acute pain. There are many forms of this inflammation. Idiopathic Peritonitis. — In this form the membrane is pri- marily affected, the disease coming on from 'cold and chill, or from exposure to excessive fatigue. Puerperal Peritonitis, — Metro-Peritonitis — Inflammation of the membrane occurring in women during or after .childbirth, and often a part of puerperal fever. Suppurative Peritonitis. — Peritonitis with the formation of matter or pus within the peritoneal cavity. A form of the dis- ease which is extremely fatal owing to the intensity of the local changes and the secondary absorption of purulent fluid from the peritoneum into the blood. Chronic Peritonitis. — Peritonitis continuing in a subdued form for a long time, and maintaining an intermittent febrile state of the system. Tubercular Peritonitis. — Inflammation of the peritoneal mem- brane induced by deposit of tubercular nuitter upon or near to the membrane. The disease often assumes an acute form, with much fever. It is very fatal. 128 LOCAL DISEASES. Adhesive Peritonitis. — A condition in which the surfaces of the inflamed membrane ultimately adhere by exuded adhesive materia], at different points, so that the intestines become agglu- tinated or bound together by the adhesions. Dropsy of the Peritoneum. Ascites. A condition of the peritoneum in which the membranous cav- ity contains an excess of serous fluid. This disease, commonly called abdominal dropsy, is, as a rule, dependent on some other organic mischief by which obstruction to the return of venous blood to the heart has been produced. It is a very common re- sult of liver disease and of organic affections of the heart. Tumors of the Peritoneum,. The peritoneal membrane may afford attachment to morbid growths non-malignant ; cancerous, and malignant colloid, — gela- tinous. It may likewise be a seat for attachment of cysts con- taining parasitic developments. Injuries to the Peritoneum. The peritoneum is very liable to injuries of various kinds. It suffers easily from contusions of the abdomen ; from wounds ; from pressure and irritation caused by foreign substances in the intestines ; and from pressure of the intestines themselves when they are forced into the openings from the abdomen, as in her- nias. The serious results of all such accidents led the older phy- sicians to entertain an almost superstitious dread of injury to the peritoneum, and although they greatly overrated the danger in many ways, their anxiety, drawn from their experience, was not without a considerable quality of sound learning and judgment. CHAPTER ni. DISEASES OF THE HEART, CIRCULATORY APPARATUS, AND BLOOD. The local diseases of the heart and circulatory apparatus are placed under various heads, according to the particular part that is affected. The parts include the pericardium, or double fibro- serous bag in which the heart is enveloped, and by which it is re- tained in position, separated from the lungs, and lubricated. The endocardium, or inner lining membrane of the heart. The struct- ure of the heart itself. The coronary or special circulatory ap- paratus of the heart. Diseases of the Pekicaediitm. The pericardium is subject to several varieties of disease. Pericarditis. There are two varieties of pericarditis. Simple pericarditis. — Inflammation of the pericardial mem- brane. Suppurative pericarditis. — Inflammation with formation of pus or matter. Adhesion. Adhesions in whole or in part of the outer layer of the peri- cardium to the inner layer which is always adherent to the heart. These adhesions follow inflammation of the membrane, and are most serious impediments to natural motion of the heart after they have occurred. With them are sometimes connected de- posits of bony or calcareous substance, which cause the heart to be more or less encased in unyielding structure. 9 130 LOCAL DISEASES. Drojpsy of the Pericardium. An accumulation of watery or serous fluid in the pericardial sac or bag, called vulgarly dropsy of the heart, resulting some- times from inflammation of the membranes, and sometimes from other causes, such as general dropsy. Dropsy of the pericardium has also been known to occur as a purely local disease, without any definite signs of pre-existent disease, and has proved suddenly fatal by the fluid compression exerted upon the heart. To this and all other affections of the pericardium those who are of rheumatic constitution are most liable. Pericardial diseases are amongst the most serious complications of rheumatic fever and the rheumatic constitution. Diseases of the Endocardium A]sd Yalves of the Heaet. Endocarditis. Inflammation of the endocardium, or inner lining membrane of the heart, occurring on one or both sides of the heart, but most frequently in the ventricle on the left side. Valvular Disease. Diseases of the valves of the heart take two varieties of name, one having reference to the name of the valves affected, the other to the nature of the disease. In relation to the valves themselves there are said to be four varieties of disease, viz. : Aortic disease. — Disease of the semilunar or aortic valves; the valves which lie between the aorta, or great out-going artery, and the left ventricle, or great out-forcing structure of the heart. Mitral disease.— Di&e2i^e of the large bicuspid or mitral valve ; the valve which lies between the left auricle and left ventricle of the heart. Pulmonic valvular disease.— Di&e&^e of the small semilunar or pulmonic valves ; the valves which lie between the pulmonary artery,— the artery proceeding to the lungs from the right ventri- cle of the heart,— and the right ventricle. Tricuspid disease.— Idi^Q^^^Q of the tricuspid valve ; the valve which lies between the right auricle and the right ventricle of the heart. DISEASES OF THE HEART AND CIRCULATION. 131 Of these valvular structures the valves on the left side of the heart, — the aortic and mitral, — are much more liable to disease than are the valves, — pulmonic and tricuspid, — of the right side. It maj' be said that valvular disease of the right side is compara- tively rare, a fact I have endeavored to explain in my experimen- tal researches on " the synthesis of valvular disease," by showing that in most instances the valvular disease is due to irritation caused by blood that has undergone an unnatural chemical change while passing over the lungs from the right to the left side of the heart. Yalvular diseases are by far the most prevalent in persons of rheumatic constitution, and are the frequent consequences of acute rheumatic fever. Divided according to the character of the disease the valvular affections of the heart are : — Vegetations. — In which small growths, resembling fungoid vegetations, occur on the margins or fine surfaces of tlie valves. Thickening. — In which the fibrous tissue of the valvular struct- ure is thickened and condensed, so that the valves do not act with due facility in opening and closing, for the admission or arrest of the blood current. Fatty and calcareous degenerations. — The fatty degeneration is called atheroma, the calcai-eous is called ossification. They con- sist of changes in which the valvular structures are transformed, in part, into a form of fatty structure, or into bony substance, and in which the regulating movements of the valves is extremely impeded. Aneurism. — Disease consisting of enlargement, — dilatation, — of the valves, or of enlargement of the vessels by v/hich the valves are supplied with blood. Laceration. — Accidental tear of the valvular structure, under great excitement or strain. In very rare instances this accident has occurred where there has been a fairly healthy condition of valve. Dilatation of the orifice of the valves. — A condition in which the opening or orifice of the valves is much dilated, so that the curtains of the valves which spring from the orifice become inca- pable of meeting perfectly in the act of closure. This condition is common in instances in which the heart is subjected for many years to severe strain from over-action, and where all its structures are dilated. It is singularly common in persons who drink freely of alcoholic liquors, few of whom, indeed, escape it. 132 LOCAL DISEASES. In certain of these forms of valvular disease regurgitation of blood is not unf requently detected by the physician. The term means that owing to the imperfect action of the valves they do not close efficiently, so that the blood which they ought to prevent from returning, and which they ought to direct in its course, flows back or regurgitates into the cavity from which it was projected. Eegurgitation through the aortic valves is the most frequent form of this derangement. Organic Diseases of the Steuctuke of the Heart. The heart, an organ composed of muscular fibre, is subject to diseases of its own true structure, and to diseases arising from nervous or functional disorder. The first of these are the organic diseases of the heart, and they range as follow : Myocarditis. Inflammation of the muscular structure of the heart. A rare form of disease, ending often in fibrous or fatty degeneration of the muscular structure. There are three varieties. Interstitial, occurring during existence of the syphilitic taint or constitution. Rheumatic, occurring in persons of rheumatic constitution. Alcoholic, occurring in persons addicted to,the free use of al- coholic drinks, and ending often in fatty degeneration. Ahscess of the Heart. Formation of matter or pus in the muscular structure of the heart. A very rare affection. Hypertrophy of the Heart. Hypertrophy is a condition in which the heart is increased in size beyond what is natural, until, instead of weighing nine or ten ounces, it increases to double, or, as I once saw it, to three times that weight. There are three varieties of the disease. Hypertrophy simple and general. — In which the whole of the muscular walls of the heart are enlarged equally, the cavities of the organ remaining of the same size. Hypertrophy simple and partial. — In which a part of the wall of the heart, usually of the left ventricle, which is naturally twice DISEASES OF THE HEAET AND CIKCULATION". 133 as thick as the right, is increased in size, the cavity or ventricle remaining of the same size as in healtli. Hypertrophy general, with dilatation. — In which the walls of the heart are generally increased in size, the cavities being also dilated or extended beyond their natural capacity. Hypertrophy partial, with dilatation. — In which one of the sides of the heart, usually the left, is enlarged, with dilatation of the corresponding ventricle or cavity. Hypertrophy in its purest forms means simple increase of the muscular structure of the heart ; but it is rarely long unattended with other changes, such as fatty deposit. It creates extreme embarrassment to the circulation of the blood. It is induced by various causes, {a) By obstruction to the circulation, and over- work of the heart in order for it to overcome the difficulty ; {h) by excessive and long-continued physical exertion, as practised by rurmers, rowers, and persistent sharp walkers such as postmen ; (c) and above all, by constant stimulation and over-action from the use of alcoholic drinks. Hypertrophy with dilatation is a fre- quent combination of disease. By some the affections of the heart are divided, according to the parts implicated, whether on the left or on the right side of the heart. They are so divided in the College record. Atrophy of the Heart. Atrophy, as its name implies, is wasting of the substance of the heart, so that the organ becomes reduced in size. The waste occurs in the inuscular structure, and, as a rule, to which however I have more than once seen an exception, is general in character, including the whole structure. The cavities of the heart usually retain their natural capacity, or they may be increased in capacity rather than diminished. Atrophy occurs during wasting condi- tion of the body, and is commonly attended by structural change or degeneration. I have seen it caused by excessive development of fat around the heart, and I believe this to be a more important cause of it than has been supposed up to the present time. Excess of Fat on the Heart. In animals fatted for the market it is found that the heart is loaded with fat, which lies in a dense layer close to the muscular structure, and which in the sulci or spaces between the auricles 134 LOCAL DISEASES. and ventricles, and between the ventricles on the exterior of the heart, exists as a thick roundish lajer that cannot easilj^ be torn away. In some instances, in the human family, in persons sub- ject to obesity, fat in like manner accumulates on the heart, and forms a firm, heavy, and cumbersome surrounding. The effect is to interfere seriously with the action of the heart, to create heart- breathlessness, — cardiac apnoea, — on slight exertion of the body, and ultimately to derange the nutrition and structure of the heart itself. Dilatation of the Heart. Dilatation of the heart is a condition in which one or more cavities of the heart are dilated without either hypertrophy or atrophy of the muscular walls ; or in which the orifices leading into or out of the cavities of the organ are expanded, dilated, and relaxed. There are two varieties, {a) Of the left side or cavities of the heart, auricle, ventricle, or both, {h) Of the right side, auricle, ventricle, or both. Fatty Degeneration of the Heart. Fatty degeneration of the heart is a change of the physical structure of the organ in which the true muscular elements which lie in transverse lines on each other in each muscular fibril, are transformed into or replaced by series of fatty particles which possess no power of contractile aggregation, and undergo no modification into motion under nervous or other stimulus. The heart so degenerated is therefore, in proportion to the extent of the change, practically dead. Fatty degeneration is promoted by indolence and luxurious living ; by living in bad air ; and, most easily of all, by the use of alcoholic drinks. It becomes an hered- itary disease. Fihroid Degeneration of the Heart. A degeneration of the muscular structure, of slower develop- ment and course than the fatty change, in which muscular ele- ments are replaced, more or less, by fibrous elementary structure which possesses no irritability, and fails to respond to the nervous stimulus. Together with this state of disorganization there is thrown out a plastic fluid, probably a modified fibrine, which is not developed into natural muscular tissue, but which fills up the DISEASES OF THE HEAET AISTD CIRCULATIOl^. 135 meshes of the fibrous structure, causing a deposit wliich enlarges, hardens, and incapacitates any remaining muscular fibres for their natural action. Fibroid degeneration is connected often, if not always, with some constitutional taint, syphilitic, rheumatic, or alcoholic. It is less rapidly fatal than the fatty degenerative change. Aneu7'ism of the Heart. Aneurism of the heart means a condition in which, owing to weakness of the muscular wall, there is a protrusion of the wall pushing before it the serous covering of the heart, and forming a pouch or sac containing blood. The disease is very rare, and when it occurs is preceded by degenerative changes. Acute Aneurism of the Heart. Another form of aneurism defined by the Royal College as applicable to cases " in which blood becomes effused into the sub- stance of the heart owing to inflammatory softening and rupture of the endocardium and muscular tissue." Rujpture of the Heart. An accident in which the heart under strain bursts, or is rupt- ured in some part, letting out its contained blood into its peri- cardial sac or cavity. Philip V. of Spain is said to have died from rupture of the heart on hearing of the defeat of his army. Some deaths are occasionally recorded from the same cause in our own time, after excitement from hurry, rage, or other form of severe excitement. In such examples there has always been some pre- ceding disease of the structure of the heart, such as fatty, fibroid, or aneurismal degeneration. The accident is rare. I once knew rupture of the heart to occur in a man who was supposed to have died of Asiatic cholera. Disease of the Cokonaey Arteries. The arteries which go off first from the line of the circulation to supply the prime organ of the circulation, the heart itself, with blood, are called the coronary arteries, because they encircle the heart, as it were, with a corona or crown. These arteries are sub- ject to various forms of disease. Dilatation. — General dilatation of the vessel. 136 LOCAL DISEASES. OhstriLCtion. — From narrowing of the vessels or deposit in them. Degeneration. — From fatty or osseous changes of structure. Aneurism. — From aneurismal enlargement of the artery. Disease of the coronary arteries leads invariably to injury of the nutrition of the heart itself, and to degenerative changes in its structure. Sudden death sometimes, but very rarely, occurs from quick arrest of the circulation of blood in the coronary circulation. Cyanosis, or Bltte Skin Disease. The heart is subject to various kinds of malformation, that is to say, in plain language, departure from the natural construction. The error of this kind which concerns us most is that which gives rise, after birth, to the disease cyanosis, so called because the body of the sufferer is blue in tint. The error in the mechanism of the heart in this disease is, that an opening between the right and left auricles of the heart, called the foramen ovale, and which previous to birth allowed the blood in the right auricle to flow direct into the left auricle without passing first through the lungs, but which ought to close after birth by a firm membrane so as to prevent that direct exit and insure that the blood is made to pass over the lungs, does not close. The result of the failure of clos- ure is that after birth venous blood passes from the right to the left side of the heart without undergoing due change from respi- ration, i.e.^ without being duly arterial ized. The person who has cyanosis is of dark bluish color ; is cold over the body ; is of feeble constitution ; and, rarely lives beyond five years, although I have known an instance of the kind in which, under extreme care, life was extended to twenty-two years. The intellect, in this form of disease, if not brilliant, may be clear and sound. Death is usually caused by congestion of the lungs, or by develop- ment of tuberculous or other disease of the breathing organs. In one instance recorded, by the late Dr. Mayne of Dublin, the deficiency of the heart above named, deficiency of closure of the foramen ovale, led to an opposite condition, namely, to the passage of a portion of arterialized blood from the left auricle back into the right auricle, and into the venous side of the circu- 'lation ; so that the person affected, a woman, who lived to be over twenty years old, was always being supplied with sujper- DISEASES OF THE HEART AND CIECULATIOISr. 137 oxygenated blood. She was the subject of profuse perspirations, attended with great lassitude and feebleness of body, like a feeble person in a tropical climate. She died suddenly after some slight exertion. Functional Diseases of the Heakt. Syncope. — Fainting Fit. A failure of the heart, leading to sudden collapse, coldness and failure of the body, with unconsciousness, called commonly deliquium, swoon, or faint. Syncope may occur from nervous shock, bodily exhaustion, loss of blood, or mental emotion. In syncope, as I have shown in a Croonian Lecture, the size of the heart is for the time reduced, and the organ, which still continues to beat regularly, is working at low pressure, in a state of " pas- sive efficiency," that is to say, in a degree sufficient to sustain its own life, but not to maintain consciousness and the other active functions of vitality. Sjjcism. of the Heart. Angina Pectoris. A sudden spasm of the chest, involving the heart, attended with severe pain, coldness of the body, and prostration, and with much difficulty of breathing. The disease occurs in paroxysms, and is vulgarly called heart or breast pang. I have proposed to call it cardiac apnoea, heart breathlessness. Irregularity of the Action of the Heart. Under the influence of organic disease of the organ, but much more frequently under nervous disturbance, the heart may un- dergo ii'regularity of movements. There are several varieties of these irregular movements. Palpitation. — Palpitation is a sudden violent over-action of the heart, during which the natural sounds are indistinguishable, and the impulse is so strong that it may even be seen through the clothes of the aifected person. The pulse, in this state, is ex- tremely rapid in movement, and when its movements are trans- lated into sound by the sphygmophone, instead of being heard as three distinct sounds, the sound is as of a wheel in loud and rapid rotatory motion. Palpitation is usually attended with flusliing of the face, sense of fulness and oppression of the chest, rushing of 138 LOCAL DISEASES. blood to tlie head, and want of power, ending in faintness or ex- liaustion. It is usually excited bj some distant irritation, in the stomach, bowels, or throat, and is often relieved immediately by eructation of flatus. Acute irregularity of the heart-heat. — An irregularity in which each beat of the heart is given in correct order of succes- sion, the one stroke to the other, but in series of five, ten, or other number of beats, differing in rate from other series. This irregularity occurs when the action of the heart is feeble, as in ansemia, and after loss of blood. Prolonged irregulai'ity of the heart-heat. — A condition in which the strokes of the heai-t may register during one minute a certain number of beats, say seventy, and the next minute a dif- ferent number, say ninety or a hundred, so that from minute to minute the rate of motion varies. This irregularity is common when there is disease of the brain, and in some acute affections of the brain in children it is a very dangerous indication. Intermittent Action of the Heart. Intermittent action of the heart is a condition in which the stroke of the heart is every now and then lost, so that when lis- tening for the sound of the stroke in the chest over the heart, or when feeling for it in the pulse at the wrist, it is lost, and does not occur when it is expected and ought to occur. If we are listening to the liealthy heart we hear always two distinct sounds, a first sound and a second sound, the second sound being followed by a pause. The first sound, which is connected with the act of contraction of the ventricles and with the sending forth of the blood over the lungs and over the whole body, the systole, — sus- tello, I contract, — is called technically the systolic sound. It is caused by the closure and tension of the great valves lying be- tween the auricles and ventricles of the heart, and resembles in sound the word liib. The second sound is connected with the time of the refilling of the heart with blood, when the ventricles are in a state of dilatation, diastole, — dia, apart, stellu, I send, and is called, technically, the diastolic sound. It is caused by the closure and tension of the little semilunar valves which lie at the base of the pulmonary artery and great aorta, and resembles in sound the word duj). So there are produced two very distinct sounds, litb^ diij), and DISEASES OF THE IIEAKT AND CIRCULATIOjST. 139 then follows apause. The first sound, luh, is equal in length to the duj? and the pause, the whole occurring within a second of time. With the lah the heart is contracting ; Math the dujj it is refilling ; with the pause it is resting, waiting, as it were, to take breath before it sends forth its charge. That little pause is, in fact, the holiday time or sleeping time of the heart ; the only rest the organ has in the three billion of strokes which it must make in a life of fourscore years ; but after all, when it is fairly obtained, one-fourth of the whole period, viz., twenty years of rest. In intermittent pulse this rhythm of work is lost. "When we listen for the luh, dup, pause, we get it a few times, and then, with a lapse which may almost make the listener start, we miss the long stroke, and get instead, duj/ y afterwards in a sort of knuckling over fashion, there follows luh, dap, dup / and, next time, in rhythm again, lich, dap, pause. If the finger be on the wrist while the ear is over the heart, the pulse, at the moment when the ear loses the luh, fails to be felt ; the systole or sending forth of blood has been, for that time, withheld. Intermittent action of the heart means, therefore, a failure in the contraction of the heart, by which the blood is sent forth over the body. It does not, of necessity, mean any disease in the structure of the heart itself, for it may be present when the heart is in the most healthy state organically ; but it means a functional disturbance owing to irregular supply of nervous stimulus. My researches, recorded in another essay, have shown that in- termittent pulse is usually the result of some form of nervous shock, — grief, anger, fear, physical injury, anxiety, and the like. It is almost always present, at times, in persons who have passed their sixtieth year, but it is often developed much earlier in life, and it may be congenital and be existent from the moment of birth. It is not of itself a fatal condition ; but when the heart is diseased, or when other diseases are present in the body, it is a source of evil, adding much to the danger. It may be considered essentially as a sign of organic nervous failure. Fibrinous Deposits in the Heart. In some forms of disease the cavities of the heart become the centres of fibrinous separations or deposits of fibrine from the blood. In some inflannnatory diseases, croup, inflammation of the lungs, malarial fever, surgical fever, or fever following surgi- 140 LOCAL DISEASES. cal operations, puerperal fever or fever of childbed -^omen, these depositions are causes of death, acting in a rapidly fatal manner. They are also met with after certain forms of disease from animal and mineral poisons. The separations of fibrine may occur in either of tlie cavities, the auricles, or ventricles, on the right or left sides of the heart, but the right cavities are then- most fre- quent seats, and the right auricle the most frequent part in which tlie process of separation commences. The fibrinous masses formed in the heart are often of pure white color, fibrous in text- ure, and so extensive as to fill the cavity of the right auricle and pass through the ventricle into the pulmonary artery and its branches. The mass is sometimes a solid cylinder, at other times tubular, and now and then a spiral, from blood having flowed around it. Diseases of the Aeteeies. The larger blood-vessels, arteries, and veins are liable, like the heart itself, to various structural changes or diseases. Those of the arteries are classified in the following order. Arteritis. Infiammation of an arterial structure, beginning in the inner lining or serous coat of the vessel. It is a rare disease, and of difficult detection during life. Fatty and Calcareous Arterial Degeneration. Changes taking place in the structure of the arteries, leading to deposits of fatty or of calcareous material. The first of these changes is called atheroma, the second, ossification. In both in- stances the vessels at the affected part lose their elasticity and their contractile power, and are easily ruptured under extra press- ure from the heart, or from back pressure due to retarded circu- lation in the veins. In this condition rupture of the arteries supplying the brain is a frequent cause of apoplexy ; and rupture of the large arteries near the heart is a frequent cause of sudden death, from internal hemorrhage. The degenerations are not common until after middle life. Narrowing and Obliteration of the Arteries. Conditions in which the arteries are reduced in calibre or completely closed. The closure is usually due to deposits within DISEASES OF THE HEART AND CIECULATIOlSr. 141 the coats of the vessels, or to pre-existent inflammation of the vessels. Occlusion of the Arteries. The arteries are sometimes occluded, so that they fail to per- mit the Ijlood coming from the heart to traverse them. Occlusion is of two kinds. («) From compression. In which an artery is subjected to compression from pressure exerted upon it by some external sub- stance, such as a tumor or growth ; or from the displacement of an organ ; or from effusion of fluid into a closed cavity ; or from the presence in the body, near to an artery, of some foreign sub- stance which presses upon the artery. (b) From impaction of coagula or clots within the arten^ Occlusion of a portion of the arterial system is much more com- monly caused by impaction, i.e., by the filling up of a portion of an arterial tube with coagula or clot of blood. The clot in these cases may fill up the vessel at the spot where it, the clot, is formed, that is to say, at the place where the process of coagula- tion has occurred. Or a small clot may be formed in one part of the arterial system, or in the heart itself, and may be carried to another part where, owing to the calibre of the vessel being less, it fills up the vessel and creates the obstruction. This latter con- dition is one of the causes of apoplexy, a small clot set free fills up an arterial trunk ; or a series of minute clots fill up the mi- nuter branches of the arterial circuit of the brain. Occasionally these detached masses which occlude the arteries are composed of other matter than coagulum of blood. Portions of warty excres- cences detached from the valves of the heart may cause the ob- struction, and a mass composed of fatty substance has also been met with. The old physicians called the larger depositions of fibrine which occur in the arterial vessels, polypi, mistaking them for polypoid growths. Dilatation of the Arteries. Dilatation is an increase in the size of an artery beyond its natural calibre, but equally in the direction of its course. Dila- tation is common in the large arteries near tlie heart in persons of advanced life, and is often attended with changes and deposits in the arterial coats. There is also a form of general dilatation 142 LOCAL DISEASES. of the arterial system common in hard drinkers and others who have subjected the arterial vessels to great pressure of blood. The dilated artery is incapacitated, to a large extent, for the work it has to perform in the economy. It has lost its elasticity to a considerable degree, so that its recoil, from the dilating stroke of the heart, is imperfect. The circular organic muscular fibres with which it is endowed are, moreover, deprived of their natural due contractile power. Aneurism of the Arteries. An aneurism of an artery is a dilatation of the arterial vessel, but with this difference from simple dilatation, that the enlarge- ment is not general in the course of the vessel, but is at one part, and is attended with thinning, or even rupture, at the affected spot of one or more of the arterial coats, which, as we have seen, consist of an investing, an elastic, and a muscular coat, and an inner or serous lining. Aneurisms are classed under several heads. The following are the most important varieties of an- eurism. {a) Fusiform aneurism. In which the dilated part is like a spindle, large in the middle and reduced at both ends. (b) Vascular aneurism. In which the dilatation is round like a hollow ball or sac. (c) Diffused arterial aneurism. In which the sac or surround- ing wall is not made by the dilated artery itself, but by the con- densed surrounding tissues, which have become united or adhe- rent with the broken arterial coats. (rZ) Dissecting arterial aneurism. In which there is partial tear or rupture of the internal tissues of the artery, and effusion of blood between the coats of the vessel, extending for some dis- tance, and dissecting its way between the coats. {e) Traumatic arterial aneurism. Aneurism in which the dila- tation has been caused by a wound inflicted on the artery. {/) Aneurism by anastomosis. Aneurism by arterial vessels which are carrying on a new circulation owing to obstruction in tlie main arterial current through which the blood originally passed. There are some other varieties of aneurismal disease whicli are of rarer occurrence, such as arterio-venous aneurism, aneu- rismal varixj varicose aneurism, and arterial varix; but those DISEASES OF THE HEART AT^D CIRCTJLATIOlSr. 143 classified above concern ns most as being the more decisive and frequent. Aneurism of the large vessels, as of the great aorta at its commencement or arch, and of the vessels springing from the arch, are the more serious and common aneurisms ; but aneurism of the popliteal artery, — the artery running through the hollow space at the back of the lower limb between the thigh and the leg, behind the knee-joint, — is also common. Aneurism is in- duced by acts which cause great strain on the arterial system, and especially when such acts subject the body to rapid jerks and sliocks. In the old posting days aneurisms of the aorta were so frequent, that the term "post-boy's disease" was applied to them. Aneurisms are specially liable to occur in persons who are disposed to degenerative disease of the arterial coats, and it has recently been observed that persons who are born suffering from syphilitic taint, or who have themselves contracted that specific disease, are more liable to aneurism than other persons who are free of such constitutional affection. The question whether an- eurism is hereditary in character has not been satisfactorily set- tled. It affects those who have approached the middle term of life more frequently than it does the young, but I have neverthe- less seen it affecting the yonng, under fifteen years of age. An aneurism is occasionally healed, spontaneously, by deposits on its inner surface of fibrine from the blood and by gradual oblitera- tion of its sac or pouch by that gradual process of deposition. Rupture of an Artery. Kupture of an artery means a breakage through the arterial coats, without preceding dilatation or aneurismal enlargement. Rupture occurs from two causes : — {a) From disease in the artery itself by which the coats are weakened and destro^-ed. (J)) From disease of the structures outside the artery and ex- tension of the disease into the vessel, as when an artery is in- volved in an abscess or in an ulceration. Diseases of the Yeins. The veins, vessels which bring the blood back to the heart after it has passed from the arteries through the minute cii-cula- tion, are subject to local changes or diseases, which, on the official collegiate record, are put under seven principal heads. 144 LOCAL DISEASES. PKlebitis. Inflammation of tlie structure of the veins. There are two varieties. {a) Adhesive inflammation. In which the vein is inflamed, and has deposited in it fibrinous coagula or blood clot. (5) Suppurative inflammation. In which purulent matter, pus, is formed at the part inflamed, often with ulceration of the vein, ending in adhesion and obliteration. Phlegmasia Dolens, White Swelling. A condition of inflammation of the iliac and femoral veins, veins of the groin and thigh, in which those vessels become ob- structed bv coagula, and the returning blood, from the lower part of the limb to the heart, is impeded or prevented. The limb thereupon becomes swollen, tense, white, and extremely painful, while the whole system becomes feverish, disturbed and pros- trated. Phlegmasia dolens occurs in women after childbirth, and is i-arely developed under other circumstances. It is sometimes rapidly fatal, the cause of it being often due to a detachment of a portion of the coagulated fibrine in the vein and the floating of the clot, thus separated, into the heart, where it becomes the centre of a lai"ger clot and an obstruction to the blood in its pas- sage to the lungs from the right side of the heart. Fibrinous Concretions in the Yeins. Separations of fibrine from the blood in the veins ; sometimes occurring from local causes, sometimes from a general condition of the blood in which there is a disposition to the separation and the coagulation of its fibrinous part. Obstruction in the Veins. Obstruction to the course of the blood back to the heart by a vein. There are two causes of such obstruction, {a) External compression. In which the vein is compressed by external pressure, as from a tight garter or bandage ; or from the growth of a tumor ; or from pressure of fluid contained in a serous cavity or cyst. {b) Disease in the vessel itself, by which its canal is filled, or its coats become adherent. DISEASES OF THE HEAET AXD CIRCULATION. 145 Phlebolites. Small loose masses or concretions, feeling like seeds, in the veins. When they are in the veins immediately beneath the skin they can sometimes be moved by the pressure of the finger. Varicose Veins. Yeins enlarged and knotted, the enlarged j)arts being filled with blood ; a condition most frequently met with in the veins of the legs. The affected vein, in these instances, is distended with blood, and the distention may even proceed, though such is rarely the case, to actual rupture or tear. Varicose veins are induced in some persons by remaining long in the upright position and taking little exercise. They are also caused by obstruction to the return of the venous blood to the heart, from liver diseases and heart diseases, in which the free current of returning blood is impeded. The tendency to varicose veins is hereditary. Nmvus Vascularis. A vascular growth, on the skin, usually consisting of a series of small capillary vessels forming a dark vascular tumor, which in some cases throbs or pulsates. A small naevus is of ten vulgarly called a blood wart. A large diffuse nsevus, not raised above the skin, is called a mother's mark or a port-wine stain. Injuries of Veins. The veins are often subject to injuries from blows, from com- pressions, and from wounds. They may be ruptured or torn without an external wound, and may give up much blood beneath the injured surface. This happens in cases of bad bruise. In some accidents a large vein having been cut or opened, air is drawn into the opening and, being carried to the heart along the vein, is a cause of fatal obstruction to the circulation of the blood through the lungs. Functional or Organic Diseases of the Intermediate or Minute Yascular System. Between the arteries and the veins there exists the wide- spread surface or net-work of communicating blood-vessels, which we already know as the minute circulation. To these vessels the 10 146 LOCAL DISEASES. term capillary, capillus, hair, was once applied. Tlie term still retains its place ; but we are accustomed now, in speaking of the system of fine vessels which lie between the arteries and the veins, to thinlc of them as something more than fine hair-like tubes for conveying blood. AYe know now that these tubes are endowed, in a part of their course, with contractile powers, and that their contraction is regulated with natural automatic precision by the nervous stimulus derived chiefly from the great centres of the organic or sympathetic nervous system, and that through the nervous system they are influenced both by physical and emotional vibrations. Hence this minute circulatory system is a centre of balance lying between supply and demand, — supply of blood for feeding and sustaining the tissues of the body, and demand, by the tissues, for the supply. Hence again,' this minute circulatory system, subject to nervous disturbance from physical and emotional shocks, derived from without the body as well as from within, is exposed to variations of action and to changes which by their mere occurrence affect in the most sensitive and explicit manner the nutrition and the powers of the body. A shock of a physical kind, a blow or stun, communicates to the minute circulation, through the nervous centres, an impulse which, for a time, more or less prolonged in proportion to the force of the impression, makes the small vessels dilate or con- tract, and so causes them to disturb the supply of blood which gives color and life to all the parts for which it is destined. In like manner mental shock communicated to this circulation, through the senses and nervous centres, causes dilatation or con- traction, making the surfaces of the body, as the face, flushed or blanched, the mental concussion acting, virtually, as if it were a physical blow. In other states this minute circulation is relaxed or paralyzed, from different nervous impressions, and the course of blood through it being then uncontrolled, the vessels become distended with blood, the heart vehement in its action, and the secreting and nutritive processes quickened to overflow and waste. The body " braced up " by exercise in an invigorating air is in a condition in which the healthy tension of the minute circulation is perfect. The body relaxed, inactive, in heated, unchanged, damp, tropical air, is in a condition in which its powers are greatly thrown away and its vital energies too much expended in DISEASES OF THE HEART AND CIRCULATION. 147 the mere acts of eliminating and evaporating the excessive pro- ducts of uncontrolled secretion and nutrition. We are beffinnins; now to discern that much of the nature of diseased action is primarily traceable to influences telling upon the nervous supply of this great though minute system of blood-ves- sels, in which animal heat is generated, animal parts selected out, animal structures built up ; in which, in short, all the animal or- ganism is being constructed during life. The minute circulation is subject to the following changes. Spcism, or Contraction, more or less Permanent. This may be produced by : — {a) Physical shocks. Blows ; stuns ; heat-stroke ; electrical stroke ; nervous concussion ; sudden exposure to great and dry heat ; high barometric condition of air. ih) Mental shocks. Passion ; fear ; sudden starts ; sudden and intense grief. (c) Substances taken into the body. Some poisons, such as strycliTiine, brucia, tobacco. {d) Some conditions of disease. Acute fever ; tetanus ; teta- noid fever ; various obscure changes in the nervous centres ; press- ure on organic nervous centres from flatulency and dyspepsia. Relaxation or Paralysis of Minute Circulation. This may be produced by : — {a) Physical depressions, such as long-continued exposure to cold, or cold and wet ; privation ; impure air ; low barometric condition of air ; excessive fatigue. (b) Mental depressions, such as long- continued grief ; worry ; anxiety ; mental strain ; prolonged as opposed to sudden fear ; minor developments of all the passions ; corroding excitements. (c) Some diseased conditions. Such as exhausting diseases, like consumption and diabetes ; organic changes in the nervous centres ; possibly, some poisons of disease, such as cholera poison, and poison of scarlet fever. id) Some poisonous agents, such as alcohol, which for fre- quency of effect stands first ; and agents like nitrite of amyl, which for suddenness of action on the minute circulation, in para- lyzing it, is the most potent. 148 LOCAL DISEASES. Organic Changes of Minute Circulation. That changes of the most important kind for the production of disease are induced by long-continued or repeated disturbance in the minute circulation is a fact which day by day is being moi-e and more recog-nized by the physician. In particular, it is now known that the organic modihcations of structure in vital organs which follow persistent indulgence in alcoholic drinks are prima- rily due to tlie continuous relaxing influence exerted by those drinks on the nervous function of the minute vessels, and tliereby on the nutrition of the structures which they supply with daily food in the form of blood. This is one, and at present one of the best illustrations ; but the whole question of the origin of organic diseases is so intimately connected with the changes inci- dent to the minute circulation, and is now being so carefully con- sidered, that much wider views and departures of knowledge in relation to it may be expected during succeeding years. It has been sufficient for my purpose in this j^lace to give a mere glance, short, but I hope to the thoughtful reader signifi- cant, of the automatic mechanism of the nutritive processes in the living body ; of the nervous action that is constantly at work to control that mechanism ; of the agencies, physical, mental, moral, by which the control or rhythm may be modified ; and of the re- sults, immediate or deferred, which may follow upon such modi- fication. In the course of the after parts of this volume, as in what has preceded, the bearings of the study of this automatic regulation and of the perturbations to which it is subjected, will be incidentally but amply represented in still more varied lights. . The Blood ts Relations' to Disease. In the whole of the present chapter we have been treating of a system of vessels and tubes constructed for the purpose of con- veying blood through the various parts of the body. It remains for me to add a few sentences on the blood itself in relation to disease, — the local diseases, as they might be called, of the blood. The authorities of the Hoyal College in their nomenclature let this subject pass, as they do that included under our last heading, without notice. To those who are not practically learned in medicine such an omission as this must seem strange. " The. blood is the life," DISEASES OF THE HEART AND CIRCULATIOJST. 149 "blood disease," "good blood," "bad blood," "pure blood," " impure blood," " poisoned blood : " these and many other simi- lar terms convey the idea that the blood is a very centre of all the diseases of mankind. • But when we come to precise facts, when we condescend to learn the true and fixed local diseases concentrated in the blood, great difficulties at once appear ; because, after all, the blood, a constantly regenerated fluid, is but the channel through which diseased conditions, lying apart from itself, are temporarily pre- sented. The blood may be the means of conducting or conveying into the tissues agents which may be poisonous, and so it may be itself poisoned from without. The blood may be the means, and is the means, of conveying poisonous products out of the body and of presenting them for oxidation and destruction to air, and so it may be poisoned frofti within. Both, however, of these states are but passing phases, and the same holds good in respect to all other conditions of disease, with a few exceptions to the contrary so rare they may be allowed to pass without special no- tice. The blood, in brief, is the whole body in transitory solu- tion, and is the representation of the body in that state. It is difficult, consequently, to name any permanent local diseases of the blood ; but it is not without service to look at some changes in its constituen t parts, which may be called its local temporary disorders or diseases. Increase of 'Water of Blood. The blood contains naturally 790 parts per 1,000 of water, and its specific gravity is 1,055. In some forms of disease, such as dropsy, the quantity of water may be largely increased. The blood of a woman who was suffering from ovarian dropsy, I found to have a specific gravity of not more than 1.016. Such blood is incapable of sustaining the natural functions of life. Decrease of Water of Blood. In certain exhausting diseases, such as cholera, where mere is a constant drain of watery fluid from the body, the blood may be left so dense from loss of its water that it may cease to be able to flow through the minute vessels. 150 LOCAL DISEASES. Increase of Fihrine in the Blood.— Hyperinosis. The blood naturally contains from two to three parts in the thousand of the plastic coagulable colloid called fibrine, which while circulating in the vessels is in the fluid state, but which, when the blood flows out of the body, sets or clots. In some conditions of the body the fibrine undergoes increase in the blood, especially in various forms of local inflammations, such as pneu- monia, or inflammation of the lungs, croup, and malarial fever. In extreme instances it may increase to the extent of nine parts in the thousand. When an increase of the fibrine of the blood is present the tendency is to its deposition and to the formation of those fibrinous concretions which the ancient physicians called polypi, and which we have seen classified amongst the local diseases of the heart and blood-vessels. Decrease of Fibrine in the Blood. — Hypinosis. In some conditions the fibrine is decreased to one or even a lesser part in the thousand parts of blood. Blood so circum- stanced is often uncoagulable ; it easily flows out of the vessels, and if a small wound be made, a wound from the bite of a leech, for example, the bleeding may continue to a fatal issue. This state of fluid blood may give rise to an eruption on the body of dark spots like bruises, and to one form of the disease known as purpura. Children are sometimes born with the blood in this state of extreme fluidity, and in exceptional instances the affection is hereditary. Decrease of lied Corjpxiscles of Blood. The natural blood contains one hundred and twenty-seven parts in the thousand of corpuscular matter, made up in great part of the little circular red disks containing a substance known as hcBmaglohin, in a thousand parts of which there is four and one-fifth of the metal iron. The corpuscles may be greatly re- duced in amount without actual danger to life ; but the reduction of them gives rise to paleness of the blood, and, as they are the bearers of the oxygen of the external air into the body, such reduction gives rise also to paleness and feebleness of the body, and to defective nutrition. The disease " ana?mia " is due to a reduction of red corpuscles in the blood, and the " ansemic state," DISEASES OF THE HEART AND CIECULATION. 151 from the same cause, is present in many lingering and wasting diseases. The term ^^jooor hlood " is commonly used to indicate this state. Injury and Destruction of Red Blood Corpuscles. The red corpuscles of the blood are subject to injury, and even to destruction, by various agents acting on the body. By admixt- ure of ammonia and of other alkalies with the circulating blood the corpuscles can be wholly or partly dissolved, made crenate at their marghis, and irregular as if indented or notched. By the smoke of tobacco they are modified in a similar form. By alco- hol taken freely into the body they are reduced in size, and lose their true rounded form, becoming long and " truncated." In blood surcharged with soluble saline substances they are reduced in size, shrunken. In blood surcharged with water they are in- creased in size, lose their flattened form and depressed centres, and become of rounded or globular shape. In instances in which the blood is surcharged with carbonic acid, the corpuscles lose their red color, and the mass of the arterial as well as of the venous blood becomes dark in color. Under all these varying states, the natural function of the blood corpuscle, its power to condense the oxygen of the air which it meets as it circulates through the lungs, and to convey oxygen into the ultimate tissues of the body for supporting the combustion and the nutritive changes, is perverted. Thereupon the healthy state of the body is rendered impossible, and various modifications of organic functions are set up, which, if long con- tinued, lead, of necessity, to natural perversion of function and proclivity to disease. Increase of the White Corpuscles of Blood. Leucocythcemia. Besides the red corpuscles there are, as we know, in the nat- ural blood a number of other corpuscles, far less numerous than the red, which corpuscles are colorless, called therefore the white or colorless corpuscles of the blood. In some forms of disease, especially from changes in certain organs of the body, as the spleen, the white corpuscles increase, and the blood becomes sur- charged with them, the red corpuscles being at the same time relatively decreased. The disease so produced is called " white blood cell disease," or leucocythsemia, a disease of serious import. 152 LOCAL DISEASES. It is accompanied with paleness of the body, great languor and depi-ession, and impaii-ed nutrition. White blood cell disease is probably hereditary in character, and up to this time has been little amenable to treatment. It was discovered in 1845 by the late Dr. Hughes Bennett of Edinburgh, one of the few illustrious in medicine of this age. Poisoned Conditions of Blood. The blood, lastly, may be charged with poisonous substances which so interfere with its function that death may be the result. These poisons may be derived from without, as when a gaseous or vaporous body, such as nitric acid vapor, or chlorine gas, or ammonia vapor is inhaled ; or they may be derived from rapid changes excited in the body itself by some animal poisons, such as snake poison, wnth which the body has been inoculated ; or they may be derived from substances which are natural to the body formed in excess, such as urea, the natural soluble salt of the urine. In yellow fever ammonia has been formed in such ex- cess in the body as to reduce the blood to a fluid like port wine in consistency, the corpuscles being dissolved altogether, and their coloring matter being diffused through the whole mass of the blood like a dissolved coloring principle or dye. CHAPTER ly. LOCAL DISEASES OF TEE BREATEING OR RESPIRATORY SYSTEM. Under tlie respiratory system is included all the orgaas and parts concerned in the act of respiration or breathing ; the nos- trils, larynx, and glottis ; the trachea or windpipe ; the bronchial tubes ; the structure of the lung proper, including the air-vesicles; the pulmonic vascular plexuses ; the nervous filaments; the elastic connective tissue ; the covering of the lung or pleural membrane ; and the space between the lung formed by the meeting of the pleura of each lung — the mediastinum. The diseases of this sys- tem represent a numerous class. Nasal Cataeeh. Coetza. N^asal catarrh is a discharge of fluid from the nose, called also common cold. It is a well-known affection, becoming often epi- demic, lasting usually from three to five days, and, when severe, attended with pain and sense of weight in the head, pain in the limbs, great depression of the physical powers, and irritability and inactivity of mind. There is usually a few degrees of fever dur- ing the presence of catarrh. Ceoup. A diseased condition of the larynx and trachea, in which the breath is drawn through those parts with difficulty, and with the production of a hard or croupy sound, which may become so in- tense as to be actually ringing and shrill. There are two distinct varieties of croup, the spasmodic and membranous. Spasmodic Group. — Called sometimes Laryngismus Stridulus. A spasm of the glottis or opening through tlie larynx into the windpipe and lungs attended with croupy breathing. The dis- 154 LOCAL DISEASES. ease is sudden in its onset. It is usually produced by nervous irritation at some part distant from the larnyx, as tlie stomach, or intestine, or the gums during the process of teething, the irrita- tion being reflected, through the nervous communications, to the muscles of the glottis. The spasm will often cease as suddenly as it came, but it is apt to recur in those who have once suffered from it. Occasionally it proves fatal by the asphyxia or suffoca- tion it produces ; but, as during suffocation, there is a tendency to relaxation of the muscles, death is not so frequent as it might be expected to be from spasm in so important a part of the respira- tory tract. Meiiibranous croup. — The membranous or inftaimnatoi'y va- riety of croup. A dangerously fatal affection. It begins often with sio-ns of cold and hoarseness, but may be developed without these preliminary warnings. It consists of a suddenly developed inflammatory condition of the larynx and windpipe, followed quickly by an exudation, upon the lining surface of those struct- ures, of a layer of fibrine or lymph, which mechanically obstructs the passage of air, and which, if the exudation be large and be not coughed up, causes, in the absence of surgical intervention, death by suffocation. The disease is rare after childhood, affects boys in greater number than girls, and is not contagious. From the severity of the throat affection it is considered as a local dis- ease ; but it is now known that in the croupy condition there is an increase of fibrine in the blood, and a tendency to separation of fibrine in the heart, so that the local manifestation is probably only a part of some general systemic disturbance. Diseases of the Lajbtnx. The larynx, the cavit}'^ or enlargement at the upper part of the windpipe, and which is marked out in the neck at the pi-orninent part vulgarly called " Adam's Apple," is subject to several forms of disease, the following being the chief. Infl'ainmation and ulceration of the ejnglottis. — Inflammation of the valvular structure, which is situated at the top of the larynx, and which falls down in the act of swallowing, to prevent liquids and solid particles from entering the glottis. Inflamma- tory disease of the epiglottis or valve may be followed by ulcera- tion or loss of structure, and in some constitutional states, the DISEASES OF THE RESPIRATORY SYSTEM. 155 syphilitic especially, the ulceration may occur without any pre- vious acute inflammatory affection. Laryngeal catarrh. — A catarrh or profuse secretion from the mucous sm-f ace of the larynx. A condition apt to become chronic, and to recur in those subject to it, particularly during the winter season. Laryngitis. — Inflammation of the larynx without specific croupous exudation. An affection not peculiar to any age of life, and occurring in the acute and chronic form. It is, as a rule, an extension of inflannnatory disease from the throat or from the tracheal and bronchial surfaces. Lar'yngeal ulcer. — Ulceration of the mucous lining of the lar- ynx, extending, it may be, into the cartilages of which the larynx is formed, and ending in necrosis, or death of the cartilages. This ulceration is most frequently seen in diseases of constitutional taint, such as syphilis, and pulmonary phthisis. It has conse- quently been divided into the syphilitic and phthisical types. Laryngeal abscess. — A circumscribed formation of matter, or pus, involving the larynx, and usually following inflannnatory dis- ease of the part implicated. (Edema of the glottis. — A swelling from exudation of watery or serous fluid into the structure of the edges of what is called the glottis, the opening beneath the epiglottis leading into the larynx and trachea. The disease is generally the result of acci- dent, from swallowing or inhaling some hot or irritant substance. It occurs occasionally during erysipelas of the head and face, and I once knew it to happen during a severe attack of nettle-rash. It is a very dangerous affection. Growths in the larynx. — The development of growths within the laryngeal cavity is a cause of local obstruction, happily rare. The gi'owths may be one of three. Warty growths, composed of structure, rather firm, and attached to the inner surface of the cavity by a broad base. Polypoid growths, soft and gelatinous, attached by a pedicle. Cysts, or hollow growths, containing, in some instances, parasitic forms of life. Paralysis, and a2)honia or loss of voice. — In the larynx are situated the muscles which move the vocal cords, the cords whicli stretch across the glottis from the back to the fore part and by the vibration of which the sounds of the voice are pro- duced. In paralysis of the nmscles of the glottis the breathing 156 LOCAL DISEASES. is rendered difficult, and the power of producing andible voice sounds is lost. The term aphonia is applied to the loss of voice, — a, not ; jjhmie, voice. Aphonia is of two kinds, the simulated and the true. The simulated form is of hysteric origin, and though it may last for long intervals of time, is temporary in character. The true is due to an actual palsy of the laryngeal muscles, is dependent on some important nervous injury or dis- ease, and is, in most instances, a permanent affection. Bronchitis and Bronchial Diseases. Bronchial Catarrli. A cold or catarrh affecting the mucous membrane of the tra- chea and bronchial tubes; commencing sometimes in a nasal catarrh, and at other times by itself. It is frequently epidemic, but is not contagious. It lasts from three to five days in its acute stage, and, when it begius in the early part of winter or spring, is apt to pass into a long chronic stage. In some persons it be- comes a disease of annual occurrence, and is attended with very free secretion of phlegm and troublesome cough. The tendency to bronchial catarrh increases with advance of life. Bronchitis. Inflammation of the mucous tract covering the inner surface of the bronchial tubes. A common affection in this country, and fatal to large numbers of persons. It presents two forms, acute and chronic. Acute hronchitis arises, in most instances of it, from taking a severe cold, but it may assume an epidemic form, and from the first be bronchial. There is with it in the earlier stages, chill, depression, a sense of constriction at the chest, difficult breathing, and pain. These signs are followed by fever, and continue until relief is obtained from free secretion of phlegm from the con- gested mucous surface. Acute bronchitis is peculiarly dangerous to the young, the old, and the enfeebled of all ages. Chronic hroiichiUs is in the ordinary way a sequence and con- tinuance of the acute type of the disease. It may nevertheless be developed without the indications of a very acute attack. It is often recurrent in those who have once suffered from it, and DISEASES OF THE EESPIEATOET SYSTEM. 157 pi'obabl}' in tliis kingdom thei'e are more permanent snfferers from chronic bronchitis than from any other disease whatever. It is attended with constant congh, and an expectoration that is often profuse. In the young it may assume a form so severe as to make it imitate phthisis or consumption, and the term hron- chial j)hthi.sis has been invented to define that form of disease, recoveries from which have, without doubt, often been mistaken, by ignorants and pretenders in physic, for recoveries from actual or tubercular consumption. Chronic bronchitis is very fatal to the aged, and it tends to become more determinate with increas- ing years. In addition to these ordinary forms of bronchitis there are other forms in which the disease is induced, as by the inhalation of various vapors, gases, and dusts. It will be shown in a fnturc part, that the affections thus, mechanically, excited nm much the same course as when they follow more common causes, and are attended with similar dangers. They are peculiarly fatal to cer- tain of our industrial populations. Capillary Bronchitis. Some authors have recognized, and I think correctly, a va- riety of bronchitis, acute and chronic, of the fine bronchial ramifi- cations or capillaries, by which the bronchial tubes communicate with the air vesicles. To this type of the disease the term capil- lary bronchitis has been applied. It is a disease intermediate between bronchitis and inflammation of the lung, — pneinnonia, — and it has also been described as pneumonia, under the name of catarrhal pneumonia. It is, in my experience, always sequential to bronchial catarrh or bronchitis, and therefore I venture to place it under the head of bronchial diseases. In the bronchial tract there may, finally, be developed various foreign growths ; tumors, malignant or cancerous, and non-malig- nant ; cysts ; and, parasitic developments. Occasionally foreign bodies from without are carried into the bronchial tubes and lodge in them. Bronchial Structural Changes. The bronchial tubes are subjected to various other changes, of which the following is a brief summary : — Ulceration. — A condition in which there is a circumscribed 158 LOCAL DISEASES. destruction of the mucous lining of the bronchial surface ; an ulcer. Cast deposits. — A condition in which a semi-organized deposit of a fibrinous character is laid down on the bronchial mucous sur- faces so as to take the cast or shape of the tubes. Such tubular casts are, in some rare instances, coughed up entire. ISTecrosis of cartilages. — The cartilages of the rings of the windpipe, and even of the large bronchial tubes into which the windpipe bifurcates or divides, may undergo necrosis or local death, under constitutional taint. There are two forms of this affection marked by their respective taints, viz., the syphilitic and the^A^!A^5^(:•(2Z. Dilatation and contraction of the bronchial tubes. — The bron- chial tubes, under long-continued disease, may become generally dilated, or dilated in parts, like the fingers of a glove, with con- tracted sections in other parts. The air passing through tubes so changed produces sounds of a blowing, wheezing, or whistling kind, which the person affected, as well as those near, may be able to hear. The dilatations which now and then are caused in the larger bronchial tubes, as a result of long-continued laborious breathing, may be virtually cavities in which large accumulations of secretion are held until they are removed by coughing and expectoration. Asthmatic Diseases of the Lungs. Spasmodic Asthma. In the strict use of the word, asthma is a spasmodic disease, in which the organic muscular fibres surrounding the bronchial tubes are thrown into a state of acute spasm, so that the entrance of air into the air vesicles, in which the bronchial passages finally ter- minate, is impeded. The spasmodic paroxysms are often sudden and rapid, but may be unattended by fever. The breathing dur- ing the attack is very oppressed and difficult ; the suffocation is severe ; the body dark, often cold, and enfeebled. Asthma may be excited in those who are subject to it by causes of irritation lying away from the lungs, and one of the most common excitants of it is irritation in tlie stomach or intes- tines, from improper food or defective digestive power. It occurs DISEASES OF THE RESPIRATORY SYSTEM. 159 in all periods of life, is hereditary in character, and rarely passes altogether away in those who are affected by it, although it may be much controlled by care in diet and regimen. Death is not common during the paroxysm, the relaxation incident to dying, if I may so express it, having in itself a tendency to cause relaxation of the spasmodically contracted muscular fibres. There are two varieties of asthma. Pure sjxismodiG asthma. — As above described. Symptomatic asthma. — In which the asthma is an attendant or indication of some other disease, such as heart disease. Thus we hear of cardiac asthma and bronchial asthma. Hay Asthma. Hay asthma, placed by the Royal College first in the list of the local diseases of the lungs, is a spasmodic affection occurring in some persons during the hay season, when the odor of fresli hay is present in the fields. There is, commonly, a sense of catarrh or cold in this affection, with some discharge from the nose, and with paroxysms of severe spasmodic cough, brought on much after the same manner as coughing and sneezing are brought on by taking snuff. The disease is supposed to be due to the in- halation of fine particles derived from the flowers of grasses, and which specially affect particular individuals. The powdered par- ticles of ipecacuanha produce a similar condition in some persons. I have observed that from Russian hemp particles are given off which cause a most aggravated form of disease of a similar kind in susceptible subjects, llay asthma continues as long as the cause remains in action, and it may be prolonged for several days, or even for some weeks, after the cause of it has ceased to exist in the air. Industrial Asthmas. Under the general term asthma, by which is meant difficult breathing, — not necessarily from spasm, but from disease caused by the inhalation of dusts which create destruction of functioii in portions of the lungs, — there are included several kinds of lung disease incident to different callings. We shall see the details of these affections more fully as we proceed, in another part of this work, but the typical asthmas thus referred to nuiy be named, so as to make our record so far complete. They are : 160 LOCAL DISEASES. Grinders' asthma ; Miners' asthma / Potters^ asthma ; Flax- dressers' asthma ; Millers asthma. These asthmas are all specially connected with the occupations by ^vhich they are defined. Diseases of the Steucttee of the Luxg. Pneuriionia.. Inflammation of the Lungs. Inflammation of the lungs, inflammation, that is to say, of the true structure of tlie lungs, the air vesicles, vessels, and the surrounding or investing tissues, which together make up the spongy texture of the lung, is called pneumonia. The disease commonly follows a nasal or bronchial catarrh, or bronchitis, but it may assume an epidemic character, and may begin without any preceding affection. The disease is accompanied with high fever, difiicult breathing, darkness of the countenance, and, after a time, with cough and expectoration of a rusty-colored fluid, due to the presence of the coloring matter of blood. Pneumonia runs a defi- nite course, and, like some fevers, has its critical days, but it is not contagions. Essentially the disease is one, but various writers upon it speak of it as of different varieties. («) Eight and left, and double pneumonia, according as the right or left lung, or botli lungs, may be affected. (Jj) Acute pneumonia ; when the disease is running its acute course, {c) Chronic pneumonia ; when the disease is attended with less fever, and the symptoms are pro- Ion o-ed. {d) Lobular pneumonia ; when the disease is confined to portions of the lung structure, {e) DiffiTse pneumonia, called also interstitial pneumonia, when the inflammatiou involves large portions of the lung structure. (/) Broncho -pneumonia, when the pneumonia is combined with bronchial inflammation, (g) Pleuro-pneumonia, where the disease is combined with inflam- mation of the pleural membrane. (A) Secondary pneumonia, when the disease comes on during the existence of other diseases of the body, especially febrile diseases, such as typhoid, typhus, small-pox, measles, erysipelas, and pyaemia. In this secondary form it is frequently the immediate cause of death. Ahscess of the Lung. A circumscribed accumulation of matter or pus in the struct- ure of the lung, following general inflammation, or produced by DISEASES OF THE EESPIEATORY SYSTEM. 161 some local irritation, such as the deposition of tubercle. It is occasionally produced by the presence of some foreign substance that has been lodged in the lung. Gangrene of the Lung. Gangrene or mortification of the lung structure usually occur- ring in the last stages of the worst forms of pneumonia, and in rarer instances from obstructed circulation. It is almost always a fatal disease when it extends over a large surface even of one lung. The affection seems to have been more prevalent in former days than it is at jd resent. Passive Pulmonary Congestion. Passive congestion of the lung is a condition in which there is stasis or arrest of the circulation of blood from the right to the left side of the heart through the lung, in the course of the pul- monic circuit. The lung, in this instance, is engorged with blood in the affected parts. Pulmonary congestion is brought on by causes which lead to weakness or palsy of the minute vessels of the pulmonic circulation from withdrawal or reduction of nervous stimulus ; or by weakness of the right side of the heart ; or by obstruction of the left side. It is induced actively, by sudden ex- posure to cold ; by over-fatigue ; by the action of some narcotic agents ; by long-continued use of alcoholic drinks ; and by suffo- cation. The most common immediate cause is exposure to cold in persons whose pulmonic circulation is already enfeebled or diseased. Rcemojptysis. Spitting of Blood. Loss of blood from the lungs is what is commonly conveyed under the term haemoptysis. Literally, the term means spitting of blood, Init the source of the loss is so fi-equently from the lungs the phenomenon is as a rule connected with those organs. Loss of blood from the lungs is active or passive. Active^ when pure blood is directly and rapidly given out ; passive, when the blood, in small quantities, tinges other expectorated fluids. It occurs in the active form, from rupture of a vessel, or from great congestion of the lungs. It occurs in the passive form, from partial conges- tion or inflammation of the lung. It is a common accompanying symptom of pulmonary phthisis or consumption in both the early and the late stages of that malady. 11 162 LOCAL DISEASES. Pulmonary Extro/uasaiion or Ajpo])lexy. An extravasation of blood from the vessels of the lung into the spongy structure. It takes place either from extreme con- gestion of the blood-vessels, or from rupture of them. Pulmonary apoplexy is often attended by passive, and sometimes by active haemoptysis or spitting of blood, (Edema of the Lung. (Edema or dropsy of the lung is a state in which the watery part of the blood is diffused into the structure of the lungs. (Edema is usually the result of obstruction to the return of ve- nous blood in the blood-vessels which supply the lungs with the blood required for their own sustainment, that is to say, the nu- tritive vessels of the lungs proper, as distinct from the vessels of the pulmonary artery. Cirrhosis of the Lung. A rare disease, in which the tissue of the lung in the whole, or in parts, is cirrhosed or hardened from condensation of the connective tissue. The disease is most commonly met with in per- sons who have indulged freely in alcoholic drinks. Envphysem^a of the Lung. A condition in which the lung structure is inflated with air beyond the natural filling of the elastic air vesicles during the act of inspiration. Literally it is a passive distention of the lung structure with air, and in a minor degree is analogous to the dis- tention which the butcher produces in the lungs of a dead animal by blowing into them forcibly in order to inflate them before he suspends them in the shambles. There are two varieties of em- physema. {a) The vesicular, in which the air vesicles themselves are dis- tended and dilated. Q)) The interlobular, in which the air has escaped from the vesicles, owing to accidental rupture of them, and has diffused through the connective tissues and lobular structure of the lungs. It is this form of artificial emphysema the butcher produces in the lungs of the dead animal, and in the human subject it is com- monly the result of accidents leading to great strain, as in the DISEASES OF THE EESPIEATOEY SYSTEM, 163 strain of congh in wliooping-cough and asthma. The most ordi- nary form of emphysema is that in which the air vesicles are dis- tended and broken the one into tlie other. Men and animals so affected are said vulgarly to be " broken winded," and the term is wonderfully expressive. In aged people, in whom the elastic tis- sues of the body are much impaired and are wanting in resilience, emphysema is of such common occurrence that the term " senile emphysema " has been employed to distinguish it as a disease that has resulted from old age. Atelectasis of Lung. A term signifying deficient expansion of the lung by breath- ing, and applied to the lungs of a child after birth, when the act of breathing has not been perfected. Tlie lung structure, wanting inflation by air, is condensed, heavy, and sinks in water. Pulmonary Phthisis. Consumption. A condition including various phases and characters of dis- ease, in which the lungs are the active seats of the evil. Nu- merous terms are used by physicians to indicate the different phases of the particular affection, which, under its constitutional designation, is called consumption or phthisis pulmonaris. Ttibercular Phthisis. True Pulmonary Consumption. True pulmonary consumption is that form of phthisis of the lung in which specific tubercular matter is deposited in the struct- ure of the lung in small masses or tubercles, which masses become centres of irritation, inflammation, and suppuration or formation of abscess, ending in destruction of the- structure of the lung and in the formation of what is called a cavity of the lung. The disease is constitutional, hereditary, and doubtfully contagious. It is most commonly developed in the period of adolescence, and in nine cases out of ten is first lighted up hy cold or some nervous depression. Ilsemopt^^sis is a frequent early sym])toin, and there is, usually, an acute stage with fever and a kind of inflammatory condition of the affected part of the lung, tubercular pneumonia. The upper parts or apices of the lungs are usually the first affected. As the disease progresses, there is constant cough, frequent spitting of blood, and wasting of the body ; three 164 LOCAL DISEASES. .symptoms, ^rhich taken together are typical of phthisis. In later .stages there are recurrent paroxysms of fever called " Hectic^'' and profuse sweatings. The disease is very wide-spread in this country, and exceedingly fatal. Acute jjneumonic phtliis is. — A condition in which pneumonia, — inflammation of the structure of tlie lungs, — is developed, in its acute form, in persons susceptible to phthisis. Clironio jyueumonio j^hthisis. — A condition in which chronic pneumonia is developed in the same constitutions. Acute miliary ])hthisis. — A condition in which there is de- velopment or deposit in the lung of a tubercular material of a miliary character, resembling millet seed and widely distributed. True tuber culccr 2)hthisis. — A condition in which the ordinary .form of tubercular substance is deposited in the lung in small separate masses, tubercles, which become centres of irritation, inflammation, and suppuration, followed by destruction of tissue, and cavities. Indxistrial jpMhisis. — A condition in which the mischief in the •lung structure, leading to phthisis, is produced by inhalation of ■substances to which persons following particular industries ai-e sub- jected. Millstone dust, coal dust, flax dust, give rise respectively to millstone workers' phthisis, miners' phthisis, flax-dressers' phthisis. Alcoholic 2MMsis. — The consumption of drunkards. A defi- nition, first applied by myself, to a form of phthisis peculiar to some persons who indulge freely in alcohol. As a rule it occurs after middle age. The various conditions leading to pulmonary phthisis fill up one of the greatest chapters in the history of disease as a whole, and the greatest of all the chapters in the local history of pulmo- nary diseases. Of all .the organs of the body the lungs are most open to invasion of disease from causes operating both from ■within and without the body ; and as in respect to every one of the phthisical maladies the hereditary law of descent is main- tained, the lungs are, taking all in all, the organs most liable to the acquired as well as to the inherited types of the malady. Diseases of the Fleuea. The pleura is the thin, elastic, semitransparent membrane which can so easily be stripped fiom the surface of the lungs. It envelops each lung as in a serous bag or sac, which is reflected DISEASES OF THE RESPIRATOET SYSTEM. 165 on to the inner walls of the chest, covering them, and which between its two surfaces produces a serous fluid for preventing friction or adhesion. The pleura is liable to several varieties of local disease. Pleuritis. Inflcmimation. Inflammation of the pleural membrane in whole or in part is called pleuritis. The inflammation may be acute or chronic. In the acute form it is marked bj fever, and bj great pain in breathy ing. The membrane is injected, inflamed, and extremely sensi- tive, being brought in the act of breathing to rub on adjacent structures. In the chronic form the symptoms are modified and prolonged, but the pain in breathing remains exquisitely acute when a deep breath is fetched, or when cough is severe. Pleu- risy, acute and chronic, is most apt to occur in persons of rheu- matic and gouty constitution. It may exist as an independent affection, but is more frequently connected by sympathetic or organic influence with some other affection of the lung. It is a frequent complication of the other acute diseases of the lungs. Eirvpyeina. Empyema is an accumulation of purulent fluid or matter in the cavity of the pleura ; that is to say, between the two layers of the pleural membrane. Practically, it is an abscess of the pleural cavity, resulting from inflammation, and from the in- flammatory products thrown out during the inflammation. Adhesion^ Thickening^ and Ossification of the Pleura. Adhesion means the uniting together of portions of oppos- ing pleural membrane which, in the natural state, would glide smoothly over each other with perfect freedom. ThicJcening means an enlargement, from deposit of plastic exudative material on the membranous structure, in patches or over the whole surface. Ossification is a transformation of a part of a pleural surface into liard structure, from calcareous or any deposition. Hydrothorax. Dropsy of the Pleu7'a. Ilydrothorax is an accumulation of watery or serous fluid in the cavity of the pleura. It is usually the result of inflammation, but sometimes is due to venous obstruction. The fluid may in- 166 LOCAL DISEASES. crease until it fills the cavity, presses on the lung of the affected side or on both lungs, and even displaces the heart itself. Pneumothorax. Pneumothorax is a condition in which air has entered, and partly occupied, the cavity of the pleura. The accident some- times occurs from rupture of the vesicles of the lungs together with the pleural covering of the lungs. At other times it is from an injury to the chest, as from fracture of a rib. In very rare instances it is from gases developed in the blood. The pleural membrane may also be the seat of cancer, simple tumor, tubercle, and parasitic growths. Diseases dt the • MEDiASTixirir. The space between the liings, formed by the two pleural membranes which cover the lungs, and called the mediastinum, is sometimes a point in which local disease is manifested. Three such forms of manifestation are recorded. {a) A.hscess, or accumulation of purulent matter. (5) Cancer, or formation of malignant tumor. (c) Simjple tumo7\ or growth of tumors which are " non-malig- nant," not cancerous. Othee Pulmonaet Affections. The lungs, finally, are liable to become the local seats of can- cer and of parasites. They are subject to mechanical injm-ies from without, wounds ; to impactions from inhalation of solid foreign materials; and to injmies from inhalation of corroding and irritating gases or vapors. CHAPTER V. LOCAL DISEASES OF THE NERVOUS SYSTEM. In the nervous system the parts and organs subject to disease are the brain and its membranes ; the spinal cord and its mem- branes ; the nervous cords and their peripheral surfaces ; the ganglia and nerves of the sympathetic chain. The diseases of the nervous system are divisible into those which are functional and those which are organic. In fact, no diseases are so distinctly divisible into the two forms of func- tional and organic as those affecting tliis system of bodily organs. It is always most difficult during life for the physician to make an absolutely correct diagnosis, or finding out, of either the acute or chronic diseases of the different parts of the brain and its membranes. The parts lie in close proximity ; the sympathy between them is most intimate ; and, the direct physical exami- nation of them is impossible. It has therefore been necessary to invent a term that shall include in a word any one, or more than one, of the individual inflammatory diseases of the parts enclosed within the skull, and that word is Enc&phalitis, inflammation of the brain or its membranes. At the same time the different parts, as examination of them in post-mortem inquiries have demonstrated, are the special seats of acute inflammatory diseases and of other resultant or degener- ative changes. Diseases of the Membranes of the Brain. The membranous coverings of the brain and spinal cord are subject to both acute and chronic diseases. Acute Meningitis. Brain Fever. The old physicians gave the name of brain fever to a condi- tion of disease which we moderns call acute meningitis, or inflam- 168 LOCAL DISEASES. raation of tlie membranes of the brain. The dura mater, the firm external fibrous covering of the brain, is the part most fre- quently affected, but the irritation which is set up usually extends deeper, to the more delicate membranous structures beneatli, the arachnoid and vascular pia mater. The disease is extremely serious, is attended with a high degree of fever, with extreme pain in the head, and with violent, often furious, delirium. It lasts for many days, and when recovered from often leaves per- manent evidence of failure of nervous power. As an uncompli- cated disease it is exceedingly rare. Meiribranous Yascular Congestion. The vascular membrane of the brain, the pia mater, may be the seat of extreme congestion. This is common under alcohol, and is a cause of the excitement which is present in that form of alcoholic poisoning known as delirium tremens. In one instance in which a man while in this state committed suicide by casting himself under a railway carriage, I saw the brain within four minutes after death, while still the fumes of whiskey were most readily detectable from it. The pia mater was injected to the extreniest degree, lying like a velvety pile over the brain, and within the convolutions. In such examples the membrane, after many excitements, becomes firmly attached, in parts, to the sub- stance of the brain. Tubercular Meningitis. In children and young persons of scrofulous or tuberculous constitution, the membranes of the brain are apt to become the seats of tubercular deposit from the blood. The deposition takes place, as a rule, beneath the dura mater, between it and the arachnoid ; but I have seen it also in the upper surface of the membranes, between the dura mater and the inner lining, or periosteum, of the skull. Purulent matter may form with this exudation. The symptoms of the disease are practically those of brain fever, and the malady is usually fatal. It is a more fi-e- quent form of disease than simple acute meningitis, and it is fol- lowed in some instances by effusion of serous fluid and dropsy of the membranes of the brain, " Acute liydt'ocepTialus.^'^ DISEASES OF THE E'EEVOUS SYSTEM. 169 Chronic HydrocepJialus. Water on the Brain. An accumulation of serous fluid in the investing membranes of the brain, between the brain substance and the outer and firm covering, the dura mater. The fluid is secreted by tlie middle or serous covering, the arachnoid membrane, and accumulates be- neath the arachnoid, in the arachnoid sac or space, and even in the ventricles of the brain. The disease may progress with very little disturbance of the bodily functions until the head has at- tained an enormous size, the yielding bones giving way before it. The disease occurs in young children of strumous or scrofulous taint, and in the end is usually fatal. Latterly surgical art has been the means of saving life in some instances of it. Thickening of the Dura Mater and Degeneration. The dura mater is subject to a form of disease in which it be- comes unduly firm and thickened in structure. In persons who are given to partake freely of alcoholic drinks, this thickening is very common. Some years ago, by the kindness of several pro- fessional friends, I was able to make an inquiry into the condition of the brain in that form of disease which has yet to be described as general paralysis. In every instance I found the dura mater thickened, firm, and dense, and often adherent to the membranes beneath it at one or more points. The I'esistance exerted by the membrane, as thus changed, tends greatly to the production of the paralysis, and I am of opinion that it is, in some instances, the cause of it. The dura mater is also subject to various degenerative changes. It is sometimes affected with calcareous and osseous degeneration, so that it is transformed, in parts, into a bony structui-e. In one instance I observed a projection of bony matter of needle-shaped character, which passed an inch into the sul)stance of the brain itself, and was probal)ly tlie cause of epileptic seizures, from which the person in ^vhom it was found suffered, and in one of which seizures he died. Diseases of the Brain. The diseases of the substance of the brain, as distinct from its membranous investments, are of several kinds. The more im- portant of these arc included under the following heads. 170 LOCAL DISEASES. Inflammation of the Brain. Cerehritis. Inflammation of the substance of the brain itself is of very rare occurrence, and the special symptoms by which it may be recognized are obscure. It is usually connected with inflamma- tion of the membranes covering it, or is dependent, as the College authorities explain, on local injury or foreign deposit. Ahscess of the Brain. As a result of inflammation and formation of purulent matter in the brain substance, abscess or encysted formation of matter may be present in the hemispheres of the brain. The positive diagnosis of brain abscess is very difiicult, and its occurrence com- paratively rare. Congestion of the Brain. Congestion of the brain is a condition in which the vessels are distended, and the gray and white matter are overcharged with blood. The pia mater is also surcharged with blood, and there may be excess of fluid secreted into the arachnoid space, and into the ventricles of the brain. Congestion of the brain is due, most commonly, to excitement and over mental work. It is easily pro- duced by the free use of alcoholic drinks, by passion, by worry and excessive study. It is the origin of much nervous disease. The symptoms of it when it is evidenced in the acute form are extremely severe. There is feverish excitement, and it may be delirium, followed by extreme prostration. In the milder and more common forms the symptoms are : a sense of fulness in the head ; dizziness ; restlessness and desire for change ; irritability of mind ; sleeplessness ; fits of slight fever followed by acid per- spirations ; and, extreme languor. Repeated many times cerebral congestion almost always leads to the production of some persist- ent and serious, if not immediately fatal, nervous disease such as diabetes or paralysis. Bloodlessness of the Brain. Ancetnia. An opposite condition to the congestive is known as anaemia of the brain. In this condition the vessels of the brain are not duly filled with blood, and the structures of the brain, gray and white, instead of being vascular and red, are unnaturally bloodless DISEASES OF THE NERVOUS SYSTEM. 171 and pale. The condition is produced bj exhaustion, mental and physical, and by insufficient food and nourishment generally. It may be the result of long-continued and excessive physical work and fatigue. The signs of it are a sense of faintness, ringing sounds in the ears, and somnolency. The somnolency may pass into deep sleep from which the person cannot be roused, coma. Softening of the Brain. Hannollisinent. Several varieties of softening of the substance of the brain have been named by different authorities, and described as, white or atrophic j red; and, yellow ^oitenrng. Atrophic softening is defined as a form of disease in which the brain substance under- goes what is called white softening, " the result of imperfect nu- trition arising from deficient supply of blood, and in most in- stances dependent upon mechanical obstruction or degeneration of the cerebral arteries." Red softening is a condition in which the brain matter, very soft and cream-like, is of reddish tint or color, the tint being de- I'ived from the red coloring matter of the blood. Red softening is assumed to have its origin in preceding inflammatory disease of the cerebral substance or in repeated and extreme congestion. Yellow softening is a condition in which the brain substance is more nearly like cream, its color being of yellow white. This form is not considered to be of inflammatory origin, but rather a fatty degeneration, somewhat analogous to fatty degeneration of the heart, the brain-cells being transformed into fatty structures. The disease is connected, by some authorities, with anaemia of the brain, and is considered to be one of the results of that malady. All these varieties of softening of the cerebral substance are irremediable, and are attended with failure or irregularity of ner vous, mental, and muscular power. Condensation of the Brain. Sclerosis. An opposite condition of the brain to any of the varieties of softening is now known as condensation of the brain sub- stance, or sclerosis. Sclerosis is a condition extremely simi- lar to what has been before us when we were treating of disease of the lung known as fibroid disease. It is in fact a condensa- tion or hardening of the connective tissue of the nervous struct- lu-e, and the term sclerosis, the same in meaning as sclerotic iu 172 LOCAL DISEASES. relation to tlie outer coat of the ball of the eye, is therefore ap- plied to it. The disease may be localized in the brain, or in the spinal cord, or it may extend through botli. It may come on in early life ; it may come on in later life ; and it may be one of the degenerations of old age. When it is present in children they lapse into imbecility. When it attacks the aged it leads to fail- ure, generally, of the vital powers, and to " the second childish- ness and mere oblivion." Paralysis agitans. SJiaJcing j^alsy. When sclerosis affects the middle-aged it causes persistent motion of the limbs, — -jyaralysis agitans, — a state of disease in which the sufferer cannot control a persistent agitation or trem- bling of the muscles of a part of the body, or even of the whole body, the tremor being attended with gradual loss of muscular power. Paralysis agitans lasts often for many years, ending usu- ally in paralysis of some of the muscles of deglutition, or of some other of the muscular structures which are essential to life, but dur- ing sleep the agitation ceases altogether. This last fact I was able to observe in a person suffering with the disorder who was under my care for many years. I also found the agitation pass away imder anaesthesia from chloroform and from methylene bichloride, but it is a slow and always progressive affection towards death. A2?oj)lexy. Apoplexy means a blow or sudden shock by which a person is stricken down. In this country the people speak of it as '' a stroke." The suddenness of the attack gives a natural meaning to the expression, for the person affected suddenly falls insensible, but remains warm, often becomes feverish, breathes with noise and difficulty, stertorously, and is sometimes convulsed. The dis- ease is rare in persons under the middle stage of life. The symp- toms are due always to some sudden pressure made on the brain, or to some sudden arrest of blood through the brain. Usually one of two accidents produces the phenomena. Either a blood- vessel of the bi-ain gives way from diseased structure and blood is poured forth into the closed cavity of the skull, sanguinous a/po- 2)lexy ,' or, the vessels are obstructed by coagula of blood form- ing in the sinuses, the veins which allow the blood to return fi-om the brain ; thereupon there is effusion of watery matter from the DISEASES OF THE ISTEEYOUS SYSTEM. 173 blood, through the vessels, into the closed cavity ; the pressure necessary to cause the phenomena is produced ; and, congestive or seroics aj.)oplex(/ is the result. Of late years we have learned to discriminate another and more limited kind of apoplectic seizure, in which the minute ar- terial vessels of some part of the brain become obstructed from coagulation of the fibrine of the blood in them, or from the con- veyance into them of minute portions of fibrinous coagulated matter. From these causes there is developed a primar}- shock, not necessarily passing into complete insensibility, followed by some deficiency of power, or partial paralysis, which may be per- manent, but from which there is often a fair recovery. JStinstroke. Sunstroke, sometimes called couj? de soleil, is a form of apo- plexy, attended in its acute representation with all the signs of common congestive apoplectic seizure, and supposed to be due to the direct action of the rays of the sun on the body, during tropi- cal weather. There seem to be two varieties ; one acute and purely apoplectic, specially affecting plethoric, full-bodied persons, who drink freely of stimulants, and who are prone to congestion of the brain ; the other, less acute, in some sense resembling faintness in respect to the symptoms excited, and affecting the prostrated and enfeebled persons. I believe them to be entirely different conditions of disease ; but being brought on by the heat of the sun, acting on difi^erent constitutions, they are usually con- sidered as one, and are incorrectly designated by the same term. IIyj)ert7'oj)hy and Atroj)h>j of the Brain. Hypertrophy means an actual enlargement or overgrowth of brain substance generally. Atrophy means a wasting of brain substance generally. Both are conditions of great significance. As common diseases dependent on physical causes they are rare ; but as conditions produced by mental activity or inactivity, re- spectively, they are, I suspect, common enough. In men of com- pletely developed skeleton, in whom expansion of the skull is no longer possible, an extreme activity of brain leads to condensation of brain substance, and, thereby, to a form of hypertro])hy which is easily transferable into degeneration. In persons of inactive brain and of mere automatic life, atrophy, — wasting of brain 174 LOCAL DISEASES. matter, — attended with sluggishness and feebleness of mind, and faulty nutrition of bodj, is the more common form of brain dis- ease. Aphasia. Palsy of intellectual speech is the nearest short definition of the disease which is known under the unfortunate term, apliasia. In aphasia the voice is clear, words can be spoken, and all the muscles mechanicall}^ required for speech are in perfect action ; but the affected person, when he tries to express himself, uses words that may have no relation to the object he would define by them. Thus, in one example I knew of, the word " sack " was used for the word " chair." Apliasia is very frequently accom- panied with paralysis of the right side of the body, right hemi- plegia, and is due to some organic change, softening, or occlusion of blood in the nervous centre for articulate speech. Aphasia is very little amenable to treatment when it is fully established. Tumors and Deposits on the Brain. The brain is sometimes the seat of morbid growths, of which there are several kinds. The more common are : {ci) Malignant growth or cancer. (J) Fibroid tumor not malignant. (ina Bifida. The spinal cord is in some newly born children the seat of a peculiar malformation called Spina Bifida or Hydro-rachites. From the cord there protrudes, by an opening through the bony structure of the spinal column, a large soft watery tumor or sac which is made up of skin, dura mater of the cord, arachnoid, and serous fluid from the arachnoidal space. The opening in the spinal column is due to imperfect closure of the two lateral halves of the column before birth. The fluid secreted by the arachnoid membrane, finding no efiicient resistance, pushes its way through the opening. The disease is now, in certain instances, amenable to surgical art. Gekeeal Diseases op the Ceeebeo- Spinal System. The cerebro-spinal nerves, issuing from the brain and spinal cord and distributed over the body, are subject to diseases similar to the brain and spinal cord themselves. They may be subjected to inflammation, or neuritis : and to atrophy. They may also be the seat of a fibrous tumor growing on or between their bundles or fasciculi, called a nerve tumor or neuroma. Paralysis. Palsy. StroTae. The most important series of diseased conditions ofiicially classified as connected with the cerebro-spinal nervous fibres or cords is included under the head paralysis or palsy, stroke, in which, owing to the failure of nervous stimulus to the muscles there is a loss of power of will to move parts under the control of the will ; or loss of the will itself to control ; or failure in a part to experience a sensation that would otherwise be received by it and communicated to the sensorium. Palsy of motion. Palsy of will. Palsy of sensation. No disease in the list of human mala- dies plays a more important 7'6le than paralysis. Paralysis is divided technically into many sections : General Paralysis. — Paralysis of the insane. A palsy in which the whole voluntary muscular system shares more or less in the catastrophe. Hemiplegia. — Half palsy. A palsy in which one lateral half or side of tlie body is stricken so clearly that it is customary to DISEASES OF THE NERVOUS SYSTEM. 177 define the condition by the use of the terms right or left ; as right hemiplegia ; left hemiplegia ; according to the side of the body that is attacked. Parajplegia. — Palsy in which the half of the body below tha chest, and including the lower limbs, is stricken by the disease. Locomotor ataxy. — Palsy indicated by ataxy, •z'.^., irregular power of locomotion. The movements of the body are not cor- rectly under the control of the will, and there is inability to walk forward without falling when the eyes are closed. Progressive nmiscular atrophy. — A form of palsy due to grad- ual failure and wasting of the muscular organs, but commencing sometimes with apparent enlargement or hypertrophy of the muscles. Infantile paralysis. — Palsy developed during infant life, and occasionally present from the time of birth. As a rule, this palsy is spinal in character, and is marked in special groups of muscles. It comes on with acute symptoms of fever and convulsive seizures, and ends in palsy of a limb, or limbs. The disease is probably allied to that form of paralysis described above under the head of spinal congestion and myelitis, and is due to some peripheral irri- tation acting on the vascular supply of the spinal cord. The dis- ease sometimes terminates in permanent paralysis. Local paralysis. — Paralysis of some special part or organ of the body. There are two marked forms of this paralysis. The first 19, facial palsy, in which the nervous supply of the muscles of the mouth and lower jaw is induced. The muscles of one side of the face are paralyzed, so that the balance of power between the two sides of the face, by which the natural expression is pre- served, is lost, and the eye on the affected side cannot be closed. The second is known as writer's palsy, and is a form of palsj^ of the hand called also scrivener's palsy, — affecting, specially, writers, like conveyancers, who, in their formal, stiff mode of writing, rest the arm heavily on the paper or parchment, and press the hand heavily down. The whole nervous supply of the hand becomes, in these persons, impaired ; they begin to direct the pen M'ith difficulty; the hand feels benumbed and heavy ; there are starts or cramps of the muscles ; and, in time, if the affection pro- gresses, there is complete loss of power, so that even the grasp of a stick or other object may be impossible. Another form of local paralysis is palsy of the upper eyelid, J9^chthalmia of infants. — Another form of purulent contagious ophthalmia occurring in infant life, especially in chil- dren who inhabit badly ventilated rooms and live under condi- tions leading to feebleness of body. Improper or insufficient nourishment is one of the most potent of these conditions. Strumous or scrofulous ophthalmia. — An ophthalmia peculiai' to those who are of scrofulous taint. It is often persistent in its course, and leads, in bad cases, to impairment or even actual loss of vision. Exanthematous ophthalmia. — An ophthalmia of an exanthem- atous or eruptive character, occurring sometimes during the pres- ence of the ordinary exanthematous or eruptive diseases, such as measles and small-pox. Gonorrhmal ophthalmia. — An ophthalmia connected with the disease called gonorrhoea, and produced by the contact of the specific discharge from that disease with the conjunctiva. An acute and very troublesome affection, leading occasionally to deep inflammation and loss of sight. Chronio ophthahnia. — A slowly progressing ophthalmia, or a continuance, in a modified form, of one of the other of the varie- ties of ophthalmia in the slow or chronic condition. In addition to these diseases the conjunctival membrane is subject to (pxlema, or dropsy, ehemosis ; to fatty and other tumors attached to its surface ; io p>arasitiG disease; to granular ch.A\^ge\ DISEASES OF THE OKGANS OF THE SENSES. 187 to a triangular or wing-like red and fleshy formation called pterygium / and to metall'tG stains derived from nitrate of silver, or from lead. Diseases of the Cornea. The cornea, the horny, transparent, cancavo-convex lens, which lies immediately beneath the nmcous conjunctival mem- brane, is subject to the following local affections : Keratitis^ or acute inflammation of its structure. Chronic interstitial keratitis. — Inflammation of long standing, with interposition of fluid between the layers of which the cornea is composed. Keratitis, luith sujjpuration. — A long, continued inflammation of the cornea, with formation of matter or pus in the layers of the structure. The appearance produced by the presence of the purulent fluid has caused the term onyx to be applied to the affection. Dicer. — A condition, following usually upon inflammation, in which there is active destruction or loss of substance of the cornea. Leiicoma. — An opacity of the cornea, due to a cicatrix. Arcus senilis. — A white line running round the cornea at its circumference, in whole or in part, and commonly seen in the old or prematurely aged. The white structure is composed, chiefly, of fatty substance. At one time the arcus senilis was viewed by practitioners of medicine as an outward and visible sign of fatty degeneration of the heart and other internal orgaiis, and great importance was therefore attached to it ; but later experience has not so fully confirmed this inference as to render it absolute as a gign of internal disease. In addition to the above, the cornea is subject to three other varieties of disease, namely, conical cornea, in which tlie structure is pushed forward in the form of a conical projection : staj)hylo7na, or a white prominence of a dead and disorganized cornea : and, jr)arasitiG disease, hydatids of the anterior chamber immediately behind the cornea. Diseases of the SclerotlG Coat. The sclerotic or investing coat of the eyeball is subject to inflammation, — sclerotitis, — and to inflammation connected with 188 LOCAL DISEASES. acute rheumatism, — rheumatio sclerotitis. These affections are extremely painful, and are attended with fever and much general disturbance of the body. The sclerotic is also subject to staphy- loma, or protrusion from its surface, and to ttiniors attached to it. Diseases of the Iris. Six out of the seven diseases of the iris or curtain of the eye, named on the College list, are inflammatory in character, and the term iritis is used to denote them. In the simplest form of in- flammation, the word iritis alone is employed. When a wound is the cause of the disease, traumatic iritis is the mode of expres- sion. Sometimes the iritis is an accompaniment of other diseases, such as rheumatic fever, arthritis, or inflammation of joints, syphilis, gonorrhoea, or scrofula. Then the iritis is said to be rheumatic, arthritic, syphilitic, gonorrhoeal, or scrofulous. The sequelge of iritis are included under this same head of inflamma- tion, and consist of adhesion of the iris to surrounding parts ; exudation of lymph and protrusion ; permanent contraction ; permanent dilatation; closure; and, irregularity of the pupil. Diseases of the Choroid and Retina. The dark or choroid coat of the eye is subject to inflammation, called, technically, choroiditis, and to congestion of its vessels, choroidal aj)oj)lexy y but these are rarely, if ever, distinct forms of disease affecting the choroid coat alone. Retinitis. — Inflammation of the retina, the nervous screen or coat lying in front of the choroid coat. Amaurosis. — A disease of the retina, dependent upon various changes of the retinal surface, and ending in an inability of the nervous expanse to receive and transmit impressions from the outer world to the brain. Amaurosis may be produced by the exposure of the eye for a long time to a white, dazzling object, like snow, and " snow blindness " is the most familiar example of this disease. It occurs also from other accidents, as from light- nins-stroke, and from blows on the head. It has sometimes its origin in degenerative changes of the retina, in inflammatory changes following exhausting diseases, and in sympathetic irrita- tion. It is occasionally induced by smoking tobacco. Muscce volita7iies. Small specks or spots crossing the field of vision, generally floating, and often taking a slight upward direc- DISEASES OF THE ORGANS OF THE SENSES. 189 tion, and then a downward course in a long carve. The specks assume different shapes ; sometimes thej are mere dark points, at other times they consist of a series of dark points lield together in lines and angles like a loose web or net-work. Again they ap- pear as rings, and not unfrequently as disks with a dark centre, resembling the magnified red corpuscles of the blood so closely that they might pass for them. Kings of this cellular shape oc- cur singly, or in line, or in broken network. Muscse voUtantes appear in yet another variety of shape, namely, in straight, dark lines, arranged in zigzag forms, with the dark edges slightly illu- minated. Muscse are, as a rule, seen most frequently in the sun- light, and as if at some yards distance. They appear greatly e^jaggerated in a fog, and then seem to be within arm's-length of the observer. In extreme instances they are visible by gas and candle-light. Tliey do not indicate actual organic disease of the structures of the eye, but are supposed to be from dtbrls of cells floating in the vitreous humor. Albinism. — A condition of disease existing in persons who are often called Albinos, and in whom the dark pigmentary sub- stance of the eyeball at the back of the iris and in the middle or choroid coat of the eye is not duly secreted. In albinism the eye is seen of a red color within the pupil, and vision, during day- light, is extremely embarrassing and painful. The disease is hereditary, and is peculiar to some families of men and to some lower aniinals. Diseases of the Crystalline Lens and its Capsule. — Cata/ract. The word cataract is an unfortunate but long-used term for defining opacity of the crystalline lens of the eyeball. In cataract the lens becomes white and opaque at some point of its surface, or in the capsule which envelops the albuminoid substance, — globuline, — of which the lens is composed. The opacity extends until, at length, the whole of the lens may be involved, and blindness rendered complete. The process of development is usually slow in its progress, except in the case of saccharine or diabetic cataract, which may be developed in a few days. The process has been called the " ripening " of cataract by the sur- geons, who have an operation for the removal, or depression, or destruction of the opaque lens, and who are accustomed to wait until the cataractous change is complete or ripened before they 190 LOCAL DISEASES. perform the operation. A few j-ears ago Dr. "Weir Mitchell of Philadelphia discovered that cataract conld be artificially j)ro- duced by charging the blood of an inferior animal with sugar. In continuation of his most important research, I observed that the same condition could be produced by nearly all crystalloidal substances, salts, which would enter the blood and increase its specific weight. There are several varieties of cataract : — Hard cataract^ in which the lens has become firm, condensed, and dark. The cataract of the aged. Soft cataract^ in which the lens is of bluish-gray tint, some- times of fractured appearance and swollen or large. The cataract of all ages of life. Fluid cataract, in which the lens is more aqueous than in soft cataract. Traumatic cataract, in which the disease has occurred from an injury to the eyeball. Diahetic or glucose cataract. — A cataract in which the disease is produced by the presence in the blood, in large quantity, of glucose or grape sugar. Congenitcd cataract. — A form of soft cataract in which the opacity is developed at birth. The tendency to cataract is hereditary, but the disease does not generally occur until late in life. Cataract is common to the lower animals, — herbivorous and carnivorous, — as well as to man. Diseases of the Vitreous Body. Synchysis. — The most distinct aifection of the vitreous humor is synchysis, in which the membranous cells are broken up, and the humor, unnaturally fluid, is charged with minute scales. The eyeball is soft, and the iris, or curtain, hangs flaccid. Before vision is lost, bright starlike spots, due to the floating scales, are constantly seen. There is no chance, according to our present experience, of recovery. The disease may be due to a blow, or to slow inflammation, or to wounds inflicted on the eyeball during operations. Morhid deposits. — The vitreous humor is the seat of morbid deposits. Flakes, or debris of its own membranous structure are the commonest deposits. DISEASES OF THE OKGAlSrS OF THE SENSES. 191 General Affections of the Eye, and Defects of Sight. Glaucoma. Glaucoma is an affection in which tlie globe of the eye be- comes large, clnll, and tense, with dilated fixed piipil, greenness of color beyond the pupil, and excavation of the optic disk. The disease, attended with much pain followed by loss of vision, exists in two varieties, the acute and the chronic. It is rather a common affliction, occurring more frequently in men than in women, and not usually commencing before the period of middle life. It has an hereditary character, afflicting those who are of worn or feeble constitution chiefly. It is frequently connected with a gouty or rheumatic constitutional taint. Hydrophthalmia. Hydrophthalmia is dropsy of the eyeball from an accumulation of the fluid secreted in the space between the inner surface of the cornea and the crystalline lens, in which space, called the anterior chamber, the iris or curtain floats. In this disease the eye is large, tense, and staring, and the pupil is dilated. The cornea may or may not be rendered opaque, and vision, if not lost, is much impaired. The disease is due to irritation of the lining membrane of the anterior chamber. Weah Sigld. Ast7ienoj>ia. "Weak or enfeebled sight, though a term commonly used, is not easily defined as connected with any special change in the eyeball. It may be present from an irritable condition of the retina ; from a fluid state of the blood ; from a want of power to accommodate the eye to distances ; from nervous anxiety about the sight ; or, from the commencement of one or other of the diseases of the structures of the eyeball. Most commonly, I think, the term weak sight is applied to one of the two defects of vision that come next before us, mj-opia or presbyopia, before they are fully developed or while they remain undetected. Short Sight. Myojna. A condition of vision in which, from the greater convexity or the position of the lenses of the eyeball, the natural focus of 192 LOCAL DISEASES. vision is not maintained. The rajs of light being f ocnssed before thej reach the retina, objects have to be brought nearer to the eyes than is natural or convenient, in order that thej may be cor- rectly seen. It has lately been pointed out by Mr. Liebreich that this condition may be induced in children by the habit of leaning forward, with the face almost on the paper, in the process of learning to read or write. The disease is of hereditary char- acter. Long Sight. Presbyopia. A disorder of vision, in which the conditions are the opposite from those which are present in myopia. The focus of vision is so deranged that objects have to be held at a distance incon- veniently away from the eyes in order to be distinguished natu- rally. The disease is common to old age, hence the term pres- byopia. Another term, hyjpertnatrojna, has been introduced to define true long sight. It is a common cause of asthenopia or imperfect vision. Color Blindness. A condition in which, fi'om defect of vision, a person cannot distinguish colors correctly, nor tell one color from another. Dr. B. Joy Jeffries of Boston defines the condition as an inability to distinguish one of the basic colors " of the spectrum, red, green, and violet, from gray. A person may be color blind in any one of these colors, red blindness being most common, green next, and violet least." The same author computes that one per- son out of every twenty in the community is affected with color blindness. At one time it was assumed that the diseased state leading to color blindness was confined to the retina, but it is now known to be connected also with changes of disease in the optic nerve, or even in the brain itself. It can be produced by nervous shocks, and, strangest, perhaps, of all, it can be induced by some cliemical substances taken into the body, specially by santonine and by alcohol. The disease is hereditary, and up to this time seemingly incurable in tliose who inherit it. The hy- pothesis as to its nature is that in the retina there is a correspond- ing nerve centre for each basic color, red, green, and violet, and that the color blindness is due to disease affecting these centres. DISEASES OF THE ORGANS OF THE SENSES. 193 Astigmatism, The term Astigmatism, irregular refraction, is applied to a defect of sight, by which the natural acuteness of vision is to some extent lost, owing to different refraction from different meridians of the eye ; so that " rays of light derived from one point do not again unite into one point." The deviation of sight is monochromatic, that is to sa}', an aberration of ravs of the same color. The cause of the aberration lies in the cornea or in the crystalline lens. There are two varieties, the regular and the irregular. In the regular variety the cornea is chiefly the seat of the irregularity. In the irregular variety the crystalline lens is the seat of the irregularity. Astigmatism is now very efiiciently i-emedied, in many cases, by the scientific adaptation of artificial lenses or glasses. Daij and NigJtt Blindness. Day blindness is a term used to describe a disease in which the person affected can only see when the light is subdued, as at night. IS'^ight blindness, on the other hand, means a condition in which there is blindness except in full light. The causes of the two conditions are often vaguely defined, but night blindness is known to visit those, chiefly, who have been exposed to intense or tropical light. The term N'yctalojyia is sometimes used to express the former and Hemeralopia to express the latter affection. Diseases of the Lachrymal Apparatus and EvELros. The lachrymal gland placed at the upper and outer angle of the eyeball is subject to inflammation and to resultant structural changes. But the most common disease connected with the lach- rymal apparatus is obstruction of the lachrymxd duct, the duct which runs from the iimer corner of the eyeball downwards into the nasal cavity, and which conveys the tears from the eyelids into the cavity of the nose to be dispersed there. The lachrymal duct, when obstructed, fails to allow the watery secretion to pass through it, and the tears then flow in continual current over the lids on to the cheek. Acute inflammation of the lachi-ymal sac, — lacryocystitls ; — chronic inflammation of the sac; and abscess aitidi fistula are other diseases of the lachrymal system. 13 194 LOCAL DISEASES. The eyelids are subject to inflammation ; to tlie small or pain- ful follicular boil called a stje, — hordeolum • to abscess ; inver- sion, — entrojyium ^ eversion, — ectropium j falling or palsy of the upper lidi^^^tosis ; cystic gi-owths ; and, cancer. The eyelashes are subject to, ingrowing, — trichiasis j and loss, — madarosis. Derangements "within the Orbit. Strdhismtis. Strabismus, or squint, is the commonest of the derangements of the eyeball within the orbit. The eye is involuntarily drawn from its straight position to one or other side, or obliquely towards one or other side, so that the natural axis of the eye at rest is not maintained. When the direction is inwards, towards the nose, the most common derangement, the strabismus is called convergent ; when it is outwards it is called divei-gent. The error is due either to shortening of one of the muscles by which the eyes are moved within the orbit ; or to spasmodic contraction of a muscle ; or to paralysis of one muscle and relative over- action of the opposing muscle. Strabismus is in some cases an acquired affection ; in others it seems to occur from hereditary proclivity. It often af- fects both eyes in the same person and in the same direction of error, double strabismus ; or it may affect only one eye, single strabismus. Proj^tosis, or protrusion of the eyeball ; abscess ; tumors^ — malignant or non-malignant \— parasitic cysts ; are other forms of disease occurring within the orbit. The orbital nerves are also occasionally affected with disease. DISEASES OF THE EAR DEAFNESS. Deafness is presented under three conditions : — 1. From functional nervous derangement. 2. From deficiency of development, deaf-mutism. 3. From disease of the auditory mechanism. Deafness from functional nervous derangement may occnr without any existing disease of the ear. Deaf-mutism may give DISEASES OF THE OEGANS OF THE SENSES. 195 no actual indication of disease, thongli the organ of hearing itself is, probably, always defective and of imperfect development. The diseases of the ear are catalogued under twenty-one heads. Four are connected with the auricle or outer projecting part of the ear ; six with the external opening or meatus leading from the external orifice of the ear down to the drum ; three with the drum itself ; one with the Eustachian tube, or tube leading from the throat to the middle ear ; three with the cavity of the tym- panum or middle ear ; four with the labyrinth or internal ear. D'iseases of the Auricle. Tlie outer part of the ear, the auricle, is the occasional seat of gouty and other dejjosits, which give lise to prominences and to irregularity of the structure ; of vascular swelling, — hcBmatoma ' of malignant and non-malignant tumors / and, of malformations. In persons of slight and delicate organization the outer ear is often exceedingly small, though it may be perfectly shaped. In persons of large build and of full-bodied circulation the outer ear is some- times large, the lower lobe pendulous and exceedingly large. As a rule, a large lower lobe of the ear indicates a free vascular sup- ply of blood to the brain, and is, to some extent, a sign of epi- lepsy, and of other kindred nervous diseases. The auricle may also be subject to enlargement, — hyperirojjhi/. Diseases of the External Meatus^ or Canal leading to the Drum. Infla7nmatio7i.—lnAsixnmationoi the mucous membrane lining the tube may be acute, attended with pain, swelling, throbbing, earache, and febrile disturbance ; or chronic, in continuation of an acute attack, with less pain and swelling but with frequent discharge, and, in some instances, with ulceration of the nmcous surface. Abscess. — Formation of pus or matter within the passage, the sequel, usually, of acute inflammation. It is accompanied with much pain, general disturbance, and fever which does not subside until the abscess breaks or is relieved by surgical operation. Accuinulation of wax. — The natural waxy secretion of the ear under some exciting influences is produced in excess, and accumulates in the meatus. The wax so placed blocks up the 196 LOCAL DISEASES. passage more or less completely, and causes temporary deafness, discomfort, and sense of fulness in the ear. Polypus. — A soft and sometimes very vascular growth within the meatus, and attached often, by a broad base, to the mucous lining. Polypus of the meatus is apt to grow rapidly and to keep up a continual irritation and discharge, with deafness of the af- fected ear. Sebaceous tumor. — A growth within the meatus, attached to its mucous lining, and containing waxy or sebaceous matter en- closed in it, as in a small bag or cyst. It is sometimes called mol- luscous tumor or growth. Osseous tumor. Exostosis. — A tumor of a bony character, springing from the bony walls of the meatus beneath the mucous lining, pushing that lining before it and filling up a part of the calibre of the tube. This tumor of bone is often very painful, and a serious obstruction to the hearing. It is most frequently met with in persons of rheumatic or gouty tendency. The meatus may also be the seat of simple tumors, cystic growths, fungous granulations, and foreign substances introduced into it from without. Diseases of the Drum of the Ear or Memhrane of the - Tympanum. The drum of the ear is the membrane which stretches across the meatus or tube at its lower part. It is a fibrous web, lined on the outer side by the mucous membrane of the meatus, and on the inner side by the mucous membrane of the cavity of the tym- panum, — a continuation of the lining of the Eustachian tube which runs from the inside of the throat into the cavity. The drum is subject to several local diseases. Inflammation. — An acutely painful affection attended often with deafness, and sometimes with fain tness in the early stage, the general disturbance and subsequent fever being also severe. The drum is often left thickened oi- hardened and imperfect in function after undergoing inflammation. Ulceration. — A destruction of surface of the mucous lining of the drum extending down into the true membranous layer be- neath. An affection exceedingly painful, and frequently leaving contraction of the drum, — cicatrix, — and imperfect hearing after the healing of the ulcerated spot. DISEASES OF THE ORGANS OF THE SENSES. 197 Perforation. — An extension of ulceration quite through the drum, so as to produce an opening from the external meatus into the middle ear. When the perforation is permanent there is a certain defect of hearing, which is, however, at times, lessened by accumulation of wax over the opening, and which can often be greatly ameliorated by the insertion of an artificial drum. In forms of disease in which the mucous membrane of the throat is implicated in inflammation, the inflamed condition is apt to spread from the throat into the Eustachian tube, and so to pro- duce " throat deafness." In extreme cases the drum is in this way affected from its inner surface, and is ulcerated and per- forated or even destroyed. One disease specially gives origin to this serious mischief, namely, scarlet fever. In my experience, which is rather considerable on this point, four out of every six examples of perforation of the drum of the ear have been from scarlet fever. Thickening and condensation. — The drum of the ear is apt. in the later years of life, to undergo a slow process of change by which it loses its resilience and becomes firm in structure, like to the nail of the finger. This condition, in which the vibration of the membrane is rendered imperfect, leads to permanent defect of hearing. The drum may also be subject to deposit of earthy or bony matter, and to collapse. Disease of the Eustachian Tiobe. The Eustachian tube is liable to inflammation from extension of disease from the throat. It is also subject to obstruction and contraction so that air cannot pass freely through it into the cav- ity of the tympanum. When this occurs the vibration of the drum is interfered with, there is pressure within the cavity, and a sense of fulness and deafness which is very oppressive. Great relief to the condition is now often rendered by the operative pro- cedure of passing a probe or hollow tube along the Eustachian canal into the middle ear. Diseases of the Tympanum or Middle Ear. The middle ear, lined with mucous membrane from the Eus- tachian canal, and containing the three little bones, the malleus, incus, and stapes — " hammer, anvil, and stirrup " — is subject to — 198 LOCAL DISEASES. Inflammation, ulceration and ahscess of the mucous mem- brane. Infljammation, adhesion and jixation, — anchylosis, — of the ossicles or small hones. The small bones are also liable to inflammation of tlieir mem- branous covering or periosteum ; to rheumatic inflammation ; to goutj inflammation ; and to incapacity of motion. By inflam- matory changes they may be destroyed and discharged ; or they may become adherent, and lose their adaptability to the refined movements which are required in the adjustments for correct hearing.. Disease of the mastoid cells. — The mastoid cells, — the cellular departments of bone which suiTound and form the walls of the middle ear, — are subject to inflammation, with effusion into the cellular structure ; to thickening with condensation ; and some- times, to constriction and reduction of the size of the cavity of the tympanum. "When the drum of the ear has been perforated and destroyed by acute inflammation and ulceration, so that the middle ear is open into the meatus, and the small bones are de- stroyed, the mastoid cellular structure may also be disintegrated and dischai'ged. Diseases of the Lahyrinth or Internal Ear. The internal ear, with its vestibule, its semicircular canals, its cochlea, and exquisitely refined nervous arrangements, is never affected by disease without becoming the seat of serious disturb- ances, extending from it to the nervous system generally. The official nomenclature gives three varieties of disease as connected with this part of the body, namely, — Organic disease, such as would result from inflammation of the membranous structure; ahscess, and adhesion of parts; and, disease from neio groioths, simple or malignant, within the cavity. JSfecrosis, or death of the petrous bone, the bone within which the internal ear is formed. Deafness, resulting from functional or nervous derangement, from actual disease, or from deaf-dumbness. To these there is added malformation of the internal ear, which is a cause, in fact, of deaf-dumbness, the fine mechanism of hearing in this part being mideveloped or impaired in develop- ment. DISEASES OF THE ORGANS OF THE SENSES. 199 Keflex Nervous Derajstgement from Disease of the Ear, and ESPECIALLY OF THE INTERNAL EaB AND AuDITORY In^ERVE. Tinnittts aurium, a noise in the ear, variously described as a ringing, a buzzing, a roaring, a singing or a grinding noise, is now considered to be often of nervous origin. Tlie observations of many recent observers indicate that from diseased and disordered conditions of the internal ear, and of the auditory nerve which springs from it, certain important general symptoms of disease are induced, such as " ear vertigo," convulsive starts and movements, nausea, and various affections of the alimentary canal. Bearing on this jDoint, Dr. Bucke, of London, Ontario, Canada, seems to me to have made one of the most important of modern sugges- tions, by showing that the auditory nerve possesses the character- istics of an organic nerve, and of being, as it were, a direct inter- communicating line betM^een the outer world and the ganglionic nervous centres. Thus the nervous mechanism at the origin of the auditory nerve, or of the nerve itself, from being subjected to an inflammatory condition or sequel of inflammation, to direct shock or irritability from shock, or to paralysis from disease or injury, may become the seat of symptoms affecting the whole of the body through the nervous organizations, directly through the organic, and indirectly, from the organic, through the cerebro- spinal system. Whether Dr. Bucke's observation should turn out to be cor- rect or noty it is now certain that many symptoms of disease, hitherto believed to be of a general nervous character, have their seat or centre in the organ of hearing ; and again, that the organ of hearing, in its turn, is subject to nervous derangements, and thereby, ultimately, to organic changes which are of the most serious import. Tliusfrom pressure on the internal ear, and from congestion, inflammation, or exudation, within the labyrinth, there is produced a variety of vertigo or giddiness, " labyrintJiine vert'ixjo^'' to which tlie name of " Mesnier's disease," after the dis- coverer of it, has been applied. Lately, Dr. AVoakes, with nnich facility of exposition, has indicated that earache in infants, and most important nervous disorders arising from acute disease in the ear, may, by sympathetic coimection, be induced from the irrita- tion from teething and from the exanthematous diseases ; that some forms of cough may, by reflex direction, be dependent on 200 LOCAL DISEASES. disease within the ear ; and that vertigo, having its primary seat in the stomach and digestive system, is frequently developed through the inter-nervous relationships of the organic nervous chain and the auditory nervous apparatus. The recent application of the electric balance by Professor Hughes, and the introduction of his most skilful instrument, the audiometer, have enabled the physician to make various new and important observations relative to disturbances in the internal au- ditory apparatus. Thus I have myself found that in instances of labyrinthine vertigo the degree of vibration that may bring on the particular symptoms connected with the affection can be ac- curately gauged, and the extent of the disease that is present estimated. In extreme examples the vibrations within a few de- grees of zero, or point of absolute silence, are suflScient to excite the remote phenomena indicative of the local derangement. DISEASES OF THE NOSE. The diseases connected with the nasal cavities and olfactory apparatus are arranged, technically, under the following heads. Hyjperti^ojphy . — A disease in which the skin and cellular tis- sue of the nose become large, the skin being vascular and mottled. It is a common result of alcoholic indulgence, not itself fatal, but often a sign of similar vascular changes in vital organs. Warts^ or watery excrescences upon the nose. Sebaceous cysts. — Cysts attached to the nasal organ and con- taining fatty or tallow-like substance. Acne rosacea. — A disease affecting the skin causing redness of the point of the nose, enlargement of veins, and an eruption of small tubercles, ending in thickening and minute scars. The affec- tion is usually produced by alcoholic excess. Ozcuna. — A singularly painful affliction, consisting of a persist- ent fetid discharge from the nose, and lasting often for long periods of time. The disease is usually connected with death and decomposition of the soft or spongy bones within the nasal cavity. It is sometimes produced without any apparent cause, as if from something imperceptibly inhaled which excited ulceration. In many instances ozsena is constitutional in its nature, and inherited. Ulceration of the lining memhrane of the nose. Ily^ertrojjjhy of the lining membrane. DISEASES OF THE OKGANS OF THE SENSES. 201 Diseases of the septum, or division hetween the nostrils. — Ab- scess ; perforation ; ulceration ; thickening. Tumors attached to the mucous surface. EpistaAs. — Loss of blood from the nose. Polypus. — A large soft growth occurring within the cavity of the nose, and creating great obstruction. There are two varieties of polypus : the gelatinous or fluid polypus ; and the fibrous, a firmer variety in regard to structure, and of slower development. Polypus of the nose, of both kinds, sometimes passes back into the pharynx, — the opening at the commencement of the gullet. It is then called, nasopharyngeal polypus. IniiKiirnient of sense of smell. — An impairment arising from organic disease or functional derangement of the olfactory nerves, tlie filaments of which are distributed to the mucous membrane of the nasal cavity. CHAPTER YII. DISEASES OF THE ABSORBENT AND GLANDULAR SYSTEMS. The glandular system is divisible, for the classification of the diseases that are connected with it, into three parts. 1. The lymphatic glandular system, consisting of the lymphatic glands and the series of lymphatics or absorbent tubes of the body gen- erally, with those of the small intestines, — mesenteric glandular system. 2. The tubular or duct glands, with their ducts or canals, sacs or bladders, and other parts or appendages. 3. The ductless glands, or glands from which there is no tube or duct to convey away secreted or excreted fluids. Diseases of the Lymphatic and Mesenteric Glandular - System. Diseases of LymphatiG Glands. Inflammation and sujpjpuration. — The lymphatic glands are subject to inflammation which may pass on to suppuration. They sometimes are acutely inflamed after the infliction of poisoned or venomous wounds, and sometimes, but rarely, after ordinary wounds and surgical operations. In strumous or scrofulous per- sons the lymphatic glands are liable to undergo slow or chronic inflammation ending in formation of matter and in bursting of the abscess formed. Glands which suppurate in this manner are very slow to heal, and in healing leave, in many instances, a deep scar, which occurring in the neck is vulgarly called " curl." The glands are subject to inflammation during the specific dis- ease called syphilis, and syphilitic inflammation of them is a com- mon result. When, in the same disease, the glands in the groin suppurate, " syphilitic huho " is said to have been produced. In the true plague accompanied with the " plague bubo " the DISEASES OF THE GLANDULAR SYSTE3I. 203 lymphatic glands are specially implicated as local centres of sup- purative changes. Malignant disease. — The lymphatic glands are often involved in malignant disease, and become themselves seats of cancer. Li cancer of the breast the glands of the axilla are often affected, sometimes before and frequently after the operation for remov. ing the affected breast. Hyjpertrophy and atrophy. — The lymphatic glands are subject to hypertrophy or enlargement, a condition very common in scrofulous persons, and perhaps almost exclusively confined to them. Indeed, scrofula, as a disease, is by some considered to be strictly an affection of the lymphatic glandular system. The en- largement of the glands may take two forms ; an acute form, in which the swelling, rapidly developed, remains for a few weeks, and then subsides ; and a chronio form, in which an acute swell- ing becomes chronic, or in which a gradual enlargement com- mences and steadily continues until the gland attains a large size, is extremely firm and dense, and, showing no tendency to sup- purate, is very difficult to resolve or disperse. The lymphatic glands may be seats of tubercular disease, and in persons of tuberculous taint are liable not only to be charged with the matter of tuberculous deposit, but to pass through the various changes incident to tubercular degeneration. The glands are again in some instances subject to atrophy or wasting of their structure. This state is presented in persons who have been subject to great exhaustion and general wasting. The atrophy is in other instances local in character, the gland or glands affected being subjected either to external pressure, or to deprivation of proper nervous stimulus, diminution of the nervous supply which should, naturally, pass to them. Disease of the Lyinjphat'ie Vessels. The Ij'mphatic vessels, like the glands, may be the seats of inflammation and of subsequent suppuration, and in examples of poisoned wounds the inflammation may extend through the ves- sels, from the point where the poison was absorbed, up to the nearest glands. To this state the term, " inflammation of the ab- sorbents," is connnonly applied. The lymphatics are further subjected to ohstruction from pressure upon them, as from a tu- mor lying in their course, or from disease and obstruction in the 204 LOCAL DISEASES. glands with wliicli tliey are connected. During sucli obstruction the vessels may burst, — " hursting of lymjjhatics,^'' — and the lymph contained in them be exuded into the surrounding struct- ures. LyiTvphatiG jistula is another condition of disease in which a lymphatic duct or tube becomes connected by a fistulous opening with some part outside of it through which it passes. Lymphatic glands and lymphatic vessels are closely connected with all the vital organs, the lungs, the heart, the liver, the spleen, the stomach, the intestines. In all these parts they are subject to the various changes denoted above. The hronchial glands, which lie near the point of bifurcation of the windpipe into the bron- chial tubes, are so far susceptible to inflammation, abscess, en- largement, malignant disease, and tubercle, that these diseases are classified in the official nomenclature as specially connected with them. Diseases of the Mesenteric Glands and Thoracic Dtict. The mesenteric glands, the glands of the small intestines, ly- ing within the layers of the mesentery, are specially named as seats of disease. These glands receive lymphatic vessels from the structure of the intestines, and also the tubes which spring from the villi of the mucous coat of the small intestine, called the lacteals, because the fluid they contain, derived from the digested food, is of a milky color. The tubes or ducts going out from the mesenteric glands terminate in the pouch, called the receptacu- lum chyli, which gives origin to the thoracic duct, the duct or tube that ends in the venous circulation. Thus these glands lie, as it were, midway between the digested food and the blood, and in them that change of the food which consists in its transforma- tion into chjde is perfected. They play therefore a most impor- tant part in living function, and disease of them is extremely seri- ous, since it leads to interference with the process by which food is changed into blood. The mesenteric glands are subject to the same diseases as the other lympliatic glands. They may be the seats of inflammation, abscess, enlargement, cancer, and tubercle. Mesenteric disease. Tabes mesenterica. — The disease to which the glands are most liable is tubercular deposit, a wasting and painful affection to which the name of " tabes mesenterica " has DISEASES OF THE GLANDULAR SYSTEM. 205 been long applied ; " tabes," — wasting, signifying the leading symptom of tlie malady, and " mesenterica " the seat of the dis- ease. In ordinaiy conversation the term " mesenteric disease " is used to denote this particular tubercular state of the mesenteric glands. Mesenteric disease is usually developed in the young who are of tubercular taint, and is attended with fever, pain in the abdomen, enlargement of the veins over the abdomen, swelling, much flatulency, sometimes dropsy, great disturbance of the bow- els, and rapid wasting. It is often but not always fatal. The tlioracic duct, the duct of tlie mesenteric glandular system, is subject to obstruction from pressure upon it from tumors, and from inflammation of surrounding tissues and organs. The ob- struction is attended with wasting of the body and exhaustion, but the detection of it is very difficult during life, and the occur- rence of it is exceedingly rare. I have only known one instance in the human subject, and then it was complicated with disease of the liver. Diseases of the Tubular ok Duct Glakds and their Parts OR Appendages. The glands included under this head possess a tubular struct- .ure, and have a canal or passage for conveying away the fluid which they have secreted or excreted. Some- of them, like the liver, have a reservoir or bladder for temporarily holding a portion of the fluid which they throw out. One of them, the kidney, has not only a tube or duct, the ureter, leading into the reservoir or bladder, but another special tube, the urethra, leading from the bladder to the outlet from the body. Diseases of the Salivary Glands. The glands which secrete the saliva, and the ducts of wliich open within the mouth, are subject to inflammation and abscess. When mercury has been taken largely these glands are much irri- tated, secrete saliva freely, and are greatly inflamed and enlarged. The term salivation, or ptyalism, is used to express this state. In the communicable disease called Qmim.jps the salivary glands are enlarged and inflamed. The glands may also be the seats of growths, malignant or non-malignant, or may bo involved in such growths. 206 LOCAL DISEASES. Salivary calculus. — From glands which, like the salivary, are furnished with a duct by which their secreted fluids are dis- charged, a formation or deposit of a hard mass, or calculus, in the duct is apt to occur. The calculus produces considerable irritation and obstruction. Salivary calculus is a concretion of this nature in a salivary duct, the deposit being derived from the saliva. The calculus is largely composed of the same earthy substance as that which is sometimes deposited on the inner surface of the teeth as " tartar." These deposits are due, to a certain extent, to unclean- liness in respect to the teeth, but some persons are, in spite of cleanliness, disposed to suffer from them. The affection is most common in those who are of rheumatic and gouty constitution. Diseases of the Pancreas. The pancreas, the large gland situated across the abdomen below and behind the stomach, is subject to the same series of diseases as the salivary glands. The pancreas resembles a sal- ivary gland in construction, and secretes a fluid which has some of the physiological qualities of the saliva. It is a large gland, six inches in length, and its duct pours its secretion into the part of the small intestine called the duodenum. The pancreas is sub- ject to iiijlammation of its structure, and to abscess. It is some- times the seat of cancer or malignant disease, oi fibroid degenera- tion., and of calculus or stone. The pancreatic duct also may become the seat of calculus. The effect of the pancreatic secretion on the food is to emulsify the fatty constituents, and to take an active part in the secondary digestive process. "When the pancreas, therefore, is functionally or organically diseased, the digestion is seriously impaired, and in organic disease of the organ the fatty substances eaten as food may pass through the body unchanged in character. Diseases or the Li\"er. The large organ or gland called the liver, the largest gland in the body, is situated in the upper part of the abdomen immedi- ately below the raidriif or diaphragm. The liver is very subject to disease, and as its uses in the economj^ are many and varied, its importance, as a seat of disease, can hardly be over-estimated. It is a common practice for persons who are ailing to attribute their DISEASES OF THE GLANDULAR SYSTEM. 207 snifering, as if bj some instinctive process, to the liver and bile, and there is often a great deal of reason in tlie observation. The liver secretes bile, and ranch of the bile so secreted and thrown into the alimentary canal is absorbed there and is burned in the body ; so the liver becomes indirectly a source of supply for ani- mal heat. The bile, if it be not duly applied, and if it be re- turned into the circulation as bile, is a poison to the blood, a cause of depression to the spirits, and when in the blood in large quan- tities a cause of yellow discoloration of the skin, — jaundice. In the liver there is a translation of the matter derived from the digested food into a substance called glycogen, which is easily changed into glucose or grape sugar. If from irregular nervous action this process be improperly carried out, glucose may be formed and given over in excess to the blood. Thus the liver may become indirectly the origin of glycosuria or saccharine urine, and of the disease called diabetes. The liver is often the receptacle of poisonous substances taken into the body, such as the metallic poisons, some vegetable poisons, and alcohol. These poisons will remain in the liver long after they have been taken, and some of them, as it would seem from researches I once conducted on the elimination of antimony from the body, are thrown out by the liver into the alimentary canal, to make the round of the circulation and to be returned to the liver for re-elimination. The liver again is a frequent centre in which parasitic growths are developed, and in certain animals, the sheep for example, it is the special seat of one parasite, the liver fluke, the faslcola hepatica. The liver, it will be seen from these facts, is a great centre of disease and the seat of many distinct diseases. Congestion. — The liver is sometimes the seat of vascular con- gestion, during which it is temporarily increased in size, to the discomfort of the sufferer, who feels pain which is often referred to the right shoulder. With this congestion there is always dyspepsia and flatulency, derangement of the bowels, and not in- frequently piles or hemorrhoids. When the congestion is great, there is usually some yellowness of the conjunctiva or even of the skin, and there is always a pasty and ansemic look of skin. Con- gestion of the liver is most apt to occur in persons of sedentary habits, and especially, in such persons, M'hcn they indulge in stimulants and in rich food. It is almost universally attended 208 LOCAL DISEASES. "witli depression of the mind, from whence, doubtless, the terms "bilious disposition" and "bilious feeling" are derived. S&patitis, or hvflaniination and abscess. — The liver is subject to inflammation, which may be simple or pysemic ; that is to say, the inflammation may originate in the liver itself, or may be one of the consequences of that condition of fever to Mdiich the word pyaemia is applied. In this climate the last-named is the most frequent form of inflammation and of abscess of the liver, the abscesses being numerous and small. In tropical climates, as in India, inflammation pm-e and simple and abscess of the liver, are of common occurrence, especially in those who indulge in alcohol. Inflammation of the liv^er, however caused, is attended with high fever, pain, great disturbance in the abdominal organs, and jaundice. If abscess follow the inflammation it leads to enlarge- ment of the liver, to irritative and hectic fever, to jaundice, and usually to death by exhaustion. When abscess of the liver is the result of simple inflammation, there is, as a rule, one large abscess, and in rare examples the abscess breaks externally and recovery is the result. I have known one such instance. Degeneration of the liver. — The liver is subject to several de- generative changes which are classified as — {a) Acute atrophy. (Z>) Thickening of the capsule, (c) Cirrhosis. (J) Fatty liver. {e) Fibroid deposit. (/") Lardaceous, amyloid, or waxy liver. Acute atrojjhy or contraction. — A condition in which the liver suddenly shrinks, its cells undergoing a rapid degeneration and becoming charged with oily and granular deposits. This disease is attended with extreme disturbance of the other organs in tlie abdomen, with arrested action of the kidney, ending in death by sleep, coma. There is sometimes yellowness of the skin or jaun- dice. The affection is rare, and except in pregnant women is almost unknown in this country. Cirrhosis. Cirrhosis is a condition in which the liver, after first being much enlarged, from repeated attacks of congestion, shrinks and becomes hard and rough on its surface, "' hob-nailed." The dis- ease has been called, from this appearance of the liver, "hob-nail liver." It has also been called, owing to its almost invariable connection with alcohol as its cause, "gin- drinker's liver." The disease is due originally to a change in the membranous structure DISEASES OF THE GLANDULAR SYSTEM. 209 of the liver, produced, most frequently, by the direct action of alcohol on the membranous structure, and ending in the con- densation and desti'uction of the secreting cells, with thickening of the connective tissue. The liver gradually contracts, ceases to secrete bile, and, becoming an obstruction to the venous circula- tion, produces ascites or abdominal dropsy, under which the sufferer generally succumbs. The term cirrhosis is taken from the yellow color, which the diseased liver structure presents. The color is due to a yellow pigment in the diseased cells. Cirrhosis of the liver, as a disease, is almost peculiar to the human subject, but in my experiments with alcohol it was shown that by administration of alcohol it could easily be induced in the lower animals. TJdckening of the capsular covering and fibroid deposit. — Dis- tinctive conditions of disease of the liver, but less common than cirrhosis. By some authorities they are connected with the vari- ous stages of cirrhosis. Fatty liver. — The liver is subject to a peculiar fatty degenera- tion in which the cellular structure is charged with fatty cells. The liver tlien resembles a fatty structure ; it floats in water and is of yellowish tint. It is also much enlarged. Fatty liver is often connected M'ith consumption of the lungs. It may be pro- duced by indulgence in alcohol. It *an be synthetically induced in the lower animals by alcohol, rich feeding, and cessation from natural exercise. Lardaceous liver. Amyloid disease. Waxy liver. — In this condition the liver, from changes in its secreting cellular structure, undergoes a o-radual enlar^-ement and a transformation toward what is conveyed in the terms lardaceous, amyloid, or waxy. The affection is perhaps hereditary, and it is mostly, if not in all instances, connected M'ith some constitutional taint, the syphilitic and scrofulous most markedly. It is slowly destructive of life, and causes deatii by some indirect influence on other organs of the body, or in cond)ination with fatty changes in other organs, such as the kidneys or heart. The liver may also be the seat of cancer ^ of syphilitic de- 2)08it / of tuhercular deposit / of sinvple tumor / and of hydatid cysts — cysts containing the larvfe of the taenia echinococcus, a variety of cestode or tape-worm, — which may increase until they break and discharge their contents externally. In addition to these states of disease the great vein of the liver, tlie venajporta.^ 14 210 . LOCAL DISEASES. whicli returns tlie blood from the digestive organs to the liver, and from whicli blood the bile is secreted, is subject to obstruc- tion from inflammation of its coats, and from deposition of fibrine within it. Obstruction of the vena porta is attended with sup- pression of the bile, constipation, dyspepsia, and. in extreme cases with dropsy of the abdomen. Diseases of the G all-Bladder and Bile-Duct. The gall-bladder or sac for holding the bile secreted by the liver, and the tu.be or duct connecting it with the liver, are liable to several forms of disease, viz., inflammation, ulcer, perforation, fistula, obstruction, and calculus or gall-stone. Inflammation of the bile-duct and gall-bladder is rarely if ever disconnected from disease of the liver, and is always a very painful affection. Ulcer is a destruction of surface from the mucous lining of the gall- bladder or tube. Perforation is an ulceration extending quite through the coats of the sac into the abdominal cavity. Fistula is an opening, from perforation, not into the abdominal cavity, but through the abdominal wall to the outside of the body, so tliat a fistulous opening from the gall-bladder or its duct is estab- lished, from which bile may be discharged externally. Caloulxis of the gall-hladder, or gall-stone, is a hard concretion deposited from the bile within the gall-bladder. This calculus, formerly said to be formed of inspissated bile, consists largely of choles- terjne, a waxy substance of crystalline character which is derived from bile and which burns like wax. There may be one calculus in the gall-bladder, or more than one. I have seen six in one gall-bladder. The calculus takes different shapes, but very often a triangular or "cocked hat" shape, from having been moulded into that form in the neck of the gall-bladder. Calculus in the gall-duct is a cause of the intensest of human sufferings when it is lodged or impacted in that sensitive structure. The pain comes on in paroxysms which nothing removes except the escape of the stone into the intestine, or its return into the gall-bladder. In very rare instances the stone is discharged by a fistulous open- ing through the skin, and in the young it is often passed into the intestine, and discharged by the bowels. In persons of middle or advanced life gall-stone is often associated with an atheromatous condition of the vessels of the brain, those vessels having under- gone a fatty change, with a deposit in their structure of the same DISEASES OF THE GLANDULAR SYSTEM. 211 kind of waxy substance as that wliicli is contained in the fall- stone. Jaundice. Icterus. Tlie old physicians gave the name of jaundice to what they considered was a speciiic disease accompanied by universal yel- lowness of the surface of the body, with or without fever, Math much depression, and in the worst cases with coma, ending in death. They connected the disease" with the circulation of bile through the blood, and we do the same in this day, but m'c differ from them in that we consider jaundice to be a symptom of dis- ease rather than a specific affection. Jaundice, in fact, accom- panies many diseases acute and chronic, though it is naturally most intimately connected with diseases of the liver and the gall- bladder. The symptom may be caused by obstruction to the course of the bile from closure of the gall-duct ; by over-secretion of bile ; and again from failure of the process by which the bil- ious matter brought by the blood into the systemic circulation is utilized. Thus there is a true hepatic or liver origin of jaundice and a systemic origin. The first is connected with hepatic dis- ease ; the second with other diseases of a more general character, such as yellow fever, pysemic fever, and bilious remittent fever. Jaundice though not a definite disease is often a dangerous com- plication of other diseases. It tells us that bile, wdiich in itself is a poisonous product, is circulating in the blood and is acting as a direct source of danger. Diseases of the Kidneys and Renal Systeisi. The two glands in the abdominal cavity, called the kidneys, have for their function a purely eliminative intention. The fluid they excrete is the grand outlet for the nitrogenous excretes of the animal body. The fleshy parts of food that are not used, and the used-up parts of the muscular system of the body itself pass out of the body through the kidney. In the course of its revolu- tion the fleshy material has become transformed from its colloidal state into a crystalloidal. It has ceased to be flesh, and lias be- come a salt. It has ceased to be insoluble in water, and lias be- come excessively soluble. It has ceased to absorb and liold water, and has assumed the power of fixing water so as to become, as it were, a part of water, flowing away with it as tiiough it were 212 LOCAL DISEASES. water itself. The nitrogenous salt which has thus been produced from muscular' or fleshy substance, and which the kidney throws off, is called urea. It is a white crystalline substance tasting something like nitre, and possessing extreme solubility. The kidneys also eliminate water very freely, in order to carry away the nitrogenous salt and to relieve the body of excess of water. They excrete some other substances. They excrete an animal acid, called uric or lithic, derived from fleshy matter. They excrete sulphates of sodium, potassium, and calcium, de- rived from food. They excrete j)hosphates of ammonia, calcium, and sodium, derived partly from food direct and partly from dis- integrated or effete brain and nervous tissue. They excrete some organic salts and coloring matters derived from the blood, to- gether with mucus from the lining mucous surfaces of the kid- ney, the ureter, the bladder, and the urethra or external passage. If we measured the proportions of all these parts as they exist in the urine, excreted by the healthy kidneys of an adult person in twenty-four hours, we should find in all forty-eight fluid ounces. If of this fluid we analyzed a thousand grains, we should discover fourteen grains of urea ; eight and a half grains of other salts, sulphates, biphosphates and chlorides ; half a grain of uric acid, and ten grains of coloring material with mucus ; thirtj^-three grains in all. The remaining nine hundred and sixty-seven grains would consist of water. The due excretion of all these parts is necessary for health, but the excretion of area and water is specially important. The saline substance, urea, if accumulated in the body, acts as a poi- son, causing the comatose state called urasmic coma, or sleep. The suppression of excreted water in due quantity by the kidney is a cause of dropsy. Imperfect excretion of uric acid, or of other salts than urea, is a cause of local diseases such as calculus of the bladder or other parts of the renal system, and of gouty deposit in the joints. On the other hand, excessive excretion from the kidney is a cause of exhaustion, and as the kidney is the channel by which many soluble saline substances find their escape from the body, its excessive excretive action becomes often a most urgent symptom in disease. The affection known as dia- betes mellitus is a case in point. In this disease the blood is sur- charged with the soluble saline substance called glucose or grape sugar, and as the sugar dissolved in the renal excretion is elim- DISEASES OF THE GLANDULAR SYSTEM. 213 inated by the kidney, tlie flow from the kidney is frequent and, it may be, many times more abundant than is naturaL In past days it was thought that the cases of excessive flow of water from the kidney was from disease of that organ itself. Xow we know that the excessive flow may be but a symptom, and that the kid- ney may be quite healtliy though forced to perform an extra amount of work. The diseases proper to which the kidneys are subject are congestion, inflammation, hypertrophy and atrophy, degeneration, and mechanical disease, CongestioR. — The kidneys may be congested or surcharged with blood, the congestion being of two kinds, acute and j tussive. Acute congestion of the kidney is sudden in its development, is p.ttended with fever, suppression of secretion, pain, sense of weight in the loins, and, in very bad cases, with dropsy, or dropsy and coma. Acute congestion is usually brought on by sudden suppression of the action of the skin, as by lying down to sleep on damp ground, or b}^ the action of some poisons, such as bella- donna or alcohol. It also accompanies other forms of disease, as scarlet fever and malarial fevers. Passive congestion is slower and less severe in its manifestation. It is sometimes a sequel of acute congestion, and it is liable to recur in those who have once suffered from it. Hijematuria. — A term applied to the passage of blood from the kidney by the urinary canal. It is rather a symptom of con- gestion, or of mechanical injury to the kidney, or of some foreign growth in the structure, or of ulceration, than a disease of itself. Wejyhritis, inHammation, and suj^j'uration. — The kidney may be the seat of inflammation and of subsequent suppuration, sup- purative nephritis. The affection ma}^ be of the simple in- ilammatory form, following upon extreme congestion, or upon irritation from some foreign body within the organ ; it may also be secondary to other acute affections, as pyaemia. The secondary form is the most connnon of the two. When the inflammation, however induced, extends to the pelvis of the kidney, — the little pouch from which the duct of the kidney called the ureter pro- ceeds, — the term pyelitis is used, in the nomenclature, to define the condition of disease that has been set up. All these inflammatory states of the kidney are of grave moment. They arc attended, generall}'-, with much fever, sup- pression of secretion, and often with dropsy. When suppuration 21$ LOCAL DISEASES. takes place the fever assumes tlie hectic character, and pus or matter may be excreted with the urine. SyjjeHrojjhy and atrophy .—Hhe kidney is sometimes much enlarged or hypertrophied. The enlargement may be uniform throughout, and simply owing to the increase of the natural sti'uct- ure as a result of excess of function. Or the enlargement may be due to effused material into the connective tissue. Atrophy or wasting of the kidney is a condition arising from two or three causes. It may accompany general wasting from privation or exhausting diseases : it may arise from failure of nervous supply : or, it may take place from deprivation of blood to the kidney, either through pressure exerted on the organ itself or from ob- struction in the arterial blood-vessels. Hypertrophy of the kidney of the simple form is usually at- tended with an increased flow of urine or diuresis. Atrophy is attended with a decrease of the renal excretion, and when from this or other cause the decrease is carried to arrest of flow of the excretion there is said to be suppression, or ischuria renalis. Degenerations of the Kidney. BrigMs Disease. A Ibuniinuria. The most important, because the most frequent, organic diseases of the kidney are those included under the head of Bright's disease, so called from the circumstance that the late distinguished Dr. Richard Bright first recognized the affections and made them known. The College authorities define these diseases as " several forms of acute and chronic disease of the kidney, usually associated with albumen in the urine, and fre- quently with dropsy, and with various secondary diseases result- ing from determination of the blood." Varieties of DrigMs Disease. There are several varieties now recognized of Bright's disease, which resolve, however, into two great divisions, the acute and chronic. Acute BrigMs disease, called also acute albuminuria, acute desquamative nephritis, or acute renal dropsy, is a disease in which the kidney becomes greatly enlarged and vascular, with its minute convoluted tubes into which the urine is primarily se- creted filled with epithelium. The epithelial scales, in the form DISEASES OF THE GLANDULAR SYSTEM. 21S or casts of the renal tubes, are voided by the urine, together with albumen and sometimes with blood. The obstruction to the How of urine and the interference Math the function of the kidney give rise to the most serious general symptoms. There is fever followed quickly by dropsy, and, in extreme instances," by coma and death. Acute Bright's disease is a rather common complica- tion of scarlet fever, and is one of the dangers most to be dreaded in that disease. It is also produced by sudden and extreme chills, and by excessive use of alcohol. Chronic BrigkCs disease is either a continuation of the acute affection, or is slowly developed without the occurrence of active symptoms. It is connected with further and permanent changes in the structure of the kidney, giving rise to three subdivisions of the chronic affections called granular, fatty and lardaceous kidney. Granular kidney, called also contracted granular kidney, chronic desquamative nephritis, or gouty kidney, is a form of the disease coming on, usually, in persons of middle age, and espe- cially in those of gouty habit. It is attended with albumen in the urine. The kidney is granular, firm, rough, hard, and gen- erally contracted, its membranous capsule adhering closely to it. Fatty kidney is a condition in wdiich the organ is white and mottled. The secreting cells are granular and contain fatty or oily deposits. Lardaceous kidney, known also as amyloid or waxy kidney, is a condition in which the organ is, as a general rule, enlarged, and presents on its surface a waxy appearance. This change seems to commence in the vascular structure of the organ, in the minute tufts of arteries that yield the blood from which the urine is secreted. The affection is often connected wdth fatty and amyloid changes in other parts of the body, as the liver, and it is, like them, associated not unfrequently with pulmonary consumption, and, speciall}', with syphilitic degeneration. In addition to these degenerative changes the kidney is sub- ject to deposit of Jibriiie v^'ithhi its structure. It is sometimes the seat of cancer, of non-malignant tumors, of cysts, oij)arasitic develoj'ments, and of tiibercle. The mechanical diseases of the kidney are : JLjdroncphrosis. — " Dilatation of the pelvis of the oi-gan, or of the glandular structure, into one or more cysts, by retained secretion." 216 LOCAL DISEASES. Calculus. — Stoue in. the kidnej^, usually iu the pelvis, or in the tube leading from the kidnej to the bladder, the ureter. It is a very painful affection, causing often faintness and vomiting dur- ing the passage of the calculus. Movable kidney. — A condition in which the kidney is, as it were, dislocated from its natural position and untixed. Diseases of the Bladder. The bladder, a membranous pouch or bag for temporarily holding ]"enal secretion, is made up of three coats or layers ; a serous layer on its outer side, which may easily be stripped off the dead bladder, and which is derived from the peritoneum ; a middle muscular layer of involuntary muscular fibres which sur- round the organ, and by their contraction empty it ; an inner or lining mucous coat, which secretes a thin mucus. The bladder is subjected to many diseases. Cystitis. Catarrh of the Madder. Vesical catarrh. — A con- dition in which the mucous surface of the bladder is in a state of extreme irritation, or is actually inflamed. The disease is acute or chronic. In the acute form it is attended with pain, fever, and frequent discharge from the bladder of ordinary secretion, con- . taining, after a time, mucus. In the chronic form of the disease the feverish and other acute symptoms are modified, but the excretion of mucus and the irritation continues. Ulceration and suj>j>uration. — Under long-continued irritation of the mucous surface of the bladder the mucous membrane may undergo ulceration at one or more points. This change is at- tended with extreme pain, and often with discharge of blood as well as mucus. When the discharge of mucus contains pus or matter in large quantities, with febrile disturbance, suppuration of the bladder is said to be present. In rare instances the bladder may undergo sloughing or actual decomposition. Fistula of the bladder. — From inflammatory mischief affecting it or its surrounding parts, the bladder may have in it an opening or fistula extending from it into other cavities. Four fistulous openings of this kind may occur from disease : {a) Vesico-intes- tinal Jistula, in which the opening is from the bladder into the intestine. {Jj) liecto-vesical fstula , where the opening is from the bladder into the lower or straight intestine, (c) Utero-vesical DISEASES OF THE GLANDULAR SYSTEM. 217 iistula, wliei-e, in the female, the opening is from the bhidder into the litems or womb, {d) Vefiico-mginal Jistula, where, in the female, the opening is from the bladder into the vagina. Hypertro])hy. — The coats of the bladder are sometimes verj much enlarged in cases where there is great obstruction to the escape of the urinary secretion. The muscular coat is the part which is most commonly hypertrophied. I have recorded an in- stance in which the walls of the bladder were nearly an inch in thickness from muscular hypertrophy. Distention. — The bladder may be distended, the distention causing it to be sacculated or pouched, bulged out in parts, from the giving way of a portion of the coats. It may be actually j'uptured. Long retention of the urine is the commonest cause of these accidents. Mechanical accidents. — The bladder may be subjected to mechanical accidents, as inversion^ extroversion., and hernia. It may contain foreign bodies accidentally passed into it. The most frequent mechanical mischief that happens to it is the deposit within it of calculus or stone. Calculus. Stone in the Bladder. This well-known affection is due to deposit from the urine of one or other of the more solid constituents. There is not always a direct deposit, for sometimes a foreign substance forms the nucleus of the calculus. There are twelve kinds of calculus of the bladder recognized in the nomenclature of disease. These are placed in the following order. 1. Uric acid. 2. Urate of ammonia. 3. Uric or Xanthic oxide. 4. Oxalate of lime. 5. Cystic oxide. 6. Phosphate of lime. 1. Triple phosphate, phos- phate of ammonia and magnesia. 8. Fusible. 9. Carbonate of lime. 10. Fibrinous. 11. Urostealith. 12. Blood calculus. The uric acid calculus, the triple phosphate, and the oxalate of lime which once was called the mulberry calculus because of its likeness to a mulberry-stone, are perhaps the most common kinds of calculus of the bladder. The first of the three, uric acid, is usually oval, fawn-colored, hard, and constructed in lay- ers ; the second, triple phosphate, is rough, firm, and drab- colored ; the third, oxalate of lime, is rough, hard, and red, like a mulberry-stone. Calculus of the bladder is more common in men than in 218 LOCAL DISEASES. women, and affects residents of certain parts of the country more than those of other parts. It depends greatly on habit of body for its formation, and is very much favored by the use of alco- holic drinks, especially of malted liquors. The affection is at- tended with irritation and pain ; sense of retained secretion within the bladder ; and often, when the calcuhis is large, with discharge of mucus in the secretion, "When the formations are minute and distinct, the escape of small calculi may occur, with much pain. Calculus of the bladder is now a remediable affection under sur- gical skill. Foreign growths of the hladder. — The bladder is sometimes the seat of simple or non-malignant tumors ; of cancer ; and of a tumor called " villous," involving the mucous membrane. Muscular affections. — The muscular coat of the bladder may be the seat of disease. We have already seen that it may be hypertrophied. It may also suffer from paralysis, irritability, and spasm. When the muscular coat is paralyzed there is what is called retention of urine, from the want of expulsive power. When the muscular coat is irritable the urine has to be voided too frequently, and there is what is known as incontinence of urine. Diseases of the Prostate Gland. In the male subject there exists in the front of the neck of the bladder a gland of the size of a Spanish nut, called the pros- tate. The gland has not one common duct, but has sixteen or seventeen small ducts, which terminate in the urethra, the pas- sage leading from the neck of the bladder. The gland is the seat of several diseases, including : — inflammation, acute and chronic ; ulceration ' ahscess y atrophy • tumors, non-malignant and can- cerous ; calculus,' cysts,' and, tuhercle. The most frequent forms of disease affecting the prostate are chronic enlargement, which may be simple or malignant ; and calculus., which occasionally be- comes of large size, and is only removable by surgical skill. Diseases of the Urethral Passage. The urethra, or tube, leading from the bladder to the outlet from the body, is the seat of several diseases, especially in the male subject. It is suljject to inflammation, urethritis, which may be simple, or gonorrheal. It is subject to ulceration, the result DISEASES OF THE GLANDULAR SYSTEM. 219 of preceding iuflainiiiatoiy disease ; to iirinary abscess ; to ex- travasation of urine ; Xo jistuZa ; to caloul us ^ oy stone lodged or impacted in it, from wliicli it may suffer severe laceration and in- jurj'- ; and to iin2^actlo7i of other foreign bodies. The most per- sistent disease of the m-ethra is, liowever, stricture^ a result, in the great majority of instances, of specific or gonorrhoeal inflamma- tion. In stricture the passage is narrowed, so that the m-ine is passed M'ith difficulty, and in worst cases is stopped altogether until relief is obtained from the surgeon. There are four kinds of strictui'e. Organic^ where the stricture is caused by organic deposit and growth ; traumatic^ where it has been caused by a wound ; sj)asmodic, where it is the result of spasm of the muscu- lar fibres surrounding the canal; and injlammatory, where it is the result of existing inflammation within the canal. Diseases op the Repeoductive Glands and Oegans. The reproductive organs include in the male subject the testes and their parts; the spermatic cord; a serous membrane, which consists of two layers, investing and reflected, forming a true membranous sac, the tunica vaginalis ; and an external pouch of skin, the scrotum. In the female subject they include the ovaries; the uterus or womb ; and the Fallopian tubes. Diseases sjyecial to tlie Male Subject. Diseases of the testes. — The testes are seats of inflammation, orchitis, which may be acute or chrouic, and which in the acute form is attended with extreme pain, fever, and often with faint- iiess ; of inflammation of the convolutions of the excreting ducts of the gland, the epididymis, epididi/mitts / of abscess / and of hernia. These glands may also be the seats of malignant disease ; of simple tumor; of cystic disease; of wasting or atrophij j of neuralgia ; and of the weakness of function known as sj^erma- torrhoia. The tunica vaginalis, or investing serous membrane of the gland, is snbject to inflammation ; to extravasation of blood into the tunic, hematocele ; and to dropsy or hydrocele, in ^vhic]l watery or serous fluid accumulates, in large quantity, in the serous sac, and greatly distends both it and the scrotum. Of liydrocelo there are three varieties : the congenital, where the dropsy is from 220 LOCAL DISEASES. birth ; the infantile^ where it occurs in infancy ; and the encysted, where it comes on in later years. Hydrocele is a disease very amenable to surgical skill. The sjjermatic cord, composed of an investing membrane, of the spermatic artery derived from the abdominal aorta, of return- ing veins, and of the excreting duct of the gland, the vas deferens, in its course from the gland toward the abdominal cavity on each side of the body, may be the seat of hydrocele, or dropsy, en- cysted, or diffuse ; and of varicocele, or enlargement of the veins, with a varicose or knotted condition, and distention of them from enclosed blood. The cord is sometimes the seat of tumors, simple or malignant, and of the painful nervous affection known as neuralgia. The scrotum or cutaneous pouch containing the glands may be subjected to sloughing j to swelling or oedema j to elej)?iantiasis j to non-malignant growth^ and to cancer. In the days when youths were made to ascend chimneys as sweeps, epithelial cancer of the scrotum was commonly developed in them, and was called chimney-sioeeper'' s cancer. Diseases special to the Female Suhject. Diseases of the ovaries. — The two glands of the female, called the ovaries, situated in the lower j^art of the abdomen on each side, and each enclosed in a layer of peritoneum at the back of the broad ligaments of the womb, are the seats of several forms of disease. The ovary itself is a very vascular structure, with a cellular net-work enclosed in three layers of membrane, called the capsule. The inner of these layers of the capsule is finely vascu- lar ; the middle thick and fibrous ; the outer, derived from the peritoneum, thin and serous. In the cellular structure of the ovary are a number of small vesicular bodies, called the Graafian vesicles or ovisacs, which contain an albuminous fluid, many gran- ules, and the body, which becomes impregnated in impregnation, called the ovum. The ovaries are liable to become the seats of inflammation, which in the acute form is attended with severe pain and fever ; of abscess ; of hemorrhage • of hyj)ertroj>hy and atrophy ', of cancer ' of fihrous tumor / of cysU / of para^tic growths ; of complex cystic tumor, colloid, and cystosarcoma j of hernia j of dislocation j and of encysted dropsy. DISEASES OF THE GLAl^DULAll SYSTEM. 221 Di'ojpsy of the Ovary. — The most remaikaLlc and most com- mon disease of tlie ovaries is the last-named ahove, encysted dropsy, commonly known as ovarian disease, or ovarian dropsy. In this affection one or more ovarian cysts form, and become en- larged and filled with fluid. The fluid accumulates until the cyst may increase to over a foot in diameter, and may attain a weight of many pounds. The fluid in the cyst is sometimes quite clear and watery ; in other instances it is thick and albuminous ; in other instances still, it is gelatinous and almost solid. The ten- dency is for the ovarian cyst to increase until it fills the abdomi- nal cavity, and to destroy life by the pressure it exerts on the breathing, the circulating, and digestive organs. Of late years, an operation, invented by Dr. McDonnell of Kentucky, and greatly advanced by Mr. T. Spencer Wells and other emiiient surgeons, for the removal of these ovarian tumors, has been attended with the most magnificent success, from seventy to ninety per cent, of cases which would have ended fatally without the aid of the oper- ation being now recoverable. Iso surgical operation discovered or invented in the present century, or indeed in any century, has been so remarkable as this operation which is called ovariotomy. Diseases of the TJterxus or Womb, — The uterus or womb is the receptacle in which the ovum is received after impregnation, and is the pouch in which the body is developed from its embryonic state into that in which it is presented at its birth. The uterus is not connected permanently with the ovaries by a duct, in the same way as the bladder is connected with the kidney ; but it is indirectly connected by means of two ducts, called the Fallopian tubes, Avhich emerge from it one on each side at tlie upper angle of the fundus or body of the organ. These little tubes, discov- ered by Gabriel Fallopius about the year 1559, extend from the uterus laterally on each side, for a length of nearly five inches, along the upper border of the broad supporting ligament of the womb. They are made up of a mucous lining, which is continu- ous from the uterus ; of a coat of circular muscular fibres lying outside the mucous coat ; and of a serous outside coat derived from the peritoneum. The tubes expand at their fi-ee ends in a trumpet-shaped fashion, and terminate in two or three fringed or fimbriated projections, which are ordinarily free, but which under excitation grasp the ovary, and enable the ovum to escape into the tube, and pass through the tube into the uterus. 222 LOCAL DISEASES. The uterus itself is made up of three coats : of a lining of mucous membrane, the inner coat ; of a circular and longitudinal layer of involuntarj muscles, the middle coat ; and of an invest- ing serous membrane from the peritoneum, the outer coat. The organ is pear-shaped, and in the unimpregnated state in the adult person is about the size of a moderate-sized pear. The upper part of it is called the fundus or body ; the smaller and lower, the cervix or neck ; and the opening of the neck, the os or mouth. The uterus is the seat of many diseases. Catarrh or LeuGorrlKBa. — The mucous lining of the uterus is subject to catarrh or excessive secretion from its surface, the se- cretion passing away as a passive white discharge, leucorrhosa. Inflammation. — The uterus is subject to inflammation, which may be of the simple kind, involving chiefly the mucous lining, or may extend more deeply into the muscular coat, and may be of a special form, called granular inflammation. The inflammation may also end in formation of matter or pus, which when diffuse is called suppurative, and when encysted or confined is called abscess. Ulceration. — The organ, is often the seat of that destruction of surface, called ulceration, brought on either by long-continued irritation, by congestion, or byinflannnation. The neck or cervix of the uterus at its os or mouth is the part most commonly affected with idceration. In rare cases the uterus is the seat of the special ulceration called rodent idcer. A.hraslon. — The mucous surface of the uterus may be sub- jected to abrasion, by which the surface is suddenly i-emoved or destroj^ed at some point. The affection usually ends in ulceration, and heals after the manner of a healing ulcer. Mechanical affections. — The uterus may be the seat of me- chanical diseases or affections, of which the principal ones are : — Utero-vesical flstula, — a fistulous opening from the uterus into the bladder ; stricture of the orifice of the cervix / stricture of the canal of the cervix / occlusion of the cervix / occlusion of the canal. It is liable to seven displacements — {a) Anteversion, tilting or turn- ing forwards ; (b) Retroversion., tilting or turning backwards ; (c) Anteflexion, bending forwards ; {(1) Retroflexion, bending back- wards ; {e) Inversion, or turning inside out of the oi-gan, an ac- cident occasionally connected with childbirth ; ( /) Prola])sus, falling or descent of the organ from its natural place ; {g) Hernia or rupture. DISEASES OF THE GLAl^fDULAR SYSTEM. 223 Ilijpertrojpliy and atropluj. — The uterus may undergo hyper- tropliy or enlargement, either from actual increase of its nmscu- lar fibres, or from deposit in its cellular connecting structure. The cervix, or neck, may also become enlarged or elongated. The uterus may undergo atrophy or wasting of its structure, and so become reduced to an extremely small size. Tumors and Growths of the Uterus — Fibroid Disease. — The uterus may be tlie seat of various growths, malignant and simple. It is liable to becoine affected with scirrhus cancer, medullary cancer, and epithelial cancer. It is the seat, in some cases, of a non-malignant but troublesome cellular or fibrous growth, spring- ing from its inner surface by a neck or pellicle, called jmlyjpus / and of a growth in its own substance, knoMm 2i.s,Jibroid disease or enlargement. In this last-named form of disease, fibroid enlarge- ment, the uterus may become of a very large size and a source of great discomfort, but the affection is not necessarily fatal, and it sometimes, accoi'ding to my experience, permits those who suffer from it to attain to old age. Diseases of the Apj^endages of the Uterus. — The Fallopian tubes may be the seats of inflammation, dropsy, stricture, occlu- sion, hernia, dislocation, and of foreign growths, simple and can- cerous. The broad ligaments of the uterus, the folds or duplica- tions of the peritoneum by which the oi'gan is supported in its place, are subject to two inflammations, — -pelvic jperitonitis and pelvio cellulitis / to abscess ; to cyst and jpelvic hcematocele / and to extravasation of blood into the cellular or connectino; structure. The vagina or membranous tubular sheath, which extends from the os or mouth of the uterus to the external surface of the body, and which is lined with mucous membrane continuously with the uterus, is the seat of several diseases, viz., catarrh ; in- flammation ; abscess ; cicatrix or band ; hernia ; cancerous growths, usually epithelial ; and non-malignant growths, including polypus. It is subject to laceration ; and to three kinds of fistula, {a) Vaginal fistula. (1)) Yesico-vaginal, — fistula into tlie Ijludder. (c) Recto-vaginal, — fistula into the lower bowel. By surgical manipulation carried in these days to great perfection, nearly all cases of these kinds of fistula are curable, and an untold amount of suffering, common in former times, is saved. Functional Diseases of the Uterus — Irregular Menstruation. — The uterus, after the age of puberty, fourteen years, and up to 224 LOCAL DISEASES. tlie age of forty -five to fifty years, is the seat of a periodical monthly change, called menstruation, daring which it discharget^, for a period of three to five days, a fluid called the menstrual, composed of uncoagulated blood, of mucous or epithelial cells from the mucous surface, and of debris of a membrane formed within the uterus, and which has, in the unimpregnated uterus, to be cast off. During childbearing this menstrual function is sus- pended, the membrane cast off in menstruation being required as a receptive membrane for the ovum when it enters the uterine cavity ; but at other times the function is necessary for the per- fectly healthy condition of the woman during the periods of her life that have been quoted above. The phenomena of menstruation are sometimes changed, in various ways, from what is natural ; and such derangements ai-e expressed under the following heads : — AmenorrTicea. Ahsent menstruation. — A condition in which the function fails from one of four causes, {a) Original defective formation, (b) Want of development at puberty, (c) Mechanical obstruction, {d) Temporary suppression of function. Scanty menstruation, — A condition in which the function is performed, but in which the amount of fluid thrown off is scanty and usually deficient in color. Vicarious menstruation. — A condition in which menstruation occurs, as it were, in place of, or vicariously for, some other dis- charge or function. Dl/smenorrkosa. Painful rnenstrtcation. — A condition in' which the act is carried out Math great pain, the pain being i-e- ferred to the lower part of the body, and being reflected severely to the back and loins. This state is often accompanied with faint- ness, nausea, inability to take food, mental excitement hysterical in character, and physical depression. Menorrhagia. Excessive menstruation. — A condition in which the function is attended with great loss of fluid. The loss may be extreme at the natural period, or it may, by frequent recur- rence, be a repetition of smaller losses. Some, therefore, speak of the first kind as acute, and of the second as chronic menor- rhagia. Hemorrhage. — A condition in which there is direct loss of blood from the uterus, uterine hemorrhage. This is most com- monly connected with childbirth, and is one of the serious com- DISEASES OF THE GLANDULAR SYSTEM. 225 plications of that act. But it may occur under otlier circumstances, as in connection with acute or chronic menorrhagia, with a pur- puric or extremely fluid state of the blood generally, with ulcer- ation of the mucous surface of the uterus, or with polypi or other tumors, malignant or non-malignant, developed in the uterine cavity. Diseases of the Breast Glands. The female breast, the gland yielding the secretion of milk in the nursing woman, is liable to many diseases. It may be sub- jected to disease at times when it is taking on the active function of secretion, and at other times when it is yielding no secretion. Infiammation and its consequences. — The breast is sometimes the seat of inflammation, which, when secretion is commencing in it, may be acute or chronic. The inflammation is attended with much pain and fever, and ends often in the formation of abscess, commonly called milk abscess., which, as a rule, either breaks or has to be incised by the surgeon. In healing there is sometimes left a small opening which will not close, and which is called a sinus. Excess and deficiency of secretion of inilJc. — In rare instances the secretion of milk is so profuse that the loss is a cause of great debility. To this state of disease the term Galactorrheea is ap- plied. In other cases, and much more frequently, the milk is deficient in quantity and in cpality. This is called deficiency of 'inilh, and is one of the most common conditions of disease in poor and ill-fed nursing mothers of all communities. Disease of the nijpjple. — The nipple of the breast is liable to two painful affections, chajp])ed nijpjple and tdcerated. It is in some instances drawn in so closely as to be on a level with the body of the gland. This is called dejpressed nipple. Ilyjpertrophy and atrophy. — The breast-gland may be sub- jected to enlargement or hypertrophy, either from excessive growth of the natural parts, or from deposit in the connective structure. The gland is subjected, more frequently, to wasting, or atrophy, in which it shrinks into very small dimensions, leav- ing the once distended skin in loose folds and wrinkles, marked with white spots and lines. Excessive action from many and prolonged nursings, with impoverishment of food, or improper Bupply of food, are the usual causes leading to this atrophy. 15 226 LOCAL DISEASES. GroictJis or Tumors of the Breast. — Tlie female breast is tlie seat of many foreign growths, non-malignant and malignant. The non-malignant are — («) Fibrous tumor, a firm and very painfnl growth immediately nnder the skin—" painful subcutaneous tu- mor." (Ij) Fibro-vlastic tumor, a deeper seated growth, :nore fixed, of slower development, and less painful, (c) Tatty tumor, a growth of fat enclosed in its own membranes, often in lobules, slow of development, rather loose, and not painful, {d) Osse- ous tumor, a very hard tumor of calcareous or bony structure. {e) Enchondroma or cartilaginous tumor, very firm to the touch. {f) Adenoid, a tumor like the gland itself in structure, and of slow growth ; called also " chronic mammary tumor." {g) Vascu- lar tumor, a tumor consisting of vascular structure, but not of rapid development, (h) Cysto-sarcorna, a tumor made up of cystic growths, with firm inter-deposited plastic matter ; called also "complex cystic tumor." (^) Simple cystic growths, (j?) Parasitic cystic developments. Cancer and Colloid of the Breast. — The mammary gland, or breast, may be the seat of malignant disease, and is perhaps the organ of the body that is most subjected to this affection in women. The breast may be attacked by ejpithelial, by onedid- lary, or by hard cancer, — scirrhus. Of these the scirrhus form is most frequently met with, and ordinarily commences as a small swelling in the gland, which at first may feel loose and give little pain, but which grows larger, liarder, and more painful. In time it causes retraction of the nipple ; and, allowed to run its own course, it continues to increase, involving surrounding parts, until the skin breaks through, and a large ulcerated surface is produced, which shows no tendency to contract or heal. The dis- ease, np to this day, is mortal, for although by surgical operation the local growth can be removed, there is ordinarily a recurrence of the affection eitlier in the other breast, in the glands under the arm, or in some other gland or organ of the body. Colloid. — Tlie breast is sometimes the seat of the gelatinous tumor called colloid. The growth may attain a very large size, and develop with great rapidity. It is doubtful whether it be malignant. From the breast of a patient under my care, the late Sir AVilliam Ferguson removed, in the year 1852, a large colloid, after which event the lady lived over twenty -five years, and died of senile decay. DISEASES OF THE GLAKDULAR STSTE3I. 227 Other affections. — The breast, lastly, is subject to a peculiar neuralgia, called tnastodynia ', and to excessive sensitiveness, hyjyerwsthesia. The rudimentary mammary gland or breast in the male is subject occasionally to disease. I liave seen it once the seat of cancel*, scirrhus. It may be the seat of inflammation, hyper- trophy, simple tumor, and cystic growth. It has been known to secrete milk. Diseases of the Ductless Glaistds. The ductless glands that demand our attention are three in number. The thyroid, or the gland in the fore part of the neck. The spleen. The suprarenal capsules. Diseases of the Thyroid Gland. Inflammation. — The thyroid gland may be the seat of inflam- mation, either acute or chronic in character. The affection is rare as an uncomplicated condition of disease. Goitre. — The disease known as goitre, also known in this country as "full throat " and " Derbyshire neck," is a disease of the thyroid gland. It is often present in connection with the condition called cretinism, and in certain districts it is specially frequent, as if from some purely local cause. The College re- porters define it as " enlargement of the thyroid gland, endemic in certain mountainous districts, but not limited to them." The enlargement is sometimes due to hypertrophy of the natural tis- sues of the gland. In other cases it is due to a cystic enlarge- ment. It often attains a very large size, and in worst examples it interferes with the circulation of the blood through the neck, or even with the passage of food through the cesophagus. Exojphthalmio goitre or hronchocele. — This term is now used to express " an enlargement with vascular turgescence of the thy- roid gland, accompanied by protrusion of the eyeballs, anaemia, and palpitation." It is the most distressing form of goitre, and in some mountainous districts in tropical regions is, comparatively, a frequent affection. It would seem to be hereditary in character. Pulsating hronchocele. — An enlargement of the thyroid gland accompanied with arterial pulsation. The thyroid gland is occasionally the seat of cancer, usnall}'" of the scirrhus variety. 228 LOCAL DISEASES. Diseases of the Spleen. The spleen, a large vascular organ, lying in the abdominal cavitj, beneath the liver, on the left side, is a ductless gland, en- closed in an elastic coat, and invested by the peritoneum. The uses of the spleen are as yet not fully understood. Important duties in the animal economy have been assigned to it, and yet, to my own knowledge, the experimental fact remains that an animal can live what appears to be a perfectly healthy life without the spleen. The spleen was considered by the older physiologists to be a compensating organ for the blood of the digestive system. When the digestive organs do not require blood, when they are not at work, the spleen, it was imagined, is the elastic spongy reservoir for blood ; but when the digestive organs are at work then the spleen gives up its blood to them. This mechanical view is not abandoned, though there is now added to it the belief that in the spleen the corpuscles of the blood, called the white corpuscles, are produced, and that in it the red corpuscles are dis- integrated or broken up. These latter views are chiefly derived from the diseased conditions of the spleen that have been discov- ered after death. The spleen is the seat of several diseases. Sjylenitis. — Inflammation of the spleen. This affection is not often distinct or uncomplicated in the human subject. Inflam- mation of the spleen in man is most commoidy the result of pysemic inflammation, with abscess as a further development of the inflammatory condition. In this way the spleen may become indirectly the seat of inflammatory disease, and is often so affected during acute diseases of other organs. Fihrinous deposit. — After some general inflammatory condi- tions of the body the spleen may be the seat of extensive deposit of fibrine from the blood. The deposit may be diffused in patches, or, as I have once seen, in lines or bars, through the structure of the gland. The deposit may undergo partial organization. Congestion. — The spleen is naturally liable to undergo vascu- lar congestion, being essentially a vascular organ. It is probable that we never experience a chill but that an excess of blood is thrown upon the spleen. The congestion is most fully developed in the disease known as intermittent fever or ague, with its parox- ysms of coldness, heat, and perspiration. In this affection, when DISEASES OF THE GLANDULAR SYSTEM. 229 it is long-continued, the spleen gains an enormous size from re- peated and prolonged congestions, and is left permanently en- larged, forming what is, expressively hut vulgarly, called ague- cake. Hypertrophy. — The spleen may undergo enlargement from hypertrophy of its natural parts, in which state its functional ac- tivity is believed to be increased. This condition is so frequently connected with the blood disease in which the white corpuscles are increased, leucocythaimia, that this blood affection is thought to be due to super-activity of the spleen, with consequent increase of the white, and, possibly, an unnatural disintegration of the red, corpuscles. Amyloid disease. — A diseased state of the spleen, in which it undergoes degeneration into a lardaceous or waxy condition. The degeneration is connected, perhaps in every case, with a similar form of change in some other organ or organs of the body, such as the liver or kidney. HodghiriJ s disease. — A disease first described by the late Dr. Ilodglvin, in which the spleen is the seat of a white deposit, and in which the lymphatic glands of the body are greatly enlarged. The disease, which has been laboriously studied and written on by Dr. Wilks as a distinct organic affection, is attended by gen- eral symptoms of anaemia or bloodlessness, with a tendency to dropsy or anasarca. Other affections. — The spleen may be the seat of cancer, — I liave once seen it the seat of medullary cancer, — of colloid, of tubercle, and of parasitic growths. It may be, mechanically, torn or ruptured. Disease of the Suprarenal Capsules. The two ductless glands placed upon the kidneys, and called the suprarenal capsules, have long been a puzzle to the physiolo- gist. Their use is yet undiscovered, but, since the days of the late Dr. Addison, they have been brought under close observation from the fact that he connected with disease of their structure a series of general bodily symptoms, which have since been desig- nated after him as " Addison's disease." Melasma Addisoni. — This disease, called commonly " Addi- son's disease," is attended by anaimia, great debility, occasional syncope, and exhaustion. But the most marked feature of the 230 LOCAL DISEASES. affection is the peculiar color of the skin. The skin assumes a bronzed or smoked appearance, which may intensify until the person affected may scarcely be recognizable from a mulatto. The affection is fatal, and is attended always with some changes of varied character, — atrophic, fibroid, tubercular, cancerous, or inflammatory, — in the suprarenal capsules. It is still doubtful whether these changes are the cause of the symptoms of bronzed skin disease or the results of a general condition of disease, in which the suprarenal capsules are invariably but secondarily in- volved. Whichever may, ultimately, be found to be the fact, — and there is a wide field for research in the investigation of the changes in other organs connected with the disease, — the original and perceptive labors of Addison cannot well be over-estimated. CHAPTER VIII, DISEASES OF THE MUSCULAR SYSTEM, TENDONS, AND APPENDAGES. The diseases of the muscular system were but little under- stood as structural diseases until the microscope became an instru- ment of research in the hands of the physician, and even in the present day the subject has not been studied with the successful zeal that has been devoted to other inquiries on the seats and causes of disease. It will be remembered that there are three sets of muscular organs : the red striped voluntary muscles, the muscles which move the body under the direction of the will ; the red striped involuntary muscles, the muscles, like the heart, which move without the direction of the will ; and the unstriped white muscles which surround the automatically acting organs, and which are purely involuntary in the direct sense of the term. The structural diseases of the voluntarj' and involuntary red striped muscular organs have been best studied, while those of the involuntary are open to much further investigation. It must 1)0 understood, therefore, that the diseases referred to as affecting the muscular system, relate, with few exceptions, to the red or striped muscular organs. Diseases trf Muscular Structure. Injlainrriation and abscess. — The muscles may be the seat of inflammation, but whether that is connected oidy with the fibrous or membranous sheaths in which the fleshy nniscular elements are enveloped, or whether it is in tlic muscular elements, is not as yet fully determined. Pure and simple inflammation of muscle is, in fact, ver}^ rare as a disease uncomplicated by rheumatic affec- tion, or by pyaemic fever. AVlien the inflammation does occur in a muscle it is attended with dull pain, inability to move the muscle, swelling, and fever. As a result, matter or pus may form in the muscle, producing abscess. 232 LOCAL DISEASES. Hyjpertrophy. — The natural structure of a muscle may become enlarged or hj'pertrophied, a result, as a general rule, of excessive work of tlie muscle. Tins is commonly illustrated in the enlarge- ment of the muscles of the arm of the blacksmith and of the leg of the opera-dancer. It is met with also in the heart, as we have already seen. Atrophy. — Atrophy of the muscles is a condition common to all the extremely exhausting diseases, and is the chief cause of the weakness which characterizes them. In pulmonary consump- tion and other diseases of the wasting class, the muscles are re- duced until they almost become like cords. In many instances special muscles, or sets of muscles, are atrophied from want of ' use, and in paralj'sis of the limbs this form of muscular failure is of common occurrence. Atrophy of the heart is sometimes ascribed as a cause of death. Progressive muscular atrojjhy. — A condition in which the muscular structure begins to waste in some part of the body, as the muscles of the upper limb, and in which the wasting continues until the whole of the voluntary system is affected in a similar manner. The disease is sometimes called wasting palsy. Strictly speaking, it is a nervous disease, and is truly a paralysis depend- ent upon inflammatory or degenerative change in the gray matter of the spinal cord. Paralysis. — The muscles are subjected to the varied forms of paralysis which have been before us already, under the heads of infantile paralysis, scriveners palsy, diphtheritic paralysis, general paralysis, paralysis agitans, and so on. It is not, however, con- sidered that these are diseases of the muscular structures ; though, from their continuance, the muscular system may undergo wast- ing and other organic changes, owing to impaired nutrition. The paralyses are of nervous origin, and are considered as belonging to diseases of the nervous system. Convulsion, Spasm, and Tetanus. — The muscles may be con- vulsed, or may be thrown into spasm or tetanus, in which condi- tions they are the seats of serious functional disorder, and may, indeed, be physically injured. The conditions, however, are not dependent on the muscles, but are due to primary nervous de- rangement to which the muscular fibre responds. These aifec- tions are therefore also classed under diseases of the nervous sys- tem. DISEASES OF THE MUSCULAK SYSTEM. 233 Exhaustion. — A muscle, or set of muscles, may be exhausted, as from a blow, or from excessive work or strain, and for a time may be imable to act freely iu response to nervous influence. This is called exhaustion of the nmscle. Foreign growths. — The muscles may be the seat of foreign growths. These include, simple non-malignant and erectile non- malignant tumors, colloid tumors, cysts, cystic growths, and cancer. It cannot be said that any of these are common affections of the muscular substance. ParasitiG disease — Trichinosis. — The muscular organs may be the seats of parasitic developments, and they are specially the seats of the parasite called trichina spiralis, the larval state of a nematode worm. The parasite infests the muscular structure sometimes in large numbers, and remains embedded in the sub- stance in points or spots, looking like small cells or beads. When the parasites first enter the muscular substance they create pain, which is often mistaken for muscular rheumatism. As the larvae become encysted the acute pain is reduced, and then there is, or may be, a prolonged period of impairment of function, the cause of which may not be discovered until after death. The trichino- sis parasite in man is derived from his taking as food the muscular flesh of lower animals affected with the parasitic growth. Re- ceived into the stomach, the larvae very quickly develop into matu- rity, causing much pain and disturbance in the alimentary system. The female trichiuEe giving forth their embryos in abundance, the embryos migrate along the connective tissue into the structure of the muscular organs, where they become encysted, as described above. Degenerations of Muscular Organs. The muscles, including the heart, are seats of degenerative changes, two of which are specially impoi'tant. Fattij degeneration,. — The muscular tissue in this form of de- generation is transformed, more or less, into a fatty condition, the truly muscular elements being replaced by fatty or oily particles. In this state the muscle fails to respond to the nervous stimulus, and thougli the structure may remain of the same size, or may even increase in bulk, it is incapacitated for active woi-k. The lieart is the muscle most frequently affected by this degeneration. Osseous degeneration. — A condition in which the muscular 234 LOCAL DISEASES. structure is converted into calcareons or bony matter. The heart may become — as I have once myself seen it — transformed, in part, into firm bone. Osseous change is attended with little acute pain, but with permanent destruction of function of muscle in the part involved in the change. Diseases from deposits. — The muscles may become the seats of special deposits, tubercular and syphilitic, and it is probable that the involuntary muscular fibres are often the seats of syphi- litic deposit, by which their action is greatly impaired, and from which impairment two diseases of the blood-vessels, namely, dila- tation and aneurism, have frequent origin. The muscles are subject to rupture or tear. The rupture may be in the structure itself. It is more commonly in the muscular sheaths. It may be caused by excessive strain or by a blow on a healthy muscle. It may occur under ordinary movement in a muscle affected or weakened by disease. Diseases of Tendons. The tendinous terminations of muscles called commonly the sinews are themselves devoid of contraction. They are, as it were, the membranous sheaths of the true muscular tissue con- densed into one homogeneous structure at the ends of the muscular bodies. They are composed of fibrous tissue, and are enclosed in an investing w^eb or sheath. They are the passive parts of muscle, and form the attachments of muscles to bone, by means of which the muscles pull or exert their power to move the bones. The tendons are the seats of several diseases. Infiammation — Thecal abscess. — The tendons are often the seat of inflammation, as a result of wounds in which they are in- volved. A common form of inflammation of tendon is that known in the finger, called thecal abscess or whitloiu, in which matter forms within the sheath of the tendon, causing a most painful local inflammation accompanied with irritation and fever. The tendons are sometimes involved in rheumatic inflammation. Sprain. — When a tendon, or a tendinous expansion, or fascia, is subject to severe stretch, or to tear, or to displacement, a sprain is produced. Sprain is a connnon injury, and is usually attended with external swelling, pain, and difiiculty of movement in the part, lasting for several days. The tendinous expansions or fascial coverings of muscles are occasionally torn across, in places like DISEASES OF THE MUSCULAK SYSTEM. 235 the calf of the leg; severe injiiiy to motion occurs from such tearings, together with great pain, swelling, sometimes ecchymosis or effusion of blood, and nsually some after fever. This painful accident is called rupture of the tendinous fascia. ^cZA^'s/wi.— Tendons, as a result of inflammation, may be- come adherent one to the other, or to surrounding parts. The effect of the adhesion is to produce more or less derangement of motion from the muscles connected with the tendon or tendons implicated. Contraction of Tendons. Tendons are liable to contraction, by which the parts they are connected with may be shortened or otherwise distorted. The contractions are sometimes congenital and sometimes the result of disease or accident after birth. The most common con- tractions are those affecting the foot and causing the various deformities called generally club-foot. Talipes or Clubfoot. There are several kinds of club-foot, talipes, some of which have received different names according to the character of the deformity. The principal of these are as follow. Talipes varus. — This is the most common form of club-foot, and may be a congenital affection. The heel is drawn up ; the inner side of the foot is drawn up and the toes are turned in- wards. The sufferer learns to walk, in this case, on the outside of the foot. Talipes valgus. — A condition the opposite to the above, in which the heel is raised, the outer side of the foot is turned up, and the sufferer walks on the inner side of the foot and inner ankle. Talipes eqxdmts. — A contraction in which the heel is drawn straight up, so that the sufferer walks on the toes, or on the toes and a small part of the surface of the foot. Talipes calcaneus. — A contraction in which the toes are drawn up, and the sufferer walks on the heel bone, — the calcaneum, or OS calcis. Talipes calcaneo-varus. — A contraction in which the toes and inner side of the foot are drawn up, so that the patient walks on the heel and outer side of the foot. Tcdipes e(juino-'valmar ganglion.''^ CHAPTER IX. DISEASES OF THE OSSEOUS SYSTEM OR SKELETON, INGLUDINO THE TEETH. The bones on their exterior are covered with a strong sensitive membrane, the periosteum, from which, as the researches of M. Oilier so ably proved, the bony structure is secreted, so that periosteum being in contact with many vital tissues, new bone is producible. In the joints the bones are covered with synovial membrane, the glistening structure which is seen when a joint is laid open and which secretes the glairy synovial fluid, by which the surfaces of the joints are lubricated and saved from friction. "Within some of the bones, within the shafts of the long bones particularly, there is also a substance made up of fatty tissue, called the medulla or marrow, which supports the blood-vessels by which the bone is fed, and also, according to a recent view, plays an important part in the formation of the red corpuscles of the blood. In considering the diseases which have their seat in the skele- ton we have, therefore, to include diseases of the bone proper, of the periosteum, of the synovial membrane, and of the medulla or marrow. It is well to recall, in relation to the diseases of bone, that the bony structure is made up of two parts, of an organic, and of an earthy or inorganic part. The organic matter is the gelatine which can be separated by the process of boiling bones. The earthy is that which is left as powder or ash M'lien a bone is burned. The animal, or organic matter, makes up about thirty- three per cent, of bone, the earthy sixty-seven per cent. Of the earthy matter fifty-five per cent, is composed of calcium phosphate, the remaining twelve per cent, is made up of magnesian phos- phate and calcium carbonate, with a little calcium fiuoride. The earthy substance gives strength and solidity to the bone ; the animal matter holds the earthy together, acts as a cement, and DISEASES OF THE OSSEOUS SYSTEM. 239 gives to bones a certain nieasnre of resiliency. Tliis is important to keep in mind in relation to disease. If the earthy matter be deficient, the bone will bend ; if the animal matter be in excess, the bone will too easily fracture or break. The bones are con- nected together by strong fibrous bands or ligaments, which inter- lace and form elaborate and important structures, while in many of the joints there are interposing structures of cartilage. To the skeleton we have to add, as part of it, the teeth, which, placed in what is called the alveolar or socket portion of the jaw- bones, are thirty-two in the second or complete set ; viz., four incisor ; two canine, four bicuspid, and six molar in each jaw ; and twenty in the first set or teeth of infancy, milk teeth ; viz., four incisors, two canines, and four molars in each jaw. These structures have to be taken into the study of the diseases of the osseous system. The diseases of the bones and teeth fill, as nl^y be expected, a long list in the local history of disease ; and yet, after all, they are not extremely complicated. In the nomenclature forty dis- eases are assigned to the skeleton ; thirty are connected with the teeth, and seventeen are connected with the process of development of the teeth. Diseases of Bone and Peeiosteum. Ostitis. — Inflammation of bone ; a disease very rare in its un- complicated form. When it occurs it is, usually, in the young who ai-e of feeble and strumous constitution. Even in them it is, I believe, always induced by some external influence, such as a cold, an injurj^, or one of the epidemic diseases. It occurs, as a rule, in the large long bones, and is attended with much pain, fever, local swelling, and it may be redness of the skin over the affected bone. Perlost'dls. — Inflammation of the periosteum, or periostitis. This, like inflammation of the bone structure, is rarely seen except in feeble persons of scrofulous taint. It is attended with signs similar to those which are noticed in ostitis, but the pain is more acute. When the inflammation is very diffuse, and matter forms beneath the membrane, acute ])eriosteal ahscess or diffuse perios- titis are the terms used to express the diseased condition. When again this ends in death of the bone structure, without death of 240 LOCAL DISEASES. the periosteum, acute necrosis^ — death of bone, — is said to have taken place. JS'odes. Persons who have contracted the specific disease syphilis, are subject to a subacute inflammation of the perios- teum, usually in the long bones, and most frequently in the leg- bone, the tibia, from which there is produced a long-shaped and painful swelling, called a node. As a general rule, the swelling passes away with the resolution of the constitutional affection. Caries. — A condition practically of ulceration of bone, in which, after inflammation, the bony substance becomes porous, and, in the acute stage, filled with a reddish glairy exudation. The bone is dead, and, left to become dry, assumes, literally, a worm-eaten appearance. It is a cause of great irritation and often of ulceration, attended with offensive discharge. Caries may be the result of injury of bone, of inflammation, or of death of the periosteum. Necrosis. — Is'ecrosis also means a death of bone and arises, like caries, from injury or from inflammation. But in necrosis the periosteum, which may remain intact, throws out a plastic fluid, and from that new bone is gradually formed, which joining with sound bone above and below causes separation of the dead bone in what is called a sequestrum or residue. The new bone thus formed may fulfil all the purposes of natural bone. The late Professor Laurie of Glasgow was wont, very happily, to de- fine caries as death of bone, and necrosis as " death of bone with regeneration." Mollities Ossium. — A condition of disease in which the bone softens, and at the same time becomes brittle. The bone loses its earthy constituents, and the animal structure of which it is com- posed is softened, it may be almost to a pultaceous state, so that the bones easily bend and break. Or the osseous matter may be left porous, so that the bone is extremely brittle, and breaks from very slight causes. The affection is most common in women, and the pelvic bones are the most frequent seat of it. It is not neces- sarily fatal, and it may last for many years. I have known it to occur in the male subject, though no doubt that is not a common event. It is connected always with some constitutional condition, usually syphilitic or tuberculous in character. An allied disease to mollities ossium is often met with in the insane, and wlien it is present very slight injuries cause fractures DISEASES OF THE OSSEOUS SYSTEM. 241 of the bones or the ribs. I knew an instance of tliis kind in which ten ribs were fonnd to have been fractured after death. In these cases the earthy matter is deficient. I found in a bone taken, after deatii, from a man who had suffered from the affec- tion, that the amount of earthy matter was, actuahy, under nine per cent. Yet that bone, which had been fractured at least twice, had undergone two attempts at i-epair from effused periosteal lymph and new ossification. Rickets. — A disease classed by the College as one belonging to the general diseases of constitutional type. Rickets is connected with deficiency of earthy substance in the bones, and the bones, therefore, unable to support the weight of the body, bend under it and give rise to curvature of limbs and spine, which may, and often do, become permanent deformities. Kickets is duo to con- stitutional taint ; to the bringing up of children in bad air ; and, above all, to the feeding of children on foods deficient in the earthy salts that are necessary for the natural construction of bone. Spontaneous fracture. — Spontaneous fracture of bone is fract- ure occurring from some simple accident or natural act of the body. In one of my medical friends it occurred in a rib, from coughing. The bone in these cases is usually diseased and brittle from deficiency of animal structure. Foreign growths of hone. — The bony structure may be the seat of several forms of the non-malignant growths, with the nature of which wo are now familiar. The growths of simple character classified as specially connected with bone are fhrous andfhro- cystic tumors / myeloid, a reddish tumor commencing usually in the ends of bones ; cartilaginous, called also enchondroma / and osseous, called exostosis. Of the last named, exostosis, there are three varieties ; the ivoi^y exostosis, in which the enlargement is hard and smooth like ivory ; the cancellated, in which the en- largement is porous or cancellated ; and the diffused, in which the enlargement is spread over a considerable surface of bone. Tlie bony structure may also, as we have seen, be the seat of cancer, osteoid. This cancer commencing in bone may be of ex- tremely rapid growth. The bony structure may, again, be the seat of cystic develop- ments and of parasitic growths. Ihjpert rnphy and atrophy. — The whole or part of a bone may become generally enlarged, or hypertrophied, from uniform iu- 16 242 LOCAL DISEASES. crease of its structure ; but it is more frequently the seat of atro- phy or wasting, in which it is generally reduced in size and ren- dered weak and fragile, the external firmer surface becoming thinned and deficient in power of resistance. To this state the ievva fragility or fragilitas ossium- has been applied. Coiistitutional changes in hone. — The great constitutional taints, syphilis and scrofula, are common causes of disease in bone, and the terms syphilitic and scrofulous disease of the osse- ous system are in common use. As a rule these terms refer to one or other of the forms of disease already named, and as devel- oped in persons who are under the taint of the constitutional affections, syphilis or scrofula. Diseases of the Joints. Synovitis. — Inflammation of the synovial or lining membrane of the joints is the first disease named on the list of affections of the joints. This inflammation, attended usually with severe pain, and when the joint is a large one, like the knee-joint, attended also with much constitutional derangement and fever, is divided into two kinds, the acute and the chronic. The acute form is often the result of injury, which may be very slight in character ; it runs a conrse of from ten to twelve daj^s, causing much swell- ing, and severe suffering under the slightest movement, in the joint. The chronic form is, as a rule, a continuation of the acute, but it is sometimes assumed without precedence of acute symp- toms. Chronic inflammation of the synovial membrane may lead to softening and to what is technically designated " pulpy degen- eration " of the synovial membrane. The inflammation of the synovial structure of joints may as- sume the rheumatic, the scrofulous, and the syphilitic character in persons who are constitutionally under the influence of these taints. E-heumatic and chronic rheumatic inflammation of the sjmovial membrane is the most common of all the varieties of synovitis. Ulceration of cartilage. — The cartilages of the joints may, from long-continued inflammation, and some think from irritation without active inflammation, become the seat of ulceration by which the joint is disabled and rendered excessively painful. This ulceration, when it is not the result of injury, is commonly connected with rheumatic or scrofulous taint. DISEASES OF THE OSSEOUS SYSTEM. 243 Ahscess. — Abscess within a joint, thongli it may occur from injury or from extension of inflammation from neighboring parts, is exceedingly rare in a healthy constitution. In scrofulous per- sons it is more common, and in scrofulous children abscess or for- mation of matter within a synovial pouch is by no means uncom- mon. The disease, in them, is called scrofulous disease of the joint, and is typified in an affection of the hip-joint known as morbus Qoxce. Anhylosis. — The stiffness of joints which follows upon inflam- mation, ulceration, abscess, or other injury, and which leaves the joint firm or immovable, so that it cannot be moved by the per- son to whom it belongs, nor even by another person without its being broken, is called ankylosis. Ankylosis may give rise to various kinds of deformity according to the position in which the fixture of the joint, from adhesion of its surfaces, has taken j^lace. Dro][>sy of the joints. — An accumulation of synovial or watery fluid within a joint is called a dropsy of the joint. It is usually the result of injury, and is attended M'ith slow and large swelling of the joint, and for a time with acute pain. It subsides, usually, from natural absorption of the exuded fluid, but in less favorable instances it demands assistance from surgical art. Diseases of the cartilages. — In addition to the ulceration of cartilage, to which reference has already been made, the carti- lages of joints are subject to other forms of disease ; viz. [cC) to degeneration, involving the articular surfaces of the bones ; (J) to separation from their natural position within joints, so that they become movable, and by movement out of their place give rise to intense suffering, loose cartilage / and, (c) to displacement at their articulating surfaces, disjplacement of articular cartilage.^ by which they cause deformity of the joint, and thereby of the limb or part with which they are connected. lielaxation of ligaments. — The ligaments or strong but deli- cate fibrous bands which hold the joints in position ai'e liable to relaxation under sprain or violence from without, or from swell- ing or tension derived from within the joint. The relaxed liga- ment becomes unable to hold the joint in its proper position, and is then readily dislocated fi'om slight causes. This is well illus- trated in those instances where the shoulder-joint is very easily displaced in consequence of the ligaments having become un- naturally relaxed, weak and incapable. 244 LOCAL DISEASES. Defor'rnities of tJie 'knee-joint. — The knee is subject to t\ro marked deformities^ which are called respectively how-leg or out- knee, and, knoch-hnee. In the first of these affections the knees are widely separated from each other, and cannot be brought to- gether, so that the legs are bowed. The deformity is con:imon amongst those who are accustomed to carry heavy weights from the shoulders, like water and milk-bearers who carry the yoke. In these instances it is sometimes the case that the thigh-bones and leg-bones are somewhat bent : but the chief deformitv is in the knee-joint, the heads of the femur and tibia being depressed on the inner side, so as to throw the limb out of the straight line. In kuock-knee, on tlie other hand, tlie knees come close together on the inner side, so that the femur on each side bends inwards, and the tibula and fibula leg-bones bend outwards from the knee, the feet standing far apart. Knock-knee is more common in women tlian in men. The deformity may, I think, become hereditary. The joints are sometimes the seats of tumors which may be either non-malignant or cancerous. The joints are not infre- quently the seats of neuralgias pain. Diseases of the Spine. The bony column called the spine is subject to a series of dis- eases which, owing to their importance, have been particularly enumerated. The ligaments and cartilages of the spine are sub- ject to ulcero.tion / the bones are subject to necrosis, caries, and ankylosis. The bones may also be involved in surrounding ah- scess in the lumbar or loin region. They may be subject to rheu- matic affection, to cancer, and to tumors of a simple character, "We have already seen in the section of the local diseases of the nervous system that the spine is subject to a particular mal- formation called Spina Mficla, — Hydrorachitis. Spinal Curvatures. The spine is subject to several varieties of distortions called commonly curvatures. The following four are named in the official catalogue. Angular deformity. Kyphosis. — A deformity in which there is bending of the spine as a result of caries, or of absorption of the bodies of the vertebra, — those thick, solid masses of the ver- DISEASES OF THE OSSEOUS SYSTEM. 245 tebral structure which lie upon each other and form the soUd part of the spinal column. This deformity occurs nsually in scrofu- lous children or adults, and is one of the worst forms of spinal disease. It is always painful, and from the pressure which may ensue, it is sometimes a cause of palsy of parts fed with nerves derived from the portion of the spine involved in the disease. Lateral curvature. Shollosls. — The spine is subject to bend- ing or curvature on one or other side of the body, a condition which may be iuherited or acquired. It is often acquired in the young by making them stand for long periods in one position while they are groM'iiig ; or by the habit of standing on one foot or of bending over to one side. The curvature shows itself first in the process of becoming high-shouldered on one side, and, finally, in a complete distortion, if it go on, of curve or bending over, the column itself being visibly bowed or bent from the pel- vis, on which it rests, over to the side to which it has been di- rected. The disease, less severe and less dangerous than angular curvature, is a defect causing weakness of the spine, and occasion- ally much weakness of tlie limbs and body. Anterior curvature. Lordosis. — Under this head is defined a curvature in which the spine is bent forward or anteriorly, but not at an angle. Anterior curvature is the frequent result of making the young lean forward for long periods when they are sitting at work, as at writing. It is sometimes acquired by the habit of stooping, and, in the poor, I have known it caused by the pressure of weights carried on the head. Mr. Liebreich has shown that anterior spinal curvature is often concurrent with short-sightedness, the two diseased conditions being produced by the same cause, viz., the bending forward of the body, and the long continuance of that unnatural position. Ltichety curvature. — The deformity of the spine known as i-ickety curvature is not, necessarily, of one curve, but sometimes of two or more curves. It commonly accompanies rickets of other parts of the body. It affects feeble rachitic children, who have been improperly nourished. It forms, almost invariably, a part of the disease rachitis. The spinal column is subject to neuralgia^ rheumatic affection of its memhrcmes, and various kinds of mechanical injuries. 246 LOCAL DISEASES. Diseases of the Jaws. The jaws, iiiclading in the upper jaw the cavitj called the antrum, are subject to fibrous, myeloid, osseous, cartilaginous, and vascular tumors. Thej are also subject to hjpertrophj^, to necro- sis, to caries, to cysts, and to cancer. In rare instances thej are subject to adhesion bj cicatrix. Ahscess in the Antrum. — The antrum, or cavitj in the body of each upper jaw-bone, is subject to inflammation, followed by the formation of matter, — ahscess of the antrum. This abscess may give rise to much enlargement of the bone and of the cheek, and may be incapable of cure until brought under surgical skill. Polypus and Tumors in the Antrum. — Tlie antrum may be the seat of polypoid growth, and such growtli may extend into the cavity of the nose, giving rise to swelling and great deform- ity of the face, which nothing but surgical operation can reach as a means of cure. The antrum may be the seat of tumor, ma- lignant or non-malignant, under the growth of which the cavity is distended and the bony walls of it thinned and destroyed. It is occasionally the seat of foreign bodies. Diseases of the Teeth. The diseases affecting the teeth are divided into — (1) Diseases which affect the true dental tissues ; the enamel or crown ; the dentine or internal bone ; and the crusta petrosa or cementum, the outer bony structure of the tooth that lies within the jaw, the fang. (2) Diseases which affect the dental pulp, a sensitive structure within the tooth made up of arteries, veins, nerves, and connective substance. (3) Diseases of the periosteum or fibrous structure surrounding the fang, and connecting it with its socket or alveolus. (4) Diseases of 'the alveolus or socket in which the tooth is inserted. (5) Specific diseases affecting the periosteum of the teeth, the alveolus, or the gum. (6) Irregular develop- ment of the teeth ; irregular dentition. Diseases of the StTuctures of the Teeth. Caries. — Caries of the teeth is a slow process of destruction or ulceration without any attempt at repair. It commences usu- ally in the enamel or crown of the tooth, but it may commence DISEASES OF THE OSSEOUS SYSTEM. 247 from inflammation affecting the dentine or supporting bony tubes of the enamel, and may extend from within the tooth outwards. In my Medical History of Diseases of the Teeth, published in 1860, I defined caries of the teeth as a slow disintegration of the hard structures, mainly of the enamel and dentine, by which a cavity in the tooth rs produced from a process of destruction pro- gressing in the dentine without replacement or development of new tissue. The definition thus given is sufiiciently correct. The disease commences, as a rule, in the enamel, either from an acci- dent or from defective condition of that structure. From thence the mischief soon passes to the dentine, the tubes of which sup- port the enamel, and as that structure dies, from ulceration, the enamel gives way. The cavity, called in common language the decayed cavity of the tooth, is thus produced. Necrosis. — jS^ecrosis means partial or complete death of the structure of the tooth, the death commencing eithcir from failure of nutrition from the vascular nervous structure — " pi^^lp " — hi the cavity of the tooth, or from the periosteum. The necrosed tooth becomes dark and dead in the parts affected. Exostosis. — Exostosis of a tooth is an enlargement of the true bony part of the organ, the cementum of the fang. The enlarge- ment is sometimes general, at other times it takes the form of a tumor or swelling at the extreme point of the fang, where it may make almost a socket joint within the alveolus, producing a tooth it is very difficult to extract. In exostosis the surrounding mem- brane or periosteum is thickened, and the disease is always at- tended with severe pain, the worst form of toothache. Absorjjtion. — Absorption of the teeth is a gradual removal of structure, owing to impoverishment of nutrition, usually fi-om disease of the external nutritive membrane, the periosteum. The absorption is rarely confined to the tooth alone, it is commonly combined with absorption of the alveolus or socket. x\s a result the tooth recedes from the jaw, and, becoming loose, is detached from its position. Absorption is most common in persons of ad- vanced life. It occurs, howevei-, occasionally, in the young, when the body is improperly nourished, or is suffering under some ex- treme constitutional taint. Partial absorption of the enamel of the teeth, causing indentations to the surface, may follow the oc- currence of some of the eruptive cutaneous diseases of the young. The jagged, saw-like appearance on the cutting edges of the 248 LOCAL DISEASES. teeth, which is seen in some persons who are constitutionally weak, is, strictly speaking, an irregular form of absorption of the liard or enamelled structure. Diseases of the Dental Dtilp. The pulp of the tooth is said to be subject to three forms of disease — irritation, inflammation, and tdceration. These may, in truth, be considered as the course of one diseased condition proceed- ing from irritation to inflammation on to destruction or ulceration. At the same time, irritation may stand alone, and may not pro- ceed to inflammation. Irritation of the pulp is rarely, if ever, a disease of itself ; it commonly is connected with some other form of disease, such as rheumatic affection or injury, or commencing caries, or exostosis. It is always attended, in the acute stages, with severe pain, and after complete desti'uction, from ulceration, it is followed by death of the internal bony tooth tissue. Gangrene of the tooth is a disease specified in the nomencla- ture. It is of the rarest occurrence, and when present is a rapid decomposition of the tooth, attended witli moist softening and offensive odor. I have seen it once, markedly, in a person suffer- ing from scurvy, who was also constitutionally affected with the specific disease, syphilis. Diseases of the Dental Periosteum. The dental periosteum or peri-dental membrane \vhich envel- ops the bony part or fang of the tooth and connects it with the alveolus, is subject to a change of texture called granulation^ to a change into hardness called calcification / and to inflamma- tion. Gum-Tjoil. — The disease commonly known as gum-boil is an acute inflammation involving the periosteum. The affection, ex- tremely painful, is resolved at last, in most cases, by the formation and escape of matter; or pus, between the fang of the tooth and the alveolus. Chronic Thiclcening. — The periosteum after inflammation, acute or chronic, is liable to undergo cln-onic thickening, accom- panied with swelling and hardness of the guin, and often with extreme pain in the tooth itself, which nothing but extraction permanently removes. Rheumatic Inflarnmation. — In persons of i-heumatic consti- DISEASES OF THE OSSEOUS SYSTEM. 249 tution the periosteum of tlie tooth is subject to rheumatic inflam- mation, followed by thickening of the membrane and continued irritation. Most of the examples of thickening of the peri-dental membrane are, according to njy experience, the result of rheu- matic inflammation. Diseases of the Alveolus. The bony structure which encloses a tooth, and which is called the alveolus or socket process, is subject to the same classes of diseases as the jaw-bones themselves, of which, in fact, it forms a part. It is liable to snffer from inflcmiiriation., caries, necy^osis, exostosis, absorption, and cysts. The alveolus is sometimes fract- ured in the operation of extraction of a tooth. Ekkors in Dentition. In the process of cutting the teeth, and in the development of the teeth, — whether the temporary or the permanent sets, — there are certain errors or irregularities which are noticed by our stand- ard authority as forms of disease. These irregularities are : {a) An irregularity in the time of eruption of the temporary or perma- nent teeth, the irregularity consisting, usually, in delay in the time of eruption : (Ij) irregularity in the position of the temporary or permanent teeth, as when one tooth overlaps or displaces an- other : (c) irregularitj^ in the number of the temporarj- or perma- nent teeth : {d) irregularity in the form of the teeth of either set : {e) development of unnatural structures in the enamel, the dentine, or the cementum. In addition to these irregularities there are also added changes in the jaws and teeth. («) Unnatural development of the sockets of the teeth in relation to size or form : (J)) defective growth of the lower jaw : (c) mechanical injuries of the sockets and peri- osteum, including fracture and hemorrhage : {d) mechanical in- juries to the teeth themselves, such as fracture, dislocation, and, a not uncommon cause of caries, friction from pressure. CHAPTER X. DISEASES OF THE SKIIi AND 3IEMBRAN0US SYSTEM. The membranous system includes, as we have already learned : {a) the covering of the body called the shin ,' (b) the lining of the external cavities of tiie bronchial surface, of the mouth, of the whole length of the alimentary canal, and of the bladder, called the mucous onemhrane ^ (c) the membranes which envelop the vital organs, as the brain, the heart, the lungs, the intestines, called fibrous and serous mejtibranes / {d) the strong membranes which envelop the bones and line the joints, caWed j)<2riosteal and synovial onemhranes j (e) the connective or sponge-like web of membrane which connects all the organs of the body together, called connective or areolar inemhrane.^ or, more commonly, cellu- lar or connective tissue. "We have studied the diseases affecting the mucous mem- branes, the serous membranes, the periosteal and the synovial membranes, in the descriptions of the diseases of the different or- gans and parts with which those membranes are connected. We have only, therefore, now to study the diseases of the skin and of the cellular or connective tissue. Diseases of the Skin. The older medical authorities have been accustomed to divide diseases affecting the skin into nine orders, according to the ex- ternal appearances presented to observation. By this method they described the following forms of cutaneous disease : — ip) The Papulae or pimples. (J) The Sqnamse, or scaly diseases. (c-) The Exanthems, flower-like or eruptive diseases. id) The Bullas, blisters or blebs. {e) The Pustulse, or pustular diseases, in which pus or matter is thrown out in points. DISEASES OF THE SKIN. 251 {f) The Yesiciilae, or vesicular diseases, in which small vesi- cles or water bladders are formed. {(f) The Tnberculse, or tubercular diseases, in which liard swelling-s or tubercles are formed. (A) The MaculcB or spots, spotted diseases of tlie skin. (^) The Ulcerous diseases, in which there is break of continuity of the skin with loss of structure. The authorities of the Royal College avoid this classification, and very properly throw out of their list the exanthematous erup- tions, like those of measles or scarlet fever, which are merely signs of general diseases. I shall, as usual, follow the College order, without, however, ignoring the classification given above, which, in many respects, is practical, useful, and distinctive. M'ythema. Under the term erythema is described redness of the skin of an acute form. It is commonly defined as " a nearly continuous redness of a portion of the skin, attended with some disorder of the constitution, but not contagious." Sir Erasmus Wilson gives another definition. He defines the especial characteristic of ery- thematous affections as " redness without exfoliation or desquama- tion (scaling), or other secondary change." There are six varieties of erythema recorded in the official list. 1. Erythema Iceve^ redness of a dark character, surrounding an old ulcer or large vein, or spreading over a limb affected with an- asarca or dropsy. 2. Erythema fag ax, the redness that suddenly suffuses the face and neck of nervous hysterical subjects. 3. Erythema marginatum, redness marginated or edged. 4. Ery- thema j^apulatum, redness very bright and in patches, with many red points or pimples, appearing on the limbs or the breast. The papuhe or pimples are usually small, and dispersed on the red surface, though distinguishable to the touch as well as the sight ; but sometimes they are in clusters, and sometimes they them- selves extend or increase fi*om their edges. The affection is com- monly acute and transient, lasting only a few days, but it may become chronic. 5. Erythema, tuherculatum, a variety in which, instead of mere pimples, small raised swellings or tumors are present. Persons affected with tubercular disease of the lungs are supposed to be most liable to this erythema, which generally comes on with some fever and constitutional disturbance. C. Ery- 252 LOCAL DISEASES. thema nodosum, erythema in raised patches of round or oblong form, occurring on the inner side of the limbs, and looking like a spotted eruption. This variety of the disease is always at- tended, according to my experience of it, by dyspepsia and slight fever. It often recurs in the same person, and may last a week or ten days. Intertrigo. The term intertrigo is applied to define the red cutaneous eruption and soreness, resembling erythema, and by some classi- fied with it, which is brought on by the rubbing of two surfaces of the skin together in their folds. The affection is apt to occur in persons who are very corpulent, and in fat infants, especially when they are not kept wholesomely dry and clean. The redness may pass into actual abrasion of the skin from the friction, fol- lowed by watery exudation. Roseola. Koseola is a word used to define a rose-colored rash on the skin which is evanescent in character and attended wdth slight fever. The rash may be in patches or general, and may resemble that of measles or scarlet fever, for both of which it is often mis- taken by the unskilled. The disease is not accompanied by sore- ness of throat, is not contagious, and only lasts a few days. It commonly comes on from indigestion, and in children is often connected with derangement of the stomach from errors in diet, such, for instance, as are incident to children's parties. It may be acute or chronic, and it is said to present four varieties : — 1. Roseola (.estiva, summer roseola ; 2. Roseola autiimnalis, au- tumnal roseola ; 3. Roseola sijmptomatica, indicative or symp- tomatic ; 4. Roseola amiulata, annular like, or in form of a ring. Urticaria. Nettle-rash. The -disease urticaria, though commonly called a skin disease, is in truth an affection of a general kind, attended wdth eruption on the skin as one particular symptom. The disease may be acute or chronic, and it is prone to recur in certain persons under conditions favorable to its development. The eruption on the skin is erythematous, with raised surfaces in wheals, or in round white points resembling closely the sting of the nettle. The skin DISEASES OF THE SKIK. 253 is often raised around the white point. The eruption is attended with much heat and irritation. Wlien it attacks the pahns of the liands or soles of the feet the burning sensation may l)e of the acutest kind, and, in tlie worst forms of the affection, excruciat- ing. There is always some constitutional disturbance and dys- pepsia, but there may be no fever, and the malady is certainly not contagious. Urticaria is stated to appear under six different varieties : — 1. Urticaria febriUs, in which case it is accompanied with fever. 2. Urticaria evanida, a short or evanescent form. 3. Urticaria j)erstans, a lingering or persistent variety. 4. Urticaria conferta^ in which the points of eruption are close or crowded together, confluent. 5. Urticaria subcutanea, where the skin is much in- flamed and raised from beneath. 6. Urticaria tuberculata, where the erythematous surface is affected with small hard swellings or tubercles ; a rare form of the disease. Urticaria seems to be almost invariably connected with de- rangement of the digestive system. It is often accompanied with much disturbance in the stomach and bowels, and is relieved most readily and determinately by purgation. It often follows the taking of certain articles of food or drink, and is therefore fairly considered as due to intestinal irritation in most instances, and to peculiar action of certain foods on particular constitutions. In persons liable to it I have seen it follow the taking of lobster, mullet, mussels, pork, oranges, and whitebait. I have known one death occur during urticaria. It was caused by the mucous membrane of the larynx becoming implicated in the eruption, with suffocation as the result. Pellagra. The term pellagra is employed to describe a disease of southern Europe which is also known under other names, as the leprosy of the Asturias and as the elephantiasis of the Asturias. It is met with in Ital}', in Spain, and in some parts of France. It com- mences as a slow cutaneous inflammation, not unlike erysipelas, and ends in hardening of the skin and accumulation of scales. The attack commonly comes on in the spring, goes through a dis- tinct series of stages, and dies away in the following winter. It retui-ns in a worse form the next spring, and still woi'se in the spring following. At last the skin is more or less covered with a 254 LOCAL DISEASES. scalj eruption, tliick and liard, resembling leprosy. As tlie local disease becomes more pronounced, various nervous symptoms ap- pear, ending in paralysis and mental alienation. Tlie disease attasks all classes of society, but chiefly the poor. It is not con- tagious and, in its early stages, is amenable to treatment. Acrodynia and Asturian rose. Acrodynia is a disease marked, as its name implies, by pain in the limbs, with changes both in sensibility and motion. It is at- tended with irritation of the conjunctival membrane of the eyes and of the surface of the skin, the skin becoming sometimes scaly and hard as in pellagra. During its course there is much disturbance of the nervous and digestive systems, and it is com- monly of long duration. In almost all severe instances of it it leaves in its train some form of nervous disease. Asturian rose is another cutaneous affection of southern Europe. It partakes of the character of an erythema, shading into pellagra, but is of a less formidable type. The diseases included in the above descriptions would be placed by the older authorities as belonging to the order " exan- themata." Prui^igo. The disease prurigo is a cutaneous eruption of papulae or pimples, attended with an intolerable itching, which in ver}^ bad cases is so severe and tormenting as to cause even disturbance of the mind. In the first stages the pimples or papulae, although raised from the surface and rough to the touch, are not changed in color from the natural skin ; but, owing to the irritation and the scratching which is used to relieve it, the skin soon becomes dotted or lined with dark marks from bleeding. The disease is not contagious. It is often of long duration, and is usually con- nected with nervous depression and failure of nervous power. Lichen. Another pimply or papular eruption on the skin is called lichen. The pimples are raised, cone-like in shape, and red. The}' spread in large patches, and often extend over a consider- able surface of skin. The affected parts are subject to severe DISEASES OF THE SKIN. 255 itching or jDriiritiis, and scales are usually thrown off from them. The College reporters give five varieties of lichen. 1. Lichen siinjjlex, the simple and most transient form. 2. Lichen jnlctr is ^ when the pimples include the roots of the hairs. 3. Lichen cir- cumscrijjtus, where the eruption appeai-s in large and fairly dis- tinct patches. 4. Lichen agrius^ a very troublesome lichen, ap- pearing usually on the arms, the papnlse being close together, scaly and moist with, it may be, fissures and cracks in the skin surface. The disease not unfrequently attacks grocers and bakers, and from the irritation it produces is called " baker's or grocer's itch." 5. Lichen trojpicus^ an extensive eruption of lichen, ac- companied by much prickly irritation and heat, from which cir- cumstances it has obtained the name of '■'' jyrickly heatP Stroj)hylus. Tooth rash. Lied gum. In infancy, especially during the period of teething, the body of the child is liable to be affected with a red pimply or papular rash called strophyliis. The affection is usually mild in character, and passes away when the irritation of cutting the tooth is over. There are said to be three varieties of strophylus : 1. Strojphylus intertinctus. 2. Strojphylus confertus. 3. Strophylus candidus. They are mere shades of the one eruption, and are all dependent on the same cause. The rash is usually slight and transient. The diseases prurigo, lichen, strophylus are included in the old classification under the order " papulae." Pityriasis. The cutaneous affection called pityi-iasis is commonly defined as a scaly eruption, in which the scales are distributed over the surface of the skin in irregular patches. The scales are often separated and reproduced, but they are dry scales. They do not form crusts, and they are not attended with cracks, soi-es, or ex- coriations. The College authorities describe one variety only of the disease, namely,— pityriasis cajntis, pityriasis of the scalp, dayidriff, which is often met with in infants, and sometimes in the aged. There are, however, two other important varieties of the affection which deserve to be noted. 1. Pityriasis rubra, a form in which the scaly eruption is attended with great redness of the 256 LOCAL DISEASES. skin, redness of the scales themselves, and separation of the scales in lines or layers which are very characteristic. This form of the disease is often combined with other severer cutaneous scaly erup- tions, and the subjects of it are usually sufferers from nervous depression and debility. 2. Pityriasis ehurna, a variety in which the scales thrown off are pure white and flat, like scales of bone or ivory. The disease pityriasis may be induced by known agents act- ing on the body. When arsenic is taken internally for a long time in small and frequently repeated medicinal doses, pityriasis may be the result,— ^ntyriasis arsenicalis. I have myself re- cently seen a sharp attack of the disease on the hands and arms of persons engaged in work which exposes the skin of those parts to the action of the bichromate of potassa. Autotype workers are exposed to this last-named accident unless great care be taken in their dealing with the bichromate solution which is used in their art. Another form of pityriasis, pityriasis versicolor, is now referred to parasitic affections, as synonymous with Tinea versicolor. Psoriasis. JLe/pra Vulgaris. At one time the cutaneous disease known as lepra vulgaris was assumed to be a distinct disease. It is now included, by our authority, under the head of psoriasis. Psoriasis is a scaly eruption wdiich may appear in separate rings or patches, each distinct from the other, the extension of each being from the circumference. This is the form of the disease which was known as lepra vulgaris, to distinguish the con- dition from that M^hich occurs when the patches unite by exten- sion, when the islands of scales — if I may be permitted the simile — blend into continents, a condition to which the word psoriasis was always applied. In truth, the nature of the eruption is, in both cases, practically the same. There is first some irritation, then eruption of scales which grow dense and white at the centre, and afterw\ards expansion of the eruption from its outer edge, which is red and occasionally slightly raised. There are five varieties of Psoriasis : — 1. Psoriasis vulgaris, or l&pra vulgaris, the forms just described, 2. Psoriasis guttata, in which the scaly eruption is spread out, like drops, on the skin. 3. Psoriasis diffusa, in which a number of patches unite together DISEASES OF THE SKIN. 257 and lose b}^ their union their original rounded form or outline. 4. Psoriasis gyrata, a modification of the foregoing, in which the patches, owing to irregular healing, assume an in and out, or gyrated appearance. 5. Psoriasis inveterata, a vai'iety of the extremest kind, in which the scaly eruption invades the greater part of the body. The face, the palms of the hands, and the soles of the feet often escape, but not always. The incrusation of scales in this variety of psoriasis is dense. After a time the skin chaps and breaks, on which there is soreness, with exuda- tion of fluid from the broken surface, intense irritation and itching, and great mental and physical exhaustion, lasting over many weeks or even months. I have never known the disease end fatally, but some authors state that they have. When the scales assume a dark appearance on a leaden-colored surface of the skin, the term jpsoriasis nigricans is used to express the modification. Ichthyosis. The disease ichthyosis, fish-shin disease, is an affection in which the cutaneous structure is thickened and firm. Ichthyosis vera ; or dense and horny. Ichthyosis cornea. It is so commonly an affection existing from birth that some have looked upon it as purely constitutional, as neither allied to psoriasis nor other scaly eruptions, but as a cutaneous malformation rather than a cutane- ous disease. Ichthyosis, with the diseases pityriasis and psoriasis, belong to the old order of skin affections, " squamse." Miliaria. In the course of some acute diseases of the febrile type there .will sometimes appear on the skin a vesicular rash or eruption, to which the name of miliarial rash or eruption is applied. The vesicles are usually compared to millet seeds in respect to appear- ance, and may be spread or interspersed over the whole surface of the body. Tliere are two varieties : — 1. Miliaria sudamina, where the vesicles are like drops of perspiration. 2. Miliaria rubra, where the vesicles are injected and inflamed. 17 258 LOCAL DISEASES. Serpes. Herpes is a cutaneous disease in which there is a vesicular eruption, comparatively transient in character, with the vesicles ranged together in clusters. The skin in the part affected is in- jected and inflamed, and at first the fluid filling the little vesi- cles is almost transparent. As the vesicle matures its contents thicken, and in the end the eruption passes away in scab-like scales. There are four varieties of herpes named in the College list : — 1. Herpes jphlyctenodes^ in which the eruption is variable in re- spect to its place on the surface of the body. 2. Herpes circi- natus, where the eruption assumes a ring-like shape. 3. Herpes iris, in which the eruption takes the form of concentric rings. 4. Herpes zoster, commonly called shingles, in which the eruption breaks out in the lower part of the chest, about the middle of the body, and, in clusters of a bead-like kind, extends more or less round the trunk as a circumscribed zone two or three inches wide. Shingles or hei'pes zoster is a painful affection, and is at- tended with fever for two or three days, and often with pain ■which is described as rheumatic in character. It is apt to recur in the person who is subject to it, and it most comnaonly recurs in the months of spring. I have no doubt that it is hereditary. The vulgar notion that it proves fatal when the eraption com- pletely encircles the body is without foundation, the disease not being fatal in its coarse unless it be complicated by some other and more serious affection. It seems to have a short period, one to two days, of incubation, and it runs a course of from five to seven days. ^Neither it nor any other of the herpetic affections are contagious. Eczema. Eczema is a most painful and obstinate vesicular affection of the skin. It is well-defined by Wilson as " an infiummation of the skin attended with a hreach of its surface.''^ There is redness, swelling, elevation of the cuticle, and a vesicular eruption in a number of minute blisters. After the vesicles break there is a copious exudation of fluid, which itself acts like a blistering fluid, and keeps up the irritation. The exuded fluid forms into scabs and crusts, intermixed it may be with matter or pus, and some- times with blood. The pain, burning, and itching are intense, DISEASES OF THE SKIN. 269 and when the affected surface is chapped and excoriated, the sen- sitiveness is intolerable. There are four recognized varieties of eczema : — 1. Eczema sivvplex, in which the disease is present in its simplest and mild- est form. 2. Eczema rubrum^ in which there is redness of sur- face or erythema, erythematous eczema. 3. Eczema imjMigi- nodes, where the eczematous eruption is coupled with an eruption of small pustules called impetigo. 4. Eczema chronicum, an eczema in which the disease becomes chronic, with persistent in- flammation, formation of crusts, and discharge. Eczema is not contagious. It is hereditary, and is apt to re- cur in a person who has once suffered from it. It may or may not be accompanied by systemic signs of disease, and it is usually connected with nervous exhaustion and feebleness. It is now largely under the control of medical art. liupia. Rupia is the name assigned to another vesicular cutaneous eruption. The vesicles are spread out in patches from which there exudes a fluid which forms a crust or scale, and has under it an ulcerated surface. The points of eruption are usually widely separated, and occur on various parts of the body. There are three varieties of rupia: — 1. Rupia sinvplex^ in which the eruption is of the simplest and mildest form. 2. Rupia prominens, in which the scale that is formed is raised, in a conical shape, layer upon layer. 3. Rupia escharotica, in which there is an extension of irritation, as from a caustic or blis- ter, with an offensive discharge. Eupia is usually due to consti- tutional specific disease, syphilis. Rupia, eczema, herpes, and miliaria belong to the old order " vesicular " of cutaneous diseases. Two other affections, which have already been described in the chapter on diseases running a definite course, namely, varicella or chicken-pox, and vaccina or cow-pox, are often put under this same order. Pemphigus or Pompholyx. Pemphigus is an eruption of a blister or bleb, breaking out on the cutaneous surface without much, or it may be without any, erythema or preceding inflammation. 260 LOCAL DISEASES. The College list names three varieties of Pemphigus: — 1, Penvphigus actitus, where the outbreak is sudden and distinct, and in more than one part at the same time. 2. Perujphigus solitarius, where one blister is developed and passes away to be succeeded by another or by others. 3. Peniphigus chronicus, where the disease is long persistent. To these varieties the late Dr. Stokes added a fourth, or epidemic variety, to which he gave the name of Pemphigus gangrenosus. Pemphigus in its active form is attended with fever, and in the ill-fed young assumes, sometimes, an epidemic type ; but it does not seem to be conta- gious. If the blister which denotes pemphigus were to appear on an inflamed or erythematous surface of skin it would be said that the disease presented was erysipelas, a disease included in the chapter on diseases which run a definite course. Erysipelas and pemphigus were formerly classed as cutaneous affections under the order " bullae." Im/petigo. Impetigo is a disease which is characterized by an eruption of a pustular character. In this respect it resembles small-pox, hut differs, essentially, in that it is not contagious, and cannot even be communicated by inoculation. The pustules are small, and form light continuous scales or scabs. The disease differs also from small-jDOx in that it is not accompanied by severe fever. The eruption usually appears on the limbs. There are two varieties of impetigo : — 1. Impetigo sparsa, in which the points of eruption are distinct and apart. 2. Impetigo conjiuens, in which the pustules run into each other. The affec- tion appears chiefly in the feeble, and is most frequently seen in children who have been badly fed. Ecthym,a. Ecthyma, like impetigo, is a pustular eruption \erj similar to the eruption of benign or mild cases of small-pox, but the spots are widely apart, and are not necessarily attended with fever. The disease is not itself contagious, but it occasionally occurs dur- ing convalescence from the communicable diseases. The pustules DISEASES OF THE SKIX. 261 are larger than tliose in impetigo., Ecthyma appears most fre- quently ill the feeble and impoverished. The diseases impetigo and ecthyma were classified by the older authorities under the order '' pustulse." Acne. The eruption called acne consists of a number of small pointed and firm tubercles. It is a slow or chronic inflammation of the sebaceous follicles of the face, and sometimes of the breast and shoulders. After a time the small tubercles become surrounded with pus or matter at their bases, and when they have died away they often leave a scar. There are said to be four varieties of acne : — 1. Acne jpunctata, in which each tubercle is distinct, and, as it were, marked out. 2. Acne indurata, in which the swelling is indurated or hard. 3. Acne rosacea, a bad form of acne, occurring in persons of ad- vanced life. It is seated, exclusively, on the nose, is attended with redness of the surface of the skin of the nose, and causes great disfigurement. The affection mostly afflicts persons who have indulged freely in alcoholic drinks, and connects itself with the enlargement of the blood-vessels which is so common a result of alcoholic disease. 4. Acne strophulosa, a form of acne attended with strophulous rash. In some cases of acne an acarian parasite, called by Owen the "Demodex folliculorum," is present in the affected follicle. Sycosis. Meniagra. Sycosis is an eruption of a tubercular character, affecting the bearded part of the face or the hairy scalp. The tubercles are large, often the size of a pea, hard, and at first inflamed. After a time they yield pus or matter which, mixing with the hair, causes a crust that resembles the cut surface of a fig. The dis- ease when it is seated on the chin is called sycosis menti, when on the scalp, sycosis capill/'tU. In some instances of sycosis menti the " Microsporon mentagrophytes," and in other instances tlie parasite " Demodex folliculorum," is present. The term menta- gra was once applied to a similar disease of tlie face, which was first observed in the reign of Til)erius, and was found to be con- tagious by kissing and other modes o£ contact. 262 LOCAL DISEASES, Elephantiasis. Elephantiasis is a term applied to two very different diseases; one a local affection, confined to the leg, called Elephantiasis Ara- hum, Elejphant leg, Barbadoes leg, or Elejihas ; the other called E lej)hantiasis Grcecorion or true lejyrosy, a general affection ap- pearing on various parts of the body, or even covering the whole cutaneous surface. Elejyhaiitiasis Arahum- is an enlargement of the leg from swell- ino" of the cutaneous tissues and of the cellular tissue beneath, the result of recurrent inflammation and serous infiltration from the blood. The affection becomes chronic, and the limb reallj as- sumes, as in a case lately under my own observation, the appear- ance of an elephant's leg and foot. It is usually a fatal disease from the exhaustion it produces, unless the affected limb can be amputated. It is not contagious. Elephantiasis Grcecorum or true leprosy is a tuberculous dis- ease of the skin, epidemic or endemic, and contagious. It com- mences with erythematous blotches on the skin, which soon be- come dark or bronzed and tubercular. The tubercles are red and raised, and the skin, generally, about them is raised and rough- ened. There is often hoarseness of the voice, fetid discharge from the nose, and ulceration of skin with the other symptoms. The disease was well described by Celsus, who lived in the reign of the Roman Emperor Augustus, in the beginning of the Chris- tian era. It is the true leprosy of the ancient world, and, as Wilson points out, was the epidemic leprosy which for fifteen centuries had a home in this country. The affection is believed to arise from a specific poison, and to have a period of incubation. It is attended in its first stages with fever. It is still present in the East and West Indies, in South America, in China, and in the Islands of the Pacific. Framb(£sia. Yaws. Frambcesia or yaws is a disease of the skin, usually classed as tuberculous, met with chiefly in Guinea, amongst persons, negroes especially, who have been badly fed. The eruption begins, gener- ally, on the forehead in white spots, like an insect bite, and then extends. The spots form matter which becomes incrusted, and beneath the crust an ulcer appears from which a fungous tubercle, DISEASES OF THE SKIN. 2G3 varying in color from white to red, rises. The eruption is apt to recur during a period often extending to nearly a year. It is not necessarily a fatal disease, and it is doubtfully contagious. Alejpjpo Evil. Under the term Aleppo evil is defined a disease of the skin commencing as a tubercle and extending until it forms a crust Avhich falls oif or divides, refomis, and at last leaves an ulcerated surface, often of large size. One or more of these spots of erup- tion may be presented. The disease in most cases continues for many months, and leaves, usually, an indelible scar, or a series of scars, behind. Molluscum. Under this term different authors describe an eruption of small tumors from the skin, appearing on various parts of the body with- out inflammation, and varying in size from a pea to that of a nut. The tumors may pass away without irritation or by ulceration. They may contain a sebaceous matter, or a semitransparent fluid, or an amorphous substance embedded in cellular structure and l)lood-vessels. The persons in whom they occur are sufferers from nervous exhaustion, are dyspeptic, and are of feeble circulation. In one remarkable instance under my own care an eruption of these small tumors, each of which resembled a large ripe M'hite currant, broke out all over the body, lasted several days, and then rapidly disappeared. Scleroderma and Leucoderma. Under the term scleroderma is included a rare affection of the skin, which consists of a chronic inflammation of the deep layer of the dermis called the corium, and attended with hardness without increase of growth. The skin is drawn up or jMickered in white lines or creases. When near to joints the hardness of tlie skin renders motion difficult. Leucoderma, sometimes called mtiligo, — veal skin, — is an af- fection of white, smooth, shining tubercles, in patches, on the skin of the face, neck, and other parts of the body. The tuber- cles are often rapid in growth and then die away in a few days, leaving white surfaces or seams in patches or lines. 264 LOCAL DISEASES. Acne, sycosis, elephantiasis, framboesia, Aleppo evil, moUns- cum, and vitiligo, have been nsnally classed nnder the order " tnbercula." Stearrhcea. An excessive oily secretion from the subaceous follicles, those of the face specially. There are two varieties : — 1. Stearrhma si'inplex, in which the secretion thrown ont is almost colorless or faintly yellow ; 2. Stearrhcea nigricans, in which the eruption and secretion are of dark color. ATbinisimis. Canities. Melasma. Albinisnms is a partial or general change in the color of the skin, from an absence of the cutaneous pigment. The skin is of a peculiar shade, like milk, and the hair on the skin is white. The disease affects the dark races, giving rise to the " piebald negro," in whom portions of the surface of the body may asume a complete whiteness, in large patches. The term canities defines change of the natural color in the hair to gray or white. Under the term melasma is included the dark eruption seen on the limbs of old people. The change is due to an excess of pigmentary substance. Chilblain and Frost-hite. Chilblain is an erythematous condition produced by cold on the hands and feet of persons of weak circulation. The erythema and congestion may be extended deeply over a large surface, and often attended with swelling and much pain. Frost-bite is a temporary death of the skin from the action of cold. The affected part, emptied of blood, is hard and in- sensible. During recovery the relaxed vessels are apt to be- come surcharged with blood, on which there is arrest of cir- culation and mortification or death of the part. The danger of mortification is often increased by too rapid an admission of warmth. DISEASES OF THE SKIN". 265 PARASITIC DISEASES OF THE SKIN. The list of the Royal College supplies the names of ten dis- eases or alTections of the skin as due to parasites or to irritation from parasitic living forms. In respect to certain of these as specific causes of the affections with M^hich they are nndonbtedly connected there is difference of opinion. Some would trace the diseases exclusively to the parasites, others would trace the para- sites to the diseases, that is to say, they would maintain that the parasite does not cause the disease by its presence, but exists at the affected spots from finding there a favoring locality for its existence. Tinea tonsurans. RingiDorm. An affection in which the scalp is the seat, marked in the first instance by shrivelling of the hair in patches of roundish or oval shape, and by falling off of the hair. The bare place is often scaly, and the roots of the hair are surrounded with dry matter. The disease often breaks out in schools, and is supposed to be very contagious. The parasite found in the affected part, in ring- worm, is the " Trichophyton tonsurans," a vegetable spore round or oval in shape, transparent and colorless. The spores multiply around the root of the hair. Ringworm lasts a very variable time, but is always recovered from, and often with unexpected rapidity. Tinea Decalvans. Alopecia, baldness. A disease of the scalp in which the hair is lost over large sur- faces, or even over the whole of the head. The surface is left, not scaly, but white and shining. In old persons baldness seems to be as natural a condition as grayness of hair, but in the young and middle-aged it is a distinct disease. The parasite said to be present in some cases of this affection is the " Microsporon Audouini," a vegetable spore. Tinea Favosa. Favus. Porrigo. Tinea favosa, sometimes called "foreign ringworm," is a severe form of disease resembling in some respects the ordinary ring- worm of this country. The hair is diseased and sometimes quite 266 LOCAL DISEASES. destroyed. The parasite in faviis is so abundantly developed that the spores, massed together, may be visible to the naked eye. The parasite is the " Achorion Schonleinii." Tinea Yersicolor. Pityriasis Versicolor. An affection o£ the cutaneous surface, sometimes included with pityriasis capitis or dandriff, which, resembling, in some respects, the scaly disease already described under the head pity- riasis, is supposed to depend on the presence of a vegetable parasite called the " Microsporon furfur," a spore of spherical shape, adhering to the epidermis and causing yellow or brownish spots of varying size. Tinea Polonica. Plique. A disease of the skin affecting the hair of the body in the scalp and elsewhere, in which the affected part is the seat of great irrita- tion and is painful to the touch. There is an exudation from the roots of the hairs which dries into a crust, matting the hairs to- gether, and causing a bad odor. The first symptoms may be attended with fever, which, however, soon subsides, and in time the growth of hair causes the crusts to be thrown off, with re- covery. The disease is specially seen in Poland, hence the name Tinea Polonica, The parasite present is the vegetable spore " Trichophyton sporuloides." Mycetoma. Madura Foot. Fungus Foot. Madura foot, a disease first observed by Dr. Colebrook at Madura, in Madras. It is an affection commencing in the skin of the foot in those who go about with the feet uncovered. It is due to the action of a fungus parasite called "Chionyphe Carteri,"' Dr. H. Y. Garter being the first authority who clearly reported on the nature of the affection and on the fungus whicli produces it. The parasite getting beneath the skin increases rapidly, and actually invades the bones themselves and causes their destruction. It is supposed by some observers that tliere is always some pre- existent local disease or injury of the foot. Mycetoma not unfre- quently ends fatally, from extension of tlie local affection, and the consequent pain and exhaustion. DISEASES OF THE SKIN. 267 Scabies. Itch. The disease scabies or itch was classed by the old writers as a pustular disease, and was defined by them as an eruption of pus- tules with much irritation and itching, but with no fever. We now know it to be parasitic in its character. The face usually escapes from the eruption, but the wrists, the hands, and the flex- ures between the fingers are almost always affected, together with the flexures of the joints and other parts of the body. It is a disease essentially of dirt, and is communicable by contact of one affected body with another. It is due to the introduction beneath the epidermis of the female of the parasite " Acarus scabiei " or " Sarcoptes scabiei." Scabies sometimes assumes the character of an endemic or even epidemic disease. Dr. Arthur Hill Hassall has indicated that what is called " Grocer's itch " is sometimes due to a similar parasite which he has found present in inferior samples of sugar. Irritation from External Parasites and Stings. The skin is liable to irritation from otlier parasites which infest it on its surface, as from the " Pediculus capitis," the " Pulex " or " Chigoe," the " Cimex " or " Bug," and the " Lep- tothrix autumnalis " or " Harvest bug." The irritations from the stings of the wasp, the bee, the gnat, and other stinging insects, as well as from the stings of nettles and other stinging plants, are also considered as forms of cutaneous affection, of a temporary character. General Affections of the Shin. In addition to the special diseases of the cutaneous surface above noted, there are others of a general kind, the natures of which have been described in previous chapters under the heads of ulcer, tumor, fissure, carbuncle, gangrene or mortification, atrophy, hypertrophy, malignant disease, and furunculus or boil. The tumors affecting the skin are the fatty, i\\e fihro-cellular, tlie sel)aceous, the cheloid, the condylornata, warts or verruca, and corns or cornua. Of tlie malignant diseases, or cancers, affecting the skin, the ejpithelial is the most frequent form, but the scirrhus and the melanotic varieties are sometimes developed in it. Of the boils the most specific is the " Delhi boil " of India. 268 LOCAL DISEASES. The skin is subject fco injury and irritation, witli swelling and thickening of strucrAire, as in the case of an inflamed bursa, aris- ing from pressure and friction. It is subject to sores and ulcer- ations from the same causes as in the hed-sores of those who lie for a long period of time in one position. It is subject to maculae or marks : — {a) spots \\k.Q freckles^ — ejjJielis : {h) the vascular mark already described as nmvus or mother's mark, of which there are two varieties ; one where the nsevus is raised above the skiu, the other where it is a stain called, vulgarly, port-wine mark : and (c) mole, a raised growth above the skin, colored by dark pig- ment, and sometimes including in it hairs which protrude through the vascular mass, noenus jjilaris. The skin, lastly, is subject to contractions from the healing of wounds, cicatrices : to hardenings or indurations, as on the palms of the hands and soles of the feet : to pruritis or itching : to anaesthesia or insensibility in parts of its surface : to profuse siceating in parts, ejjhidrosis : to absence of sioeat, — anidrosis : to wasting in lines, linear atroj)hy. Diseases of the Nails. The nails are subject to several kinds of disease, of which the following are the more important. 1. Ingroion 7iail, the growing in of the nail into the skin, a condition most common in the case of the great toe nail. 2- Onychia, inflammation of the matrix of the nail. 3. Onychia maligna, a rare and severe form of onychia. 4. Whitloiu, an inflammation arising near the nail, ending in abscess involving the theca cf the tendon, thecal ab- scess. 5. Atrojjhy, or wasting of the nail. 6. Psoriasis and eczema, affections causing much destruction and disfigurement of the nails, and usually occurring in persons subject to the same diseases on the skin. I have delineated, from nature, in my " Clinical Essays " a striking illustration of the disease psoriasis affecting the nails of a person who was also suffering from lepra, — psoriasis vulgaris. The affection commences with a tingling sensation beneath the nails, often described as " pins and needles." After a few weeks the nails look glazed, as if they had been smeared over with varnish of a yellow tinge. They then begin to show little indentations, as if they had been pricked over with the point of a pin, and afterwards rubbed with a dark substance. Finally, thickening occurs beneath the nail, with crumbling of DISEASES OF THE CELLULAR TISSUE. 269 the nail structure and destruction. The disease is amenable to treatment. A new nail is generally reproduced in the process of recov'ery. Diseases of the Cellular Tissue. Infiamviation. — The cellular tissue is often iha seat of inflam- mation and of changes, connected with the inflammatory process, ending in the formation of purulent matter in a circumscribed form, abscess. Such inflammation is apt to follow under circum- stances in which the skin is wounded, and in which the wound extends into the cellular structure. It also occurs from internal injuries, and from extension of inflammatory disease into the membranous cellular tissue. In deep-seated boils and abscesses, generally, there is extension of the inflammatory mischief into the cellular membrane. Inflanimatory induration^ or hardening of the cellular struct- ure in the newly born, is another disease of this structure, of which I have narrated several instances in my essay on " Diseases of the Foetus in Utero." In these instances the surface of the body is rendered in parts hard and inflexible. Sometimes even the whole surface of the body is involved in the induration. Sloiogh or Phlegmon is another disease of the cellular tissue consequent on acute inflammation, and extending from the sur- faces over or underlying the cellular layer. In erysipelas the in- flammation may extend in this way, and rapidly involve large tracts of the cellular tissue, phlegmonoxis erysipelas. Carhunde or Anthrax is another special inflammatory affec- tion in which the cellular tissue is involved. The inflammation is usually limited or circumscribed, and ends in the formation of pus or matter, which, after great swelling, tension, and redness, breaks through the skin in a number of suiall percolations, unless it be relieved by operation. The cellular tissue is involved, in like manner, in the disease called malignant pustule. Ohesitij. — The laying up of fat in the cellular tissue beneath the skin and other membranes that are connected with the cellu- lar structure becomes, when the fat is in great excess, an actual disease called obesity. Obesity is fertile of many mischiefs. It makes the body altogether pendulous, heavy, and cumbersome ; it loads the intestines and interferes with their functional activity ; and, when it surrounds the heart it very seriously impedes the 270 LOCAL DISEASES. action of that organ. No mistake is more commonly made and no mistake is greater than that of accepting the external evidence of a free deposit of fat in the cellular tissue beneath the skin as a sign of robust health. Emphysema. — When air or other gas finds its wav, as it some- times does, intq the cellular tissue, and diffuses through it, the disease called emphysema is produced. Emphysema may occur from a wound in the cellular tissue, as when the end of a broken rib pierces it, and I have once seen the whole of the cellular tissue beneath the skin injected with air, as it is injected in the carcass of the dead animal when the butcher inserts a knife into it, and distends it by his breath. Emphysema may be present in any part where there is connective tissue. It is often present in the lungs. Anasarca. — When water exudes in the cellular tissue beneath the skin, the form of dropsy called anasarca is produced. In anasarca the surface over the affected part becomes spongy, and " pits," on pressure, like dough. Lastly, the cellular tissue is a common seat of simple tumors. It may, also, be the seat of hemorrhagio effusions^ oi parasitic cysts, and of cancerous growths. BOOK L PART THE THIRD. DISEASES FROM NATURAL ACCIDENTS. CHAPTER I. DISEASES FROM NATURAL ACCIDENTS. The liistoiy of natural disease would not be complete were reference not made to certain accidents to which the human kind is subjected. These may be divided into four classes. I, Acci- dents which are purely mechanical. II. Accidents which arise from poisonous substances developed within the body. III. Ac- cidents from venomous organic substances. IV. Diseases from animal or vegetable substances, taken as foods. Y. Accidents in the female, connected with pregnancy and labor. Diseases feom Mechanical E^atueal Accidents. Lightning Shock. Primary effects. — The passage of lightning through the body may produce varied phenomena, from mere temporary shock, to shock with insensibility, and to shock that is fatal either at the moment or shortly afterwards. These phenomena may or may not be attended with marks of distortion or external injury. The fatality is in proportion to the intensity of the shock, and those discharges which by their intensity kill most readily, may leave least mark of distortion or external injury. In cases where the lightning shock has produced instantaneous insensibility, followed by recovery, the stricken persons have been, in some cases, alto- gether unconscious of receipt of injury. It may be inferred, therefore, that instant death by lightning is, as Franklin taught, the most painless of all deaths. The injuries inflicted by the shock are internal and external. In my observations on animals killed by electrical lightning shock, I discovered that the course of the discharge through the body was, preferentially, by the blood, and that coagulation of the 1)lood, general rigidity of the muscles, and decomposition of the tissues were the three proofs of death. 18 274 DISEASES FROM NATURAL ACCIDENTS. Secondary effects of lightning shock. — When the lightning stroke does not actually kill, a series of secondary effects, consti- tuting what may be called actual diseases, may be induced, and may be named under the following heads. Keactive fever ; apo- plexy ; convulsions and epilepsy ; paralysis ; catalepsy ; and blindness. Reactive Fever. — Sir Erasmus Wilson once directed my atten- tion to a remarkable illustration of this effect of lightning in a woman sixty-one years of age, who was saved from instantaneous death by the wires of her crinoline which acted as conductors. After the shock, the woman, who had been suffering previously from indigestion, vertigo, and numbness of her limbs, remained insensible for twenty minutes, uttering an occasional groan. When consciousness returned, she stated that she had felt nothing at the time of the accident, although she had several burns on her body, but she complained of nausea and oppression about the chest, which were relieved by vomiting, ller skin at this time was cold and clammy from perspiration, and her pulse extremely weak. Subsequently she was attacked with fever, accompanied with delirium, and it was not until the end of ten weeks that she was reported to have recovered her usual strength, the burns being at the same time healed. At this period it was stated that she was quite cheerful, except when left alone, when she was dis- posed to sleep too much, and a feeling of great lassitude an- nounced to her the approach of a thunder-storm, before its coming was perceived by others. " The case," adds Sir Erasmus, " is one of deep interest in its illustration of the influence of nervous shock, and its phenomena are most suggestive ; — for example, a concussion of the nervous system, the loss of consciousness, the sickness of the stomach, the oppression of the lungs, the prostra- tion of the heart, the reactionary fever, and last, but not least, the morbid sensitiveness of the nervous system to electrical iin- pi-essions, enduring for a time, and probably for life. Is not this the oft-told tale of many of our fevers ? " Apoplexy. — Phenomena of apoplexy from lightning shock have been observed. In these instances the countenance is livid, the body affected with a cold clammy sweat, the breathing op- pressed and stertorous, the pulse strong and full, and the powers of sense and voluntary motion suspended. The shock producing this condition is one of low tension, and is much like the shock LIGHTNING SHOCK. 275 from sunstroke. Hecoverj has been 'known to take place on let- ting of blood. Convulsions and Epilepsy. — Convulsive actions and epileptic or epileptiform seizures have been recorded as following upon' lightning stroke. The paroxysm conies on some time after the shock, and it may return after apparent recovery. Paralysis. — Paralysis has been observed to follow lightning stroke, the paralytic condition being either local or general. In all cases of lightning shock there is some degree of paralysis of sensation and of motion. It has been observed that during recov- ery sensation returns first. Catalepsy. — -The most remarkable phenomena of lightning shock are those of catalepsy. I have related an instance in which a man was struck by lightning in Grinsthorpe Park. He was rendered unconscious, but recovered and managed to reach home and go to bed. He was confined to his bed for several weeks, re- fused food, and sank into a cataleptic state which simulated death so closely that he was thought to be dead, was laid out by two women, and was tolled for in due order. He knew all that was going on, but was unable to move until he heard the women talk- ing of his death and caught the sound of the passing bell. Under the dread impression that he should certainly be buried alive, he succeeded by a great effort in moving one of his thumbs, which fortunately attracted attention. He was then treated as one alive and recovered. During his convalescence he was annoyed by a strong smell of sulphur which seemed to come from his whole body ; a phenomenon which was also observed by Gaultier Clau- bry, who experienced it for several days while recovering from lightning shock. Blindness. — Blindness has been observed to follow lightning shock, and may be present from two conditions. (1) From a direct change in the sti'ucture of the cornea. (2) From nervous shock, without any visible mark of injury. To these may be added temporary blindness from the excitation of the light of the lightning flash without shock. E-xternal injuries and tnarhs left after lightning stroke. Burns. — Burns are sometimes left on the body or on the hair after lightning stroke. The burnings differ in degree from mere singeings of the hair or skin to extensive cauterizations. Burns 276 DISEASES FROM N"ATURAL ACCIDENTS. are more likely to happen where the person is not destroyed by the shock. The reason of this is that the ilash is of low tension, is of the character of a flame, and is not penetrating. Metallic Impressions. — The impressions of metallic substances may be left on the bodies of persons struck by lightning. In a case I have reported, a man subjected to lightning shock had left on his body impressions of ornaments which he wore, namely, a chain, a coin, and a cross. The stain produced was of a dark brown color, and the impression was well marked. The nature of the mark is very simple. It is an ecchymosis or bruise through the metallic substance of which it presents a rough outline. Ecchymoses. — Simple ecchymoses and livid spots having no reference to metallic or other substances in contact with the skin are sometimes seen on the surface of the body after lightning stroke. These spots M'ere deeply marked on Professor Keichman, of St. Petersburg, the first martyr to science who lost his life by receiving a shock in the laboratory Mdiile drawing electricity from the clouds, on the 6th of August, 1753. He was killed instanta- neously. On his forehead was a red spot, from which issued some drops of blood without wound on the skin. On the heel of the left foot and on the left side of the body were several blue spots resembling leather that had been shninken by being burnt. Ai'borescent marks. — Marks of an arborescent kind have been noticed on the bodies of persons who have been struck by light- ning, which marks have, naturally though wrongly, been sup- posed to be representations of the figures of trees. The truth when explained is very simple. The arborescence is not the figure of a tree, but is an anatomical outline of the trunk and branches of the superficial veins of the body of the person struck. Loss of hair. — In some instances where the nervous centres have been affected by lightning shock, death of the hair has been produced. On June 1st, 1864, at Moussy in the Yosges, a mason, aged fifty-nine, was caught in the rain and took refuge under a tree, where he was struck by lightning. He became unconscious, and thought four hours elapsed before he recovered his senses. He then found that he had lost the use of his legs, and could not speak, and it was not until after nine days that the paralysis ceased. The electric fluid had come into contact with the back of his neck, had passed down his lower extremities and had es- caped, hurling his shoes to a considerable distance. Soon after EXPOSURE TO COLD. 277 the event, tlie hair on the head and body of this man fell off entirely, the eyebrows, eyelashes, and beard being completely re- moved. There were no other external evidences of lightning shock. Sunstroke — Coup-de-soleil . Sunstroke, or coup-de-soleil, has been referred to under local diseases of the nervous system, at page 173. There are two kuids of it ; one apoplectic in its nature, affecting persons of plethoric habit, and especially those who indulge in stimulants ; the other syncopal in its nature, and affecting the feeble. The first is true sunstroke, as I should define it strictly, from what I have seen. The affection is rare in this country, except, in summer, when the heat is intense. It then happens to persons wdio go out without being protected from the direct rays of the sim. I have seen in- stances of it in adults of both sexes, and twice in children. The person affected is seized with a sudden giddiness or vertigo, fol- lowed by unconsciousness and want of power in the limbs. In the apoplectic variety of the disease the face is livid, the veins swollen, the temperature of the body raised, the heart labor- ing, and the breathing heav}- and stertorous ; signs wdiich in fatal cases continue until death. AVhen recovery occurs it is often very rapid. The syncopal variety is, according to my experience, rather an extreme faintness or oppression from heat than the effects of a sudden wave of heat. It is attended with coldness, faintness, clammy perspiration, and often with convulsion or hysteria, the attack "lasting for several hours, and being followed by some reac- tive fever and a long- continued dyspepsia. I have known it to be succeeded by partial paralysis of the right side of the body, but it is much less serious, both immediately and subsequently, than the apoplectic form of the malady. Exposure to Cold. Exposure to cold is an accident fatal to life in two ways. First, by extreme action, as when a person is exposed to glacial cold without due protection from it; and, secondly, when a per- son in an enfeebled condition is exposed to the influence of mod- erate cold. 278 DISEASES FROM JSTATUEAL ACCIDENTS. Under the first of these states, which may be called acnte ex- posure, the extremities of the body, such as the nose and tips of fingers and toes, may be temporarily destroyed by the action of the cold, the parts being rendered entirely bloodless and insensible to pain, frost-bitten. In such cases, if due care be not taken to restore the circulation gradually, the frozen part is completely de- stroyed and removed by mortification. If the whole body succumb to the influence of cold the ten- dency is for it to experience a sense of benumbing sleep, under which it falls into deep torpor and gradually dies, apparently without pain or sense of dissolution. Under the second of the states of accident from cold the en- feebled person exposed to it becomes subject to congestion of some internal organ, which congestion passes into inflammation, with fever, and the sequelae of both. The lungs are the organs which suffer the most severely, and from this exposure congestive bron- chitis or congestive pneumonia are the forms of disease commonly manifested. Aged people, who in winter weather retire to rest in bedrooms insufficiently warmed, afford striking examples in all cold seasons of the dangers incident to this insidious action of cold. Starvation. The natural accident of starvation is presented under three sets of circumstances. 1. From actual deprivation of food, ab- solute famine. 2. From deprivation of certain portions of food which are essential to life, 3. From inability to swallow food, owing to disease or obstruction in the canal leading from the mouth to the stomach. Starvation may be an acute or a chronic manifestation. When it is acute, that is to say when food is altogether withheld, there is rapid emaciation of body, fever with failure of muscular power, nausea, fetor of the breath, and, subsequently, a condition in which the ability to digest food and even the desire for food passes away. It has been shown by Mr. Cornish, in his observa- tions upon the Indian famines, that when the second stage is reached the most skilful feeding rarely succeeds in saving life. The limits to which deprivation of food may be carried, without destruction of life, have not been fixed. Much, it would seem, depends upon the circumstance whether water is or is not sup- STARVATION. 279 plied. If water be withheld, death, probably, is inevitable in from seven to ten days even under favorable circumstances, much sooner if the surrounding air be dry and cold. But the evidence is clear that with a free supply of water the body may be sus- tained for a period extending over five weeks. I have myself seen an instance of such maintenance of life without food. In examples of starvation from insufficient or improper supply of food the phenomena may present two characteristic forms. The disease which has been described at page 48, as relapsing or famine fever, may be the result of the starvation ; or, there may be merely a feverish state and feebleness, ending in general ex- haustion, ulceration of the surfaces of the body, paralysis of parts of the body, and general deterioration from which, at the best, recovery is but imperfect. Starvation from improperly selected foods is often well marked in young children who are fed on a diet which is too exclusively starchy, and does not contain the elements for building up the muscular and osseous systems. Such children become of lax and feeble muscular fibre and rickety in the skeleton, the muscles failing to receive their proper aliment and the earthy matter necessary for the solidification of bone being insufficiently supplied. CHAPTER II. DISEASES FROM NATURAL POISONINGS AND FROM AC- CUMULATIONS OF POISONOUS EXCRETIONS WITHIN THE BODY. In the course of some diseases symptoms occur which are of singular importance, and which seem to be due to the presence of poisonous substances M^hich have been developed in the living body itself. These poisons may be considered as natural products or excretes of the body. Sometimes these excretes are nothing more than the natural products of excretion, excretes which are regularly made, and do no harm whatever so long as they are duly thrown off, or, as it is said, technically, eliminated. In health they are so eliminated, but under disease of the excreting organ the function of throwing them off is impaired, from which circumstance they may continue to be formed within but do not continue to be cast out of the body. They then accumulate in the blood and in the secretions, and, after a time, from such accumulation, exert all the effects of an active poison. The above is one form of natural poisoning, but to it must be added another. It would seem that during certain forms of dis- ease new poisons, which are extremely virulent in their action, are produced by modified chemical changes. It is probable that poisoning so induced is much more common than is generally supposed. I shall have occasion to touch on this subject again when I come to treat of the causes of disease. In the iiiean time it was necessary to point out the two divisions of natural poisonings which have now been specified, and having briefly performed that task I may proceed to present short notices of the phenom- ena of disease incident to both forms of poisonous action from natural sources. DISEASES FEOM NATURAL POISONINGS. 281 Diseases from Retained Excretions. Uremia and Uremic Coma. We have seen in tlie chapter on the " Local Diseases of the Glandular System," p. 212, that the kidneys by their secretion eliminate, with every thousand grains of the secretion, fourteen grains of a substance which is called urea. Urea is a very solu- ble saline substance, a cyanide of ammonium. It is a white crys- talline salt, easily separable from the secretion, and admitting of being made, artificially, out of the body. Like nitre and other saline substances which easily absorb water, it is, I found, an ex- cellent antiseptic ; but that which is most important to us is the fact that urea, if present in the body in excess, acts after the manner of a narcotic poison. In my original researches on this subject I found that whenever an animal body was charged with one part per cent, of urea, symptoms of sleep or coma were the result, and that in proportions above this amount the symptoms were, as a rule, invariably fatal. Similar observations have been made by other inquirers, and much discussion has taken place on the question whether the effects are due directly to the urea, or indirectly to another ammoniacal salt, the carbonate, into which it is easily decomposed. It is unnecessary here to discuss this point. It is sufficient to state that urea accumulating in the body leads to symptoms of a poisonous character Avliich are always alarming, often fatal, and called uraemia or uraemic coma. The conditions of disease which give rise to uraemia are con- nected with organic changes taking place in the structure of the kidney. In scarlet fever the minute uriniferous tubes cast oft" their epithelial lining profusely and become blocked up by it, whereupon the- secreting power of the organ is impaired and, urea ceasing to be freely eliminated, accumulates in the blood and gives rise to the symptoms of uraemic coma, marked by prostra- tion of the body, dilatation of the pupil, vomiting, darkness of the skin, convulsions, deep sleep, and insensibility — coma. In scarlet fever uraemic coma is a common cause of fatality. In acute congestion of the kidneys, produced by exposure to wet and cold, described at pp. 212-13, the function of those or- gans ma}' again be suppressed, with the result of causing uremic coma, and with the same risks as happen when scarlet fever is the exciting cause. 282 DISEASES FROM NATURAL POISONINGS. In those forms of disease of the kidney described as " Bright's Disease," page 214, ursemic svmptoms are apt to be developed, and in the chronic form of these maladies, in aged persons, urse- mic coma is always to be dreaded. The symptoms often come on with an irresistible desire to sleep at almost any time or place. With this there may be deficiency of sensation in the limbs, occa- sional confusion of mind, feebleness, listlessness, and ammoniacal fetor of the breath. Persons so affected are readily influenced by cold or anything that checks the free action of the skin, and they often die with symptoms which, in former times, were called apoplectic. They are seized with drowsiness, vomiting, convul- sion, and insensibility, under which they succumb. Such per- sons, when in a comparatively healthy state, are easily influenced by some medicines, such as opium, and, above all, mercury. They fall I'eadily into nraemic disease under slight exposure to these deleterious influences. It will be seen from these data how large a part the excreted substance urea may play in the role of disease. Asphyxia. Cyanostjeia. Other illustrations of phenomena of disease from deficient elimination of a natural excretion are shown in instances where the product of respiration, called commonly carbonic acid, is not duly eliminated by the lungs. Certain of these phenomena are most strikingly seen during conditions which lead to what is known as asphyxia. If, under any circumstances, the respiration be interf erred with, so that a due quantity of air is not taken into the lung, or a due escape of air does not take place from the lung, as occurs through suffoca- tion from hanging, drowning, immersion in a mephitic atmos- phere, and the like, there is accumulation of the carbonic acid in the blood and symptoms of danger and death from that cause. These symptoms are darkness of the face and surface of the body generally, coldness, convulsion, and insensibility. They are the acute symptoms of suppressed respiratory excretion. In some instances the suppression of the respiratory excretion may be slower in character, and may give rise to symptoms very painful to bear and to witness, but not necessarily fatal, imme- diately. These states are usually brought about from some defect in the mechanisms of the circulation and of the respiration. In DISEASES EKOM NATURAL POISONINGS. 283 the newly born it occasionally happens that there is an imperfect expansion of the air vesicles of the lungs, so that a portion of the hmg structure is not brought into play. Therenpon there is diminished inspiration, which, if it do not prevent, from the first, the manifestation of life, leads to difficulty of respiration, cold- ness of surface, and impaired nutrition, with the common risk of early death from respiratory failure. To this form of disease the term atelectasis has been applied. In other instances the opening from the right to the left side of the heart, the foramen ovale, which naturally closes after birth, remains open, and the blood from the right auricle of the heart, which ought to go altogether into the right ventricle, escapes, in part, as venons blood into the left auricle, and in this state, un- charged with oxygen, circulates through the body. Under these circumstances the body is rendered dark in color over all its sur- face, cold and enfeebled, a diseased condition which has already been under our observation at page 136, where it is defined under the head cyanosis. In persons who are subject to spasm of the minute bronchial tubes, persons who are often called asthmatic, the same dangers from imperfect elimination of the expiratory excretion often occur, and death from asphyxia would be easily induced but for the circumstance that the prostration produced by the seizure leads to relaxation of the constricted tubes, and so permits the air once more to enter the temporarily occluded lung. I do not doubt that there are many other conditions in which a deficient excretion of the respiratory products leads to disease, and even to death, by natural process of poisoning, and I know that much remains here to be explored and explained. Under the title " Asphyxia commencing in the Blood," I have described in another place various conditions in which this kind of poison- ing may occur. It is enough for me in the present place to state the few well-defined illustrations which have been supplied under this head of Asphyxia and Cyanosuria. Bilious Toxaemia. When the secretion of bile is suppressed from organic disease affecting the liver or gall-bladder, so that there is not a proper secretion of bile, or when a proper secretion finds an imperfect 284 DISEASES FEOM NATURAL POISONINGS. escape into the alimentary canal, the constituents of the bile are carried into the circulation and excite symptoms of bilious poison- ing, jaundice, convulsion, coma. We have already studied some of these symptoms in treating of diseases of the liver, under the head " Jaundice," pages 211-12, and to these we need not again refer. There are, however, certain minor symptoms due to the sup- pression of bilious secreti^on which deserve to be noticed under this head. These are commonly called symptoms of biliousness, or sufferings from bile, and consist of headache, nausea, depres- sion of spirits, constipation, lassitude, and inability to apply the mind or the body to their respective labors. I believe it not un- frequently happens that more serious symptoms than these result from suppressed liver secretion, but 1 have named those which are most common. Diseases from New Poisons developed in the Body. I said in the opening sentences of this chapter that in various conditions of disease new products may be formed in the body, products which are not the natural excretions, but which are pro- duced from unnatural decompositions progressing within the organism during some forms of disease. In my Reports to the British Association for the Advancement of Science I have pointed out that the substance amylene, an organic product which can be easily constructed in vital chemical changes, produces phenomena identical with those of somnambulism and with some of the phenomena of hysteria. I have pointed out, in the same Reports, that another organic product, called mercaptan, sulphur alcohol, causes, Mdien inhaled, symptoms of profoundest melancholy, and that, in the process of being eliminated by the breath, it gives to the breath an odor which is identical with the odor evolved in the breaths of many patients who are suffering from the disease called melancholia. From these observations I have ventured to suggest that various forms of mental affection and of nervous affection, depend, for their development, on the presence, in the body, of organic chemical compounds, formed and distilled through an unnatural chemical process carried on in the body itself. I have endeavored to develop this subject somewhat further DISEASES FROM NATURAL POISONINGS. 285 by my researches on the action of lactic acid on animal bodies. 1 have shown by experiment that this acid, diffused through the body by the blood, acts as a direct irritant npon the lining mem- brane of the heart, the endo-cardium, and all the fibro-serous membranes of the body, so that a synthesis of heart disease and rheumatism can be established by its means. Lactic acid is the most copious product thrown out in the disease called rheumatic fever, and as many of the phenomena resulting from that disease take the same form and character as those producible by lactic acid, I infer, from the best evidence attainable, that this acid, the product of a fermentative change going on in the body during acute rheumatism, is the cause of the secondary structural affec- tions which so frequently follow acute rheumatism. It has been for some time past observed, by several able physicians, that persons who are suffering from the affection known as diabetes give off a peculiar odoi- from their breath, an odor which to some is like that of vinegar, to others of sour beer, to others a mixture of ether and chloroform, to others of acetic ether. I should compare it myself to the odor of grains as it is detected in a brewery. When this odor is observed in the breath of diabetic patients it frequently happens that they become sleepy, cold, and unconscious, with the result of coma and death. At one time it was supposed that these phenomena were ursemic, and were due to the presence of urea in the blood ; but the absence of convulsion and of some other symptoms destroy this hypothesis, or at all events shake it. It is now believed that the symptoms owe their origin to the decomposition of the diabetic sugar which is in the body, and to the production from that de- composition of a volatile ethereal fluid called acetone, a fluid which has been discovered in the blood and secretions of these aifected persons, who are said therefore to be suffering from the disease " acetonsemia." From the action of acetone upon animal bodies I infer that the theory of acetonsemia is founded on good evidence. Lastly, under this head of poisoning from natural products of disease, I have to name the phenomena produced by the secondary absorption of poisonous material from abraded and ulcerating sur- faces during the presence of acute febi'ile and contagious affec- tions. The secondary absorption of diseased secretion from the throat in diphtheria and malignant scarlet fever, and the second- 286 DISEASES FROM NATUEAL POISOjSTHSTGS. ary absorption of poisonous matter from wounds, are all illustra- tions in point. The matter absorbed, entering the body and cir- culating through the blood, sets up new conditions of disease, which lead to various changes occurring within the blood itself, to separations of fibrine, to breaking up of the red corpuscles, and to various other changes of the most serious character. Some- times in these decompositions ammonia is produced. Dr. Blair observed that sufficient quantities of ammonia are produced in yellow fever, to cause a degree of fluidity of the blood, which re- duced that fluid to the thinness of water, so that it resembled a dark wine rather than blood, refused to enter into combination with oxygen, and became altogether incapable of sustaining life. Such observations as have been noticed under this short head lead to a study of another new point, namely, the possibility of the formation of organic alkaloids in the body during some conditions of disease. Scientific discovery has not, however, advanced so far as to enable me, at this moment, to do more than allude to one of the newest and most important studies in modern medical research. CHAPTER III. DISEASES FROM VENOMOUS ORGAmC SUBSTANCES. The College autliorities classify, in their list, diseases arising from the body being subjected to certain animal and vegetable poisons. Under this head they include : {a) Poisoning by venom- ous animals, namely, snakes, scorpions, and stinging insects, (b) Poisonings by animals having infectious diseases, namely, glan- ders, farcy, equinia mitis, malignant pustule, hydrophobia, rabies and cow-pox, affections, all of which have been described in our chapter on diseases running a definite course, pages 44-58. (c) Poisonings by inoculation of dead or diseased animal matter. {d) Poisonings by animal or vegetable substances, used as foods. Diseases fkom Yenomous Animals. The venomous animals called snakes, M^iich by their poison affect man, are best known as the viper, the cobra di capello, and the rattlesnake. The peculiar secretion which is produced by these animals, and which is communicated in what is called their bite, is not poisonous unless it be injected into the body subcutaneously, or by a wound. Tliis was proved by the famous experiment of the distinguished Dr. Mead, who himself swallowed some of the poi- son of the viper without suffering any bad effect. When, however, the poison i^ introduced into the skin or mu- cous membrane by a bite, puncture, or injection, the phenomena of disease are rapidly set up. After the bite of the v{j)er there is usually acute pain at the bitten part, often immediately and always within the hour. The pain rapidly extends and swell- ing and inflammation follow. Soon afterwards the general symp- toms set in. The stomach is disturbed, the heart intermits or grows feeble j there is faintness, vomiting, dyspnoea, and complete 288 DISEASES FROM VENOMOUS SUBSTANCES. prostration. In extreme cases the collapse ends fatally witliin a few hours. There is as yet no known antidote for this disease. The poison of the cobra, like that of the viper, is only effective when it is introduced by bite or incision. The action is, in the most deadly poisonings, not unlike that of the viper poison, but the depression is usually more immediately general and complete. In other and less virulent instances the symptoms are prolonged, time is given for the development of local changes, namely, death of the cellular tissue at the bitten part and surrounding inflam- mation. The blood also may be rendered extremely fluid ; there may be vomiting, convulsion, and gradual stupor preceding the fatal collapse. The precise mode of action of the poison is still not understood. The poison seems to be easily destroyed in the digestive system and rendered harmless there, and I discovered that its powers as a poison are rendered abortive by exposure of it to sunlight. At the same time it may be retained in an active state for many years, if it be dried and carefully preserved in the dark. Its action seems to be immediately directed to the nervous system. According to my observation the poison that most closely resembles it in operation is nicotine. The symptoms produced by the poison of the 7'attlesnalce ap- pear to be still more rapid in development, and in certain in- stances have been followed by a sudden collapse almost as deci- sive as that which follows a blow on the stomach. The mode of action of all these poisons is probably the same. The mortality from the poisonous snakes is exceedingly large. In the Madras Presidency of India alone there are sometimes as many as two thousand deaths per annum by snake-bite. Yarious antidotes have been suggested and tried for the poisons of the cobra and rattlesnake as well as for that of the viper, but, unfor- tunately as yet, with negative results. Disease from Stings of Insects. The affections from the stings of insects such as the wasp and the bee, are usually only local in character, but are now and then very painful and troublesome if not dangerous. I have seen the sting of the wasp produce a local inflammation, followed by ery- sipelas, and prove dangerous though not fatal. The local symp- toms induced are due to the fluid secretion conveyed by the sting, DISEASES FROM VENOMOUS SUBSTANCES. 289 and the effect has been supposed by some to depend on a zymosis or ferment. I am inclined myself to look upon it as resulting from the action of an organic acid. Diseases from the Jelly-fish or Medusa. Tlie jelly-fish produces a peculiar secretion which, coming in contact with the skin, sets up an acute erythema, attended some- times with an irritable vesicular eruption. The eruption is ac- companied by a bnrniijg and tingling, and may last for several hours. In one instance, which came imder my own cognizance, a bather in the sea, where a considerable number of jelly-fishes were floating, became so entangled in the meshes of a group of them that " he was stung over almost all the surface of his body." He suffered from an acute eruption which did not disappear for sixteen hours, and which was attended with two degrees of fever. In another instance, which also came under my own cognizance, a bather while swimming on his back, with open mouth, was stung in the throat, and was affected with so severe an inflamma- tion as to cause considerable anxiety for several hours. The poi- son of the jelly-fish is, I believe, an organic acid poison. Disease from Inoculation of Dead Animal Matter. Post- mortem Poisoning. Under the head of disease from venomous substances we may include examples of diseased phenomena arising from inoculation of the living body with fluid or semifluid material derived from bodies that are dead. The most striking examples of tliis affec- tion are witnessed in what are called post-mortem wounds. A physician or surgeon is performing a post-mortem operation, or a student or professor is making a dissection of the dead body. He accidentally wounds himself with a needle or knife which he has in use, and thereby inflicts a poisoned wound. If he can im- mediately suck out the poison or destroy the part by caustic he may escape. If he is not so fortunate he is subjected, in a few hours, to pain in the wounded spot, with redness round al)out it, inflammation riuniing along the lymphatics, swelling of the lym- phatic glands and fever, ending, not nnfrequently, in prostration and death. In less formidal^le cases the acute sym]itoms are brought to a crisis by the formation of an abscess or abscesses in- It) 290 DISEASES FROM VENOMOUS SUBSTANCES. volving tlie lymphatic glands, as the glands of the armpit if the hand has been the part that has received the poison. In such ex- amples the formation of the abscess may lead to subsidence of the more dano-erous symptoms and slow recovery may be the result. The disease thus induced is, I think, less frequent in these days than it was formerly, owing probably to greater care and cleanliness. I have seen four instances of it in my career, three of which terminated fatally. The nature of the poisonous mat- ter or infection is little understood, but it seems to be a poison having a comparatively short duration in the dead subject. It does not seem to be formed immediately after death, and it ap- pears to be destroyed very soon after the dead structure begins to undergo putrefaction. The late distinguished anatomist, Dr. Amadee Deville, who had seen many examples of the affection, told me that he had on no occasion witnessed the poisoning from a subject that had actually undergone decomposition. Cases of poisoning somewhat similar to these are sometimes due to the eating of food which in a partially decomposed state comes into contact \vith an abraded surface or a wound in the mouth. I have elsewhere described an accident of this kind which affords a good typical example. A man partook of some jugged hare the flesh of which had become high previous to cook- ino-. Beneath the tongue of the man there was an abraded ulcer- ated spot caused by friction from the stuuip of a broken tooth. A portion of the animal food lodged in this sore, and within twenty-four hours the symptoms of acute poisoning, local and general, had set in. The tongue became enormously swollen, there was intense fever and rapid prostration. The offending matter was sought for and removed, but without avail. ' The patient gradually succumbed. I have on two or three occasions witnessed symptoms of dis- ease in persons who have partaken of decomposing or, as it is vulgarly called, "high" food, although no wound was inflicted. The phenomena are those of indigestion, nausea, fetid breath and prostration : they continue until the poisonous material which has been swallowed is eliminated from the body. Accidents somewhat similar to the above are occasionally met with by surgeons and veterinary surgeons when they are profes- sionally engaged in dressing the wounds or sores of living ani- mals. The accident may occur in very rare instances without the DISEASES FEOM VENOMOUS SUBSTANCES. 291 infliction of a wound on the person who becomes infected, that is to say, by absorption through the skin. I have known one ex- ample of this kind where tiie poison from a specific wound came simply into contact with the reddened surface of an inflamed fin- ger. More frequently a fresh wound is the centre of the infec- tion, and the poison is thus directly inoculated. A surgeon of my acquaintance was once, unfortunately, inoculated fatally from a point of bone in the limb of a patient upon whom he was per- forming an operation. The symptoms induced in these instances of poisoning vary according to the disease affecting the person from whom the poison is taken. If the poison is that of specific disease, — syph- ilis, — the person inoculated suffers from that disease should the poison take effect. In this manner it sometimes happens that the disease in question is communicated in vaccination by the use of impure lymph, that is to say, lymph taken from the arm of a subject who is at the time a sufferer from the specific affection. In other instances the accidental inoculation of the morbific matter excites erythema in the part immediately around the wound that has been inflicted, which erythema may spread, and assuming the character of erysipelas may pass into an attack of erysipelatous inflammation. In these forms of poisoning by inoculation the period of incu- bation varies according to the nature of the poison that has been introduced. The development of symptoms from the specific poison of syphilis is slow, the incubation being forty days. The action of the poison of erysipelas is rapid, the incubation being from a few hours to four days at the latest. The action of the poison derived from a post-mortem wound is still more rapid, commencing generally within a few hours after the infliction of the injury. Disease from Wool. Wool-sorteb's Disease. In the process of sorting wools, especially that kind of wool called Van mohair, the workers are subjected to a peculiar and often fatal disease which ai-ises from something which they in- hale or absorb. The disease runs a fairly definite course, the period of incubation being about four days. The first symptoms are those of headache and pain in the chest with chilliness. These 292 DISEASES FEOM VENOMOUS SUBSTANCES. signs are followed bj restlessness, nausea, and, very frequently, vomiting. The countenance assumes a dark color, as in cyanosis. The breathing is difficult, the pulse fails, there is clammy per- spiration of the body, reduction of animal warmth, insensibility, muttering delirium, and death. This is a description of an ex- treme but by no means unusual case, for the mortality in wool- sorter's disease is very great. It is supposed by some that the disease is due to a bacterium called haGcillus anthraGis. The evi- dence is as yet inconclusive. CHAPTER IV. DISEASES FROM ANIMAL AND VEGETABLE POISONS TAKEN AS FOOD. Disease fkom Poisonous Fish. Siguatera. In tropical climates the perch, the gurnard, the goby, the sar- dine, and the two varieties of globe fishes, the diadon or two- tootlied and the tetradon or four-toothed, are all, at pai-ticular seasons, causes of disease when they are taken as food. The poisonous substance is developed in their digestive organs, in the spawn, and in the liver of the fishes ; it is most potent in those fishes which have arrived at maturity of growth. The Spanish colonists give the name of Siguatera to the symp- toms of acute disease which result from the eating of poisonous fishes in hot climates. The phenomena of disease that are pre- sented are of two kinds — gastro-enteric and nervous. The gastro- enteric form of disease begins with a severe attack of indigestion, followed by great pain in the stomach, and by all the indications of gastro-enteric irritation, viz. : nausea, vomiting, first of food then of mucous fluid, diarrhoea, coldness of the body, depression of the pulse, and cramps. The nervous type of tlie disease is marked by sudden muscular prostration : the face of tlie sufferer becomes flushed and then pale ; the pupils are contracted ; the lips are swollen and blue ; the pulse is weak, quick, and intermit- tent ; and, very soon, there is general convulsion w-ith inability to exert any volitional power. Death quickly occurs unless skilled help be at hand. Both these forms of the siguatera are dangerous to life. Re- covery from the gastro-enteric form is rapid when it commences, but the nervous type of the malady causes, for several, days, ex- treme debility and irregular action of the heart. The poison, 294 DISEASES FEOM P0IS02^0US whatever may be its natm-e and composition, excites, it is cleai', a most effective irritation of the pneumo-gastric nerves, an irritation as trulj energetic as that which might be excited by submitting the nerves to the influence of a series of electrical discharges. Mussel Poisoning. Some very serious forms of disease have been produced by taking mussels as food. There are certain persons who seem specially liable to irritation of the stomach even from taking a small quantity of mussels. There are others who suffer from nettlerash from the same cause. These facts are so general that the inference has been drawn that at certain seasons the mussel produces an irritant poison. In exceptional cases poisoning from mussels has been extremely severe and even fatal, the symptoms resemblino; those which have been described above as constituting the disease siguatera, with other peculiar nervous symptoms. The indications are those of nausea and vomiting, followed by con- striction of the mouth and throat, difliculty of speech, numbness of the limbs, muscular exhaustion, coldness of the body, and death with faintness and torpor. ^Notwithstanding the violence of the symptoms, the appearances after death have been rarely of sufficient importance to explain any fatal phenomena. The real nature of the poison remains up to this day unknown. At one time it was supposed to be a salt of copper with which the mus- sels themselves were charged, but analysis, in fatal cases, has failed to establish this vie\v. The probabilities are that the poison is of an organic kind, and is produced by tlie mussel itself at particular seasons. The oyster has been accredited with producing disease under some circumstances, and I have myself known one example of oyster poisoning ; but the occurrence is extremely rare. The symptoms are those of nausea and hnitation of the stomach. In the books of a recent past day treating on disease from foods, references are made to poisonous effects produced by the taking of sausages, pork, milk, and otlier animal substances. The symptoms cited refer, in nearly every case, to irritation affecting the alimentary canal, and various speculations are offered to ac- count for the plienomena that have been observed. In these days much light has been thrown on that part of the subject which re- lates to disease from sausages, pork, and bacon, owing to the dis- SUBSTANCES USED AS FOOD. 295 covery in such foods of tricliinse and other parasitic forms of life. It is probable tliat in nearly all the instances of the kind recorded by the older writers the iriitatioiis described were dne to para- sitic introductions. We know now also that milk may be the bearer of various organic poisons, such as the poisons of typhoid fever, cholera, and probably diphtheria. Poisoning by Vegetable Substances. Instances still occur in which peculiar forms of disease are produced by accidental feeding on vegetable substances which are poisonous. Fortunately these accidents are much less frequent than they were in former times ; but, the College authorities still refer to the disease known as ergotism produced from taking ergot of rye ; to disease from poisonous fungi and mouldy bread ; and, to disease from certain poisonous grains or seeds, especially of the everlasting pea, — lathyrus satwus. I need to dwell only on two of these, namely, on ergotism and disease from the poison- ous fungi. Disease from Ergot. Ergotism. Ergotism is an affection of a very distinct character, produced by eating the spur which forms on rye and other grasses, ergot, secale cornutum. This spur is a growth affecting several kinds of grain, especially rye, and the disease wdiich it produces has, consequently, been most commonly observed in countries where the poor have fed on rye bread. Ergotism, the disease caused by the ergot, takes two forms ; one called convulsive, the other gangrenous ergotism. Convulsive ergotism is marked by vertigo, yellowness of the skin, thirst, pains in the limbs and chest, cramps and convulsions, insensibility and death, with, in some examples, an eruption of dark spots on the body. In districts where the rye has been largely used the disease has assumed the epidemic form. From the analogy wiiich exists between the symptoms above described and those which characterize the severe affection re- cently recognized as cerebro-spinal meningitis or tetanoid fever, I have suggested that this latter disease is probably due to taking a diseased grain analogous in character to ergot. This view has received confii-mation from the observations of the late Dr. Day of Stafford and of Dr. Baker of Michiijfan. 296 DISEASES FEOM POISOlSrOUS SUBSTANCES. Gangrenous ergotism is a disease of much slower development and longer dm-ation that the convulsive variety. It commences with debility and sense of tingling over the surface of the skin. The limbs then become cold, pale, and so benumbed that thev are insensible to pain from external impressions. After a time pain comes on independently in them and is followed by death of the extreme parts, so that the fingers and toes completely die off by a dry gangrene. These last symptoms have given rise to the name gangrenous ergotism. Poisoning from Fungi. It still occasionally happens that accidental poisoning occurs from taking poisonous fungi, — those especially which are mis- taken for the common mushroom, agaricus campestris. Christi- son defines that most fungi which have a warty cap with frag- ments of membrane adhering to their upper surface are poisonous ; that all which grow in tufts or clusters from the trunks or stumps of trees are dangerous ; and, that the sure tests of a poisonous fungus are an astringent styptic taste and a disagreeable pungent odor. The poisonous principle seems to reside in the juice of the fungus, and has narcotic and irritant properties. The symptoms produced by the poisonous fungi vary, but, taken as a whole, are definable as narcotic and irritating, the irritation being seated in the alimentary canal and leading to great disturbance of the stomach and bowels. Sometimes the narcotic symptoms are dominant, in others the irritative. In an example under my own observation, where the fungus called toadstool was eaten by four children in mistake for mushroom, three suffered entirely from intestinal irritation, and one from the narcotic effect, which lasted until the offending substance was re- moved by purgation artificially induced. During the time when the fungus is producing its effects the body is cold and faint, wliile in the reaction which follows there is fever which lasts for several hours. The acute symptoms of poisoning occur, as a rule, within one or two hours after the fungus has been taken, but exceptions have been known in which several hours have elapsed before the development of the phenomena. CHAPTEK Y. DISEASES AND ACCIDENTS CONNECTED WITH PREG- NANCY AND CHILDBIRTH. During the pregnant state the female of human kind is liable to suffer from various local affections which are considered special to her condition at that time. Some of these affections are most distressing, but happily it is rare that the worst of them become fatal. In this brief chapter I will condense what needs to be said under different heads, according to the parts or systems of the body that are particularly affected. Disorders of the Digestive System. One of the earliest derangements of pregnancy is a depraved and capricious appetite. The ordinary sense of taste is often much perverted ; there is particular distaste for certain articles of food, and particular desire for others, such as shell-tish, cream, and various other delicacies not specially cared for under ordinary circumstances. This perverted taste and desire will often last for two or three months. Occasionally, with or without perversion of taste, there is a free and excessive secretion of saliva — saliva- tion. Nausea and. Yomiting, are other common dyspeptic affections in the earlier periods of pregnancy, and in cei'tain instances they continue until the late months, giving rise to extreme misery and exhaustion, and remaining unchecked by any and every attempt at relief. The nausea or vomiting commonly comes on period- ically, and most frequently in the early morning, lasting for many hours each day. IleaTthurn., or cardialgia^ is also a dyspeptic plicnomenon in pregnancy, and when it is frequent it becomes very oppressive. It is commonly accompanied by eructation of acid fluid from the stomach into the iao\\t\\,—p]/rosis or water-lrash. 298 DISEASES AND ACCIDEJS'TS COjS'NECTED WITH Intestinal cramj), or colic, is another affection of the pregnant state, which causes severe suffering if it take place in the later staores when the uterus has attained a laro^e size. Derangement in the action of the hov^els is by no means infre- quent during pregnancy. In some persons the derangement is from constipation, in others it is from relaxation, or diarrhoea. Together with these derangements of the bowels there may be disorder of the livei", with joAindice as a temporary accompani- ment. Disorders or the Circulatory System. The circulatory system is apt to become painfully affected during the pregnant state. An obstruction to the flow of blood back to the heart by the large veins, an obstruction caused by the pressure of the enlarged uterus or womb, may give origin to en- largement of the veins in the lower parts of the body. Thus may arise large or varicose veins of the lower limbs, and hemorrhoid', or piles. From the same pressure and obstruction to the return of ve- nous blood there may be effusion of serum into the peritoneal cavity, — ascites y a serous effusion into the cellular tissues of the lower limbs, — oedema. From irritation connected with the uterus in various stages of pregnancy, and from reflex nervous action, the heart is sometimes disturbed in its movements and rendered irregular ; or, tlie rapid action of the heart, known ?[^ palpita- tion, may be induced ; or, the motion of the heart may be brought temporarily to partial arrest, and syncojje or faintness be the I'e- sult. Disorders of the Respiratory or Breathixg System. Three disorders of the respiratory or breathing system are noted in the College lists as specially connected with the pregnant state. The flrst is Dysj)ncea, or difficult breathing, an affection most commonly developed in the later stages, when the enlarged womb pressing upwards upon the diaphragm interferes with the movements of that great muscle of respiration, and encroaches on the cavity of the chest itself. This oppression of breathing, though not in itself dangerous, except in the rarest instances, is distressing, and frequently remains until the end of the condition PKEGNANCY AND CHILDBIETH, 299 from which it springs. The second difficulty named is called or- thopnoea, and is, in fact, a dyspnoea, or difficult breathing, during which respiration can only be earned on, effectively, when the body is sitting up or standing. On lying down the chest cannot be duly filled with air. This derangement is not, as a rule, de- pendent on pregnancy alone. It is usual for the person in whom it occurs to be at the same time affected with some actual de- rangement of the breathing organs themselves, such as asthma or chronic bronchial disease. The third disorder named is described simply as cotcgh, and refers to a frequent or it may be a constantly recurring cough, excited by reflex nervous action from uterine irritation. The cough is most commonly developed during the early part of pregnancy, and often goes away, entirely, in the later months. Disorders or the ISTekvous System. The nervous system is most apt to be subject to disorder during the period of pregnancy. The following are the derange- ments officially defined as the most important. Neuralgias. I^euralgiac pains, of a very acute kind, are of rather common occurrence. They often start suddenly, without any previous warning, excite excruciating pain, and then pass away in a mo- ment, with as little apparent reason for ceasing as for coming on. There are three varieties of these neuralgias of pregnancy, each one named after the part affected. 1. Odontalgia, a sudden and severe neuralgia in a tooth, presenting itself as a toothache of the intensest character. The tooth or teeth in pain may be quite free from organic disease. 2. Cephalalgia, a similar intense pain affecting the head, and producing what is described -as violent and intolerable headache. 3. Mastodynia, an extreme neuralgic pain affecting the breast ; perhaps the most intense of all, but happily the least frequent. To these forms of neuralgia might also prop- erly be added facial neuralgia, — tic dolour 6} ix ^ stomach neural- gia, — gastrodynia I and neuralgia of the sciatic nerve, — sciatica. I have known these last-named derangements happen as fre- quently during the pregnant condition as the three specially no- 300 DISEASES AND ACCIDEISTTS CONNECTED WITH ticed, although thej are not so severe, and are, therefore, not distinctively classified. Chorea and Convulsions. The affection which we have already had before lis under the name of chorea, or St. Vitus' dance, is sometimes present during pregnancy, as if dependent on the peculiar condition of the pa- tient. When it is called forth the sufferer is, I think, always pre- disposed to it, or to some allied nervous disease. The chorea, in the majority of instances in which it is present, is marked in the earlier stages and subsides in the later, but I have known it to continue quite to the end, and only cease after childbirth. In this form of chorea there is no necessity for the existence of any or- ganic disease as its cause. It may be entirely dependent on uter- ine irritation in a predisposed subject. Convulsive seizures may take place during pregnancy, and may be hysterical in character, or true. The hysterical convulsion is commonest in the earliest portion of the period, and though alarming to those who look on is, in reality, attended with little danger, and is not likely to be of permanent nature. The true convulsion is commonest in the later stages of pregnancy, is often due to the uterine pressure and temporary congestion of the spinal cord, and may be of serious import. Fortunately the convulsive derangement ceases, with few exceptional instances to the con- trary, at childbirth. HYPOCHOlirDKIASIS AND MaNIA. The pregnant woman may be subject to that singular depres- sion of mind and morbid sense of fear and fancy, which we have had before us in a preceding chapter under the head hyjyochondri- asis. The affection is exceedingly uncommon in women at any time, and is not very common in tlie pregnant woman. I have seen but one illustration of it in practice. When it does occur the sufferers are, constitutionally, of a nervous temperament, hj^ster- ical and desponding, and the symptom which lasts during almost all the period is not always removed by the act of childbirth. It should be looked upon rather as a constitutional than a special condition. Mania is a less uncommon disorder of pregnancy. It assumes PREGlSrAlSrCY AND CHILDBIRTH. 301 the character of an acute madness when it is developed. It is developed in any portion of the period, though most often in the second or third month ; it may be of short duration, but it is apt to be recurrent. It is, I think, only seen in those in whom the proclivity to mental derangement is strongly marked. DiSOEDEKS OF THE GlANDULAK SySTEM. It has been stated that salivation or overaction of the salivary glands is an occasional symptom during pregnancy. Other glands are sometimes affected, the kidneys being those most likely to be implicated. This may easily be assumed when the position of the kidneys in relation to the increasing pressure produced by the en- larged uterus is considered. Albuminuria from the pressure of the womb on the kidneys, and the congestion incident to the pressure, is a functional de- rangement of moment when it is present. The symptoms are those w^hich have been described under the head of acute Bright's disease at page 214. Tliey are, fortunately in the large run of cases, only temporary in character, and they disappear when the act of childbirth has passed over. Dysuria, or difficulty of voiding the renal secretion ; inconti- nenxie, or difficulty of retaining it ; and retention, are other tem- porary derangements incident to the pregnant condition, which, though very painful to bear, are rarely prejudicial to life. Deean"Gements of the Uterine System. During pregnancy the organs most concerned, the uterus and its neighboring parts, are apt to be subject to derangement beyond the changes natural to their function in the process of child-bear- ing. The uterus during this state may be affected by inflam- mation, metritis, giving rise to uterine irritation, to fever, to sym- pathetic pain in the stomach, and to hysteria. It may be liable to discharge of watery fluid, hydrorrhma ; to rheumatism • to acute nervous pain unattended with inflammation, hysteralgia j to spurious pains like those of labor; to severe spasm or cramj) • to discharge of fluid colored with Miood, sanguineous discharge ,' to actual loss of blood, hemorrhage • and, to the tliree kinds of displacement: (a) prolapsus; [7/) hernia; (c) retroversion, which have been explained in a preceding page. 302 DISEASES AND ACCIDENTS CONNECTED WITH Affections connected with Delivery .or Parturition. The delivery of tlie child may be contrary to natural course from three causes : 1. From delivery before the completion of the development of the child to the extent of enabling it to exist as an independent life ; dboi'tion. 2. From deliveiy after the time when an independent life could be sustained, but before there is complete development for natural birth ; jy^6m(2;^?/re hirth. 3. Fi'om development out of the uterus itself, as in the Fallopian tube ; extra-uterine gestation. When the period of development has attained its natural dura- tion and the growth of the child is complete, so that it is ready to be born, there may be affections connected with its birth, from uterine or other causes, which are briefly classified as fol- lows : Atony, or want of power in the muscular walls of the uterus for due expulsive eifort. Over-distention of the uterus, (a) From excess of the liquor aranii or fluid surrounding the child. {I) From presence of twins or triplets. Mechanioal obstruction to the action of the uterus from a variety of causes, {a) From occlusion or closure partly or wholly of the mouth or neck of the womb or of the passage below. (^) From rigidity, narrowness, cicatrix, cystic growth, cancerous growth, prolapsus of the bladder, distention of the lower bowel, or, prolapsus of the bowel, (c) From tumor ; uterine, ovarian, pelvic, or external, {d) From polypus. () Irritant dusts, derived from woods ; from ivory ; from textile fabrics, such as fluffs of wool, silk, cotton, flax, or hemp ; from hair ; from clay. Soluble saline dusts, derived from soluble crystalline substances. (hthisis^ — lias been attributed to it. The nervous system is perhaps of all others the most impressed by this transmitted influence. Epilepsy ; chorea, or St. Yitus' dance ; other forms of convulsive disease ; and, paralyses of various kinds have been traced, by Dr. Hughlings Jackson, to inherited structural tendencies springing from syphilis, I have, for my part, become so familiar, in practice, with the fact of the con- nection of inherited syphilis with the wide field of nervous dis- ease, that I never see a case of the kind now without making an inquiry as to the hereditary history. The sensory organs, the organs of sight and hearing particularly, are subjected to disease from the same taint. Many of the most ordinary born failures of sight and hearing are also derived fi^om an imperfect development, resting on an imperfect nutrition, the syphilitic constitution being the foundation of the imperfection. The four other great systems of the body, — the glandular, the muscular, the osseous, and the membranous, — come in like man- ner under this malicious taint. The bony structures are often, most significantly, the parts so affected. Mr. Jonathan Hutchin- son, whose admirable labors on heredity in disease cannot be overpraised, has described, from the teeth, an absolute test of syphilitic taint. This consists of a marked diversion from the natural shape of the two central incisor teeth of the permanent set of the upper jaw. These two teeth in their natural state are chisel-shaped and broader at their cutting edges than at their in- sertions into the gum. But in persons of syphilitic taint they are narrower at their cutting edges than at their insertions into 516 CONGENITAL, HEEEDITAEY, OE the giira, and they are usually notched. When such teeth are present other signs of feebleness of the bones, or of deformity, are commonly present also, the cause being the same. Disease of the membranous surfaces of the body from the taint of syphilis is almost as common as disease of the neryous structure, and indeed the two conditions are so closely connected, it is, on many occasions, difficult to distinguish Ayhich has prece- dence, the membranous affection seeming to be closely connected with nervous failure. All the membranous surfaces are suscepti- ble to injury from the taint, but the skin is the most frequent seat of mischief. The skin, imder this influence, becomes easily affected with psoriasis, — lepra vulgaris, — with rupia, alopecia, eczema, and, perhaps, pityriasis. It will be seen from the above how intense a taint is this first of the hereditary causes of diseases on our list ; and I have but glanced at the subject. It is of common observation amongst us medical men that the symptoms implanted on the constitutional disease are so varied and so extensive we do not really know how far they extend. Dr. Hughlings Jackson says on this point, most correctly, that it is only by studying a longer "base line" that we can discover how widely different symptoms arise out of the one degraded bodily state which the offspring of syphilitic parents present. "Whilst," he adds, "the eldest child of a family may show external signs of syphilis, such as nebulous cornea, scars about the mouth, or loss of the uvula, the rest of the family may be undamaged externally, and yet be ready to suffer in more obscure ways from a smaller share in their sad common inherit- ance. It would seem, in acquired syphilis at least, that the symptoms are directly due to a fault beginning in a common tis- sue, the connective, and the wide distribution of this tissue shows how we may have very different symptoms from its failure in organs or parts of high or of low function." This is admirably spoken, and carries with it all that I have space to say on syphilis as a cause of disease, except one more observation; namely, that the cause acts, unhappily, through more than a single generation. I regret to add, that I have seen it operating certainly through three, and, possibly, through four generations. On the person primarily affected, the effects, in the opinion of Professor Gross, never die out. With this I more than agree, for I am inclined to supplement that view by saying that CON^STITUTIONAL CAUSES OF DISEASE. 517 the effects in the members of the first succeeding generation never die out. The Sc7'ofulous and Tuberculous Taint. The condition of disease called scrofula, or struma, is con- nected with a taint of a definite kind. There are, as will be seen on p. G3, two varieties of scrofula ; viz., scrofula with tubercle, and scrofula without tubercle. In both cases the taint is pres- ent, and those born with it are the victims of scrofulous or tuber- cular disease. Whether there are two distinct taints, or whether tliere is but one taint, which tends to produce differing phenom- ena of disease under the differing circumstances to which the per- son who is subject to the influence of the taint may be exposed, is a question of the extremest difficulty to answer. I have made many careful analj^ses of facts bearing on the point, but am still unsettled in my mind as to the solution of the difficulty. I have seen many become consumptive who have never shown symptoms of scrofula in the way of scrofulous tumor or glandular enlargement of any kind, their parents or close i-e- lation^ being of consumptive tendency. I have seen scrofulous persons escape tubercular consumption. But, again, I have seen in a scrofulous family, derived from scrofulous parents, certain members affected by scrofula, others by consumption ; and, I have often seen those who were scrofulous become consumptive. Thus the evidence is peculiarly complex, if not contradictory. The only conclusion we can draw from it is that the taint, in pass- ing hereditarily from one person to another, may, under varying states of an external kind which act upon it, undergo changes which modify its ultimate effect. There is a view now gaining ground to the effect that the scrofulous taint is a variety of the syphilitic. This view is strongly enforced by my friend, Professor Gross. " The word scrofula," lie says, "for centuries past in such common use, has, it is well known, a special import with respect to the deformed condition of the neck, assimilating it to that of a swine. At the present day the affections included under this denomination amount to upwards of twenty. Among the more common are chronic en- largements of the lymphatic glands, various eruptions and ulcera- tions of the skin, embracing the milder forms of lupus, chronic 518 CONGENITAL, HEEEDITAEY, OE abscesses, especially psoas and lumbar, Potts' disease of the spine, psorophtlialniia, chronic tonsillitis, caries and necrosis, ozoena, strn- mons inflammation of the eyes, strumous hip-joint disease and white swelling, malignant onychia, otorrhoea, rickets, arachnitis, hydrocephalus, pemphigus, sycosis, keratitis, and the notched and irregular condition of the teeth of infants and children, so ably discussed by Mr. Hutchinson." These facts lead this learned author to assume that " scrofula is generally, if not uniformly, merely a transformation, a degen- eration, or a remote effect of the syphilitic virus. Through how many generations scrofula may retain its specific powers, we have, he thinks, no means of determining ; but children of consump- tive parents are almost invariably scrofulous, and the taint thus engendered runs through several generations, uprooting not un- frequently entire families. On the other hand, it sometimes skips a generation, and reappears in the next succeeding one, just as family likenesses sometimes do. Still it is scrofula." To these views I should myself give entire assent. The hereditary taint of pulmonary consumption is so intensely marked, that out of three thousand instances of the disease which have been before me for treatment, in general and public prac- tice, I have not found it absent in so many as ten per cent, when all cases presenting any real doubt were excluded. Malignant or Cancer Taint. All the varieties of malignant disease or cancer defined on p. 61 are connected with the constitutional taint. This is, I believe, 9,s true in respect to one variety as to another. In every inquiry which I have been able to make, in public practice, in private practice, and in what I may call insurance practice, — I mean the selection of lives for insurance, — I have never met with one ex- ample of the disease, cancer, in a person suffering from it without finding some pre-example of the same affection in one or other member of the family. The disease occasionally skips a gener- ation, but it is nearly always to be found as hereditary. The malignant taint appears, according to our present knowl- edge of it, to be specific. One variety is not, however, always produced by transmitted taint of the same variety. I have known scirrhus, or hard cancer, in the parent, followed by the same in ■the next generation ; but I have as often known scirrhus in one CONSTITUTIONAL CAUSES OF DISEASE. 519 generation followed by epithelial, or by medullary, cancer in another, and vice versa. It is probable, therefore, that the virus or taint is the same, but that it is capable of some modification, under which it leads to a different variety of the disease in dif- ferent subjects. What the nature of the cancer taint is we cannot say. What the structure is in which the taint is impressed or implanted we cannot say. I have ventured to think, from various studies of the question, which I must not enter on here, that the nervous system is the primary seat of the impressed evil. This, however, is mainly speculative, and must be accepted as nothing more. The taint, whatever it may be, does not give evidence of its pres- ence, except in rare examples, until after adolescence, and it often waits for some exciting injury or shock to call it into action. Eheumatic and Gouty Taints. The rheumatic and gouty diseases have an unquestionable basis in morbid impression or taint, derived from parentage. These affections, at the same time, must be considered as differ- ing in two particulars from some that have been named before ; firstly, that they more frequently than the others seem to spring up without pre-existing taint ; and, secondly, that the impression or taint which they transmit is less persistent. I believe that, in two generations, these diseases lose their taint, although the taint is often very severe in the second generation affected from the primary source. I knew one instance in which a woman, who had no traceable rheumatic history, became affected with rheumatic fever from living and sleeping in a damp, newly-built house, and who afterwards gave birth to seven children, every one of whom inherited her acquired disease. In like manner I have seen gout transmitted, by heredity, from a parent who, as far as evidence of his past family history could be trusted, had himself acquired the affection by his own luxurious mode of life. Plow the tendency to these diseases is passed on we have as yet no clue. Whether something material and active is passed on from one generation to another ; or whether it is a purely physical impression, or vibration, which is transmitted, we cannot pretend to say. For the moment we must accept the fact of the transmission and wait for its explanation. 520 CONGENITAL, HEEEDITARY, OR Nervous Impressional Taints.. So many nervous impressional taints, indicated by aberration oi; failure of function of the nervous system, are passed from one generation to another, it vs'ould almost be to go through the his- tory of all the nervous diseases to record them. I will name those which are most striking. Epilepsy is one of the transmitted affections, though whether it should be considered, when so transmitted, as a distinct disease or as the symptom of another disease, like syphilis, remains an open question. Chorea admits of being placed under the same description. The various forms of palsy or paralysis are often connected with an inducing tendency or taint ; and it is probable that apoplexy would come into the same position. All the emo- tional and mental derangements and diseases are, or may be, con- nected with the inherited tendency or taint. Hysteria is often so connected ; melancholia is often so connected ; liypochondriasis is often so connected. Insanity and that development of mental deficiency called idiotcy are, as a general rule, dependent on a taint. The taint in the matter of insanity is as definite as the taints of cancer, scrofula, or syphilis ; it may skip more than one generation, and then appear in as distinct a form as it presented in the early family representative of it. A form of purpura de- pendent upon deficient nervous control over the minute circula- tion is another phase of nervous failure clearly connected with hereditary susceptibility or taint, and exercising an nifiuence pass- ing through two, if not more, generations. Alcoholic Taint. Intemperance acquired by those who indulge in alcoholic drinks sets up a tendency or taint whicli may pass from one gen- eration to another. I think it is possible that more has been made of this inherited evil than the facts wicli bear upon it, carefully collated and studied, justify. I am quite sure from direct observation that there is an inherited alcoholic intemper- ance, for I have, unfortunately, been obliged to witness it too often to be in any doubt about it. At the same time there are here so many ways in which we may be deceived in observation ; there is so much in those affected that might have been directly acquired by mere imitation ; and there are so many intemperate CONSTITUTIONAL CAUSES OF DISEASE. 521 people who attach their own folly and weakness and vice to the curse of inheritance, it is impossible to be too circumspect in ar- riving at a conclusion. Of all the taints derived from parentage or ancestry the alco- holic is probably the least permanent. Unless the habit it engen- ders be kept up, I believe that the worst taint is removable in two generations. It is often removable in one, and I doubt whether a strong taint may not be kept under control in a second generation, when the circumstances for self-restraint are favorable. ZymotiG Taint. "We have seen that one disease, essentially a contagious dis- ease, syphilis, is often developed by the communication of a taint in the hereditary line. It is a sound inference from this fact that other contagious diseases may be connected with a similar favoring agency. The evidence is not so clear in respect to the general run of contagious maladies, as it is to syphilis, that they are heredi- tary ; and yet it is fairly demonstrative to this effect. Typhoid and diphtheria are, I consider, well proved instances of diseases which have an hereditary history. Scarlet fever, by a negative proof, shows a similar position, for I have known a family the members of which, though exposed to the poison of scarlet fever in the fullest degree, have shown an insusceptibility to suffer from it. Small-pox has, in all probability, a strong tendency to pass by inheritance, and at one time, when inoculation for it was gen- eral, it must have been an almost universal inheritance of the direst kind. Mixed Taints of Disease. In studying the constitutional or hereditary causes of diseases we have finally to consider the fact of mixed types of such causes. It happens in certain families that the hereditary taint is so strongly developed in one direction that the single taint over- shadows or covers all the rest. In other instances a taint derived from one branch or side of a family is commingled with a taint derived from a different branch or side of the same family. There is then established what I have described as the intermar- riage of disease, a subject the importance of which impresses me more and more deeply as my professional life advances. The worst combinations of types are those where the taints 522 CONGElSriTAL, HEEEDITAEY, OE of extremely fatal diseases are represented. The combination of the taint of cancer with that of consumption is a striking case in point. Under such combination one form of taint will be mani^ fested in some members of a degenerated family ; the other form in other members ; while certain of them may present what seems to be a mixed type of tainted organization. Thus I have seen following an intermarriage of disease of the kind named, cancer in one member of the tainted family, tubercular disease of the lungs in anothei-, and that form of doubtful cancerous disease, called luj)us, probably a mixture or cross between cancer and scrofula, in a third. Combinations of rheumatic and gouty taints with consumptive lead to another class of intermediate diseases in which the bony framework of the body is easily implicated. That peculiar dis- ease of the hip-joint described at page 243 as morbus coxae, is, I think, due to the admixture of the rheumatic with the scrofulous taint. Hydrocephalus is probably another illustration of the same combination. The diseases of bone called rickets and mol- lities ossium, described at pages 241-2, are due, I believe, to a combination of the scrofulous and syphilitic taints. Racial Heredities. "With the whole of this question of hereditary transmission of disease is blended the much wider question of race and disease. The value of life in different races is very different. In this country the Semitic race presents a vitality which is much more favorable than that belonging to either the Saxon or the Keltic races. This is the fact through all the ages of life. It is also true that the different races exhibit special immunities and spe- cial proclivities to disease. The Saxon people show an unusual tendency to scrofula and consumption, and to diseases allied to these in character. The Keltic people are, according to my observation, more liable than either of the other races to acute affections of the brain and nervous system. The Jewish or Se- mitic people are subject to one hereditary disease, cancer, quite as determinately, I believe, as the Saxon and Keltic, and they are also subject to melancholia ; but tliey are less subject to the acute nervous diseases, to suicide, to the tubercular class of mala- dies, and to the contagious or infectious group of fatal affections. CONSTITUTIONAL CAUSES OF DISEASE. 523 From epidemics the Jews have often escaped, as if they possessed a charmed life. These tendencies for and against particular diseases and classes of diseases are no doubt hereditary. How far they are due, in the first instance, to habit and mode of life ; how far they de- pend upon some particular power or faculty impressed primitively on the race, it is perhaps impossible to explain and, perhaps, dan- gerous to submit to speculation. I shall therefore only venture to express that acquired and transmitted qualities, and specific ex- isting social peculiarities, are sufficient agencies for the produc- tion of all the known variations of disease belonging to particular races. CHAPTER III. ATMOSPHERICAL, METEOROLOGICAL, AND CLIMATIC CAUSES OF DISEASE. It is one of the commonest as well as one of the oldest ob- servations, that some diseases affecting the bodies of men and ani- mals are due to atmospherical conditions, and to climatic changes. We attribute, usually, the contraction of colds or catarrhs to pe- culiarities in the wind or weather, and it has been customary to connect the great epidemics witli atmospheric peculiarities. The older physicians seem to have attributed all pestilential diseases to the atmosphere. Sydenham considered that small- pox itself arose from some unknown particles of the atmosphere unconnected with contagion, and this view was largely maintained until the early part of the present century. Dr. John Adams, in his essay entitled "An Inquiry into the Laws of Epidemics," was, I believe, the first to distinctly refute this impression, and to put the matter in its true light. Without disputing that atmospheric changes may be causes of disease, Adams laid down a rule, which was exceedingly precise and correct, namely, that "nothing can be called a contagion unless the person affected by it can induce a similar disease in others without regard to season, climate, or any local circumstances." This was an important enunciation, because it separated the ideas of the air itself as a cause of disease from the air as a mere carrier or bearer of contagion. We start then in this chapter with the fact clear in our minds, that the diseases truly of atmospherical origin are not diseases dependent upon contagious matter borne by the atmosphere, because the purest and best atmosphere, as Adams says, may be such bearer. We have to consider the atmosphere itself as a cause of disease. It is necessary at the same time to understand that while at- CLIMATIC CAUSES OF DISEASE. 525 mospheric changes may not be the immediate cause of diseases of the contagious type, they may very considerably influence the effects of the true causes of those diseases, and this specially in regard to the mortality induced by the diseases. Here we are brought into contact with what we may call the secondary action of the atmosphere in respect to causation. It is also necessary to bear in mind that the border line between the class of diseases springing directly from atmospherical causes and the class spring- ing from contagion is often very refined, and that it is possible that some diseases which are induced by atmospherical variations may pass into the diseases which are communicable by contagion. Common cold, or catarrh, is one of these diseases on the border line. That common cold is sometimes communicable from one person to another is an hypothesis based on repeated observation ; and that from common colds other diseases, more distinctly con- tagious, such as influenza, may arise, is a theory resting on a good basis of fact. It might be advisable for the sake of a rigidly systematic de- scription to divide the subject now before us into two parts ; the first dealing with the direct and positive effects of atmospherical variation in producing disease ; the second treating on the indirect or secondary eifects of the atmosphere in modifying the intensity, course, and results of affections produced, primarily, by another agent. On the whole it will be best, and least confusing, to avoid such division, and briefly to present what can be said respecting atmospheric causes of disease in their secondary as well as their primary character. For the proper arrangement of this study it will be necessary for me to consider the general effects of season in relation to disease and mortality. Afterwards I shall have to take up certain details relating to atmospheric temperature and moisture, atmospheric pressure, electrical conditions of the air, the influence of particular winds, and some climatic variations in reference to disease and its terrestrial distribution. Before, however, I touch on these topics two preliminary statements of facts deserve attention. The first relates to what may be called the physiological changes effected on healthy people at different seasons. The second bears upon some peculiar physi- cal conditions of the air itself, and of life under such conditions. 526 ATMOSPHEEICALj METEOEOLOGICAL, AKD Influence of Seasons on Healthy Persons. The facts bearing upon the influence of seasonal changes on persons in health to which I would first refer, were recorded by the late Mr. Milner of Wakefield. From his position as surgeon to the convict establishment at "Wakefield, Mr. Milner was enabled to weigh every prisoner at given periods, to compare the gain and loss throughout the year, and to estimate such gain and such loss, by individual against in- dividual, and by diet against weight. The prisoners upon whom the observations were made had been sent to Wakefield to un- dergo the first portion of their punishment. They were kept in separate cells for a period of nine months ; they were all males between the ages of fifteen and sixty, and they were all in good health when they arrived. Their cells having an equal capacity and the same means of ventilation, they were served with the same quantity and character of air, and the mean temperature of the cells was in every case 61°. The men were all fed on the same kinds of food, they were all dressed in the same attire, and they were made to take the same amount of exercise. They were weighed on admission, and again at the latter end of every calen- dar month during their stay. The number of men weighed ex- ceeded 4,000 ; the period occupied in observation was ten years ; the average number of prisoners weighed monthly was 372 ; and the total number of individual weighings was 44,004. With the first months of the year, Milner found that the body undergoes an average loss of weight in January, February, and March, the proportion of loss being 0.14 in January, 0.24 in Feb- ruary, and 0.95 in March. During the months of April, Ma}^, June, July, and August, there is gain in the following propor- tions : for April, 0.03 ; for May, 0.01 ; for June, 0.52 ; for July, 0.08 ; for August, 0.70. In September, October, and December, there is a loss in proportion of 0.21 for September, 0.10 for Oc- tober, and 0.03 for December. ISTovember presents an exception to the months that precede and follow it, there being an average gain of 0.004 ; so that, at first sight, November would seem to be an exception, in a very slight degree, in the losing series of months that precede and follow it. But Mr. Milner points out that this apparent exception was caused in the prisoners by the arrival of large numbers of men each year, and by the fact that the men CLIMATIC CAUSES OF DISEASE. 527 usually gain weiglit for a short time after they are received ; so that this break in the series results from the influence of the stage of imprisonment. On the whole, there is an average loss begin- ning in December, and increasing rapidly up to March. In April there is an abrupt gain, which extends irregularly until August. In September there is a rapid loss, which continues less rapidly through October. From these facts Mr. Milner drew the following important inferences : 1. The body becomes heavier during the summer months, and the gain varies in an increasing ratio. 2. The body becomes lighter during the winter months, and the loss varies in an increasing ratio. 8. The changes from gain to loss, and the reverse, are abrupt, and take place about the end of March and the beginning of September. Influence of the Air under Peculiar Physical Conditions. The second point to which I would draw attention has refer- ence to some changes which take place in the air itself, and which affect life independently of what are commonly called changes of weather or season. At the meeting of the British Association for the Advancement of Science, held at Oxford in 1860, I narrated a series of reseai'ches which had been carried on then for ten years, in order to determine the effects of oxygen on animal life, and which had led me to discover the following; facts : (1) That if the life of warm-blooded animals is supported on pure oxygen at the temperature of 75° Fahr., the gas produces a quickened combustion of the bod}^, hy^ercausis, or increased burning. (2) That in order for this condition to be maintained, it is necessary that the oxygen should be freshly made, and steadily supplied in current. (3) That if this be not done, the oxygen soon begins to fail to support proper vital action, however carefully the products of res- piration are removed ; the animals inhaluig it become drowsy and fall into gentle but complete sleep which ends in death if the in- halation be continued. (4) That this rule applies to all warm-blooded animals, but that cold bloods, like frogs, are unaffected. From these observations I drew the following conclusion : Oxygen when breathed over and over again, although freed 528 ATMOSPHEEICAL, METEOPwOLOGICAL, AXD entirely from carbonic acid, or other known product of res- piration, loses its power of supporting the life of warm-blooded animals ; the process of life ceasing, not from the introduc- tion of a poison, but as by a negation or a withdrawal of some principle extant in the primitive oxygen which is essential to life. In a later series of researches I found that in this negative condition of oxygen, the decomposition of dead animal substances is very much accelerated. To air thus changed or deteriorated I gave the name of de- vituUzed air, and I believe it to apply to conditions in which the air is deteriorated l)y the presence of organic matter, as in close rooms, crowded cities, and sometimes even in open situations in particular localities noted for closeness and oppression of the atmosphere. Still further, on the same line of investigation, 1 found that by submitting the negative or devitalized oxygen to the electric spark it resumed its activity, and I was thus led, in conjunction with the late Dr. Thomas Wood, to test the action of electrified oxvo'en, or ozone, on animal life. In these experiments a different series of results were brought out. We found that the air of the laboratory in which we worked produced decisive effects upon ourselves, namely, headache of an intense kind, a disagreeable pricking sensation of the nostrils, a severe catarrh attended with copious discharge from the nose, and ultimately quickened and difficult respiration. These symptoms were so definite we felt it necessary each time before we began to produce ozone in large quantities, to diffuse the vapor of ammonia through the air to neutralize the action. Before the conclusion of our research, which ended in 1864, we discovered that in warm-blooded animals the effects of ozone were the same as upon ourselves, and that the continued inhala- tion of ozone by them led to congestion of the lungs, rapid coagu- lation of the blood, and death in a brief period, often in the course of an hour, if warmth, which greatly accelerated the action, were added. At a temperature of 40° to 45' Fahr. a warm-blooded animal would live, without being seriously affected, for many hours in air charged as fully as it could be with ozone ; while at 70° Fahr. tlie action commenced immediately, and led to fatal results within the hour. CLIMATIC CAUSES OF DISEASE. 629 We learn from these data that there are two differiiio; condi- tions of oxygen, one active, the other negative ; and as either of tliese conditions may, according to Schonbien, be present at dif- ferent times in tlie atmosphere, the effects incident to their pres- ence require to be borne in mind in the chapters which immedi- ately follow. CHAPTEE lY. Olf WEATHER AND SEASON AS CAUSES OF DISEASE. The distingiiislied Arbutlinot was of opinion that every season has its special diseases, a view which he supported most ably, and which, as the facts about to be stated will show, is sustained in a remarkable degree bv modern investigation. The prevalence of diseases as a whole, and of the mortality arising from them, is well-marked in various periods of the year. In 1853 I made a careful analysis of the facts bearing on this sub- ject, and obtained very important results. The analysis referred, only to the diseases of certain parts of England, and was derived fi-om mortality tables, viz., those published by the Registrar- General ; but from its wide basis, its results gave a fair picture of the special season diseases of England. The analysis included deductions made from not fewer than 139,318 deaths, occurring during years extending from 1838 to 1853, and arising from the following diseases: small-pox, measles, scarlet fever, whooping cough, croup, diarrhcea, dysentery, cholera, influenza, ague, remittent fever, typhus, erysipelas, quinsy, bron- chitis, jaundice, and carbuncle. The districts of death were Lon- don, Devon, and Cornwall. Out of 139,318 cases thus chronicled, as occurring from the above-named diseases, and estimating the gross mortality accord- ing to the season, without reference to particular years, the per- centage of mortality in the different quarters ran as follows : In January, February, and March, 25 per cent. ; in April, May, and June, 21 per cent. ; in July, August, and September, 24: per cent. ; in October, I^ovember, and December, 28 per cent. Plaving learned thus much, I set about ascertaining, on the same large scale, whether the fatal diseases were in any way special to the seasons. The answer to the inquiry was to this effect : AS CAUSES OF DISEASE. 531 Whooping-cough, croup, small-pox, and bronchitis were most common in the first quarter. Small-pox Whooijing-cougli Croup Bronchitis 1st Quar. 27,352 32,704 27,523 36,793 2d Quar. 24,551 27,825 25,100 20,301 3d Quar. 22,824 17,116 19,919 10,327 4th Quar. 25,272 22,354 27,456 32,570 Pneumonia, I believe, might very properly have been added here. In the second quarter quinsy only stood ahead. Thus : 1st Quar. 2d Quar. 3d Quar. 4th Quar. Quinsy 21,762 30,596 21,231 26,410 In the third quarter diarrhoea, dysentery, and jaundice took the lead. Diarrhoea . Dysentery Jaundice . In this third quarter, Asiatic cholera, when epidemic, assumes a greater mortality and prevalence than at any other season. In the fourth quarter influenza, ague, remittent fever, typhus, scarlet fever, measles, eiysipelas, and carbuncle took the lead. Influenza Ague Remittent Fever. Typhus Scarlet Fever . . . . Measles Eiysipelas Carbuncle 1st Quar. 2d Quar. 3d Quar. 23,539 12,171 4,502 22,857 24,285 20,000 23,077 26,315 23,481 25,741 24,825 22,912 20,809 18,978 26,234 19,864 21,466 26,234 25,144 23,444 22,337 26,771 1 19,685 24,409 4th Quar. 59,784 32,851 27,125 26.521 33,976 32,434 29,174 29,133 In a pathological as well as a statistical point of view, these results are most intei'esting ; for they prove, in a great measure, that diseases, analogous in their general characters, group tliem- selves singularly together at special periods. Thus we see that, 532 WEATHEE AND SEASOJST in the autumn quarter, there are grouped together those diseases which have for one of their essential symptoms an exudation from the intestinal surface, or from that large abdominal organ, the liver. In the first quarter, the diseases of the respiratory system — croup, whooping-cough, and bronchitis — stand forth promi- nently, while in the fourth quarter, a large family of diseases of the febrile or inflammatory order take the first position. It is not by mere accident that these divisions occur ; they are the effects of fixed, though nearly unknown, physical or chemical laws. It is worthy of special remark that the fourth quarter of the year is that in which the number of diseases causing a prominent mortality is, as a general rule, greatest, and that next to it is the quarter commencing with the new year. As the cold of winter more decidedly sets in we begin to see developed, almost of neces- sity, an increase of deaths from pulmonary diseases, and of low fever amongst the poor, if provisions become high in price and insuflicient in quantity or quality. , In public practice, it is almost always to be observed that diar- rhoea is a common symptom amongst the poor during intensely cold weather. In this form it does not, however, prove very fatal ; and hence it stands low at that time in the mortality re- turns. It seems to occur simply from internal congestion, arising from long exposure of the external surface to the cold. The views above expressed were published in my paper on " Season in Relation to Disease " in the " Journal of Public Health " for December, 1855, pages 366-9. They have been generally sustained by other writers. Recently the learned officials of the Scottish Meteorological Society, Mr. Buclian and Dr. Mitchell, have, in the most elabo- rate and laborious manner, illustrated this subject by an analysis of mortality returns of London from 1845 to 18Y4, a period of thirty years ; and those of ISTew York from 18T1 to 1877. The work of these authors is so important I feel it necessary to offer a summary of the facts which they have supplied. I should premise by stating that the results of their examina- tion of the data before them is expressed throughout by a curve on a mean line. I give one illustration, from their calculation of the mortality of whooping-cough, as a representative of all the others. AS CAUSES OF DISEASE. 533 CURVE OF MORTALITY FROM WHOOPING-COUGH FOR ALL AGES AND BOTH SEXES. Derived from Calculations of 34 Years. 30 per cent. Mean Jan. ^ 1 1 h Feb. 1 1 1 Mar. 1 1 1 April. May. 1 1 1 June. 1 i 1 July. 1 1 1 Aug. 1 1 1 Sept. 1 1 1 Oct. 1 1 1 Nov. Dec. Ill iin 50 per cent. I! i 1 1 1 1 1 1 1 1 ! ! 1 1 1 1 i 1 1 1 1 T?r 1 i 1 1 1 1 Ml 1 1 3p A glance at the above will show that the height of the curve above the line, and the depth of it below the line indicate the periods of maximum and minimum mortalities from the respec- tive diseases. The facts thus collected are summarized in the subjoined extracts, in which I have onlj departed from the authors' plan in the matter of the arrangement of the diseases, in order to maintain the system of arrangement which has been carried on throughout this volume. Abstkact on the Influence of Weather on Mortality from Different Diseases and at Different Ages in London AND AT New York. By Alexander Buchan, F.R.S.E., and Arthur Mitchell, M.D., LL.D., F.R.S.E. [From tlie " Journals of the Scottish Meteorological Society," 1875-8.1 PEEIODS OF MOETALITY IN VAEIOUS CONDITIONS OF DISEASE. Irritation. Teetldng. London. — Maximum. — January to middle of June and end of July ; ab- soliTte, March, April. Minimum. — Middle of June to end of December, with excep- tion of last week in July ; absolute, October, November, Dropsy. London. — Maximum. — November to April ; absolute, February, March. Minimum. — June to October ; absolute, July, August. Atroplnj. London. — Maximum. — July to September ; absolute, August. Minimum. — October to end of June ; absolute, May, June. Curve is allied to that for tabes mesenterica and bowel dis- 534 WEATHER AND SEASON Mo7'tification. iowc?o?i.— Maximum.— Beginning of December to beginning of May ; absolute, March, April. Minimum. — June to beginning of December ; absolute, Au- gust and September. Senile Decay ; Old Age. London. — Maximum.— Close of November to end of April ; absolute, January. Minimum. — May to close of November ; absolute, July to October. Very rapid rise in tbis curve in November. PEEIODS OF MORTALITY IN DISEASES EXJNNING A DEFINITE COUESE IN BOTH SEXES AND ALL AGES. London and New Yokk. Small-pox. London. — Maximum. — Last week of May. Minimum. — Last week of September. Above the average from Christmas to end of June. New YorJc. — Maximum. — May. Minimum.— Sej)tember. Above the average from January to July. Measles. Zo?icfo72.— Maximum.— Larger, November, December, January ; smaller, May and June. Minimum. — Larger, August, September, October; smaller, February, March. New For^.— Maximum. — Larger, July ; smaller, February. Minimum. — Larger, September ; smaller, Aiaril. Scarlet Fever. London. — Maximum. — September to end of year. Minimum. — February to end of July. Highest death-rate through October and November. New Foryt.— Maximum.— December to Jime ; absolute, April. Minimum. — July to November ; aljsolute, September. Typhus. London, — Maximum.— Januaiy to beginning of May. Minimum.— Middle of May to end of September. Except hot season of July and beginning of August typhus is below average from middle of May to end of September. AS CAUSES OF DISEASE. 535 Typhoid Fever. LtMii/ow.— Maximum.— October and November, Minimum.— Middle of May to end of June. Falls below average last week of February ; begins to rise gradually in July. New ForA:.— Maximum.— August to November ; absolute, September. Minimum. — Nearly equal over other months of the year. Remittent Fever. io«fZo?i.— Maximum.— Larger, April to June ; smaller, middle of De- cember. Minimum. — September. Diarrhoea. io?2C?on.— Maximum.— Middle of July to beginning of August. Minimum. — Absolute, March and April. Maximum commences slowly in June ; after August decreases (at a slower rate than it rose) until December. New York. — Maximum. — July and August. Minimum. — ^December, January, February, and March. Death-rate begins to increase in April, two months earlier than in London. Simple Cholera. London. — Maximum. — July and August. Minimum. — March and April. Malignant Cholera. London. — Maximum. — September. Minimum. — Apiil and May. Mortality begins to rise in June, rises rapidly in July, main- tains high and steady position in August, raus up to abso- lute maximum in September, and then rapidly falls. J)ip>htheria. London. — Maximum. — September to end of the year. Minimum.— Middle of March to beginning of September. Deaths remain above the average from September to the beginning of March. New Yoi'k. —Maximum. — December. Minimum. —August. Deaths above average from October to February; below it duiing the rest of the year. 536 WEATHER AND SEASON Whooping-cough. London. — Maximum. — Febmary, March, and first half of April. Minimum. — September and October. Death-rate above average from middle of December to be- ginning of June. JVeu! YorJc. — Maximum. — Larger, September ; smaller, February. Minimum. — Larger, November ; smaller, June. The two maxima occur from August to September, and from February to April. The two minima are from October to January, and from May to July. Influenza. London. — Maximum. — November, December, and January. — March and April. Minimum. — Other months of the year. Owing to rarity of epidemics and the suddenness with which the disease appears and disappears, this cannot be accepted as the true curve of influenza. Erysipelas. London. — Maximum.— November. Minimum. — Middle of June to middle of September. Deaths from erysipelas are above the average from the middle of September to end of March ; below for the rest of the year. Puerperal Fever. London. — Maximum. — November to March. Minimum.— From middle of June to fourth week of Sep- tember. The curve of mortality tallies closely with that for eiysiiselas. Hydrophohia. London. — Maximum. — June, July, August, September, December; ab- solute, December. Minimum. — February, March, April, May. Calculation is based on fifty-six deaths in thirty years, twenty- three of which occurred in 1865-6-7. Fevers in general. London. — Maximum. — Beginning of September to end of January, Minimum. — From April to Aiigust. This curve has a well-marked character, though the departure from the average is never great. AS CAUSES OF DISEASE. 637 PERIODS OF MORTALITY IN GENERAL DISEASES OF CON- STITUTIONAL TYPE, BOTH SEXES AND ALL AGES. Rheumatism. Zow(^o?i.— Maximum. — End of November and beginning of December. Minimum. — August and beginning of September. The large November December maximum is prolonged, but in a diminished form, to the spring months. Gout. ix>rtc?wi.— Maximum.— Middle of March to end of April. Minimum. — Beginning of June to end of year ; absolute, Sep- tember. A large increase takes place in last week in year. Another in middle of March ushering in annual maximum. Cancer and Cancrum Oris. London. — Maximum. — ^None. Minimum. — None. Scrofida. I,o?ic?o?j.— Maximum.— Larger, middle of April to first week of August ; smaller, in October. Minimum.— January, February, September, November, De- cember. 3fesenieriG Disease and Scrofula. London.— Maximum.— Middle of July to middle of September. Minimum.— End of December to beginning of February. The mortality follows curve of temperature very closely. New ForA;.— Maximum.— -Inly, August, and September. Minimum.— December to early part of June ; absolute, De- cember and January. Diabetes. London. — Maximum. — None. Minimiim . — None. Purpura and Scurvy. Lcmdon. — Maximum. — March to July. Minimum. — December to beginning of January. 538 WEATHEE AND SEASOIST PEEIODS OF MOETALITY OF LOCAL DISEASES IN BOTH SEXES AND ALL AGES. Diseases of the Digestive System. Thrush. London. — Masimiim. — Last week in July to third in Angtist. Minimum. — For the rest of the year ; absolute in April and May. The curve is identical in chief features with that of bowel complaints. Cynanche — Quinsy ; Tonsillitis. London. — Maximum. — Middle of October to end of March ; absolute, end of December and beginning of January. IVIinimum. — August and beginning of October. Maximum period is attended with a fall during February. London. — Maximum. • — None. Minimum . — None. Gastritis. Enteritis. London. — Maximum. — End of June to beginning of October ; absolute, first week in August. Minimum. — Januaiy, February, March, April, May, Novem- ber, December. Dyse}ite7y. London. — ^Maximum. — June to November ; absolute maximum, second week in September. Minimum. — April and May. From November to June death-rate under the average. Lntussuscejytion. Jjondon. — ^Maximum. — March, August, December, and fii-st half of Januaiy. Minimum. ^ — September to November, and again in February. Features very imperfectly marked. Hernia. London. — Maximum. — End of December, and beginning of Januaiy. Minimum. — End of May and beginning of June. Below average from May to middle of November. AS CAUSES OF DISEASE. 539 D1SRA.SES OF THE HeABT Airo CiRCUIjATION. Pericarditis. Zoji(/o7i.— Maximum.— Middle of October to middle of May; absolute, November. Minimum. — Middle of June to middle of September. Curve resembles that for rheumatism. Heart Disease Generally. London. — Maximum. — November to March; absolute, December and January. Minimum.— Middle of April to middle of November ; abso- lute, middle of August to middle of Sej)tember. New For/t.— Maximum. — November to May, with fall in February ; abso- lute, December and January. Minimum. — Middle of June to middle of October. Curves for London and New York correspond closely. Eespikatoby Oegans. Croup. London. — Maximum. — Middle of November to end of A]Dril ; absolute, February and March. Minimum. — Middle of May to end of Sejatember ; absolute, middle of June to middle of August. Absolute maximiam is in early spring ; absolute minimum in middle of summer. New York. — Maximum. — From October to A^^ril ; absolute, November and December. Minimum. — May to September ; absolute, Jiily and August. The cui-ves for London and New York essentially agree. Laryngitis. Lcmdon. — Maximum. — Beginning of December to end of May; abso- lute, last three weeks of March. Minimum. — June to November ; absolute, second week in September. Sharp fall in January in maximum. Bronchitis. London. — Maximum. — November to March ; absolute, second week in January. Minimum. — April to October ; absolute, August. Above the average from November to April ; below from May to October. 640 TTEATHEE A^'D SEASOjST l^ew York. — Maximum. — November to Marcli ; absolute, middle of March. Minimum. — June to middle of ^November; absolute, fiist week in August. The number of deaths from bronchitis in Xew York is only one- twentieth of the whole deaths, while in London it is one-eighth of the whole. Astlima. London. — Maximum. — From Xovember to April; absolute, second we in Januaiy. Minimum. — The beginning of May to end of October; abso- lute, August. Pneumonia. London. — Maximum. — November to Apiil ; absolute, December. Minimum. — Beginning of May to end of October; absolute, August. The curve generally same as for bronchitis, but absolute maximum earlier. New Poj'Z:.— Maximum. — Beginning of November to middle of May; ab- solute maximum, March. Minimum. — Middle of May to beginning of November ; ab- solute, Jidy and August. Plithisis. London. — Maximum. — January to middle of June, and middle of No- vember to middle of December ; absolute, middle of March. Minimrmi. — Middle of July to middle of November ; absolute, fourth week of September. The deaths from this disease are nearly one-eighth of all the deaths that occiu*. Nev: York. — Maximum. — Middle of December to middle of May ; absolute, March. Minimum. — Middle of May to middle of December ; absolute, June. The deaths from this disease in New York are greater than in London, ^t.z. , one-seventh of the whole. Pleurisy. London. — Maximum. — Middle of November to second week of June ; absolute, December and Januaiy. Minimum. — Beginning of July to end of October ; absolute, July and August. The cmwe is subject to numerous fluctuations, and resembles cuiwe for rheumatism and pericarditis rather than bronchi- tis, pneumonia, or asthma. AS CAUSES OF DISEASE. 641 Lung Disease Generally. London. — Maximum. — From beginning of November to end of May ; absolute, December and January. Minimum. — June to November ; absolute, July and August. This group includes all diseases of the lungs not already spe- cified. D1SKA.SES OP THE Nervous System. Cephalitis. London. — Maximum. — From beginning of February to end of Jiily ; ab- solute, beginning of April. Minimum. — From beginning of Sej)tember to January ; abso- lute, September, October, and November. Curve fluctuates considerably. Neio Torh. — Maximum. — Beginning of February to end of August ; abso- lute, July. Minimum. — Beginning of September to beginning of Febru- ary; absolute, November. Hydrocephalus. London. — Maximum. — From second week in February to beginning of August ; absolute ; March and Ai^ril. Minimum. — Second week in August to beginning of Febru- ary ; absolute, last week in October. Mortality shows secondary increase in July as a constant feature. New York. — Maximum. — January to beginning of August ; absolute, April and July. Minimum. — Second week in August to first in January ; abso- lute, October, November. Apopleccy. London. — Maximum. — Middle of November to middle of April ; abso- lute, December, January. Minimum. — Middle of April to middle of November, with a rise in the last week in June ; absolute, third week of July to beginning of September. New York. — Maximum. — Beginning of December to end of May; absolute, March. Minimum. — Beginning of June to end of November; absolute, July, August, Sei^tember. 542 WEATHER AND SEASOjST Paralysis. London. — Maxinmm. — Middle of November to end of April ; absolute, end of January. Minimum. — Beginning of May to middle of November ; ab- solute, thii-d -R-eek in Sexatember. Differs from apoplexy in having maximum fatality in mid- winter. Epil&psy. London. — Maximum. — Last week of December to tbird week of April ; absolute, third week of March to first week of April. Minimum. — Middle of July to fii'st week of September ; ab- solute, last week in August. Convulsions. io?icZo?i.— Maximum. — December to end of April; absolute, Febniaiy and March. Minimum. — Beginning of May to middle of November, with a small secondary maximum in July ; absolute minimum in September — October. New YorJc. — Maximum. — June, July, and August ; absolute, July. Minimum. — End of Sejatember to end of December; abso- lute, November, December. Slight maximum in July in London is much exaggerated in New York curve. Insajiity. London. — Maximum. — December, January, June, March, April ; abso- lute, December and January. Minimum. — Beginning of July to November ; absolute, Sep- tember, October. The curve is very iiTcgular. All Nervous Diseases. London. — Maximum. — Beginning of December to close of April ; abso- lute, March, April. Minimum. — Middle of May to close of November ; absolute, September, October. New York. — ^Maximum. — Februaiy to end of May slight, and close of June, July to middle of August ; absolute, July. Minimum. — Middle of Augaist to middle of Januaiy ; abso- lute, November. Curve differs in New York from London owing to great max- imum in July from sunstroke. AS CAUSES OF DISEASE. 543 Brain Diseases. London. — Maximum. — From beginning of December to end of April, with slight increase in July ; absolute, March. Minimum. — From end of July to end of November ; absolute, September, October. Curve almost identical with that for epilepsy. Includes all brain afltections, except convulsions, epilepsy, paralysis, apoplexy, cei^halitis, insanity. Diseases of the Absokbent and Glandtilab System. Hepatitis. Londoyi. — ^IVIaximum. — Beginning of May to end of September; abso- lute, August. Minimum. — October to end of April ; absolute, December, January. Jaundice. Londcm. — Maximiim. — March slight, June with a fall in July, through July, August, Sej^tember ; absolute, August. Minimum. — November to June, with slight rises above the average in February, March, April ; absolute, December, January, February. Curve much resembles that of Hepatitis. BrigMs Disease of Kidney. London.— M.&xmmm.. — October to May ; absolute, February, March, with a dip in December. Minimum. — Middle of May to end of September ; absolute, August, September. Kidney Disease (General). London. — Maximum. — End of November to end of April; absolute, December, January, and April. Minimum. — Middle of May to September; absolute, June, August. Diseases of the Membranous System. Slcin Disease. London. — Maximum. — October to middle of January ; absolute, Novem- ber. Minimum. — End of May to beginning of September ; absolute, June. This curve comprehends all skin diseases except phlegmon and ulcer. 544 WEATHER AND SEASON" Diseases fbom Nattjbal Accidents. CUldhirili. (Mother.) London. — Maximum. — Second week of October to end of March ; abso- lute, December, January. Minimum. — May, June, July, August; absolute, June to August. Premature Birth. London. — Maximum. — January, Febraary, May, July, August, December. Minimum. — During remaining months. Curve shows little Tariation from the average through the year. Privation. London. — Maximum. — December to middle of April. Minimum. — Middle of April to end of November. Curve allied to that of disease of respiratoiy organs. Want of Breast Milk. London. — Maximum. — Jiily, August, and September; absolute, July, August. Minimum. — October to end of June ; absolute, May. This curve is allied to that from diseases of abdominal organs. Alcoholic Diseases and Delirium Tremens. ■ London. — Maximum. — Beginning of May to end of September; abso- lute, July. Minimum.— Beginning of October to beginning of May, with rise to the average in October, and slightly above the aver- age in first week of new year ; absolute, January, February, March, December. The cui-ve for delirium tremens stands alone, resembles no other curve, and is steady. Suicide. London. — Maximum. — Latter part of March to latter part of August ; absolute, end of June. Minimum. — End of August to March ; absolute, beginning of February. New York. — Maximum. — Beginning of April to end of September ; abso- lute, May. Minimum. — Beginning of October to beginning of April ; absolute, Februaiy. Both cui-ves have the maximum period in spring and early summer. AS CAUSES OF DISEASE. 545 From the details of important facts above recorded we gather information of the most useful and practical kind. There is probably nowhere in medical science such an epitome of disease as that recorded in Messrs. Buchan and Mitchell's papers. From the researches of these distinguished men we can indeed forecast, in these islands, the course of many diseases with a precision that may to a large degree be called exact. 35 CHAPTEE Y. ATMOSPHERICAL, METEOROLOGICAL, AND CLIMATIC CAUSES CONSIDERED IN DETAIL. From the array of facts which have passed under our observa- tion we have been able to arrive at certain general conclusions, which are of extreme practical value. It will be instructive now to inquire whether the facts relating to disease can be accounted for as connected with particular atmospherical conditions. In other words, are the phenomena of disease dependent upon partic- ular atmospherical variations, or upon particular combinations of them ? Atmospheric Temperature and Damp. The influence of temperature on disease has ever been a fer- tile subject of observ^ation by skilled inquirers. Dr. William Farr, however, was the first to treat upon it with precision, and to bring the effects of variation of temperature on life into what may be called a calculable form. In one of his early tables he described that after twenty years of age the danger of dying from a fall of temperature is doubled every nine years. Thus, out of the same members living, if one die at thirty years, two will die at thirty-nine, four at forty-eight, eight at fifty- seven, sixteen at sixty-six, thirty -two at seventy-five, and sixty- four at eighty-four, from the same wave of cold. The wave of cold cannot, however, of itself be taken as the cause of all that depends upon climatic influence, and Messrs. Buchan and Mitchell, recognizing this fact, have commented on temperature and moisture, together, in relation to disease. They divide the London year into six periods, each one of which has a climate peculiar to itself. The periods are as follow : The first period, extending from the fourth week of October to the third week of December, is marked by dairvpness and cold. ATMOSPHERICAL AND CLIMATIC CAUSES. 547 The second period, extending from the fourth week of Decem- ber to the third week of February, is marked by cold. The third period, extending from the fourth week of Feb- ruary to the second week of April, is mai-ked by dryness and cold. The fourth period, extending from the third week of April to the fourth week of June, is marked by dryness and warmth. The Jifth period, extending from the close of June to the fourth week of August, is marked by heat. The sixth period, extending from the first week of September to the third week of October, is marked by damjmess and warmth. Daring the first of these periods, marked by dampness and cold, seventeen diseases show a rapid increase of mortality, and twenty-five a mortality greatly above the average. Ten diseases, namely, measles, diphtheria, typhoid fever, childbed fever, rheu- matism, pericarditis, aneurism, pneumonia, skin disease, and cyanosis, present an absolute maximum. Fourteen diseases, half of which are connected with the nervous system, show an in- crease of mortality. Twelve show a mortality considerably below the average, three of these being scrofula, cephalitis, and jaun- dice, and nine bowel complaints, or diseases connected with the nervous system. In the second jjeriod, characterized by cold, six diseases begin to show an increased mortality, whooping-cough showing a rapid increase. Forty present a mortality considerably in excess. Sev- enteen, namely, small-pox, quinsy, typhus, delirium tremens, paralysis, insanity, convulsions, heart disease, bronchitis, pleurisy, asthma, other lung diseases, hernia, kidney disease, ulcer, child- birth, and old age, present the annual maximum. Seven diseases begin to decrease, five showing a rapid decrease. Twelve fall much below the average ; five, namely, purpura and scurvy, de- lirium tremens, tabes mcsenterica, hepatitis and suicide, reaching the minimum. Diseases of the respiratory organs show the greatest mortality during this period. In the third period, characterized by dryness and cold, three diseases show an increase of mortality, and three of them a rapid increase. Thirty-four 3'ield a mortality greatly in the excess. Fifteen, namely croup, whooping-cough, privation, dropsy, mor- tification, consumption, hydrocephalus, apoplexy, chorea, epilepsy, 548 ATMOSPHERICAL AND CLIMATIC convulsions, brain disease, laryngitis, Briglit's disease, and teeth- ing, j^'elding a maximum. Twelve begin to decline ; four present a rapid decline ; eleven fall below the average, one of them, scar- let fever, declining to the annual minimum. Diseases connected with the nervous system show the highest death-rate in this period, and no complaint of which the nervous system is believed to be the seat has its minimum at this season. In the fourth period^ characterized by dryness and w(wmih, nine diseases begin to increase in their mortality ; nine show a rapid increase. Fifteen rise above the average, nine of which, namely, ague, remittent fever, gout, purpura and scurvy, scrofula, cephalitis, intussusception, joint disease, and suicide, attain or re- tain their annual maximum. Nineteen begin to decline from the maximum ; nine show a rapid decline. Eighteen are below the average, eleven of them, namely, diphtheria, typhoid, dysentery, diarrhoea, cholera, w^ant of breast-milk, thrush, enteritis, ulcer, atrophy and debility, reaching their annual minimum. This is the healthiest of all the periods ; the diseases of the respiratory and nervous systems rapidly diminish, and bowel complaints are at the lowest until just upon the close of the period. In the fiftfh period, characterized by heat, four diseases begin to increase in their mortality, ten showing a rapid increase. Six- teen are above the average, diarrhoea, summer cholera, want of breast-milk, delirium tremens, thrush, tabes mesenterica, gastritis, enteritis, jaundice, and atrophy and debility, attaining their an- nual maximum. Ten diseases begin to decline, nine showing a rapid decline. Thirty-one are below the average, twenty of which, namely, croup, erysipelas, childbed fever, rheumatism, dropsy, mortification, apoplexy, epilepsy, pericarditis, heart dis- ease, laryngitis, bronchitis, pleurisy, pneumonia, asthma, other lung disease, Bright's disease, kidney disease, skin disease, and cyanosis, attain or maintain their annual minimum. The marked diseases of this period are bowel complaints. Delirium tremens has also its maximum in this period. In the sixth j)eriod, characterized by dampness and warmth, twenty-one diseases begin to increase in their mortality, nine showing a rapid increase. l!sine run above the average, three of these, namely, scarlet fever, dysentery, and cholera, attaining or maintaining their annual maximum. Six begin to decline from the maximum ; seven show a rapid decline. Twenty-seven are CAUSES OF DISEASE. 649 greatly under the average, fifteen of these, namely, small-pox, quinsy, whooping-cough, typhus, remittent fever, gout, consump- tion, hydrocephalus, paralysis, insanity, convulsions, brain disease, hernia, teething, and old age, attaining or remaining at their annual minimum. Scarlet fever is the only disease which reaches its maximum death-rate during this period, viz., in October. The period altogether is very healthy. A further analysis of these researches indicates that heat and not cold is the great destroyer of the infant life of London, while cold and not heat is the great destroyer of the aged. We find an explanation of the effects of cold by estimating the force of vitality at different ages. We may assume that the body reaches its maximum of development at the age of thirty. At this period, if it be quite healthy, it generates by its own chemical processes so much force as shall enable it, within given bounds, to work its own machinery, to call forth at will a liuiited measure of extra force, and to supply a fluctuating loss that may be conveyed from it by contact with the surrounding air, and by other substances that it may touch, and that are colder than itself. The body yields, therefore, applied force, reserved force, and waste force ; and these, under ordinary circumstances, are sufiicient to maintain the perfect organism in effective life. So much active force gives the body the power to perform so much labor ; so much reserved force supplies it with the power to perform a measure of extra labor to meet emergencies ; so much waste force enables it to resist the external vicissitudes without trenching on the supply which is ever wanted to keep the heart pulsating, the chest heaving, the glands secreting, the digestive apparatus digest- ing, and the brain receiving or thinking. Let this distribution of force be disturbed, and straightway the life-power is reduced. If we use the active force too long, we become exhausted, and call upon the reserve ; and if we still continue the process we fail at last, unless sleep forces itself upon us, and brings, with the rest it insures, renewal of power. If we are robbed of the waste force quicker than we can supply it again, exhaustion is produced ; insufficient nervous control over the vas- cular canals succeeds, and therewith that congestive condition of the lungs and other vascular organs, under which death is so easy when exhaustion is severe. That the exhaustion should be more rapid in the man who 550 ATMOSPHERICAL AND CLIMATIC has reached his prime is but natural. In his past he lias been a growing, developing body, and in the course of development he has used up an excess of force commensurate with the demands of his growth. When he stops in development, and stands on a fair level with the external forces opposed to him, then his own force, for a short time balanced, soon becomes second in command. lie feels cold more tenderly ; if his rest be broken, his demand for artificial heat is urgent; if he lose or miss food, he fails rapidly ; and, returning to our facts on the influence of external temperature on mortality, these many sources of failure are the reasons why a fall in the thermometer sweeps away our popula- tion so decisively according to its age. The influence of temperature is very decisive in regard to certain acute diseases. Thus, as Boudin shows, yellow fever de- mands a temperature of 68° Fahr. in order that it should take the epidemic form ; while epidemic plague ceases in Egypt when the temperature approaches 82° Fahr. Phthisis pulmonalis, so fatal in Great Britain, diminishes as the climate becomes warmer, as in the West Indies, Ceylon, and Mauritius. It also diminishes as the climate becomes colder, as in Canada and ISTova Scotia. Atmospheric Pressure. The effects on health of changes of weather preceding rain have long been known, and since the discovery of the atmos- pheric pressure, and of the instrument called the barometer, with which that pressure is measured, the idea that there is a close connection between a fall of the barometer and certain painful affections, like neuralgiac and rheumatic pains, has become gen- eral. In our day this subject has been remarkably illustrated, on one side of it, by the observations which have been scientifically made on the effects of pressure upon men who are obliged to work in compressed air, and who suffer from the affection de- scribed at p. 392-4 as caisson, or coffer-dam disease. The subject has also been studied on the other side by observations on the effects of reduced pressure upon persons who are ascending moun- tains, or upon those who are rising, in a balloon, into a higher and rarefied atmosphere. The influence of atmospheric pressure, which I have briefly described in the pages above referred to, is variable according to CAUSES OF DISEASE. 551 the susceptibilities of the persons who are subjected to it. In fact, there is nothing which shows more conspicuously the differ- ence of human susceptibilities to external influences than the pressure of air. Dr. Andrew Smith, in his record of the phe- nomena he noticed in the caisson of the East River Bridge at ]^ew York, found that a large proportion of the men bore the excessive pressure, — reaching at last to thirty-six additional pounds to the square inch, — without the slightest ill effect ; whilst in others some severe symptoms resulted from a very short ex- posure to slight pressure. In one instance a student of engineer- ing, after a brief stay under an additional pressure not exceeding fifteen pounds, was seized on coming into the air under ordinary pressure, with temporary paralysis. The difference, Dr. Smith thinks, lies in the difference of efficiency of the vaso-motor system, or perhaps in the structure of the blood-vessels themselves, so that in one case the vessels resume at once their natural condition when the pressure is removed, while in the other case the abnor- mal distribution of the blood persists in certain parts of the vas- cular surface. " Whatever," he argues, " the predisposing condi- tion may be in this latter class of cases, we have only to assume its existence in an exaggei*ated degree to bring the subject within the range of ordinary barometrical changes. If one man can bear a change of ninety inches, and come out of it to the ordinary pressure without feeling it, while another is paralyzed by a change from thirty inches of pressure to the ordinary, it is not incredible that a third may have aching limbs as a result of being subjected to a fall of two inches of pressure," This is the reasoning suggested by Dr. Smith, and from these inferences, as well as from many others which he has drawn from his unrivalled field of research, he explains why some cicatrices, — scars, — such as those following gunshot wounds, are specially prone to be subjected to neuralgiac pains during change of weather. He also explains why, on bright days, when the air is light, and the barometer is high, — when, that is to say, the greater atmospheric pressure on the surface of the body drives the blood into the interior of the body, and especially into the organs in closed cavities, such as the brain, — the mind is active, and the muscles vigorous ; while on damp, foggy days, mental effort is irk- some, the limits drag, the appetite is small, and the whole tone of the system lowered. 552 ATMOSPHERICAL Aj^D CLIMATIC The changes are more distinctive still in those who are prone to disease, and in whom the vessels are already enfeebled or changed in structure. There can be no doubt that the effects of reduced pressure tell with intense force on large populations who are already enfeebled. I have dwelt on variation of the atmospheric pressure as a cause of disease, on account of its great practical meaning. It embraces so much. Whether the variation from high to low pressure ever acts as a primary cause of disease it is impossible to define, but that it acts as an exciting cause, of the most serious character, on persons predisposed to disease there can be no doubt whatever. A sudden reduction of the atmospheric pressure, which means a fall in the barometer, is attended with risk of pressure of blood, leading to pressure on nervous fibre and production of pain ; to internal congestion ; to fever ; to apoplexy : while an increased pressure, which means a rise in the barometer, is at- tended with greater risk of injury from physical or mental shock. The effect of the variation extends in yet another direction. I have pointed out in an essay on '' Meteorology in Relation to Sur- gical Practice," that the atmospherical pressure plays an important part in the results of surgical procedures, and that with a falling barometer the chances of success are reduced. Thus the time \s, favorable for operation, — {a) When the barometer is steadily rising. ih) When the barometer is steadily high. (c) When the wet-bulb thermometer shows a reading of five degrees lower than the dry-bulb. {d) When, with a high barometer and a difference of five de- grees in the two thermometers, there is a mean temperature at or above 55° Falir. The time is unfavorable for operation, — {a) When the barometer is steadily falling. (5) When the barometer is steadily low. (c) When the wet-bulb thermometer approaches the dry-bulb within two or three degrees. {d) When, with a low barometrical pressure and approach to unity of reading of the two thermometers, there is a mean tem- perature above 45° and under 55° Fahr. On the same point Dr. Addenill Hewson has published in the Pennsylvanian Hospital reports a register of 259 operations with CAUSES OF DISEASE. 553 the accompanying meteorological conditions, and the results con- nected with the operations. These results, as stated by Dr. Ilew- son, stand as follows : — " On the occasion of the 259 operations, the barometer was ascending in 102, descending in 123, and stationary in 34. Fifty-four of the whole number were fatal ; 11 of them were operated on when the barometer was ascending, 35 when it was descending, and 8 when it was stationary. Of the successful cases, 91 were operated on with an ascend- ing barometer, 88 with it descending, and 26 with it stationary. " From which it would seem," says Dr. Plewson, " that we got a mortality, w^hen the operation was performed with the barometer ascending, of not quite 11 (10.7) per cent. ; of over 20 (20.6) per cent, with it stationary ; and over 28 (28.4) per cent, with it descending. Of the fatal cases, the average length of time which the patient survived the operation was only seven days when the barometer was ascending, and thirteen when it was descending ; and of the cases which died within three days over 75 per cent, were when the barometer was ascending." Electrical Conditions of the Air. From the experimental data recorded in the last chapter but one, it may readily be inferred that varying electrical conditions of the atmosphere lead to important states of body and to disease. The common experience tells us that many persons of an impres- sionable nature are painfully affected by electrical storms, and are indeed able to predict such storms. The subject invites a long essay, but it also calls for more research than has yet been made in regard to it. One of the best series of observations I have ever read was sent to me by my friend Mr. Ilingeston of Brighton. " If watched attentively, the clouds," says my friend, " will be seen to approach and recede from each other in a manner similar to bodies charged with positive and negative electricity. They may be observed also to rotate on an axis of their own, this rotation being from left to riglit. When these clouds are seen the wind is as a rule from the west. The mortality is low, but illness of a curable and transient nature is frequent. Virulent epidemics do not prevail. The influenza a.d. 1729 passed over Europe from 554 ATMOSPHERICAL AISTD CLIMATIC S.E. to K.W. with a moist, cloudj, foggy season ; and the spotted fever of a.d. 1847 passed from E. to W. over the north of Europe, across Great Britain and Ireland, till it finally reached America." During the passage of white-headed cumuli the electrometer is very active ; in mists the electricity is negative, feeble, or nil. During " thundery weather," as it is called, head affections and bowel complaints are noticed. There is a peculiar symptom, analogous to that which arises in cases of injury to the spine, viz., the colon being greatly surcharged with wind : it is an evidence of direct exhaustion of the nervous centres. The large white-headed cumuli that collect in clear bright days are rotary storms of hail, rain, or thunder, gyrating from left to right. Several of these gyratory storms keep marching onward in alternate spaces, marshalled in a vast circular array, and rolling round a circumference of bright translucent calm. On the approach of one of these masses of vapor, the mercury of the barometer and thermometer first falls, and then rises with great rapidity. The accompanying and residual state of the at- mosphere is congenial to health. Cases of debility experience a favorable reaction, the air we breathe at these moments being antagonistic of disease. With the breaking up and dissolving of these large cumuli there is electric action, and most likely explosion, just as the vapor is being condensed into water. The entire atmosphere changes. Everything is dull and gray. In the damp weather dyspepsia chiefly prevails — the acid indiges- tion of gouty habits, the scrofulous, indolent, and pitiable host of "never- wells." Rheumatism, which some have supposed to arise from a sud- den loss of electricity, occurs in damp weather, when the amount of animal electricity is the smallest, and the most readily parted with. During the prevalence of cholera the cirrus cloud is rare ; but the cirro-strati, which occupy a lower stratum of the atmosphere, are frequent at noon, and accompany the sun for three or four hours in his meridian height. A calm prevails. Indolent cirro- cumuli lodge over the hills. The distance is dim, and a sticky vapor, charged with small black flies, pervades everything. The barometer stands obstinately at 30, and the wind is from thoN.W. CAUSES OF DISEASE. 555 or S.E. During the cholera of 1854 the wind was from the S.E. to KW., and so it was in 1832 and 1849. Some observers have remarked that the declination of the needle is very great during the prevalence of the Asiatic cholera, and that it also corresponds with certain changes in the vegetable kingdom, as, for instance, the potato rot. We have some facts to show cause why we should connect dis- ease with the greater or less amount of electricity, signified by the electrometer. It would seem that, in the non-electric states of the air, diseases of a low type prevail. Thus, in the Registrar- General's return for the week ending 14th July, 1855, we find it stated, " weak positive electricity throughout the week," and the mortality return of the same date shows that the chief deaths were from small-pox, whooping-cough, scarlatina, diarrhoea, and typhus. On the contrary, in the week ending 8th September, electricity is "positive," and mortality "not high for the season." On the 13th and 14tli September, 1854, when cholera was at its maximum, it is reported of electricity, " none was shown." Again, for week ending 22d September, 1855, mortality " shows a decrease of about one hundred in each of the three previous weeks, and indicates a satisfactory state of the public health ; " while the electricity was " positive," strongly positive, " and active throughout the day." If we consider that every living creature is as much an elec- trical machine as each cloud ; that the earth itself is the largest and most powerful electrical machine of all ; that all things are always exchanging their electricities with each other ; and that lightning destroys myriads of insects, as well as some animals and human beings, at a single flash, it is past contradiction that elec- tricity must be a grand actor in every form of life, whether of health or disease. The violence of the winds, if not their directions, seem to be electro-magnetic. And the partial rarefaction of the air b}^ heat, and its condensation by cold, hitherto employed for explaining the force and current of the winds, are, n)ost likely, only stiiking parts of terrestrial electro-magnetism. Moreover, the sensorial effects of the electric fluid are proof paramount of its pathological energy. We have, therefore, every possible reason for regarding the kind of clouds as indications of the kind of atmosphere in re- lation to disease ; and the various forms assumed by the vapors 556 ATMOSPHERICAL AND CLIMATIC condensing or dissolving in the air maj be considered, not only as picturesque beauties in the landscape, but also as criteria for judg- ing of some of the most potent effects resulting from the opera- tion of an experiment, silently and delicately performed, upon the functions and sensations of animated beings. These signs only require reducing to some familiar characters, in order to render them practically serviceable; and then, when once recognized, they might be read off at a glance, and brought into daily use as easily as the dial-plate of the electric vp^ire, or the minute-hand of our watch, in counting the pulse at a patient's wrist. In 1854 the late Dr. Moffat joined me in contributing an essay on meteorological changes and disease, in which he formed the hypothesis that there were certain periods during M^hich ozone was present in the air, and that during such periods, called by ray colleague, ozone periods, diseases affecting the respiratory organs were peculiarly prevalent. Dr. Moffat continued his observations until the close of his useful life, and was led to trace a connection between periods of phosphorescence and the acute forms of dis- ease. A review of his laborious work leads me to the conclusion that it remains incomplete. On the Influence oe Paeticulae Winds and on General Climatic Diffeeences. That certain winds are provocative of certain symptoms of disease, and that they intensify cei-tain symptoms in those who are suffering from disease, is a part of universal, as well as of medical, knowledge. Thus the southwest wind is known to be unfavorable to acute inflammatory conditions ; the north and northeast winds to neuralgic and rheumatic conditions ; while the drying, cutting, depressing east wind is fatal to those in whom the store of vital energy is very low. But here we are wanting in sound method for determining the precise part played by the winds as causes of disease. It is not obvious that the winds de- termine the origin of any disease ; and whether they intensify any by a special action of their own, independently of heat, cold, moisture, electrical tension, and other such active influences, re- mains to be discovered. It has been surmised that during some great perturbations of nature, changes may take place in the cliemical constitution of the CAUSES OF DISEASE. 557 atmosphere, and that these changes may account for phenomena of disease. The passage of air over certain soils has been con- sidered sufficient to disturb its natural chemical state, and to ren- der it directly noxious to human life. In the Grotto del Cane, and in some other rare positions, the air is sufficiently admixed with a poisonous gas (carbonic anhydride) to render it dangerous to breathe; but beyond these exceptional and well-known in- stances, we have no proof whatever of any such modification of the chemical constitution of the atmosphere as would provoke a special disorder, although we have seen that the oxygen of the atmospheric sea may be changed in physical quality, with injuri- ous effect on life. To all our present experience the combination, or more cor- rectly, the mechanical admixture of the gases that make up the atmosphere, — the oxygen and niti-ogen, — remain always steadily balanced and fitted to support the vital processes. The dangers which spring from vitiation of atmospheric air, from undue re- moval of oxygen, from introduction of carbonic acid or other poi- sonous gas or vapor, are, therefore, artificial dangers, invented and promoted by our own hands, and due, consequently, to the con- trollable errors of social life. On the general subject of winds and geographical distribution of disease we are much indebted to the researches of Mr. Alfred Haviland, who has devoted many years of splendid labor to this investigation. His inquiries extend particularly to four classes of disease ; namely, rheumatism ; its concomitants, heart disease and dropsy ; cancer in females ; and, pulmonary phthisis. Respecting heart disease and dropsy, which Mr. Haviland considers are almost entirely dependent on rheumatism, he infers, — That wherever the sea air has uninterrupted access, as over a fiat country, up broad vales or valleys, and elevated country, we find a low mortality from heart disease and dropsy. And that, on the contrary, in places where the tidal wave has no access, wliere the rivers run at right angles to its course, or to that of the prevailing winds, there is the highest moi'tality from the same causes of death. Respecting cancer, Mr. Haviland infers, — 1. That the hardest and most elevated rocks, or the most absorbent, like tlie oolite and chalk, are the sites where the least mortality from cancer is found. 558 ATMOSPHERICAL CAUSES OF DISEASE. 2. That alone; the river-courses which flood their banks, sea- sonally, are to be found the districts in which the highest mortal- ity from cancer takes place. 3. That wherever, froni the nature of the rocks forming the watershed, the floods are nmch discolored by alluvium, and where, from the flatness of the country, the floods are retained and not easily drained off, there we find the greatest mortality from cancer among females. Respecting pulmouary phthisis or consumption Mr. Haviland infers, that districts with sheltered positions yield a low rate of mortality from the disease. That districts with a general aspect favorable to the malign influence of the east wind yield a high death-rate. That damp day soil is coincident with a high mor- tality ; and, that elevated ridges of non-ferruginous and infertile carboniferous limestone and coal formation, and elevated, hard, unfertile, and non-ferruginous Silurian formations, form districts of extensive high mortality from the disease. That elevated parts exposed to westerly, north-westerly, easterly, and south-easterly Avinds are characterized by high mortality. That a sheltered position, a warm, fertile, well-drained, ferruginous soil are coinci- dent, as a rule, throughout England and Wales, with low mortal- ity from phthisis. Touching this last question I may add that the influence of a seafaring life as a preventative of phthisis has been matter of im- portant observation. In 1856 Boudin showed that while the deaths from consumption in the British army were, in the Line, 8.9 in 1,000 men, and in the Guards, 12.5 in 1,000 men, in the British navy from 1830 to 1856 inclusive, the deaths from phthisis were 1.76 in 1,000 men. CHAPTER YL On Parasites in Connection avitii Disease, A certain number of diseases have for their cause the intro- duction into the body of what are called parasites. These parasitic forms of life are of two or, as some would opine, of three kinds. Certain of them are of distinct animal character ; others are as distinctly of vegetable character ; others, it is assumed, lie between the animal and vegetable kingdoms. Of late years the subject of the origin of disease from para- sitic forms of life, taken into the body by means of food or air, or received upon the outer surface of the body, has attracted an unusual degree of attention, an attention, indeed, which has led to neglect of other branches of learning relating to the study of causes of disease in their entirety, and thereby to retrogression of knowledge. The real knowledge which has been acquired in respect to the action of parasitic forms of life in producing disease is very clearly of three distinct values. Some part of it is quite certain, and is of the greatest value. Another part of it is theoretical, and is waiting for more proof in order to become valuable. Another part is entirely hypothetical, and is in various ways so exaggerated and childish as to be valueless, if not mischievous. The Royal College of Physicians, to which I have so often referred as my authority for classification of disease, places the " Human Parasites " in three subdivisions under the following names : I. Entozoa. Of which there are three classes : A. CcELEiiMiNTHA. English synonym, Hollow worms. Definition : Worms with an abdominal cavity. B. Sterelsiintha. EnrjUsh synonym, Solid worms. c. Accidental PAU^vsrrES. Depiition : Internal parasites, having the habits, but not referable to the class, of entozoa. 560 PARASITES IN COFNECTIOTT WITH DISEASE. II. EcTOzoA. In which are inchided the various acari, or lice, which infest the outer surface of the body. III. Entophyta and Epiphyta. In which are included the algae, fungi, and mycroderms, that have been found on the surfaces or in the cavities of the body. Studied in relation to diseases of the different systems of the body in the manner followed out in this volume. Parasites may be classified as follows: — PAEASITES AFFECTING THE DIGESTIVE SYSTEM AND INTESTINAL CANAL. Entozoa. Class A. Coelelmintha. Ascaris lumbricoides. (Linnseus.) Habitat : JxAe^tines. Ascaris mystax. (Eudolplii.) Habitat : iMie^imes. Trichoceplialus dispar. (Rudolphi. ) Habitat : Intestines. Sclerostoma duodenale. (Cobbold.) Syn. Anchylostonmm duodenale. Habitat: Duodenum. Oxyuris vermicularis. (Bremser.) Etiglisli synonym, Thread-worm. Habitat: Rectum. Class B. Sterelmintha. Bothrioceplialus latus. (Bremser.) Habitat : 'Ln.iestm.e^. Bothrioceplialus cordatus. (Leuckart. ) Habitat : Intestines. -Taenia solium. (Linnseus.) Habitat : Intestines. Taenia mediocanellata. (Kiicliennieister. ) Habitat : Intestines. Taenia acanthotrias. (Weinland.) Habitat : Intestines. Taenia flavopuncta. (Weinland.) Habitat : 'hiiesiiaes. Taenia nana. (Siebold.) Habitat : Intestines, ^ Taenia lophosoma. (Cobbold.) Habitat : Intestines. Taenia elliptica. (Batsch.) Habitat : IniesXines. Oysticercus of the Taenia marginata. Synonym, Oysticercus tenuicollis. Distoma crassum. (Busk.) Habitat : Jiuodiemim.. Distoma lanceolatum. (Meblis.) Habitat : Hepatic duct ; intestines. Class C. Accidental. CEstrus hominis. (Say.) English synonym. Larva of the gad-fly. Habi- tat: Intestines. Anthomyia canicularis. (A. Fan'e.) Habitat : Intestines. Entophyta and Epiphyta. Leptothrix buccalis. (Wedl. Eobin.) English synonym. Alga of the mouth. PARASITES IN CONNECTION WITH DISEASE. 561 Oidium albicans. (Link.) English si/nont/m, Thrush, inngns. Habitat: Mouth in cases of tlirusli, and certain mucous and cutaneous sur- faces. Sarcina ventriculi. (Goodsir.) Habitat : ^tom&ch. Torula cerevisise. (Turpin.) Synonym, Cryptococcus cerevisise. (Kiitz- ing.) English synonym, Yeast-plant. Habitat : Stomach ; bladder. PAEASITES AFFECTING THE BLOOi^. Entozoa. Class B. Sterelmintha. Hexathyridium venamm. (Treutler.) Habitat: Yenoushloodi. Filaria sanguinis hominis. (Manson.) iZa&ztoi; ; Venous blood. Distoma Hsematobia. (Bilharz.) Habitat: Yenonshloodi. PAEASITES AFFECTING THE LUNGS. Entozoa. Class A. Coelehnintha. Strongylus bronchialis. (Cobbold.) Habitat : Bronchial tubes. PAEASITES AFFECTING THE OEGANS OF SENSE. Entozoa. Class A. Coelehnintha. Filari oculi. (Nordmann.) Synonym, Filaria lentis. (Diesing.) Habi- tat: Eye. Class B. Sterelmintha. Distoma ophthalmobium. (Diesing.) Habitat : Eye. PAEASITES AFFECTING GLANDS. Entozoa. Class A. Coelehnintha. Eustrongylus gigas. (Diesing.) Habitat : Kidney ; intestines. Class B. Sterelmintha. Tetrastoma renale. (Delia Chiaje.) Habitat: Tubes of the kidney. Fasciola hepatica. (Linnaeus.) Habitat : IAnqy . Hexathyridium pinguicola. (Treutler.) Habitat: Ovaxj. Class C. Accidental Parasites. Pentastoma denticulatum. (Siebold.) Habitat : Tuvfex ; small intestines. Pentastoma constrictum. Habitat : Liver. 36 562 PARASITES IJSr COJSnSTECTIOlSr WITH DISEASE. PAEASITES AFFECTING THE MUSCULAE SYSTEM, Entozoa. Class A. Coelehnintha. Tricliina spiralis. (Owen.) Habitat : Muscles. PAEASITES AFFECTING THE SKIN AND CELLULAE MEMBEANE. Entozoa. Class A. CcelelmintTia. Filaria Medinensis. (Gmelin.) Synonym, Dracunculus Medinensis. English synonym, Guinea- worm. Habitat: Skin and subcutaneous tissues. Class B. Sterelmintha. Cysticercus of the Taenia solium. Synonym, Cysticercus telae cellulosse. EcMnococcus hominis, or Hydatid of the Tsenia echinococcus. (Siebold.) Ectozoa. Phthirius inguinalis. (Leach.) English synonym, Crab-louse. Pediculus capitis. (Nitzsch.) English synonym, Head-louse. Pediculus palpebrarum. (Le Jeune in Guillemeau.) Eyebrow-louse. Pediculus vestimenti. (Nitzsch.) English synonym, Body-louse. Pediculis tabescentium. (Burmeister.) Sarcoptes scabiei. (Latreille.) Synonym, Acarus. English synonym, Itch-insect. Demodex foUiculorem. (Owen.) Pulex penetrans. (Gmelin.) English synonym, Chigoe, Habitat: skin and cellular tissue. Chionyphe Carteri. Definition : A cotton fungus occurring in the disease called Mycetoma. Habitat : Deep tissues, and bones of the hands and feet. Achorion Schonleinii. (Eemak.) Habitat: Tinea favosa. Puccinia favi. (Ardsten.) Habitat: Tinea favosa. Achorion Lebertii. (Eobin.) Synonym, Trichophyton tonsurans. (Malmsten.) Habitat : Tinea tonsurans. Microsporon Audouini. (Gruby.) iJaWto!;.- Tinea decalvans. Trichophyton sporuloides. (Von Walther.) Habitat : Tinea Polonica. Microsporon furfur. (Eichstadt.) Habitat: Tinea versicolor. Microsporon mentagrophytes. (Graby.) Habitat: Follicles of hair in Sycosis or Mentagra. Entophyta and Epiphyta. In addition to the parasites classified in the official nosology under this division as algae, there must now be named some \Yhich, PARASITES IN CONNECTION WITH DISEASE. 563 since the nosology was published, have received great attention from scientific observers. Algce. BacteriacecB. A family of the order Schizomycetes, the individuals of which . consist of spherical, oblong, or cylindrical cells, sometimes twisted, and which increase by transverse division, and live separately or in cell groups. Drs. Power and Sedgwick in their admirable " Medical Lexicon " divide them, after Cohn, into four tribes. ^'^ Sjyhcerobacteria, in which the cells are spherical. " Microbacteria^ in which the cells are short and cylindrical. " Desmohacteria, in which the cells are filamentous. " Sjtirobacteria, in which the cells are tortuous or screw- shaped." Bacteridium. "A genus of the family Yibriones, according to Devalue, fili- form, straight or bent, more or less distinctly articulated, in con- sequence of an imperfect spontaneous division, and always mo- tionless. Other members of the Bacteridia have been included as globular. The filiform are described by Cohn as Bacillus^ the globular as Micrococcus^ The Bacteridia which are most important to name here are, — Bacteridium anihracis or Bacillus anihracis. The bacillus found in malignant pustule. Bacteridiutn fermenti. The bacillus described as occurring in the leaven of wheat or barley. Bacterium. According to Cohn, Bacterium is the single genus of the tribe Microbacteria of the family Bacteriacese. The term most fre- quently applied to members of this family is " Bacteria.'''' Bacteria are described by Power and Sedgwick as short, cylin- drical, or elliptical cells, hanging in pairs whilst undergoing trans- verse division. Under favorable nutrient conditions, and with good supply of oxygen, they move, freely, .at times. They form no chains or threads, but they propagate in a connecting gelati- nous mass, zooglcea, in regard to which they are distinguished from the sphserobacteria by the firmness of the intermediate substance, 664 PAEASITES IN CONIS'ECTIOX WITH DISEASE. and by the absence of any finely granulated appearance. Those most important to name in this place are, — Bacterium carhunculare, said to be found in the blood of men and animals who ha\^e died with carbuncle. Defined as " motion- less, flat, straight, highly ref ractile, without inflexion when short, and with one or two inflexions when long." ^'"Bacterium catenula fchain-like), a doubtful species, sup- posed to have been found in typhoid fever. " Bacterium cuneatum (wedge-shaped), said to exist in putre- fying blood, and in the intestines of horses and dogs dying of putrefactive diseases. " Bacterium termo. described as two to five times as long as broad, about .0015 mm. in length ; often two-jointed, with a vacillating movement, produced by a terminal flagellum. Found wherever putrefaction of either animal or vegetable matter is going on, and believed, by many, to be the active agent in that process. When putrefaction ceases they cease to be found." Bacillus. Meaning a little stick. (Power and Sedgwick.) " A genus of the tribe Desmobacteria of the family Bacteriacese. Distinguished from the other genus of the same tribe, Yibrio, by the straight- ness of the rods. " Bacillus anthracis. Homogeneous and unj ointed when fresh, and developing spores. It is found in the blood and diseased structures in the splenic fever of animals, and in malignant pustule. " Bacillus lepra. A form of uncertain existence, supposed to be the cause of leprosy. " Bacillus rtialaria. A form discovered by Krebs and Tom- masi-Crudeli in the air and soil of malarious districts, especially in the Pontine Marshes, and believed by them to be the cause of intermittents. It consists of small, narrow, longish cylindrical spores, about half a micro-millimetre long, and rods of about tlie same breadth, and seven micro-millimetres in length. In the body of animals the spores develop into long filaments, which sub- sequently undergo transverse segmentation, so as to form a chain, in the segments of which new spores grow. They develop most freely in the spleen and the medulla of the bones." PARASITES IN CONNECTION WITH DISEASE. 565 Spirillum. In addition to the divisions named above must be added the Spirihum, a parasite of the class algae, and coming also under the head Bacteria. Spirillum is ranged by Dr. Vandyke Carter amongst "Bacteria (Schizophytse), forming (like Bacillus) a mem- ber of the jSTematogenous subsection, in which the component cells are arranged in rows, and come into a small group character- ized by colorless, screw-shaped threads embracing three genera : — Vibrio, in which the filaments are short and slightly undulating ; Spirillum, in which they are short, spiral, and stiff ; and Sjrtro- chcBte, in which they are long, spiral, and flexible." Bacillus Tuberculosis. A Bacillus supposed to be found in the sputa or expectoration of persons suffering from some forms of consumption, and in the walls and contents of tubercular cavities. The parasites, rendered visible by a process of double coloration, and usually demonstrated colored with methyline blue, are seen as minute rods about the third of a diameter of a blood corpuscle in length, and about one- sixth of their own length in breadth. In some of them spores are said to be evidenced, but in the specimens I have seen none were manifest. CHAPTEE YII. On Paeasites as Causes of Disease. The reader who has studied carefully the history of disease in the part of this work devoted to the description of local diseases of natural origin, will easiljhave connected many of the parasites described in the last chapter with the diseases in which they have been found, and will to a considerable extent have learned the part they play as factors of disease. It will, however, be advisable to consider this subject a little further on, in order to understand how far the presence of a para- site growth may be taken as a iirst or second cause of the phe- nomena of disease in the cases of disease in which the growth is discovered. In this review it will, I think, be most convenient to follow out the exposition by a reference to the parasites under the three great divisions in which they are described at the opening of the last chapter, namely, as : Entozoa, or AVorms. Ectozoa^ or Acari. Entqphyta and Epiphyta, or Algae, or Fungi. Diseases EEOii the Extozoa. There are three kinds of the Entozoa, or worms, which affect the body as parasites. 1. The l^ematode, or round worms. 2. The Cestode, or tape worms. 3. The Trematode, or fluke worms. ISTematode Disease. The Xematode or round worms include the Tricliina spiralis ; the Ascaris lumbricoides or common round intestinal worm ; the PAEASITES AS CAUSES OF DISEASE. 567 Oxjui'is vermiciilaris or thread worm ; the Dracimciilus medinen- sis or Guinea worm ; and the Filaria sauguinus hominis. Trichiniasis. The trichinous flesh-worm disease, — Trichiniasis, — has as- sumed in some countries the character of an epidemic, but in England we have learned its historj, chiefly, from isolated ex- amples of it. In order that the disease may be induced the trichinous parasite must enter the body by the alimentary canal. The human subject derives the larval trichinee from the muscular flesh of some animal on which he has fed. The parasite as it exists in this flesh is in the larval state, — the state intermediate between the eggs and the perfectly developed growth,- — and in this condition it remains so long as it is embedded in the flesh. Keceived into the stomach of a man, or of any other animal, it develops into maturity in a few day. The female trichinae give forth their embryos in abundance, and the embryos at once make their migrations through the cellular connecting network which holds all the active and muscular organs of the body in close con- nection. In this country, disease from the presence of trichinae in the tissues is very rare, and few English physicians have had opportu- nities of studying it. I have seen one portion only of a trichinous muscle derived from man, and in that case the existence of the parasite was not detected prior to death. On the continent there have been epidemics of Trichiniasis, attended, in extreme in- stances, with intense symptoms. When the trichinous disease occurs it is marked in its mo>t developed form by three stages, {a) A stage of intestinal irrita- tion, gastro-enteric, — corresponding with the period of full devel- opment of the trichinae, and the evolution of embryos within the canal, (b) A stage of moderate fever, attended with pains in the muscles like those of rheumatism, and accompanied, in some few examples, with a red rash, and boils, — corresponding with the time when the embryos find their entrance into the muscles and are becoming encysted there, (c) A prolonged or chronic stage of impaired muscular movement with emaciation, — correspond- ing with the after-period when the larvae arc entirely encysted in the muscle and arc fixed in position. This last stage is not always well marked. 568 PAEASITES AS CAUSES OF DISEASE. "When the first or acute affection is over, and the parasite is duly lodged in its home, it happens, usually, that the evidence of the disease gradually ceases, and that the presence of the foreign intruder is not, actually, discovered until after the death of the person into whose organism it has intruded. Such was the state of the body which presented the one single instance I have known of trichinous affection. The trichinous parasite in its larval condition enters the body, as we have seen, with infested animal food. There is no satis- factory evidence, however, that it ever becomes active when it enters after the food it infests has been subjected to perfect cook- ing and to the temperature of boiling watei*. This degree of heat, 212° Fahr., destroys quickly and completely the life of the em- bryo. The worst cases of disease have been those in which the sufferers have swallowed raw or imperfectly cooked infested flesh. IS^evertheless, the larvse enjoy a tenacious life ; they exist ready for development into the mature state even when the flesh in which they are encysted has passed into decomposition. The flesh of the pig is the most frequent carrier of the trichinous larvae. Luwhricoid Disease. Other nematode worms, two of which are M^ell known, pro- duce symptoms of disease in tlie human subject. The large round worm, the Ascaris lumbricoides, is one of these common parasites. It attains often a considerable size, resembling in its appearance the ordinary earthworm. It is developed and retained in the intestinal canal, and creates, frequently, extreme in-itation, leading to convulsions and comatose sleep in children, and to that emaciation which almost invariably occurs when a body foreign to the alimentary surfaces is long in contact with them. Thread-woron Disease. The small round woi-m, known as the thread or wire worm, Oxyuris vermicularis, is another parasite w^hicli infests the lower part of the alimentary canal, and in children is a frequent soui'ce of extreme irritation. As a rule it infests children only, but the rule is not without its exceptions. For a long time I had under observation a middle-aged man who, throughout his life, has recurrently been tormented by this parasite. The symptoms it PARASITES AS CAUSES OF DISEASE. 569 induces do not usually pass beyond those of local irritation, but occasionally there is extension of irritation, with phenomena of reflex muscular spasm. The history of the migration of the Ascaris lumbricoides and Ascaris vermicularis, is not so clearly defined as we could wish ; but it is certain that by some article of food or drink the larvae of these parasites enter the alimentary canal, after which entrance they develop there. It has been assumed that the introduction is through impure water, or by vegetable substances and fruits which carry water containing the larvse. Another nematode, the Ascaris mystax, has been discovered by Cobbold to be occasionally present in the alimentary canal of the human subject. The same patient and original observer, whose great work on the Entozoa does such honor to the English school of medicine, has also shown that the Strongylus bron- chialis, a nematode allied closely to Strongylus micrurus, — the thread worm found often in abundance in the windpipe of the calf, — has been discovered in man. These parasites, when they are developed in the body, are also cai-ried by food. Guinea-worm Disease. Dr. Spencer Cobbold opens his chapter on the Guinea worm — the Dracunculus or Filaria medinensis — with the opinion that the "fiery serpents" which afflicted "the children of Israel during their stay in the neighborhood of the Ked Sea," were neither more nor less than specimens of this human parasite. The parasite is found within certain tropical limits in Asia and Africa ; and is described by Cobbold as the adult female con- dition of a nematode parasite, which is parasitic only during the final stages of its life period, after it has taken up its residence in the subcutaneous and intermuscular cellular tissues of man, dogs, and horses. The parasite takes literally the form of a serpent or worm when full grown, having a head with spirules, an uniform cylin- drical body, and a termination called commonly a tail. It is viviparous, and reproduces abundantly. It exists naturally in water, and, as Cobbold explains, " gains access to the human body without reference to age, sex, race, or country, the only necessary condition being that the skin be exposed to water in those locali- ties where the Dracunculi flourish." 570 PAEASITES AS CAUSES OF DISEASE. The parasite enters the bodj direct from the outer surface, not by the mouth, but by the sm-face of tlie skin, and probably by the sweat-pores. Getting into the cellular tissue it attains a great length, and has to be extracted by gently winding it out on an ivory rod or a quill. The lower limbs are the parts usually affected, and sometimes great irritation is produced by the parasite. After prolonged monsoons the disease, according to Cobbold, is not un- frequently severely endemic ; the parasite growing with consider- able rapidity within the tissue of the bearer of it, and giving rise to a formidable entozootic affection to which the name of dracon- tiasis is applied. Filarial Disease. Another form of disease from worms of the filarial kind, is produced by the Filaria Sanguinis Iloniinis., and is one of the most curious of the affections of the human family that has ever been revealed by minute scientific research. We are indebted to Dr. Patrick Manson for so much that has been made out on this subject that we may look upon him as the discoverer of the leading facts. In the filarial disease the filarial embryos are found in the blood of the person affected by them, but only at certain times in the twenty-four hours. The entrance of the embryos into the blood begins some hours before the usual time for going to sleep and ends a few hours before the time for waking. In the blood this minute embryo is of snake-like appearance, having, as Man- son describes it, a perfectly structureless body, enclosed in a deli- cate and, for the most part, closely applied tube, within which it shortens and extends itself, giving rise, from the collapse of the tube when the body is retracted at either end, to the appearance of a lash at the head and tail. The embryos may escape from the body by the excretions, and have been detected in tears and urine. It is necessary indeed that the embryo should escape from the host which received the parent worm, in order that it may undergo further development. For this reason a man infested by these embryos is saved from death. In the dog, and in man infested with filarial embryos, Manson has calculated that there may be at one moment two millions of the embryos. If these were to begin to develop into the full-grown filarial worm, their volume, long before they had attained one- PARASITES AS CAUSES OF DISEASE. 571 hundredth part of the mature iilaria, would occupy a space many times greater than that of the hody of the animal in which they exist. They escape, therefoi-e, from the original host. How they escape from the person or animal in which they are found, and increase and re-infest the higher animals, is one of the most remarkable histories in the range of natural science. Where the troublesome animal called the onosquito exists there may the filarial disease exist, with the mosquito as the fecund ator and car- rier. The man infested with the embryo filaria, if bitten by the mosquito at the time when the embryos are in his blood, gives up to the mosquito some of the embryos with his blood. In the digestive apparatus of the mosquito the embryo passes through three metamorphoses into full development of the filarial worm. About the fourth or fifth day, after feeding, most mosquitoes die. Dying in water the filaria escape into it, and luan using that water comes in contact, accidentally, with the parasite. The para- site may j)enetrate his skin, but more frequently he swallows it with the water he drinks. It finds its way through his system to its final resting-place, wherever that may be, fecundates there, and from thence yields its embryos to the blood and tissues, to appear, cease to appear, and reappear periodically. The perfectly-developed parasite, as it is removed from the mosquito, is described by Dr. Manson as armed with a boring ap- paratus, toothed or saw-like, with which it cuts its way into the tissues of the higher animal or host, and out of the body of the mosquito or nurse, — the intermediate host. It is endowed with marvellous power and activity. It rushes about, forcing obstacles aside, moving indifferently at either end, and appears quite at home, and in no way inconvenienced by the water in which it has been immersed. The formidable animal, thus fully equipped for independent life, is quite ready to quit its nurse, and if man be- comes its host is equally ready to take every advantage of its posi- tion, and charge him with periodically-appearing embryos in his blood. The periodicity of the appearance of the embrj^os in the blood is still a puzzle. Dr. Myers, who has studied the phenomenon, has ventured the opinion that the parent worm from whence the embryos come reproduces a swarm daily, and that the product dies every day, leaving the blood free until a new swarm is given forth. To this view, in many respects very natural and reason- 572 PAEASITES AS CAUSES OF DISEASE. able, Dr. Manson objects, and retains an opinion, wliich he origi- nally formed, that the embryos, after remaining in the blood-stream for a certain number of hours, retire to some other parts of the organ or some other set of vessels. He holds that in all cases filarial embrvos o-et into the lymi^liatic vessels, and that when lymph containing them, by the accident of a rupture or tear, finds its way into an excretion like the urine, the parasite is always fomid in the excretion. With regard to the periodicity. Dr. Ste- phen Mackenzie adopts a view, which was first advanced by Dr. Mortimer Granville, namely, that the said periodicity is due to some influence like that which leads to the recurrence of sleeping and waking. On the whole I conceive that Myers' hypothesis is, perha]3s, the best, although it is far from conclusive. Syrivptoms erf Filarial Disease. The facts relating to occurrence of Filaria in the body are sufficiently striking ; but it is even more strange still to know that the parasites may actually be present in the body, and may make their periodical inroads into the blood, without giving rise to any very marked symptoms of disease. TThen symptoms of a persistent kind do arise from them they are those of lymphatic abscess, or of the disease of the skin called elephantoid disease, — elephantiasis. The way in which this is brought about is believed by Manson to be due to what he designates the miscarriage of the filarial worm which gives forth the progeny. ]S^aturally, this worm gives forth her young or embryos living, and they, from their small size, -3 oVo ^^ ^^ inch, in diameter, travel with as much ease as blood corpuscles themselves. They pass through the gland structures from the lymphatic vessels, reach the thoracic duct, and get into the stream of venous blood readily. But some- times from accident, such as the death of the parent, the ova are evolved before the embryos included in them are set at liberty. The ova haviug a diameter of between -g^ and yi^, they cannot pass the glandular structures so as to reach the blood. As a result they accumulate, block up the lymphatic vessels, cause enlarge- ment of glands, and produce, by lymphatic obstruction, that dis- ease which in the East is known as elephantoid. The history of Filarial Disease is as singular in its way as that of the pearl-dust disease described at pp. 380-1 in the pre- vious book. It is a splendid illustration of the success of careful PARASITES AS CAUSES OF DISEASE. 573 and painstaking inquiry in the unravelling of the phenomena of disease, and of modern facilities for physical research. Cestodb Disease. The Cestode or tape-worms include the Toenia or ordinary tape-worms, and the Cysticerci or bladder-shaped worms, — Hyda- tids. The phenomena of disease induced by the Cestode, or tape- worms, are all related to foods, and the relationship is singularly exhibitive of the success of scientific experimental research in its application to medical and sanitary science. Ta/pe-worrrh Disease. The tape-worm is the cestode with which the community is most familiar ; but it is, in fact, one only of several phases of a distinct parasitic growth. It does not enter the body as tape- worm, but is derived from a larval form which is present, usually in the encysted state, in the fleshy or visceral parts of animals that are consumed as food. The commonest tape-worm in the human subject is theTlema solium^ a flat, ribbon-like worm, divided into numerous segments, and reaching sometimes a length of many feet. The longest I have seen extended to sixty feet, but some observers have spoken of a leno;th far exceedino; even that. This worm is derived from the hydatid known technically as the Cysticercus cellidosce. The embryo of the Cysticercus, swallowed accidentally by an animal which is to become human food, the pig for example, enters the alimentary canal, piei-ces the mucous surface, migrates along the cellular or connective tissue, and becomes embedded in the inter- muscular spaces. In this position the embryo undergoes develop- ment into Cysticercus cellulos^e, and so, infesting the flesh of the animal, gives rise to that diseased condition of food commonly known as measly pork. The measly food is the source of the tape-worm. By booklets with which it is armed, the living Cysticercus connects itself with the wall of the bowel of him who swallows it, and sprouting, as it were, from the attachment it has made, becomes the many- segmented, long, flat tape-worm. 574 PAEASITES AS CAUSES OF DISEASE. Hydatid Disease. There is another side to the question of induced diseases from the cestodes. The imperfect cestode worms from which the tape- worms are developed, are, in their turn, the causes of diseases which were characterized by the old writers as hydatid diseases, and which amongst the people are still known by that general name. The liydaiid disease originates from the tape-worm, and a simple illustration of the fact is derived from the history of parasitic disease in the inferior animals. The dog is commonly infested with the tape- worm called the Tmnia ccenurus. The sheep is infested with an encysted hydatid, the Cmnurus cere- hralis, which affects its brain, and gives rise to the disease called the " staggers " or " sturdy." If a sheep be fed with tsenia from a dog the csenurus will be produced in the brain of the sheep ; and if a dog be fed with csenurus from a sheep the tape-worm will occur in the intestine of the dog. Experimental researches have since proved that the two forms of disease can be thus, reciprocally, induced. The illustration extends to the human subject. A little tape- worm which is found in the dog, and is called the Tmnia echino- coccus, yields a larval form which is cystic, — the bladder-worm, or hydatid of man, EchinocoGcus Ilominis. In its embryonic state this parasite, introduced into the intestinal canal by food or water, permeates the tissues, and becomes in time encysted in one or other of the vital organs. The liver is the organ most frequently attacked, but no organ is actually free from invasion. The em- bryo in due course becomes developed into an easily recognizable animal form enclosed in its cyst. It has a head with a double crown of booklets, a body containing calcareous particles, and four suckers. Through what precise articles of food or drink embryo of the echinococcus is introduced is not yet completely known ; but the experimental evidence of introduction by alimentary substances is demonstrative. Synvptoms of Cestode Disease. The phenomena of disease caused by the cestodes are many and important. The tape-worm is a source of constant irritation, and the knowledge of its existence in the body often causes much depression. PAEASITES AS CAUSES OF DISEASE. 575 The most dangerous forms of disease from parasites are those which follow the insertion and development of the true hydatid, the echinococcLis, in the tissues and vital organs. The echinococ- cus, as if it had a roving commission, plants itself in the most various and important viscera. The brain, the spinal cord, the eyeball, the lungs, the liver, the intestinal glands, the kidney, the urinary bladder, the muscles, and even the cavernous portions of bone itself, are homes in which it may live. In consultation with the late Dr. Herbert Barker of Bedford, I once saw a man who threw off the echinococcus by the renal secretion, and we traced in this instance the mode of entrance of the larvse of the tsenia. The man had for years subsisted almost altogether on fresh pork, in so far as animal food was concerned, and twice weekly had feasted on pig's fry, a dish made up of the intestinal part of the swine. On some one of these many feasts he had, by acci- dent, partaken of a fry containing an embryonic parasite which the swine had picked up while feeding, and which had come from the tape-worm of a dog. Trematode or Fluke-worm Disease. Disease from the Trematode or fluke-worms is rare in man. In sheep, the liver fluke, Fasciola hepatica, is, as is too well known, a cause of most serious and extensive disease, and the same parasite has, in a few instances, — not ten probably alto- gether, — been found in the human body. ]jy some happy acci- dent or necessitj^ man has, up to this time of his history, missed the food that conveys this fatal enemy ; an accident the more to be wondered at when it is known, as Cobbold truly says, that the liver of a single sheep may, at any given time, harbor several hundred specimens of the fluke, and that every mature specimen may contain many thousand minute eggs. The fluke known as the D '/.stoma Hwmatohia, or Bilharzia Hcematohla — from the name of Dr. Bilhartz, its discoverer in man — is sometimes a cause of fatal disease in Egypt, Mauritius, and the Cape of Good Hope. The adult male worm is nearly lialf an inch long, and is broad ; the female is longer but nar- rower than the male. The worm was first found in the portal veins of the infested subject, and the blood seems to be the seat in which it is located. Its ova make their way into the excretory 576 PAEASITES AS CAUSES OF DISEASE. organs, as the kidney, and may be voided by the urine. They give rise to great congestion of the affected organs, to irritation, and in worst cases to extravasation of blood. The mucous mem- brane of the colon has been found charged with vegetative-looking growths filled with eggs of this parasite. The parasite or its ova probably finds its way into the body by means of drinking water. Diseases fkom the Ectozoa. The diseases caused by the Ectozoa, parasites affecting the outer surface of the body, are of three classes. One class is due to the presence of pediculi or lice ; a second to the acarus or itch insect ; a third to fungoid or vegetable parasitic growths. Some authors divide these parasitic diseases into — 1. Diseases dependent on animal parasites : — {a) Phthiriasis. Diseases from lice. (5) Scabies. Disease from acarus scabei or itch insect. 2. Diseases dependent on vegetable parasites : — (a) Favus, or scald head. (b) Tinea tonsurans, including herpes tonsurans, sycosis, herpes circinatus, and Tinea Polonica. (c) Pityriasis versicolor. {d) Alopecia. {e) Mycetoma, or cotton fungus disease. Phthiriasis. The parasites producing the diseased conditions included under the present sub-section, are of three kinds, — the pedioulis capitis, the j>ediculis pubis, and the pedlcidis corporis. The first is the insect which is found on the hair of the head ; the second on the hair of the pubes ; and the third on the body. The first is smaller than the other two ; the second, crab-shaped, is usually adherent to the root or base of the hair ; the third is large, and moves rapidly, causing much irritation. The first never leaves the head ; the second is always found where there is hair, but not on the head ; the third never invades the hairy parts at all. These parasites give rise to prurigo, — itching, — and sometimes, as a consequence of irritation, they produce, indirectly, an eczema. They are promoted by uncleanliness of person, and are transmis- PARASITES AS CAUSES OF DISEASE. 577 sible, directly or by their eggs, from one person to another. Some persons of unhealthy constitution are affected by them with special facility. ■Scabies. The parasite called Acarus scabei or itch insect is one of the most definite of causes of jjarasitic disease. The insect burrows under the skin, and produces intense itching and irritation. The body is first infested by the female acarus, which pierces the skin to the lower layers of the epidermis and there makes its home. As it deposits its eggs it burrows still deeper, and in thirteen to fourteen days the new acarus is hatched and set free. This comes to the surface of the skin. The male insects remain on the sur- face, but the females after impregnation burrow into the skin, like the mothers from which they came, and thus the disease continues to be extended. The female acarus having once bur- rowed under the skin does not return to the surface. The eff^ect of the insect on the skin is to produce a painful eruption, which is often pustular at places where the skin is pierced. The irritation leads to much itching, and the friction used to relieve this symptom is a cause of further irritation. When freshly separated from one of the infested spots, the fe- male acarus is large enough to be seen without the aid of a mag- nifier, and is easily seen by the help of a Codrington lens. It has a roundish body ; a head armed with mouth, but not provided with eyes ; and eight legs. The male insect is much smaller than the female. Some years ago Dr. Hassall discovered an acarus in some varieties of coarse sugar, and inferred, I have no doubt cor- rectly, that the disease called grocer's itch is caused by the hand of the grocer coming into contact with the impregnated female insect from the sugar. In a case of this kind I found an acarus on the person affected, but failed to find any insect in the speci- men of sugar from which the patient believed he had become affected. The disease, scabies, is mechanically communicable, and is rarely met with except amongst very uncleanly people ; but it may, by accident, be contracted by cleanly people. The flexures of joints, and the spaces between the fingers at the points where the fingers meet, are the parts most easily infested. By very simple means the acarus scabei can be killed, and the disease it produces removed, or, as is commonly said, cured. 37 578 PARASITES AS CAUSES OF DISEASE. Diseases from the Yegetdble Parasites. Disease connected with Achorion Schonleinii. — The Achorion Schonleinii is intimately connected with the disease named Favus, described at p. 265. The parasite is a fmigoiis growth, consisting of sporides of about -g-oVo ^^ ^^ inch, in diameter, containing, sometimes, granules ; and of pointed tubes, of about -^-^ of an inch in diameter. Diseases connected with Trichojphyton tonsurans and sjporu- loides, and loith Microsporon mentagrojjhytes. — The parasites here named are connected with, if they be not the cause of, Tinea tonsurans, — ring-worm of the head ; Sycosis ; Herpes circin- natus ; and, Tinea Polonica, diseases described at pp. 261--266. The parasites are composed of very minute spores and sporules, strung together but unaccompanied by tubes. Disease connected with Microsj^oron furfur. — The Micro- sporon furfur is a vegetable sporule or spore of rounded shape, and with short branching tubes. The spores run in clusters, and adhere firmly to the epidermis or scarf-skin. The parasite is the cause of or is connected with the disease called Tinea, or Pity- jiasis versicolor. It produces yellow or brown spots on the sur- face of the affected skin. Disease connected xvith the Microsporon Audouini. — The af- fection called alopecia areata — baldness — is attributed by some writers to the vegetable parasite, Microsporon Audouini, which is made up of minute spores and fine tubes or filaments. The spores are sometimes met with in the hair itself, producing in the hair-tube a swollen or bulbous appearance which is very char- acteristic. Disease connected with Chionyphe Carteri. — Cotton Fungus Disease. The parasite called Chionyphe Carteri is a cryptogam, which getting beneath the skin invades even the bones of persons whom it infests, and gives rise to the diseases called Mycetoma, Madura foot, and Pungus foot, described at p. 266. The three diseases, similar in character, are attended with apparently different para- sites, due probably to different stages of development of one original form. The parasite exists in round firm masses of mould- like character. PARASITES AS CAUSES OF DISEASE. 579 In describing some of the assumed vegetable parasitic affec- tions, I have headed the paragraphs introducing them so as to connect the parasites with tlie diseases in which they have been found rather than to put them forward as primary causes of the diseases. This is necessary, for the opinions of the best obser- vers are still divided as to whether the parasites are causes, coincidences, or effects. I do not think, for my part, that they are ever first causes. They would not exist, I mean, unless the diseased conditions which favor their life had not been made for them. Viewed in this light, they become symptoms or con- sequences, or, at most, aggravations of disease rather than causes of it. Diseases fkom the Entophtta and Epiphyta, including Alg^, Fungi, and Mygeodekms. Disease connected with Lejptothrix Buccalis. — Leptothrix is an alga affecting the mouth. It has been discovered in concretions on the teeth, and on the tonsils. It is not a known cause of any serious local disease. Disease connected with Oidium Albicans and Torula. — The filaments and spores of Oidium Albicans are always found in the eruptions of thrush in children, and are always attended with an acid secretion of the mouth, a fact which leads Dr. Leonard Sedgwick to consider the parasite as a cause of fermentative change in the mouth. This minute parasitic vegetable growth has been assigned as a cause of other diseases. M. Collin reported to the Academy of Medicine, in the year 1S64, that three persons who were cutting vines, by an accident cut themselves, and were poisoned by the oidium. They all suffered after a few days from loss of appetite, shivering, and fever. Their wounds, which originally were slight, became gangrenous, and their limbs swollen. In all of them i\\e\-ewQ.Q '•'■ riiuguet^'' of the mouth, which consisted of a cryptogamous product called the " oidium " of the mouth. That the parasitic cryptogamic oidium albicans may, by in- oculation, become a cause of disease in the human subject, was an hypothesis already advanced in May, 1858, by Professor Laycock, the late distinguished professor of medicine in the University of Edinburgh, on his discovering the Oidium in a pellicle or false membrane that had formed in the throat in a case of diphtheria. 580 PAEASITES AS CAUSES OF DISEASE. It lias been inferred that disease may be taken from the nse of a flour containing a similar parasitic fungns— " Oidium, au- rcmtiacuniP This fungus was discovered by the late Dr. Eobert Dundas Thompson in a specimen of bread made from an inferior kind of flour which easily becomes acid when exposed to moisture, and which emits the well-known sour smell, even after it has been turned into bread, if it be for a short time exposed to moist air. The spores of the Torula Ceremsice, or yeast plant have been discovered in the secretions of the body, and were at one time believed to be connected with choleraic disease. The hypothesis has not been sustained. Disease from Sarcina Yentriculi. The parasite called Sarcina, and which is made up of a series of rods held together in square-shaped masses, has been found in the secretions of the stomach, in some excretions, and in the fluid of the ventricles of the brain. It is most commonly found in the secretions of the stomach, and hence the common name Sarcina Yentriculi. When present there it develops with great rapidity, and keeps up an incessant irritation which causes vomiting of a peculiar sour fermenting fluid. In one instance of this kind, which was under my own care, the irritation lasted for months owing to the presence of the parasite, and as the digestion of food was almost stopped death itself became imminent. At that crisis the symptoms suddenly ceased, and recovery was completed in a few weeks. Sarcina has been detected in the fluid vomited in pyrosis or water-brash, and the late Dr. Tilbury Fox believed that he had discovered the parasite on the skin. Its precise mode of intro- duction into the body is not as yet understood. Disease in Connection vnth Bacteria and Bacilli. At the close of the last chapter a list is given of the various uses assigned to the terms bacteria and bacilli, and of the diseases which are assumed to spring from these parasitic organisms. Bacterian and bacillian parasites are now found to be present, but not always present, in the secretions of many contagious dis- eases, and in those of some other diseases which are not ordinarily considered contagious. The reader may, therefore, turn to the PAEASITES AS CAUSES OF DISEASE. 581 chapter on diseases which run a definite course, and attach a par- asitic growth to many of them, as well as to phthisis, ague, and leprosy. I do not propose here to enter into the controversies which have arisen in relation to the presence of these organisms in the diseases named, or in regard to their position as causes or effects, because I must refer to that subject later on when treating on the causes of zymotic affections. But I add one remarkable instance of a disease attended with a bacterial parasite in the blood, as a good typical illustration. ' Spirillum in Famine Fever. In the relapsing or famine fever of India, Dr. Yandyke Carter has discovered that the vegetable unicellular parasite described as spirillum is found in the blood of the affected persons. Respecting this fever it is admitted by Dr. Carter that no precise information was procurable as to the origin of the epi- demic disease, in the Bombay Presidency, from which his obser- vations were made. But as, in the country districts, the fever seemed to appear simultaneously wdth famine, he alludes to the possibility of an independent origin of the disease. Supposing that the blood spirillum in some way represents the blood poison, it becomes conceivable, he thinks, that in certain impaired states of the frame, — the result of starvation and bad hygiene, — it might originate by a spontaneous variation of the spiro-bacterium of the saliva. Or the organism might be derived from the spiro-bac- terium of impure water, wdiich in a similar impaired state of the body finds an effective entrance otherwise debarred to it under healthy states. Possibly, he adds, germs of the spirillum are commonly present, but remain inert from absence of a nidus in the normal blood, but which find a suitable soil for some stage or degree of their development in an impoverished blood. Such gei'ms produced during previous illnesses might long lie dormant in the earth or a building, e. cj. as " lasting spores " until a return of the conditions adapted to their growth ; this would account for the seemingly independent origin of some fresh epidemics. The whole of the evidence brought forward by this laborious investigator tends to show that in the epidemic he witnessed the parasite spirillum was present, as a rule, in tlio blood of the affected. At the same time he affords no proof that this was the primal cause of the fever, while he proves, incontestably, that 582 PARASITES AS CAUSES OF DISEASE. sucii primal cause is essentially related to poverty and famine. In a M'ord, a certain diseased condition of tlie blood and tissues must be present for either fever or spirillum to be manifested. The precise part played by the parasite in the disease has yet to be demonstrated, together with the fact of its presence in all epi- demic visitations of the same affection. Disease Connected with the Parasite Actinomyces. Recently Professor Ponfick of Breslau has described a disease which is contracted by man from the ox. The ox is attacked, sometimes, with a tumor affecting the jaw, usually the lower jaw, from which the infection is assumed to be directly or indirectly conveyed to the human subject. In the diseased person fistulous openings occur in the skin of the neck and back, ending with sup- puration and phlegmon, or with pneumonia, pleurisy, or perito- nitis. The discharges from the openings contain yellow millet-like seeds of fatty character resembling what is present in the ox. The millet-like seed consists of a number of small elementary bodies of Mycelium or fungus which Bollinger had found in the ox, and called actinomyces. The disease in the ox is called Ac- tinomycosis ; in man Actinomycosis hominis. On the Parasitic Origin of Phthisis Pulmonalis or Consimvption of the Lungs. ■ We have already seen that a bacillus may be found in the expectoration and in the contents and walls of cavities of the lungs of persons who are suffering from phthisis. This observa- tion was first made by Professor Koch, and from his experiments on the communicability of symptoms of phthisis to inferior animals it has been inferred that the bacillus is the cause of this disease. The subject has excited the keenest interest in the med- ical world. From the controversy wliich has been elicited, and which I have followed with the closest attention, I gather that in the enthusiasm of the controversy, conclusions have been arrived at wliich are far too comprehensive to be even near the expected realization of truth. In order to prove the origin of phthisis from the bacillus of tubercle it has been all at once assumed that phthisis is one dis- ease. Constitutional tubercular phthisis; alcoholic phthisis, which need not be constitutional ; syphilitic phthisis, and every other PARASITES AS CAUSES OF DISEASE. 583 variety, have been thrown into one. This is entirely opposed to the facts of experience relating to the history of the disease. To support the speculation still further it is insisted on that the disease is always coniujunicated from one person to another by contagion. This view is of course essential to the hypothesis. But there is no evidence that the disease is ever carried by con- tagion. I was for fourteen years physician to a hospital for dis- eases of the chest, and in the large public experience there gained, together with that obtained in private practice, I have treated over three thousand cases of the disease. In that large field of observation, extending over thirty years, I have noted no ques- tion more carefully than that which relates to contagion, and I cannot recall a single instance in which I could trace, in a clear and satisfactory manner, that the affection was communicated fronx one person to another. I have known persons who were susceptible to the disease exposed to what would have been the extremest peril if there had been contagion, but have never known contagion to result under such circumstances, I have known three members of the same family die of phthisis, the first affected being in closest com- panionship with the others, without any communication of the disease at the time. Yet years afterwards those same persons, on the mere accident of taking cold, have contracted the disease. I never knew a nurse, a doctor, or any other attendant on the con- sumptive take the affection from contagion, nor anything that at all resembled such relationship. The suppoi'ters of the bacillus hypothesis, in their anxiety to make it true, ignore tlie overwhelming evidence of hereditarv tendency to phthisis. If all M-ere susceptible to the disease all would take it, and the fact of taking by infection or contagion would be obvious to every observant mind. But, in truth, few if any suffer from the commonest foi'm of consumption, that which attacks the young, except they are born with the proclivity to it. In the cases I have seen over ninety per cent, were hereditarily disposed to the malady and became stricken with it, as an all but universal rule, while living with other persons, and under the same conditions as other persons who were not affected with it. Once more, in order to give credit to the hypothesis, the pe- culiar condition of body of those who suffer is practically set aside as of no moment. It is well known that they who are disposed 584 PARASITES AS CAUSES OF DISEASE. to consumption are of delicate build ; have commonly a narrow, pointed, or pigeon-shaped chest ; a feeble respiration ; a delicate skeleton ; and, generally, a feeble frame. We, indeed, who from practice have learned the lesson, know at once the people who are of phthisical type, and we feel sure they are in danger, inde- pendently of any exposure to special contagion. Lastly, to make the phenomena of the disease fit in with the necessities of the hypothesis, it is suggested that a susceptible person or an unsusceptible is safe so long as he or she does not come into contact with the bacillus which excites the disease. But we who have observed the phenomena of the commencement of phthisis pulmonalis, are aware that the common excitant of the first symptoms is catarrh, or common cold, contracted, usu- ally, when tlie body is exhausted from overwork, from anxiety, from fatigue, or other depressing influence. I can scarcely recall a case in whicli the origin of the disease was not from a cold ; and the eminent physician of our time, who has lately passed from us. Sir Thomas Watson, once expressed to me when we were meeting in consultation in a case of acute tuberculosis brought on by an exposure to a severe chill, that there was no observation in medicine of which he was so assured as that of the development of phthisical disease, in the predisposed, from taking what in other persons would be simply called a cold. To pass by all these practical facts because they do not chime in with a newly-launched hypothesis, is, I venture to submit, out of reason. jSTo experiment that has yet been performed is in any sense the counterpart of so much experiment from experience. Moreover, experiment admits of being used in another way. In the same kind of lower animals as those in which phthisical dis- ease is supposed to be induced by inoculation, I induced similar disease by making animals inhale an atmosphere containing vapor of nitrite of amyl. Here an effect produced directly on the nervous system and on the nutritive changes under the nervous control, was the exciting cause of the changes in the pulmonary structure; but he would be an extreme advocate of an hypothesis, who would argue thereupon that nitrite of amyl is the cause of phthisis in man, although such an hypothesis is just as rational as the germ hypothesis. The only piece of evidence which runs practically with the hypothesis of the parasitic origin of phthisis, is that having refer- PAEASITES AS CAUSES OF DISEASE. 585 ence to the fact of the hijurious mfluence of close air on those who are predisposed to the disease. I have shown over and over again how easily phthisis is developed in predisposed persons who sleep in a confined and iinventilated room, and I have quoted the history of the barrack -life of our household troops some years ago, and of the ravages of consumption in them when they were housed in confined and close air. Such facts at first seem, truly, to give some countenance to the parasitic hypothesis, and if they stood alone they would be forcible if not demonstrative. As it is, they can only be taken in combination with the other facts above stated, upon which they are found to tally so completely with the constitutional and neuro- pathological theory of origin that they need no other explanation. The confined and devitalized air acting as a depressing influence on vital action favors predisposition, and enables any disturbing cause to set up the first series of nutritive changes in the lung from which the rest proceed. On the whole, then, all that it seems to me can be honestly admitted in respect to the parasitic nature of phthisis pulmonalis, is, that in certain instances of it, perhaps in many instances of it, a vegetable parasite is found in the affected structure, and in the expectoration. But even this requires still further proof. Summary. The summary of what is reliably known respecting parasites as causes of disease may be placed as follows : 1. The embryos of certain parasites enter the body by the alimentary canal, remain in the canal and develop there, causing much local irritation. Example : — Lumbricus, Taenia, Ascaris. 2. The embryos of some other parasites enter by the canal, develop there, pierce the tissues, and by their presence produce irritation and various subsequent changes of disease in the tissues and organs with which they are brought into contact. Example : — Trichina Spiralis. 3. There is one parasite affecting the blood, the embryos of which appear and disappear from the blood with periodical regu- larity. Example: — Filaria Sanguinis. 4. There are some parasites which pierce the skin and pro- 586 PARASITES AS CAUSES OF DISEASE. duce disease by lodgment in tlie tissues. Example : — Filaria Medinensis, or Guinea-worm. 5. There are parasites which affect the outer surface througli the several pores and produce specific diseases of the skin. Ex- ample : — Acarus Scabei. 6. There are some parasites which light upon the skin or its appendages and grow there, aggravating the symptoms of disease, but probably not producing disease ah origine. Example : — Achorion Schonleinii. Y. There are vegetable parasites, which would be placed under the College lists as of the nature of Algae, They are the simplest forms of life, and are found in the blood, in the secretions, and in the structin-es of the body in numerous diseases, as in typhoid, thrush, relapsing fever, syphilis, gonorrhoea, ague, leprosy, malig- nant pustule, pyaemia, phthisis pulmonalis, and other diseases. To these parasites, colorless and unicellular, the name Bacteria has been applied. They are arranged by Cohn, as already shown from Power and Sedgwick's description, as Sphserobacteria, globe- like, including Micrococcus and Sarcina ; Microbacteria, rod-like ; Desmobacteria, larger rod-like ; Filobacteria, thread-like, includ- ing Yibrio and Bacillus; and Spirobacteria, spiral-shaped, in- cluding the Spirillum. The most important of these simple colorless organisms, in the view of those who attach primary meaning to them as causes of disease, are tlie Sphserobacteria, which give the micrococcus that has been observed in some of the contagious diseases and in silk-worm disease ; the Desmo- and Filobacteria yielding tlie bacilli, which, as we have seen, are found in anthrax, tubercle, and malarial fever ; and the Spirobacteria which yields the Spirillum, discovered by Carter, in relapsing fever. There may also be added as belonging to the vegetable parasites, the fungus which is met with in mycetoma, Madura foot, or fungus foot disease. To this summary I have the privilege of adding the following brief notes, on the question of the probable derivation of the vegetable parasites, from the pen of a microscopical observer. Dr. Braxton Hicks, who of all men has been most minute and impar- tial in investigation : " {a) The vegetable parasites on the human body are mostly of the ftm.fjfus, rarely of the algce, tribe. "(5) Both have many modes of growth or different phases of PAEASITES AS CAUSES OF DISEASE. 587 existence, so that when we come upon one mode, we have but slight knowledge of the total of the plant. " (c) Bacteria, for example, is only one phase. If it is of fungus origin then also we must look in other directions for the other phases. " (d) If, for instance, one looked in other parts of the body for that supposed to be the cause of phthisis we should expect to be disappointed ; in other parts one would expect to lind some other phase — e.g. mycelium. " (e) Specimens exhibited from lung structure in phthisis seem sometimes to be clearly a form of ' Binary segmentation ' of some fungus. The fungus might in that situation go on multiplying in that form till some general change of the condition of the system or lung occurred ; then it might alter its mode and continue in the altered state until another change occurred. " (y ) It may be inferred that these parasites are fungi rather than alg^e, because algse like light. The lung cavities are suitable to fungi, and low states of health favor fungus growths. " (g) Hence it is exceedingly difficult to say whether, supposing the lung cavities to be filled with these segmentating cells, they are the cause of phthisis or the accidental condition. " (A) The same remarks apply to all diseases of Bacterial origin, — I mean till observation and experiments have proved that the introduction of a specific Bacteria reproduces the growth and accompanying disease." In this review of the parasitic origin of disease, I have kept closely to the diseases of the human subject, and have avoided reference, except in the most incidental manner, to those human diseases which are supposed to be of zymotic origin, and whicli are believed by many to be excited by parasites acting as fei-- ments. To tlie last-named topic attention will be du'ected in the chapter which immediately follows. CHAPTEE YIII. ZYMOSIS OR FERMENT AS A CAUSE OF DISEASE. I ENTEK in this chapter on one of the most debatable subjects in the whole range of medical science ; I mean the part played by the process of zymosis or fermentation in the production of disease. The idea of fermentation as a cause of disease is very old. At various times it has been held up as the origin of all diseases which run a definite course, and which seem to be communicable from one person to another. At other times it has subsided as an hypothesis almost altogether. When, in fact, the theory of dis- ease being dependent on changes in the secretions or humors and in the blood from which the secretions come, — a theory designated the Immoral pathology, — has been prevalent, then the zymotic hypothesis has prevailed. When the theory of diseases being due to nervous impressions and to aberrations in nervous func- tions, — a theory designated the neuro-jpathology , — has been in the ascendant, then the zymotic hypothesis has all but passed away. The works of Thomas Willis, of Yan Ilelmont, of Becher, of Stahl, did much during tlie two last centuries to support the humoral pathology. The labors of Hartley and Erasmus Darwin in the last century, and of Bicliat at the close of that century, with those of Charles Bell, Walker, Gall and Spurzheim, Pro- chaska, and Marshall Hall in the present, did as much to support the neuro-pathology. These two theories have been specially refl.ected in theorizing studies on the origins of disease. After Wihis's great book on fermentation all the contagious diseases were thought to be of zymotic origin, and the hypothesis will be found recorded, for a long period of time, as if it were proven. If the reader will turn to a book published so lately as 1835, Sir Pichard Phillips's "Million of Facts," he will find the word con- tagion thus commented on at p. 123. ZYMOTIC CAUSES OF DISEASE. 589 " Contagion is one of those generic words which, like attrac- tion, bewitching, suction, mislead and obstruct inquiry. The dif- ferences about it among the faculty are intellectual phenomena. Is not contagion, says Dr. Dwight, such a fermentation of an ani- mal body as generates animalculse, and, hence, the danger of con- tact ; and is not exemption, after affection, evidence that the germs in that subject have been exhausted ? Do we not subsist on such germs, and is not the class of contagious diseases evidence that they have overcome the usual economy of the subject ? The separation of animalculse in our microscopic experiments prove the universality and indestructibility of tlieir seeds or germs." In the present day the tendency is again all towards the hu- moral pathology, and so strong has this tendency set in that the hypothesis of disease from fermentative changes is once more in full tide. In the force of this current of opinion it is, in fact, very difficult to steer safely. It carries those who are upon it away from all old landmarks and soundings. N^ervous phenomena are ignored altogether, and the nervous system itself is almost for- gotten. Hereditary proclivities to disease are treated as of little moment, or are discredited. In a word, nothing is required to account for the symptoms of any disease except a germ to excite some kind of fermentation indicated by symptoms which, in reality or in imagination, may be due to a process resembling fer- mentation. The extreme advocates of the zymotic interpretation of dis- ease hardly see, and hardly, it is plain, care to see, to what results their unchecked course is carrying them. If they wish to be au- thors of an instauration founded on demonstration, they must go to the complete proof that the continuance of life itself is by a germ derived from without by every animal that propagates its species. It must not merely be so many germs so many diseases, but also so many germs so many animals ; and the germs of ani- mals, not less than of diseases, nmst be floating in the air, — in- visible, but there. I shall endeavor in this chapter to avoid the extreme views Mdiich I have here described. I shall try to put the facts we have, up to this time, in hand in their fair and legitimate position, and having done this, I shall leave the matter to the judgment of the reader. In following out the plan thus declared it will be best for me 590 ZYMOTIC CAUSES OF DISEASE. to present an outline of the subject in so far as there is a concur- rence of opinion amongst reasoning scholars, and amongst those Avho have studied the natural history of disease rather than nat- nral history pure and simple. Thus placed, the following may be accepted as common subjects of agreement. I. Among the many diseases affecting mankind there is a limited number which may, from certain points of analogy, be placed in the zymotic gronp, and be commonly called zymotic affections. These diseases are as follows : Plague. Cholera. Malignant pustule. Scarlet fever. Diphtheria. Influenza. Pertussis. Puerperal fever. Pysemia. Carbuncle. Glanders. Erysipelas. Farcy. Grease. Dengue. Gonorrhoea. Eelapsing or Famine fever. Variola — Small-T)ox. Vaccinia — Cow-pox. Varicella — Chicken-pox. Measles. Eotheln. Typhus. Typhoid Mumps. Malarial fever. Syphilis. Hydrophobia. To the above list some others may be added, regarding the na- ture of which there would not be the same unanimity of opinion. These are : — Catan-h. Quinsy. Croup. Hospital gangrene. Sloughing phagedsena. Phagedsena. Remittent fever. Intermittent fever. Choleraic diarrhoea. Dysentery. Cerebro-spinal fever. Bheumatic fever. II. The diseases of the first of these groups, abont wdiich there is fair unanimity, are marked by certain stages which have already been described (pp. 44-58). To ns now, as bearing on cause, ZYMOTIC CAUSES OF DISEASE. 591 the first stage is the one that is of most importance. This stage is called the stage of iiicitbation, and is that which intervenes hetween the reception of the promoting agent and the first mani- festations or symptoms of its action. To Dr. Squire we are specially indebted for the correct knowledge we now possess on the periods of incubation, and in ihe subjoined passages I offer, practically, his description. The periods of incubation are placed under five heads, according to the number of days demanded for incubation by each particular form of disease. The diseases are thus arranged into those of shortest, of short, of medium, of long, and of longest incubation. 4 Shortest. a. Diseases of Shortest Period of Incubation — 1 to 4 days. — Malignant cholera. Malignant pustule. Plague. Catarrh. Dissection wound dis- ease. Short, h. Diseases of Short Periods — 2 to 6 days. — Scarlet fever. Diphtheria. Dengue. Erysipelas. Yellow fever. Pyaemia. Influenza. Pertussis. Glanders. Farcy. Grease. Croup. Puerperal fever. Medium. c. Diseases of Medium Periods — 5 to 8 days. — Eelapsing fever. Gonor- rlicea. Vaccinia. Inoculated small-pox. Long. d. Diseases of Long Periods — 10 to 15 days. — Natural small-pox. Va- ricella. Measles. Rotheln. Typhus. Tyi^hoid. Mumps. Malarial fever. Longest. e. Diseases of Longest Periods — 40 days or more. — Syphilis. Hydro- phobia. Accepting these as the truest expression of knowledge up to the present time, we have still much to learn. We exclude in the list several diseases which probably have some stage of incubation, and we are obliged to grant exceptions in respect to those that admit of being classed together. The diseases of the first group are fairly steady in respect to incubation, but a question may be raised by some as whether catarrh, eitlier superficial or deep, — cellulai-, — should be classed amongst the zymotic diseases. 592 ZYMOTIC CAUSES OF DISEASE. Of tlie diseases of the second or third group, exceptions may be adduced in whicli the disease may, in particular cases, have a shorter incubation than is assigned in tiie classification. Such exceptions must be admitted, and a case of scarlet fever, quoted by Murchison, shows for this disease, occasionally, a very brief incubation, — six hours at longest. The diseases of the third and fourth groups will be accepted as fairly steady. Relapsing fever, as I knew it in 1847, had a longer period than five days of incubation, but hy inoculation it is said to have five days. In the last group syphilis will be accepted as having the long incubation of forty days ; but hydrophobia is the most difiicult disease to define. It may have a few days of incubation only ; it may have months or even years. III. The agents which are capable of exciting the zymotic diseases, and of acting during the periods of incubation, are organic sub- stances, either living or dead. In the doubt which still remains as to the vitality of these agents, they may be called organic disease-producing ^^rtT'zJicZe-s. lY. It is pretty generally assumed that the j)artide is special for each special disease. To the particles, therefore, the term sjped- ficity in respect to their action may be applied. In other words, one particle will not produce two diseases. Some exceptions may, however, be taken to this rule. There is some evidence in favor of the view that the particle of scarlet fever may produce child- bed fever. It is assumed by most observers that the particular organic causes of the zymotic diseases may be received into the body by all the surfaces that can absorb them. They may be received by a wound, — inoculation ; by the air in breathing, — inhalation ; by the alimentary surface, — fluid absorption. At the same time each poison is not receivable by the same surface. Some which act quickly when inoculated do not act if taken into the stomach as food is taken. But if a special disease-producing particle will ZYMOTIC CAUSES OF DISEASE. 593 effect action through more than one surface, it is found to be most prompt in action when it is introduced into the body by inoculation. Thus the period of incubation in the disease small- pox is shortened when the poisonous particle which causes it is inoculated into the susceptible body. YI. In order for the specific disease-producing particle to exert its action, it must have a susceptible subject on which to operate. A community or a person is, therefore, defined as susceptible or in- susceptible to the poisonous or zymotic influence. As a rule also to which, nevertheless, there are many exceptions^ persons who liave once been affected by a specific zymotic particle are, for a time, insusceptible to a second action of the same. Snch persons are said to be protected, or under immunity, from the disease. The protection, however, does not last necessarily all through life. Many persons who are protected through a course of years, be- come again susceptible, and though, as a rule, these are subjected to a milder attack than would occur if they contracted the disease for the first time, they are not always so fortunate, for it occasion- ally happens that a second attack is as severe as the first, and that such an attack ends fatally. It is pretty generally agreed upon that there are some peculiar conditions of tlie body during which there is extra susceptibility to the action of the infecting particles of disease. Thus women during childbirth are specially susceptible to erysipelas and to scarlet fever. YII. In some instances the attack of a mild form of disease acts as a preventative to, or protection against, a severer form of a similar disease. Thus the mild form of scarlet fever, called commonly scarlatina, is probably a protection against the severer forms of scarlet fever; more distinctly still the mild form of small-pox, called cow-pox, is a protection to the severer disease small-pox. The specific causes of the zymotic diseases, the specific infect- ing organic particles, travel, under certain conditions, from one 38 594 ZYMOTIC CAUSES OF DISEASE. place to another. Some travel in solid form, like the fine dusts seen in the snnbeain, and with which dusts they commingle. Others appear to approach the physical cpality of a vapor, and are probably carried in the air with the vapor of water. The first are wafted, the second are diffused. The particles which travel most readily in the solid form are those of small-pox, scarlet fever, measles, typhoid, erysipelas, ophthalmia, hospital fever, ague, and cholera. Tlie organic mate- rials which travel in or on vapor are, probably, those which pro- duce typhus and diphtheria. In respect to some of the disease-producing particles it seems essential that the infecting organic substance should come into direct contact with an absorbing surface, or with the blood. The affection of hydrophobia is an illustration in point, the infecting substance having to be inoculated. There is evidence of a circumstantial if not demonstrative character, that the infecting particles of certain diseases may travel through food or water, and may produce disease by being swallowed accidentally. Typhoid, cholera, and, some think, diph- theria are diseases that may be contracted by this method of communication. The infecting particles, which are of solid character, seem to have the property of adhering to articles of clothing or to other substances, and are, presumably, carried by this means. IX. The organic infecting particles possess under favoring circum- stances the power to act for long pei'iods of time, when they are dried and kept dry, or when they are locked up by cold. The virus of small-pox and cow-pox affords illustration of this truth. The virus can be retained in the fluid or dried form for many months, or even years. Exposure to moisture for a long time, or a certain extreme degree of dilution of the infecting particle in water, destroys the power of the virus, probably by causing its decomposition. Exposure to a high degree of heat also destroys the power of the virus. Exposure to sunlight for a long period has, probably, the same effect. ZYMOTIC CAUSES OF DISEASE. 595 X. Susceptibility to tlie action of tlie virus of any of the zymotic diseases is always the primary factor ; and in the susceptible the presence of a minute particle of infection may be as potent as a more concentrated portion. In other words, the extent to which the infected body is inHuenced depends more on its own condition or state than on the amount of infecting matter to which it has been subjected. Thus a mere point of small-pox virus will pro- duce the disease in a susceptible person, while the amount many times multiplied would not aifect one who was insusceptible. In this respect the organic virus differs entirel}'^ from an inorganic poison, which, as a rule, injures in proportion to the quantity in which it is received into the body, irrespective of susceptibility or insusceptibility. It is naturally inferred from these facts that the zymotic virus, when taken into the body of those who are susceptible to its action, either undergoes multiplication by living growth, during the period of incubation, or, by its presence, transforms something else, within the body into its own virulent nature and character. XL It seems to be a true reading of the natural phenomena of the diseases called zymotic, that those diseases of the class which have a short period of incubation have a prolonged period of conva- lescence, and remain for a long time as sources of further com- munication of disease from the affected ; while the diseases which show a long incubation give a quicker convalescence and a more rapid freedom from danger, as sources of communication. XII. It is generally admitted that external surrounding conditions modify the course, intensity, and result of the diseases of the zymotic class. Each disease, for instance, seems to have its favor- able season for development, and many have assumed that what is called an atmospherical epidemic influence is essential for the origin and spread of all the epidemic affections. The more reason- able and now more commonly accepted view is that these affec- tions will spread in a susceptible community under all conditions, 596 ZYMOTIC CAUSES OF DISEASE. but that tliey will spread with much more virulence, and be attended with a much higher mortality, under some atmospheri- cal conditions than under others. A reference back to the dis- eases incident to particular seasons (pp. 531-545) will make this important point sufficiently clear. In these twelve sections I have endeavored to epitomize the views which are held by, I think I may say, all scholars who have inquired with due care and labor into the nature of the diseases which are called zymotic. I must now briefly pass from what is common agreement to what is often disagreement; from practical assent to disputed theory or hypothesis. Theories and Hypotheses on Zymotic Disease. Before entering into the description of the theories or hypoth- eses as to mode of origin of zymosis, — or fermentation, — within the body, it is necessary to consider some points relating to zymosis itself. I would begin by repeating a view which I advanced in 1861 in my " Clinical Histoi-y of Scarlet Fever," that zymosis, instead of being a process foreign to the body, is, in truth, a natural act always going on and essential to life. I see no reason whatever now to alter that view. The food which we take into our bodies is the pabulum which undergoes fermentation. There is a sub- stance or principle in the blood corpuscles, or in the fibrinous material, which in the presence of oxygen, derived through res- piration, has the property of setting up natural zymosis. The result of this natural zymosis is the regular production of animal heat and of the ultimate products of animal decomposition, viz., water and carbonic dioxide. This I should call perfected animal zymosis. If this be true, then zymotic diseases, so called, are, as a class, mere symptoms of aberration from a natural state of life, which is, in fact, nothing more than the history of all natural disease. The action of an organic particle or virus entering from r.n infected organism into a healthy organism is, then, rather to modify or render imperfect the natural zymosis of the healthy organism than to excite a primitive zymosis. How for it is true that a modified zymosis or fermentation does take place in affected bodies is still a matter of inference ZYMOTIC CAUSES OF DISEASE. 597 rather than of demonstration. At the same time the inference is without doubt exceedingly fair and reasonable. It is not demon- strable as applied to every so-called zymotic disease, because the results of zymosis are not present in every such disease. One result of zymosis is production of heat, and it is admitted that most of the zymotic diseases are attended with increase of heat. But some are not so attended. Malignant cholera, for example, is accompanied by a decrease of temperature even to extreme coldness until the stage of reaction from collapse has set in. Cholera, therefore, might be excepted as a zymotic affection. Ordinary zymosis is attended with production of organic acids other than carbonic, such as lactic, acetic, formic. But in many of the zymotic diseases, indeed in the majority, these secondary products have not been detectable. Other results of zymosis out of the body are those of putrefactive change ; but every phy- sician knows that in the vast number of so-called zymotic diseases putrefaction does not occur until after death, and that it does occur whatever be the mode of death, zymotic or other. Such evidences as these qualify greatly the absolute specula- tion of the zymotic origin of what are classified zymotic maladies, and would go far to upset the speculation altogether, were there not some other and counterbalancing testimonies of its truth, which are of the following character. There is one particular disease, acute rheumatic fever, which carries out the zymotic hypothesis in the most striking manner. In that disease — which, by the way, some exclude from the zy- motic class altogether — there is not only increase of temperature, but an acid product, lactic acid, identical with that which is ob- tainable by one form of fermentation — fermentation of milk. Still more, this affection is sometimes lighted up by another zymotic disease, notably by scarlet fever. Rheumatic fever fails, however, to represent a zymotic disease when it is in its pure and simple form, because it does not yield an organic product which will, by transmission, excite the same disease in another person. But scarlet fever does yield such a product, and therefore rheu- rriatiG scarlet fever offers all the conditions of a true fermentation in a complex yet specific disease. Again, some other affections, like small-pox, and like yellow fever in certain of its forms, and like typhus in certain of its forms, are capable of yielding the phenomena of putrefactive fer- 698 ZYMOTIC CAUSES OF DISEASE. mentation, and this may perhaps be extended to malignant pus- tule. On the whole, therefore, we may accept tlie zymotic hypothe- sis of the cause of tlie diseases now under consideration as the best, and most probable. In explanation of the zymotic theory in relation to mode of oi'igin, that is to say, in relation to the mode in which the healthy zymosis of the body is modified, or a new zymosis set up in the body, there are three hypotheses. To these 1 would assign the following names : — 1. The jxirasitiG kyj)othesis, which traces the phenomena of zymosis to the introduction into the body of a parasite of the vegetable kind, like Bacteria, Bacillus, or Spirillum. 2. The vital germ hyjMhesis of Dr. Lionel Beale, which traces the zymosis to a diseased living germ produced in the body in self . 3. The nervous hjjyothesis, which I have ventured to origi- nate, and which traces the zymotic affections to diseased secretions produced under nervous derangement in the body itself. The Vegetable Parasitic Hypothesis. The strongest evidence in favor of the origin of zymotic dis- eases from living parasitic cells or germs is derived from analogy ; and, indeed, we may say that the hypothesis rests, considerably, upon analogy. What that analogy is has been admirably stated by Dr. John Dougall of Glasgow, and as he is an opponent of the hypothesis, I select his description, as being free from bias in its favor. " Zymotic poison," he says, " in no way resembles any other toxic substance, excepting that it is a 'a deadly poison.' It differs, on the other hand, from all other such bodies, in respect that it cannot be confined in stoppered bottles, measured in min- ims, nor weighed in grains ; and, in particular, it diffei'S in this important point, that, while the actions of other poisons are con- fined to the individual affected, it renders the person it poisons poisonous. " For example, one may attend closely on a patient suffeiing from a fatal dose of opium or strychnia without danger of becom- ing narcotized or tetanized by the opium or strychnia which the patient has swallowed. But one M'ho has not suffered the special form of zymotic poisoning with which a person is affected could ZYMOTIC CAUSES OF DISEASE. 599 not attend Lira with impunity, because lie might poison his attendant, his nurse, or doctor, nay, even his friends or neiglibors in the same house, witli the identical virus by which he himself is poisoned. This body is, for the time being, an alembic in which a special vii'us is elaborating and multiplying enormously by an apparent destructive distillation of the blood and secretions, so that the tissues may literally be soaked and the body enveloped in an atmosphere of virulent infection. The blood, saliva, breath, sweat, urine, fggces, and epidermis may all be saturated with it. " This poison is named from the Greek word ^vfirj, or leaven, and a person under its influence is held to be in a condition of zymosis or fermentation. It was so denominated because, when it enters the blood of an individual susceptible to its influ- ence, it gives rise to phenomena very analogous to those caused by the addition of yeast to a substance capable of fermentative change. Supposing, for example, there is added to an aqueous solution of honey, or of grape or other sweet fruit juice, a single cell of the yeast plant, torula cerevisice. This speck of matter is about the size of a human red blood corpuscle, and hence only visible under the microscope. Supposing, further, that this solu- tion is kept at a temperature of about 70° Fahr., then in a few hours, or at most a day or two, from the single yeast cell millions are produced, so as to make the liquid turbid, and foi-m a frothy scum at the top, and a sediment at the bottom. During these changes the temperature of the fluid is increased, and carbonic anhydride largely evolved, until latterlj' the heat begins to re- turn to the normal, and the evolutioil of gas to cease, when the solution is found to have lost its sweet taste, and to be changed into a mixture of alcohol and water incapal)le of further fermen- tation. " JSTow for the analogy between this process and that of zy- motic poisoning. Supposing I were to wet the point of a needle with lymph from the body of a small-pox patient, and push it under the skin of a pei'son who had neither been vaccinated nor suffered from small-pox ; then, a thousand chances to one, that in a few days, the recipient of the lymph feels out of sorts, has nausea, vomiting, lieadache, thirst, back-ache, a high pulse, and hot skin. In about three days afterwards a papular eruption ap- pears on his body, which soon changes into small blebs or vesicles. These vesicles may be few or many, separate or confluent, but 600 ZYMOTIC CAUSES OF DISEASE, the clear and apparently homogeneous fluid which they contain has the identical specific infective nature as that with which the needle was wetted, the minute portion on the needle h;iving now multiplied to an enormous extent in the blood of the person inoculated. " I need scarcely say that the symptoms enumerated are those of small-pox, and that the lymph introduced into the blood by the needle is zymotic poison. " The putting of the yeast cell into the sweet solution, and of the minute portion of small -pox lymph into the human body, are both cases of pure infection, and the zymotic phenomena evoked thereby are almost perfectly analogous. " For, observe — 1st. That the saccharine solution was sus- ceptible to the action of the yeast, and the human blood to that of the lymph. 2d. The extremely minute portions of yeast and of lymph employed. 3d. The rise of temperature in both cases : the sweet solution becoming abnormally warm ; the small-pox patient highly fevered. 4:th. The great multiplication of yeast in the sweet solution, and of small-pox lymph in the blood. 5th. The yeast frothing to the surface of the fluid, and the small-pox eruption forming lymph bubbles or vesicles on the skin. 6th. Both are infectious : a cell of the new yeast would cause fei-men- tation in a susceptible fluid ; a speck of the new lymph would cause the small-pox in a susceptible person. 7th. The sweet solu- tion is no longer capable of fermentation, owing to the chemical change it has undergone in fermenting ; the small-pox is no longer susceptible to small-pox, also from some chemical change pi'oduced in the body by that poison. 8th. The sweet solution will ferment, as it were, spontaneously, that is, without putting 3'east cells into it intentionally, because such cells are constantly floating about, and fall on its surface ; so a person ma}' take small-pox spontaneously, by inhaling air containing that specific poison. These are both cases of pure infection, though in neither is the infecting agent visible." Following up this exposition in practice, the advocates of the hypothesis now under consideration contend that all the contagious diseases which run a regular course, and which, being passed through, leave the person who has been invaded safe fi-om a further attack, depend on a vegetable organism. Dr. Thudichum, with his usual facility of fixing what he says on the mind, in- ZYMOTIC CAUSES OF DISEASE. 601 eludes the whole hypothesis of contagious disease above defined under the name of " vegetable parasitism.''^ If this hypothesis could be carried out with the unanimity of simplicity which its promoters wish for it, it would indeed be a happy solution to the whole of the difficulty. Each vegetable parasite possesses, they think, the power of exciting in the body into which it is introduced a fermentation, upon which special symptoms of disease are manifested. So the particular disease is made. But the vegetable parasite is itself a living contagion, and finding its proper pabulum, is reproduced, to be cast off by various secretions and to set up further and similar disease in all persons susceptible to its influence. To sum up. The hypothesis supposes : First, that there are as many vegetable parasites capable of setting up the special diseases as there are zymotic diseases. Secondly, that in every susceptible person there are as many pabulums for the support of the various vegetable parasites capa- ble of producing a specific zymosis as there are zymotic diseases. Thirdly, the hypothesis endeavors to explain the reason of im- munity from second attacks. It suggests that the pabulum on which the vegetable germ was reproduced in the body having be- come exhausted, the disease ceases if the patient lives, and that the protection is due to the fact that the pabulum necessary is not, as a rule, formed in the same body a second time. The Yital Germ Hypothesis. The author of the vital germ hypothesis, one of the most illustrious of the original thinkers and workers of this day. Dr. Lionel Beale, supports his views in the following manner. He argues that in the body during life there are two condi- tions of matter : one living, the other dead. The living matter he calls Mojjlasm, the dead m2iitQv formed material. Every tissue, intercellular substance, and matter resulting from changes in the cells are formed from bioplasm. He shows that masses of bioplasm after reachhig a certain size, usually less than one-thousandth of an inch in diameter, undergo division, and that as soon as any mass of bioplasm has attained a certain definite size it divides, that portions move away and at length detach themselves from it. If the bioplasm were to con- 602 ZYMOTIC CAUSES OF DISEASE. tiniie to grow, the distance to be traversed by the nutrient matter, or pabuhiin, before the inmost parts were reached would soon become so great that these would be practically beyond reach, and could not be nourished or subjected to the constant action of currents of fluid. Death would begin in the central part of such a mass, and would soon involve particle after particle, as its ravages extended outwards, until the whole of the living- mass was dead, — a most improbable order of events. Eespecting bioplasm, or living matter, the distinguished au- thor says that it is clear, colorless, structureless, soft, and when growing quickly almost diffluent. It is enclosed in a capsule of equally colorless formed material, which, however, is lirm and sometimes even hard. When this simple organism is nourished, nutrient pabulum dissolved in water permeates the capsule of formed material, and comes into contact with the bioplasm within. The non-living matter then undergoes changes most wonderful, in the course of which it acquires the same properties and powers as the bioplasm, already existing, possesses. Thus under favor- able circumstances the particle grows and separates into two or more parts, which move away, and through which the process is continued. These are vital actions differing absolutely from any actions known to occur in any kind of non-living matter whatever. They cannot be imitated, and no actions known can be fairly said to exhibit any true analogy with them. These vital phenomena do not characterize the formed material, for the production of this is coincident with the death of the bioplasm. As the formed material is produced bioplasm ceases to live, and no kind of formed material can grow and transform matter and direct its forces as living matter is known to do. Of hacterium, Beale shows that its living matter is, probably, the lowest, simplest form of bioplasm in nature. He has figured some bacteria less than the one ten-thousandth of an inch in diameter, while the germs from which the little particles spring are far more minute. It would be difficult to say where bacteria germs do not exist. In air, in water, in the soil, adhering to tiny particles of every kind ; in every region of the earth, from the poles to the equator, they are to be found. At all periods of tiie year they retain their vitality. Extreme dryness does not destroy them, and they withstand a temperature far below freezing point. ZYMOTIC CAUSES OF DISEASE. 603 Under adverse circumstances they remain dormant, and are not destroyed by a degree of heat which is fatal, probably, to every other living organism. In the substance of the tissues, in the cells of almost all plants, and in the interstices and tissues of many animals, bac- teria germs exist, and no part of the body of man and of th.e higher animals is entirely destitute of particles which, under favorable circumstances, develop into bacteria. Upon the skin and upon the surface of mucous membranes tliey exist in profu- sion, and they abound in the mouth and in the follicles and glands. Changes in the process of digestion are soon followed by the mul- tiplication of bacteria in every part of the alimentary canal, and within a few hours countless millions may be developed. They multiply in the secretions, under certain circumstances, almost as soon as these are formed, and the germs exist even in healthy blood. In the very substance of some cells he has seen them, and in many cases, in which little granules have been discerned in connection with bioplasts, there is reason to believe that some of them are really bacteria germs, passive as long as the higher life is maintained in its integrity, but ready to grow and multiply the instant a change favorable to them and adverse to us shall occur. As the germs of bacteria are found in healthy tissues and or- ganisms, and grow and develop? into bacteria when disintegration and decay occur, we need not be surprised at their existence in disease. Bacteria prey upon morbid structures, and upon the substances resulting from the death of morbid bioplasm. They are found in great numbers among pus corpuscles which have ceased to live, and they grow and multiply with great rapidity hi fluids which contain disease germs as soon as these begin to lose their specific powers and to undergo decomposition. In the tis- sues and fluids of the body altered by fevers they are abundant, and exist, as is well known, in many instances during life. In the evacuations of cholera, and not only of cholera, they are very numerous, and in the columnar epithelium of the small intestine many have been found. In all parts of the bodies, in the fluids and amongst the solid tissues of animals destroyed by cattle plague, bacteria are present in varying number. Turning from this physiological definition of bioplasm or liv- ing matter, Beale is led to look upon the changes and degradation 604 ZYMOTIC CAUSES OF DISEASE. of bioplasm as causes of disease. Increased growth, owing to an increased access of nutrient pabulum, is the first change that oc- cui's in inflammation, and is essential to the inflammatory process. From every form of bioplasm in the body pus or matter may in all probability be produced by descent from some form of normal bioplasm of the body. The pus corpuscle is bioplasm which has been so produced. Bioplasm always tends to grow. It must grow if it be supplied with nutriment ; but it has within itself no power of regulating or controlling its own growth. Touching upon the origin of contagious disease, the author dwells on the loss of formative power, which occurs as the i-ate of growth and multiplication of bioplasm increase. Every particle of bioplasm which might have taken part in tissue formation will, if it grows and multiplies too fast, not only lose its power of forming tissue, but the particles that may be produced from it, by descent, never regain the wonderful capacity that has been lost. But although formative power is lost, new powers or properties may be, nevertheless, acquired. These are remarkable for destruc- tion, never for construction. Some forms of pus acquire during their production the most wonderful capacity for rapidly growing and multiplying, as well as for living and resisting the influence of external conditions. The little offsets or particles that are de- tached from them may rise in the air, live for a time in water or milk, or other fluids containing organic matter, adhere to a sponge or probe or other substance, or be carried in the living state on the foot of a fly or some other insect, and thus be transported to an organism at a distance from the one which was the seat of their production. The minute germs, being in contact with ma- terial adapted for their nourishment, rapidly grow and nmltiply in their new situation. Such forms of virus have been produced ab-initio^ fostered and propagated to the destruction of hundreds of human beings. Thus, according to Beale, the phenomena connected with con- tagious animal virus are due to a minute particle of living bio- plasm produced, by descent, from the natural bioplasm of the body. "This particle of deteriorated bioplasm, Mdiich in some cases may be seen, is a ' diseased germ,' and of these ' contagium ' consists." The contagious bioplasm results from natural bioplasm, the life of which has been carried on, for some time, under un- usual conditions. ZYMOTIC CAUSES OF DISEASE. 605 An ordinary form of diseased bioplasm, pns, often originates in the bioplasm of epithelium and in that of connective tissue, and certain forms of pus have specific virulent properties, are, in fact, animal poisons which may be inoculated. The author of the living germ hypothesis does not, however, entertain the opinion that all contagious diseased germs spring from the bioplasm of epithelium or connective tissue. Some may come from white blood corpuscles. But he considers that the contagious particles concerned in propagating many of the most serious specific fevers have been derived from the living matter of man's body, and that they are not germs of fungi or bactei-ia of any kind whatever. Indeed in certain instances they may be seen in far greater multi- tudes in the tissues of the diseased organism than bacteria, which latter, as is well known, are found often enough in countless multitudes in cases in wdiicli there is no specific disease of any kind. In these few pages I have, I hope, condensed in a clear form t\\e living germ hypothesis of Beale. It differs, it wall be seen, from the previous hypothesis, that while it traces the changes of phenomena which mark the zymotic disease to a living particle or germ as the primary cause of those changes, it derives the par- ticle from an affected body itself, in the first instance, and traces the continuance of the disease-producing particle from such body instead of from the parasitic vegetable world. The Neevous or Neuro Hypothesis. When, at the commencement of the Registrar-Generars Re- ports, Dr. William Farr formularized the list of diseases belong- ing to the zymotic class, the view started by Liebig of the cause of zymosis or fermentation was the accepted view. Liebig sug- gested that in organic nature there were certain bodies wliich are capable of undergoing fermentation, and other bodies which, by their presence, are capable of exciting fermentation. The sub- stances which can ferment are of amylaceous or saccharine nature, and the substances which excite fermentation are of albuminous or nitrogenous nature. Thus, in the illustration which was given a few pages back, from Di-. Dougall, the sweet solution, which was referred to as undergoing fermentation on tlie addition to it of yeast, was said to ferment in consequence of contact with the 606 ZYMOTIC CAUSES OF DISEASE. 5"east, Tvliicli is fi nitrogenous substance. The torulae, or living things in the jeast, were, it was known, there, and the fact of the increased growth of the torulse during the process of fermentation was also known. But it was considered that the living thing was merely an attendant thing, and that the increased growth of the living thing was resultant, not causative, coincident, not essential. It was thereupon assumed, very naturally, that changes either re- sembling fermentation, or really fermentative, might take place without any connection at all with living germs or living particles, whenever nitrogenous matter in decomposition came into contact with fluids susceptible of fermentation. When the hypothesis of zymosis in relation to disease came under consideration, this view of Liebig, as to the cause of ordi- nary fermentation, w^as taken as explanatory of the general pro- cess in the affections designated zymotic. The material which passed from the infected persons, tlie contagium, was assumed to be a virus or poison of a nitrogenous character possessing the property, when it .was absorbed by a person who was susceptible to its influence, of promoting a specific fermentation and a specific disease in that susceptible person, with more of the specific virus itself. Thus each disease produced its own specific ferment. As a student of this physical reading of zymosis, I conducted between the years 1856 and 1863 a long series of experimental inquiries as to the propagation of disease, from one animal to an- other animal, by the inoculation of the secretions of an affected animal into a healthy. I lighted in this manner upon many curi- ous facts. I found that disease could be transmitted from animal to ani- mal by inoculation of various secretions, and, in addition, I learned that the secretion became more and more actively virulent as it became derivable from new stocks of infected animals, i.e., the virus increased in intensity of action by passing through and af- fecting an animal body. Again, I found that the virus or infecting secretion would not ■ only act as a virus by being directly inoculated into the body of the susceptible animal, but that it could be transformed into an alkaloidal substance, when it would still continue to produce the specific effects. Some fluid drawn from a wound in a patient under the care of Mr. Spencer Wells, — fluid which during surgi- cal fever had been excreted into the peritoneal cavity, — afforded ZYMOTIC CAirSES OF DISEASE. 607 a virus wliicli I reduced to the alkaloid al state in the form of a crystalline alkaloidal salt, A solution of this salt gave rise, when it was inoculated into a susceptible animal, to the most distinct form of disease of specific febrile character, and the secretions of the infected animal reproduced, by inoculation, the same type of disease in other susceptible animals. In the end I came to the conclusion that any secretion of the living body might be charged vrith a poisonous substance wliich was capable of acting as a con- tagium. To this hypothetical substance I gave the name of se])- tine, and I called the diseases induced by a septine, septinous diseases. As the inquiries which led up to the experiments with septine progressed, I was led to form a view as to the nature of the poi- sonous base and as to its mode of origin. As I have already said, it seemed to me to be an alkaloid, or chemical substance, resembling, in physical properties, morphine, strychnine, and other bodies of that class, derived, not like them from vegetable but from animal organic matter. The difficulty in assuring this lay in finding a reason for the various eifects of the septinous material. If it were a common base like that which I suspected I liad found, why should it not always produce the same form of septinous dis- ease ? Why should it, on the other hand, produce, as virus does, many kinds of disease, each having a certain general likeness to the others, but each at the same time different in many important details, as different, for example, as small-pox is from scarlet fever, or measles from hydrophobia. The difficulty, in this way suggested, led me to reflect on the connection which might exist between the bases of the diiferent secretions of the animal body and the matter I had called septine. Each secretion yields some organic product ; the gastric secretion pepsine, the salivary seci-etion ptyaline, and so on ; and each secretion plays a diiferent part in function, although the organic bases of them all may present a general similitude of construction. Thereupon 1 was led to the conception that the secretions of the animal body are the sources of the zymotic diseases, and that the various diseases are, in fact, all of glandular origin ; that in every case of disease the virus producing it is nothing more and notliing less than a modified form of one or other secretion, and that as regards the organic poisons tliemselves and their physical properties, the great type of them all is represented by the poison 608 ZYMOTIC CAUSES OF DISEASE. of a venomous snake. If we puncture the poison bag of tlie cobra, for example, there exudes a peculiar fluid substance almost like clear gum-water. That is the poison. If we gentlj dry that poison down, it becomes a darkish, somewhat powdery, half- glistening mass. If this substance be mixed with water and inoculated it is still poisonous, and if an animal be inoculated with the virus so as to be poisoned by it, the secretions of that animal in their turn yield a virus whicli produces similar symptoms. On this explanation as to the production of a specific virus, it is inferred that the increase of virus in an affected animal does not depend upon multiplication from a germ, as offspring multi- ply from parents, but that a particle of any one of these poisons brought into contact either with the blood of the living animal or with certain secretions of the living animal, possesses the property of transforming that secretion into a substance like itself. The process of change is catalytic. It is a change by which a body is transformed by the presence of some other body whicli does not itself undergo change. The multiplication of the poison takes place through the force of secretion of the person affected, not through the deposit of vegetable parasites and multiplication of them, nor from prop- agation of living germs. If, for example, the poison from the eye of a person suffering from contagious ophthalmia passes to the eye of another person, presently there is a free secretion, which in turn becomes affected and poisonous. It is not that the particle of poison has propagated a new particle, but it is that the natural secretion of the eyeball has come in contact with a speck of poisonous matter, and immediately at that point, where the speck of poison was implanted, there is a change in the secretion. This process widens the circle, more secretion pours out, more poison is produced, and the increase goes on until, in the end, the whole body of the animal may become affected by absorption of poisonous matter into the blood from the injured surface. As a general rule the human body furnishes, I believe, all the poisons that the human body suffers from, that is to say, ordinary secretions may change and become poisonous without previous infection. This has been remarkably brought out in the case of puerperal poison, where a secretion from the hand of the ac- coucheur has produced the puerperal fever. In the case of peri- tonitis, or inflammation of the peritoneum, there is a secretion ZYMOTIC CAUSES OF DISEASE. 609 wliicli may be carried on the hand of a healthy person and pro- duce the disease. Typhus may be produced by the overcrowding of persons in a room, through the vaporization of oi-ganic matter at a low temperature. Thus we may have springing up de novo an organic poison which afterwards, on being introduced into one particular body, becomes increased by the secretions of that body. The organic virus so formed may be transmitted in each of three ways. It may travel as dry solid matter, wafted or carried in the air. It may be borne by linen that has been tainted with the secretions of patients and then dried. It may travel in water or in water suspended in the form of vapor. The mode of the entrance of organic virus into the body, although contact is always required, -varies with its different kinds. The virus of measles, scarlet fever, and typhus is, I believe, al- ways inhaled. The virus of small-pox, diphtheria, glanders, erysipelas, and hospital fever, may act either by being inhaled or inoculated. The virus of ophthalmia requires direct contact. The virus of cholera, yellow fever, and typhoid fever seems always to be swallowed ; each may be called, specifically, a poison of sew- age, travelling, usually, in the fluid form ; each may, nevertheless, travel for short distances as fine dust, or in water in the form of vapor. The thought that the virus of the various spreading diseases is a secretion, and nothing more, came naturally out of my researches. I realized, as it seemed to me, that all these spreading and com- nmnicable diseases spring out of the living body itself. That they are as distinctly the offspring of living animals as real prog- eny are, and that to look to outside sources for them, to look to vegetative growth for them, for example, or seedling, is merely to ignore the basic facts which lie obviously before us for lesson and learning. As well suppose that proci-eation of animals is due to an external vegetable product or other product dissevei'ed alto- gether in its origin from the animal, as that the virus which cre- ates disease of a communicable kind is in such manner dissevered, as to its origin. Another thought which occurred to me in the course of my labors, and which I expressed in the earliest records of them, has relation to the force by which the poisons of the various diseases are developed and thrown off. It is well known that the produc- tion of the poisons in a living body, infected by one of them, is 39 610 ZYMOTIC CAUSES OF DISEASE. limited in respect to duration of time of production even when the body lives and recovers. This fact seemed to me to prove to demonstration that the poison itself is produced by the affected body, and is determined, in its productioUj by some natural func- tion of the body or of some part of it. On the basis of my hypotliesis that the virus in every case is a modified secretion, this view of the force of production of the secretion is easily accepted as in accordance with natu]-al law. The force of production is the force of secretion, and so long as the secretion continues changed in character, so long it is thrown off as a poisonous secretion ; but so soon as the modification of secretion which rendered it poisonous is stopped, so soon the se- cretion, flowing onward as before, is rendered innocuous, that is to say, no longer poisonous. If this were not the case, there is no reason, as far as I can see, wliy, in every instance of infection, the infected person should not die. Endow the poison itself with independent forces of life and of reproduction, give to it a distinct reproductive life of its own, and why should it ever cease to reproduce? Why should it not, in every case, continue to in- crease within the infected body, indefinitely, until it kills the body, and why should any one ever recover ? But consider the poison as a part of the animal body itself, a substance to be eliminated from the body by natural methods, then the process of removal of the poisonous condition comes into the natural order of events, and recovery is a natural process, unless some unusual conditions occur to interrupt the natural course. We see in a common nasal catarrh the outline of this process. There is first a dryness of the secreting surface, with i-eflex ner- vous irritation and much nervous depression, and disturbance thereupon, in the circulation of the blood. After a time there is a copious secretion from the nostrils, which continues until the disturbed nervous balance is brought back to steady natural ac- tion. At this time the overflow of secretion is checked, and noth- ing more is left than the local effects of hardened secretion, or scale, due to desquamation arising from the excessive previous action. In outline this is really the natural course of every zymotic disease, with the exception that the secretion of a catarrh is not definitely proved to be a contagious secretion. I believe it may ZYMOTIC CAUSES OF DISEASE. 611 be so, and sometimes is so ; but I need not press the point. The ilhistration is adduced merely to show that the course of the dis- ease is from within outwards, and that it is checked in its course by restoration of internal natural function. If catarrh were pro- duced by some external vital agency, reproductive in character, lighting upon the nasal tract ; if it M^ere due to the colonization of the nasal tract by an army of foreign invaders which settled there, and began and continued to replenish and multiply, when would the catarrh cease ? It would, as far as I can see, continue, until, by destruction of parts and continued abstraction of secre- tion and extension of mischief over a wider tract of surface, it killed inevitably. A catarrh, according to my view, is typical of all the diseases which run a given course, and are called spreading diseases. It springs up constantly from external atmospheric variations ; it runs a given course ; it subsides. It is often epidemic, and it %vould be a true contagious epidemic if the matter secreted from the nasal cavity and the conjunctiva were not so innocuous. As I have hinted already, I believe it may be contagious. I am quite sure that many times in my life I have taken catarrh by coming near to a person who was affected by it, but whether this conta- gion is sympathetic or toxic, I am not able to define. On these intimate relations I shall have more to say on a future page. In continuance of observation I have noted that the number of the distinctly communicable diseases is closely related to the number of secretions. The poison of hydrophobia is from the sal- ivary secretion ; of diphtheria from the mucous glands of the throat ; of scarlet fever, I believe, from the lymphatic glandular secretion ; of glanders from the mucous secretion of the nasal sur- face ; of typhoid from the mucous glands of the intestinal surface. In some instances the blood itself is infected, and the corpuscular matter becomes the seat of the catalytic change. On the ground that the virus is always from a secretion I have been led to the conclusion that under certain influences affecting glandular action the virus may be made to originate directly through nervous impression without the necessary intervention of an infecting particle. In many epidemics it is common to see a number of examples of the prevailing disease the origin of wliich is traceable only to fear or anxiety. We call these nervous cases, and we try to define them as such and as distinct from cases due 612 ZYMOTIC CAUSES OF DISEASE. to contagion of a direct kind. But the symptoms are tlie same as those which follow actual contagion, and in epidemics of cholera they take even a fatal character. My view explains, fully, the reason of this. It indicates that an extreme nervous impression acts on the glandular nervous supply, paralyzes the glandular function, and thereupon produces the same phenom- ena as is produced, in other instances, by the action of a specific poison. The hypothesis in this manner accounts for the origin of an epidemic disease from an impression made on the nervous system without the direct contact of poisonous matter, as well as for the after-propagation of the disease by distribution of poisonous par- ticles when they are communicated from an infected to a healthy person. It accounts equally w^ell for the production of disease and of a poisonous glandular product under conditions of starva- tion and cold, by which the nervous tone is reduced. Again, it accounts for the production of disease and of a virulent glandular secretion under special atmospherical conditions, in which the activity of the atmospheric oxygen is reduced in sustaining power. It has occurred to me further, as a result of the study of the action of the poisonous particles, that when they are brought into contact with the secreting surface, their action towards the body at large is, in the first instance, directly on the nervous fibre. They act in the first instance as irritants on the peripheral ner- vous surface, and their effect may, I believe, extend particle by particle, as by diffusion, through the whole length of the ner- vous cord to the nervous centre. I have no doubt this is what slowly takes place in hydrophobia. I believe this is what takes place in diphtheria when paralysis is the sequel of the acute symptoms of the malady. I believe the same mode of progres- sion of the poisonous influence is what happens after inoculation with matter of smalhpox ; that the severe nervous symptoms which mark the onset of that disease are due to the extensive in- jury inflicted on the nervous organization ; and, that the diffusion of the eruption over so wide a surface of the skin and mucoi;s membrane is the reflex on the peripheral nervous surface from the nervous centres. It is worthy of special notice in connection with this part of my subject, that in the communicable diseases attended with an eruption on the skin or nervous surface, the eruption, as a rule, ZYMOTIC CAUSES OF DISEASE. 613 takes a circalar form. If it be a point of vascular blusb, a petechial spot, it is a rounded spot ; if it be a pustule it is rounded ; if it be a more diffused rash it commences in centres which are rounded points. This appearance is an indication of nervous injury. The rounded surface is the radius of injury done to the nervous supply of that part. It is a paralysis of the centre of nervous distribution over the affected part. My researches on the influence of extreme cold on nervous function are strikingly illustrative of this. They suggest that the nervous impressions sent from the centres to a peripheral surface spread out when they reach the peripheral surface, such as the surface of the skin, like circling waves ; as water spreads out in circles on a pool when a stone is made to impinge on it. The time required for this change is, I conceive, the period of incu- bation in zymotic diseases. Some other recent investigations on the mode of action of the poisons of the communicable diseases have led me to suspect the source of the symptom which is so common to most of them, and which is known as the attendant fever. The fever is of three kinds : primary, reactive, and remittent. The primary fever is that which precedes and attends the eruption of an eruptive dis- ease. The reactive fever is that which succeeds the extreme col- lapse of an acutely-exhaustive disease, and is like that which follows exposure to extreme cold. The remittent fever is that which succeeds upon an acute form of disease, and indicates that there has been either secondary absorption of matter from an abraded surface in contact with poisonous substance, or that some fibrinous or pustular matter has formed within the body, and become a new and permanent centre of infection. The first of these forms of fever is, I believe, due to the impression on the nervous centres by the poison, in the manner I have described above. The second, the reactive fever, is, I believe, due to the same action as that which locally may be induced by extreme cold, viz., by an influx of blood into vessels that have been paralyzed, and by a rapid radiation of heat from extensive surface of blood. The third form of fever, the remittent, has an origin, I believe, specifically its own. I have found that pustular matter and all secretions containing fibrinous or cellular structure have the prop- erty, by their presence, of liberating oxygen from solution. This 614 ZYMOTIC CAUSES OF DISEASE. extends, as I have found, to blood charged with oxygen, and I am led to the inference that when there is an absorption of such matter into the circulation it causes an undue liberation of oxy- gen, with a quicker combustion, or fever, which lasts until the exciting matter is itself destroyed and eliminated, and which does not recur until there is re-absorption of more of the exciting agent. In this physiological mode I sliould explain all the phe- nomena of the remittent attack ; the cold stage incident to the ab- sorption of the exciting matter ; the hot stage incident to the period when, by its presence, the exciting matter is setting free excess of oxygen ; the sweating stage when, by rapid elimination through the sweat glands, the equilibrium of temperature is restored. The study of the nervous hypothesis of the communicable dis- eases has suggested to me another thought, which observation of the diseases fully confirms, namely, that these diseases, like all which have their root in nervous derangement, present a distinct heredity. The impression of disease made on a nervous centre is transmitted. There can be no doubt as to transmission of ten- dency to particular communicable diseases. Any physician in full practice can find any amount of evidence on this fact by simple natural inquiry. Typhoid fever is clearly a disease possessing hereditary transmissible quality. Diphtheria is the same. Scar- let fever is the same, and small-pox I should suspect was once, almost universally, so characterized. These facts alone, one of them alone, is sufficient to stamp the origin of the communicable diseases as from the animal body itself. It is cei'tainly one of the best of proofs of the truth of the hypothesis of the nervous origin of the poisons. It will be seen by those who look with sufficient patience, that the mode of connection of the diseases in hereditary line is the same as that which connects hereditary types of eveiy kind, physical type, mental type, all else that binds many individuali- ties into one family. Lastly, the study of this hypothesis of the communicable dis- eases enables me to offer the most rational explanation of the phenomenon of non-recurrence of the diseases after they have once attacked a person susceptible to them. It is well under- stood that, as a rule, a person who has been affected by a com- municable disease is not affected a second time. To this rule there are many exceptions, but on the whole it holds good. On ZYMOTIC CAUSES OF DISEASE. 616 ray liypotliesis the reason of the phenomenon is simple enough. Tliej who are susceptible are born with a nervous impression tending to the production of a diseased secretion easily changed into a poisonous secretion imder the direct action of contact with poisonous matter, or even under the influence of a central nervous depression whereby the glandular function is deranged. But when such a person has passed through the ordeal, the tendency, for a time at least, disappears, owing to the complete modification of glandular function that has been induced, to the free elimina- tion that has been established, and, probably, to the change in the nervous matter itself that has resulted from organic modification. Hence the organism becomes insusceptible. for a time, and if the tendency be not intense that time may mean the whole of the life. Indeed as life advances and nervous susceptibilities, derived directly from ancestry, lapse into individual self- sustained sus- ceptibilities, these tendencies to disease subside as a general fact, and lose their activity if not their existence. It is not therefore a new pabulum that is formed to insure a repetition of infection, but the removal of the capacity to produce a new virus which will act on existing ordinary pabulum. Lastly, this hypothesis connects together in natural order the relationships of the physical to the moral contagious diseases, the border land between which is often all but undefinable. In both instances of communication of contagion, the first impression of the contagion is on a peripheral nervous point or surface. For the moral contagious phenomena, the peripheral expanse of an organ of sense is the receiving point. For the physical contagious phenomena, a point in the peripheral nervous expanse of skin, of mucous membrane, or of serous membrane, is the receiving point. The diseases which spring from contagion are all, therefore, primarily, nervous in their mode of develop- ment in the bodies of the affected. The physical contagions are either absorbed tlirough nervous matter, or they excite, by contact, a change which extends along the nervous matter, the period of incubation being the period during which the contagion is extending its influence to the nervous centres, so as to excite central disturbance. In some instances the first effect of such contagion is indicated in a few hours, as in cholera; in other instances the effect is delayed for many weeks, as in the case of hydrophobia. 616 ZYMOTIC CAUSES OF DISEASE. Tlie active organs of the body first and specifically affected by the physical contagions are the glands. When the contagion is moral, and extends from irregularity of nmscular motion to func- tional change of organs, the action, caused by the nervous dis- turbance, is also on the glands. It is a nervous reflex of some glandular affection that has been observed by the sufferer. It is like the weeping which some persons exhibit at the sight of weep- inw, though they themselves may be unaffected by the primary cause of sorrow. Moral contagion is the mere continuance of motion from one person to another ; a direct impression made through the senses into the internal nervous centres. It is like the motion which can be excited in a compass needle by bringing a magnet within the sphere of communicable action. It acts at sensible distances. Physical contagion is the movement of a point of affected matter into contact with a surface of the body through which the nervous organism can be reached. It acts at insensible distances. The diseases arising from moral and physical contagions are so closely related, that one may lapse directly into the other. Both assume sporadic and epidemic forms. Practically, they are of the same origin, and are convertible phenomena. Summary or the Hypotheses. The reader has now before him the three hypotheses of the origin and cause of the so-called zymotic diseases. The first assumes for the cause a vegetable parasite whicli exists outside the body and which carried into it sets up a fer- mentation, if there be pabulum in the body to undergo the pro- cess of fermentation, and is itself reproduced so long as there is any pabulum for its sustainment. The second assumes that the cause is a living germ, w^hich belongs to the body itself, but which has UTidergone change of deterioration, in which condition it reproduces, from a favoring pabulum, its like in large quantity, and thus excites disease. The third assumes that the virus which excites the disease is a modified secretion which has the power of communicating, by an interference with nervous function, its own properties to a healthy secretion, and wliich continues in action until natural nervous function is restored. ZYMOTIC CAUSES OF DISEASE. 617 By all these hypotheses the same results are reached in one particular. They all assume that the affected or diseased body produces or reproduces something which is oi-ganic and material, and which passing over fi-om the diseased to the healthy but sus- ceptible person, is capable of exciting the same disease in the susceptible. To which view the nervous hypothesis adds that the phenomena of the disease may also be excited de novo, that is to say, without the contact of infection, by the following modes. — («) Change of a secretion from simple nervous disturbance. — (b) Change of secretion excited by atmospheric conditions — so-called epidemic influence. — {c) Change excited by irregular and imper- fect sustainment of the body. This hypothesis also connects the ordinary or physical with the moral contagious affections. In favor of the first or pai-asitic hypothesis there is the matter of analogy. It cannot be denied that the illustration with which I prefaced that hypothesis, in which the fermentation of saccharine solution by yeast was compared with the action of small-pox virus on a susceptible living body, is striking, as an illustration. There is, admittedly, an analogy. Here, however, analogy, always a doubtful argument unless it be supported in every detail, is altogether unreliable. Even in regard to small- pox it does not hold its ground, because in the virus of small-pox a vegetative growth similar to that which is detected in yeast is not detectable, and cannot be, what is called, cultured ; so that at the very outset the analogy breaks down. AVhen we extend the analogy fi-oni one disease to the diseases of the whole of the zymotic group, the failure is even more con- spicuous. If it were true, a particular parasitic growth should be detectable in every disease, which is not the fact. If it were true, specific forms of fermentation yielding specific products of fer- mentation, should be met with in every case, which is not the fact. If it were true that living germs possessing an independent growth and vitality enter the animal body, that every disease of a communicable kind is due to its own external living germ, and that the germs continue to multiply and increase by an indepen- dent action of their own ; if this M-ere indeed true, why do the germs after a certain time cease to multiply and allow the sick person to recover ? Why do they not go on multiplying until the person is infested in every part and fatally stricken? Who would get well from a disease due to living self-propagating con- 618 ZYMOTIC CAUSES OF DISEASE. tagions ? Again, wlio, if the hypotliesis were true, would escape fertilization ? A general fertilizing diffusion of self-propagating matter, in minute invisible form, entering the body as the air may enter, could hardly be expected to select a small minority of a population, and if it did so at the first, why should it do so when it had seized upon many centres in which it could increase 'i But the history of all the communicable diseases shows that each epidemic affects individuals individually at different periods in the course of the epidemic, according, as a rule, to exposure to the infected, and that the period of the disease is limited by a development and a course rendered in certain periods of time. If, again, the parasitic hypothesis were true, the question of heredity in respect to tendency to particular diseases could have no place. A germ of disease extraneous altogether to the body until it came accidentally into contact with it, can have no connection with heredity as a first cause of disease. As a secondary cause such a germ may truly find a part ; I mean, that M'hen a dis- ease is once excited, a floating vegetable germ in the atmosphere may find, in the diseased body, a home in which it can multiply, pabulum on which it can live, and a function which may rather be useful than otherwise to the aifected, by playing, as Professor Owen has put it, a scavenger's part. But this is not the produc- tion of disease ; it is merely an illustration of one of George Herbert's happiest proverbs, singularly applicable here, " Mies a?'e busiest about lean horses.'" Of Dr. Beale's hypothesis, the living germ hypothesis, I would speak with the greatest possible respect, and in regard to its application in one direction, the production of pus, or purulent matter, in the living body, it is the most rational, as it seems to me, of all the views that have ever been propounded. At the same time I cannot apply it to the whole series of spreading and communicable diseases, with their varying periods of incubation, their varying phenomena, their varying modes of termination. I think it sometimes forms a part of the history of every one of these diseases, modifying them in their course, or determining their end. But I cannot see it as primary. On the whole I abide by the last hypothesis, or that which attributes the so-called zymotic diseases to a change in the natural zymosis, induced by an impression made upon the nervous sys- tem. I believe that this view explains fully why the first symp- ZYMOTIC CAUSES OF DISEASE. 619 totns of all the diseases poiDt to nervous derangement ; why there are varying periods of incubation ; why there are hei'editary^ tendencies for and against the particular diseases ; why a certain measure of protection is afforded by an attack of one of these diseases ; why a purely mental or nervous act excites these affec- tions ; and why there is so close a correspondence, running even with season, between physical and moral outbreaks of spreading and contagious affections. Lastly, I maintain the hypothesis of nervous origin because of the practical usefulness of it in relation to prevention of dis- ease. If the view were true, that the air around us is charged with invisible germs which come from whence we know not, which have unlimited power to fertilize, which need never cease to fertilize and multiply, what hope is there for the skill of man to overcome these hiddden foes ? AVliy on some occasion may not a plague spread over the whole world, and destroy life uni- versally ? The nervous hypothesis presents an altogether different aspect. It says to living men and women, it is you who are the producers of the communicable diseases, or if it be not you yourselves it is one of your lower earthmates in creation, some domestic animal that shares with you the power of producing a poisonous secretion and of giving an hereditary stamp of production to such poison- ous product. It looks on the man or animal affected with a contagious disease as one precisely, for the time, in the position of tlie cobra or other animal that is naturally secreting a poison ; and, recognizing this fact, it suggests at once that the danger is all but limited to the person affected. Isolate that person from the rest of mankind, take care that his secretions, vohitile, fluid, or solid, do not come in contact with the secretions of susceptible healthy persons, and the danger is over. With the recovery of that person, that is to say, with restoration in him of a natural secretive process, the poison is destroyed ; or should he, unfortunately, die, then with the failure of his power to produce further secretion the danger is over, ex- cept some of the poison formed before the death be actually carried away from the dead body. In a word, if the hypotliesis be true, we sanitarians have complete mastery over the diffusion of the poisons of all the communicable diseases. AV^e have but to keep steadily in view that the producing and reproducing power 620 ZYMOTIC CAUSES OF DISEASE. is in the affected body itself, and we can then limit the action to the propagating power of that body, — its power, I mean, of secret- ing and diffusing secretion,— even with our present knowledge, all but completely. Beyond this, if the hypothesis be true, we must expect, as we reduce the communicable diseases of one generation to reduce the tendency to them in the next generation, so that in time the he- redity to particular spreading disease shall be thoroughly wiped out. CHAPTEE IX. INDUSTRIAL AND ACCIDENTAL CAUSES AND ORIGINS OF DISEASE. In tlie last chapter I brought to a close the study of the prin- cipal causes of the natural diseases affecting mankind. The causes of the diseases which are induced by our own acts and deeds were exposed as the diseases were, one by one, described in the chapters of the Second Book on Acquired Diseases. I need, therefore, do little more in this present chapter than condense the chief of these acquired causes, as they affect the industrial popu- lations, into the following classified forms. Indtjstbial Causes. PaBTS Ai'i'ilCTED. Diseases Induced. Cigar-making Dyspepsia. Lace frame-making Pottery- Gastro-enteric Painting and lead-working irritation. Fur-dyeing Nausea and vomiting. Bronze-founding Paper-staining Digestive System. Pyrosis (water brasli). Tinning and brazing Muguet. Needlework O Tailoring Choleraic Diarrhoea. Clerk's work Colic. Draper's work Vine-dressing Constipation. Potteiy working Painting and lead working Aniline dye-making Chemical manufacturing Working in bisulphide of carbon Working in bisulphide of mercury Brazing Fur-packing Engine-driving Railway service Coffer-dam working Cigar-making The Brain and Nervous System. Vertigo. Cerebral exhaustion and paralysis. Cerebral congestion. Apoplectic coma. Neuralgia. Mercurial Rheumatism and Neuralgia. Dementia. 622 INDUSTEIAL AND ACCIDENTAL CAUSES Industbial Causes. Parts Aiteoted. Diseases Induced. Cigar-making Lace frame-making Bleaching Hat-making Fur-dyeing Aniline dye-making Needlework Tailoring Draper's work Dock laborer's work Drayman's work Potter's work Postman's work Groom's work Bone-boiling Blacksmith's work Farrier's work Boatman's work Laundry work Clerk's work Coal-heaving Butchering Waiting Porter's work .Blood and Cir I culatory System. " Palpitation and irregular action of the heart. Intermittent action of the heart. Enlargement of the heart. Valvular disease. Degeneration of the struc- ture of the heart. Aneurism. Cyanosis. Extreme fluidity of the blood. Anaemia. Pottery working Millstone and stone-cutting Pearl-cutting Sandpaper-making Needle and knife-grinding Hemp and flax-dressing and spinning Eag-working Milling and flour-working Wood and ivory turning and carving Cigar and tobacco manufac- ture Walking-stick-making Hair-dressing Brush-making Fellowship porter's work Burnishing Paper-staining and artificial flower-making Mining Trimming-making Alkali-making Tailoring Draper's work Clerk's work Paving The Eespiratory System. Phthisis pulmonalis or pulmonary con- sumption. Bronchitis, acute and chronic. Bronchial phthisis. Bronchial initation. Emphysema. Asthma. Spasmodic and Flax Asthma. Chest spasm. AND OEIGIlSrS OF DISEASE. 628 IXDUSTEIAIi CaTJSES. PaETS AFFECTEa). Dock laborer's -work ^ Carpentering and cabinet- I making Waiting Butchering | Needlework J I The Respiratory |- System I (Con tinned). Diseases Induced. f Phthisis. I Asthma. Emphysema. Bronchial irritation. Bronchial phthif^is. Bronchitis, acute and chronic. Vine-dressing ~| Working in bisulphide of | carbon Working in Cyanide of po- tassium J Working m mercuiy | Working in lead | The Sensory System. The Glandular System. Ophthalmia. Double vision. Impairment' of vision. Amaurosis. Deafness. In'itation of salivary glands and salivation. Nephrosis. Chronic in- flammation of Kidney. Paralysis. Pottery making Painting and lead working Fur-packing Cigar-making Working in merctiiy Working in bisulphide of carbon Bronze founding The Muscular System. f Mercurial tremor. I Cramp. I "I Spasm. Atrophy. \_ Inflammation of bone. Pearl working Fur-dyeing Working in mercury Working in phosphorus Domestic service Coal-heaving Porter's work The Osseous System. Necrosis. Deformities of limbs. White swelling. Caries of the teoth. Aniline dye-making ] Working in mercury I Working in bichromate of | potassa Working in arsenic Working in crude paraffine | Working in soot J ! Skin and Mem- J [ branous System. ' f Aniline discoloration. Ulceration and exfoli- ation. Follicular inflammation. Soot ulcer. 624 IlS^DUSTRIAL AND ACCIDENTAL CAUSES JRelationshvps of Occupation to Disease. In studying the relationships of occupation to disease, I may observe that many occupations attended with disease and with a high mortality should not necessarily be considered as unhealthy from the mere influence of the industry itself. The businesses of the printer, the draper, the needle-w'oman, the tailor, the clerk, are illustrations of industries which in themselves are harmless, but which are connected with a very indifferent vitality. The butcher has not more hours of work than the carpenter, blacksmith, shoe- maker, or baker, yet his vitality is below theirs. The business of dock laborers would not seem to be more injuri- ous than that of sawyers, 3^et they are much less healthy and have a higher death-rate. These differences are not traceable to the occupation itself in any of the instances named, but to the conditions under which the work is carried on. These conditions are, in the main, exposure to impure air, to alternations of temperature, often great and sudden, and to exposure to damp. The needle- woman and the tailor are perhaps the fairest repre- sentatives of those who suffer from close and impure air. Packed together in small rooms, imperfectly heated, or over-heated, and imperfectly ventilated, frequently, in fact, not ventilated at all except through the crannies of window and door and the occa- sional open door, tliese people soon become subjected to the poi- sonous influence of their own exhalations. Being at the same time overworked, badly fed, and unbef riended. by any glimpse of change of scene and life, they rapidly fall victims to the most fatal of diseases, the disease consumption being the most common of all. They live from day to day in that form of devitalized atmosphere which I have described, in a preceding page. By day this is the atmosphere of their workrooms, by night it is the atmosphere of their small miserable bedrooms, and between the bedroom and workroom where is the life ? If the class of workers named and others kindred to them do not suffer from consumption, if, in early life, they struggle past that peril, they still know nothing of health in the happy sense of the word. The women are depressed in mind and body, anae- mic, bloodless, emaciated, always dyspeptic, and incapable of meeting the maternal duties in such a manner as to be just to AND ORIGINS OF DISEASE. 625 themselves or to their offspring. The men are pale, emaciated, restless, and unhappy, so that even the songs they try to sing, and the conversation they endeavor to carry on in order to relieve the mental gloom, soon become mere automatic monotonies, lighted np with fitful outbursts of petulance or passion, or deepened darkly by seizures of silence and intense melancholy. The plain truth is that the workers are placed under what may not improperly be called experimental conditions for the development of disease. In them the disease of nervous feeble- ness is very easily lighted up if they become subjected to any change that leads to congestion of the lungs. They are exceed- ingly susceptible to atmospheric variations. They are tenderly susceptible to cold. They keep their rooms close in order to keep them warm, and the slightest exposure to quick and severe cold subjects such susceptible beings to a fatal shock which, though it be not immediately fatal, is the beginning of fatality. The suf- ferers " take cold," the cold is renewed in vicissitude of season, especially of the spring season, and with the frequent repetition congh becomes established and disease usually of the consumptive type is developed. In an institution for diseases of the chest, to which for many years I acted as physician, this mode of development of consump- tion was told me over and over again, a stereotyped story. Con- stantly victims of the disease were not even aware that it had commenced, although it had already passed into a stage beyond the art of the physician for the hope of cure. Clerks and printers are to some extent subjected to the same dangers from impure air as the classes above-named, and both printers and clerks are too often subject to overwork. Printers also are apt to be affected by late hours at work, and especially by working in gaslight. In a less degree than the above-named workers drapers may be enumerated as sufferers from confinement for long hours in close and impure air. The goods with which the draper's shop is filled are specially disposed to catch and retain dust, and also to retain every organic emanation that is capable of taking a hold on textile fabrics. The draper suffers greatly from chest affec- tion as a result of living under these conditions. In my -work on "Health and Life," I have pointed out these facts in ]-eferenceto drapers, and for the sake of a striking illustration have instituted 40 626 IISTDUSTRIAL AND ACCIDENTAL CAUSES a comparison between the draper and the grocer as indicatinej how much more favorably the grocer is placed in respect to the value of his life. I have shown that 108 drapers die to 76 gro- cers, and have pointed out how the difference depends upon the comparatively out-door life of the grocer, though he too is a shop- man, in contrast with the effects of the pent-up life of the draper. Exposure to great heat is a source of risk incident to some industrial callings, such as those of the stoker, glass-blower, and laundress. If, however, there be a free ventilation in the work- place and such lightness of clothing as permits free perspiration the danger is not great. Laundresses suffer most from the great heat, for in their case the heated air is often laden with moisture, and the stoves in which the irons are heated produce a very dele- terious atmosphere. Exposure to damp is another cause of serious derangement of health and impaired vitality amongst some members of the indus- trial class. Harbor and dock laborers are marked illustrations of this type. They, exposed not only to severe labor but constantly to wet and inclement weather, generally die very rapidly, their mortality being 121 compared with a mean standard of 100. During exhaustion they become exceedingly susceptible to colds and affections of the chest which are destructive in character. They do not suffer so much, however, from consumption proper as from bronchitis, and from a wasting bronchial affection which, at one time, was often confounded with true consumption, but which is very distinct from true consumption, and to. which, in modern times, the name of hronchial j>ht}iisis has been applied. It is well worthy of remark in this place, because the facts that have been before us in the last chapter render the illustra- tion very complete, that affections of the chest brought on by exposures to unfavorable external conditions vary, with much regularity, according to the circumstances of exposure. When the exposure is to confined air within-doors the chest disease in- duced or favored is, as a rule, tubercular consumption. When the exposure is to inclemency and vicissitudes out of doors the tendency is towards bronchial affection, Avliich, though less spe- cifically fatal to the young, is commonly fatal at a comparatively early period of the middle stage of life. The dock-laborers, and others who like them are subjected to the influence of damp, wet, and sudden variations of temperature, are, moreover, commonly AND ORIGINS OF DISEASE. 627 the victims of another form of disease, viz., rheumatism and the attendant physical evils whicli are developed npon it, heart dis- ease and dropsv. Many of these suffer from acute rheumatic fe- ver, which rarely leaves a perfectly sound heart. Others, without the acute attack, undergo recurrent minor attacks which, in time, leave them more or less crippled in limb and generally disabled in the heart. The deranged action of the heart increases the difficulty of breathing and sets up symptoms usually called asthmatic, with much aggravation at every bron- chial attack. Sometimes dropsy, from the embarrassed state of the circulation, proves a fatal sequel to the embarrassment. Butchers, like dock-laborers, are much exposed to the inilu- ence of wet, damp, the variations of temperature, and other sim- ilar inconveniences. The slaughter-houses in whicli they carry on their occupation are cold, draughty, damp. The floor is usually of brick, and during the operations of tlie trade is per- sistently sluiced with water. The business of slaughtering is most depressing to mind and body. I have seen the strongest built men in the prime of life most painfully affected by it, and I have never met witli one who could be said to have become per- fectly inured to it. They all get rapidly weary of their work, and the work, independently of the slaughtering process, is fatiguing to an extreme degree. Every step in dressing an animal is car- ried out wath great rapidity, so that the operator is made very hot from the work, while at the same time he is using water freely, and is in constant contact with the moist tissues of the dead animal. A man placed nnder these favorable conditions for the development of cold and rheumatism can scarcely escape, and in point of fact very few do escape. I am not far wrong in saying that no butcher can be found, in our large towns, who, after eight or ten years' daily work at the slaughter-house, is free from the effects of bronchitis, rheumatism, or heart disease, heart disease being the most prevailing malady of the class. The mor- tality of the butcher is, as a necessity, far above the average ; 111 butchers die to a mean of 100 of those who follow 69 other occu- pations. CHAPTER X. SOCIAL AND PSYCHICAL ORIGINS AND CAUSES OF DISEASE. We have traced out in detail in the history of the acquired diseases, most of the causes which are at work to produce those diseases. It remains for me now to summarize a few, and these the most prominent, of origins and causes of a social or moral character. Such causes sometimes act independently. At other times they act in combination with sets of causes differing from themselves. They thus become directly active, indirectly active, or connectively active. AIgoJioUg IntemjMrance as a Cause. Amongst the social causes of disease I place alcoholic intem- perance first, because it not only directly affects but indirectly leads to some additional evil, to pauperism, to worry, to crime, to violence, and to the lust which gives rise to specific disease. 1 made a formal estimate, when I was preparing the Cantor lectures on alcohol, of the mortality caused by alcohol in Eng- land and Wales, basing the calculations on the mortality returns of the Registrar-General. The result could not possibly be so accurate as was desirable, because the returns rarely state that alcohol is an actual cause of death. They give the diseases which we know are often incident to the use of alcohol, and from the facts so rendered we infer what should fairly be attributed to it. On this method, after making what seemed to me to be the fairest deductions, I was forced to the conclusion that alcohol led, in this country, to about one-fourteenth of the whole adult mor- tality. Recently the Harveian Society of London, a distinguished medical body, has made a most valuable effort, through a special committee, to arrive at the number of deaths produced by alcohol SOCIAL AND PSYCHICAL ORIGINS OF DISEASE. 629 ill the metropolis. The committee collected from medical men in practice in London the cei'tilicates of ten thousand cases of death amongst adults. The facts connected with these deaths were very carefully analyzed. The 10,000 cases, as returned, were broadly divided into three classes : — " (A), Deaths in no wise due to alcohol. (B), Deatlis accelerated, or pai'tly caused, by its abuse. (C), Deaths wholly due to it. And their respective numbers were : A, 8,598 ; B, 1,005 ; and C, 397, which gives 1,402 deaths, as nearly as pos- sible 14 per cent., in the causation of which alcohol appears to have j)layed some part. If this part were, in all cases, a leading one, it would correspond to an annual adult mortality of about 5,870 from alcohol in London, or 88,971 for England and Wales, assuming for the moment that the metropolitan figures would apply to the whole country." The returns, however, required to be weighed as well as counted, and the committee consequently took every circum- stance connected with them into due deliberation. Of the deaths in the lists B and C, the latter (C) were, with a few partial exceptions, entirely composed of genuine instances of death not only supervening on, but caused by, alcoholic excess, and may be thoroughly relied npon. The former (B) was a heterogeneous group of deaths, in the causation of which the share attributable to alcohol ranged from the almost exclusive to the scarcely appre- ciable, the fact remaining that they were all deaths of persons known, or reasonably suspected, to be addicted to drink, in wdiich the practitioner in attendance, or the coroner who investigated the death, or the registrar or pathologist of the hospital where it occurred, considered whether, on sufficient or insufficient grounds, that death was accelerated by, or was partially due to, alcohol. On the whole, the returns seemed to show that, in London, a percentage of adult deaths, which may be variously estimated at from little more than 1.5 to 4, is directly due to alcohol ; while a further proportion of 10 per cent, of those who die have in- jured their health in a greater or less degree by alcoholic excess. These in brief were the general conclusions arrived at by the members of the committee. Li a further part of their labors, however, they studied the particular diseases which make up the mortality caused by alcohol. They summarize as follows: — " We find, therefore, upon the whole, reason to think that, in 630 SOCIAL AND PSYCHICAL the metropolis, the mortality among anj considerable group of in- temperate persons will differ from that generally prevailing among adults in the following important particulars, viz., a fourfold in- crease in the deaths from diseases of the liver and chylopoietic viscera ; a twofold increase in the deaths from disease of the kid- ney, a decrease of half as much again in those from heart disease, a marked increase in those from pneumonia and pleurisy, a con- siderable increase and an earlier occurrence of those from disease of the central nervous system ; a marked decrease in those from bronchitis, asthma, emphysema, and congestion of lungs, a de- crease nearly as great in those from phthisis, and a later occurrence, or at least termination, of the disease ; a veiy large decrease in those from old age, with an increase in those referred to atrophy, debility, etc., and the addition of a considerable group referred in general terms to alcoholism or chronic alcoholism, or resulting from accidents." I need add little to these conclusions, in so far as mortality from one cause of disease is concerned. That they do not repre- sent many lesser evils done by alcohol, in the production of diseases of body and mind, evils which are not fatal, our previous chapters in Book II. will sufficiently testify. But they give a fair abstract of important series of facts. It will be seen by re- ferring to the Report that the organs of the digestive system suffer most severely from alcohol ; that the organs of the circula- tory and respiratory systems seem, comparatively, to suffer less ; that the brain and nervous system suffer very severely ; and that the glandular organs, the liver and kidnej' especially, are subject to extreme danger from alcohol. These inferences are, I believe, strictly correct with the ex- ception of those which refer to the effects of alcohol on the cir- culatory and respiratory organs of the body. 1 am convinced, both from experience of symptoms, and from pathological inquiry, that these organs suffer from alcohol as severely as the others. Dietary and Cooliery as Causes. Bad dietary and bad cooking are active causes of disease in, perhaps, all classes of the comnmnity, but especially amongst the poorer. In the industrial classes the greatest differences prevail in this respect. Amongst the stocking-M-eavers of the Midland counties we see, as a rule, the most striking evidence of defi- ORIGINS OF DISEASE. 631 ciencj of food ; and the same extends, thoTigli perhaps in a minor degree, to the majority of the industrial calhngs. Together with deficiency there is combined the most serious errors as to qual- ity of food, the tendency, for the sake of economy, being towards a too exclusive starch dietary, and to the omission, in great part, of nitrogenous food. Thus the muscles and other nitrogenous structures are imperfectly developed, a thin emaciated state of body is maintained, and a parched and feverish state of the sys- tem is engendered. ISTaturally these conditions lead to dyspepsia, and from the dyspepsia, in those who are disposed to the disease, the phthisical tubercular malady readily commences. Lastly, on this point, in cases were the food is fairly good in quality as it first comes to hand, it is so destroyed by the various processes of cooking and preparation that half its proportions as digestible, wholesome, and sustaining nourishment, are sacrificed. It is not until these facts are actually witnessed, it is not until the cold, uncomfortable, indifferently prepared artisan meal is seen, that the mischiefs arising from it can be appreciated. The mischiefs extend through all ranks of the industrials with more or less of intensity, and through all periods of life from childhood to old age. We can scarcely wonder that alcohol should be so frequently substituted as a false replacement of a dietary that is so generally objectionable. While these errors in dietary are the rule amongst the indus- trial classes, some exceptional errors of an opposite kind are met with in certain localities. Thus, to take one example which I have noted. Amongst some colliery operatives I have not only known provisions abundant but luxuries holding a prominent place. In the early part of the week, when they have their wages in hand, these industrials " play," as they call it, and live in sumptuous style. They select the choicest viands that can be obtained, and will have whatever is in season. Ducks, geese, lamb, game, aspar- agus, everything that money can buy they purchase, so long as there is money in the locker, Not unfrequently they keep up this feast for three or four days in the week, and then they fall to work again and live on anything they can get, faring as badly as they before fared sumptuously, the ordinary staple of animal sustenance being pork. The diet of a population leads, almost, to tlie introduction of racial peculiarites, and no estimate of vitality resulting from 632 SOCIAL AISTD PSYCHICAL labor is of strict value until the diet is known ; for, in truth, labor is the conversion of the force contained in food into motion and work ; but with the millions, the natural intention of food is hardly understood ; they eat as animals eat, from the impulse of instinct. In the infant population bad feeding is a cause of intestinal mischief. More than half the diseases of the digestive system which occur in infancy are due to improper food and feeding. Amongst the adult rich the errors of over and luxurious feed- ins; are common causes of organic deterioration. The digestive system is iirst injuriously influenced by errors in dietary, but many other of the vital systems, including, spe- cially, the circulatory, the nervous, the glandular, the muscular, and the membranous, are injured by these errors in respect to supply of food for the sustenance of the body. Moral Surroundings as Catises. Amongst the industrial classes there is another set of causes at woi-k which lead both to mental and physical derangement of health. I refer to the moral influences affecting the industrial classes. The necessity of having to work in masses in the same building, and at the same monotonous, ever-repeating labor, in which the muscles are moving with automatic regularity, and the brain is left unemployed except to brood over real or im- aginary injuries, affects life to the core, and exerts a lasting and injurious effect on the vital value of the manufacturing classes. The agricultural laborer may work hard, fare badly, be housed shamefully, but he has advantages. He is engaged out of doors in the fresh air ; he has all the beauties of the external nature to delight and refresh him. His work is varied. There is the spring-tide season, with its sheep-washing and shearing ; the summer with its hay-time ; the autumn M^ith its harvest ; the other months of ploughing and sowing ; — a constant roundelay of work, with varied change for the mind as well as the body. The artisan has no such reliefs. He passes day by da}', month by month, year by year, through the same monotonous labor, until at last his mind recognizes but one scene ; his hands fall but to one automatic routine. To the end of his career he sees no change, nor chance of being made independent by his skill and his industry. He, therefore, is naturally apt to become ORIGINS OF DISEASE. 633 fretful, anxious, irritable, the victim of smonldering passions, which wear out his heart, and lessen his nervous resistance to the man J external shocks to which he is daily subjected. Moreover, the limitation of his means leads to limitation in the necessary comforts of his home. He who is in these straits is rather to be pitied than blamed, if in false measure of the deed he seeks ignorantly still more sorrow in alcoholic indulgence. When we add these difficulties up, the struggle against penury and actual want, the confined dwelling-room, the badly- ventilated, over-stocked bedroom, the indifferent couch, the lim- ited sleep, the ever-returning toil, and the rarity of wholesome relaxation, either of mind or body ; when, I say, we add up these difficulties, we have before us evidence of vital strain which prac- tically is resisted longer than, at first sight, we could imagine to be compatible with human endurance. The late Dr. George M. Beard, of ISTew York, in an admirable essay bearing on this subject, thus felicitously condenses the conditions I have glanced at. " Almost all muscle- workers," he says most truthfully, " are born to live and die poor. To live on the slippery path that lies between extreme poverty on one side and the gulf of starvation on the other ; to take constant thought of to-morrow, without any good result of such thought ; to feel each anxious hour that the dreary tread-mill by which we secure the means of sustenance for a hungry household, may, without warning, be closed by any number of forces over which one has no control ; to double and triple all the horrors of want and pain by anticipation and rumi- nation, — such is the life of the muscle-working classes of modern civilized society ; and when we add to this the cankering annoy- ance to the workman that arises from the envying of the for- tunate brain- worker who lives in ease before his eyes, we marvel not that he dies young, but rather that he lives at all." The nervous system is the chief suffering system from bad moral surroundings. Uncleanliness as a Cause. Uncleanliness is one of the commonest causes of disease. It extends in its bad action from the acquired diseases to those dis- eases which are called natural. Uncleanliness in respect to food favors many of the diseases which are manifested in the diges- 634 SOCIAL AND PSYCHICAL tive system, and especially of those affections which are of a parasitic nature. Animal and vegetable food which is charged with parasitic life is unclean food, and, as we have seen, is a cause of some of the most troublesome as well as of some of the most dangerous affections. Water containing organic or inor- ganic impurities is uncleanly, and is a cause of many diseases affecting the alimentary system. Thus water as the bearer of or- ganic virus is, indirectly, the uncleanly cause of the disease called typhoid fever, and, as the bearer of the inorganic poison, called lead, it is the indirect cause of lead colic. Some affections of the nervous system are induced by uncleanliness in feeding. Thus those who work in lead, and do not take care to cleanse their hands, are, as we have seen, subjected to paralysis from absorp- tion of lead. The same fact applies to uncleanliness in regard to other agents which are absorbed by the skin in uncleanly occu- pations and which affect the nervous centres. Air rendered uncleanly is a cause of numerous diseases af- fecting the blood and the circulatory and respiratory systems. We have seen this fact illustrated in a variety of ways in the preceding pages. All the diseases produced by impure vapors and by dusts are due to this form of uncleanliness, as well as the affections attributable to a deteriorated or devitalized atmos- phere. The cutaneous or external membranous surface of the body is of all parts most subject to suffer from uncleanliness of person. Man}'- of the parasitic diseases, scabies particularly, are deter- mined by uncleanly habits though they be not directly generated. Sores upon the skin and abrasions in folds of the skin are the common results of accumulation of dust and dirt on the surface. We have seen how in disease from paraffin and soot (pp. 370- 72) the skin suffers in this manner. Uncleanliness of the skin leads also to general ill health of body. When the skin acts im- perfectly from being oppressed with a covering which closes up the perspiratory ducts and prevents free evaporation of water from the body, there is an excess of transpiratory function, vicarious function, thrown upon the lungs. When there is excess of work, vicarious work, thrown upon the lungs, the liver soon begins to suffer, and the digestion becomes, thereupon, deranged. With this there is accumulation of gas or flatus in the stomach and intestines and greatly impaired digestive activity. Hence persons ORIGINS OF DISEASE. 635 who are not given to ablution of the body are always troubled with flatulency and indifferent digestion. In addition to the above-named causes, I might add those which have passed before us as worry, unnatural physical exer- tion, and moral contagion, all causes which tell, primarily, upon the nervous systems, and afterwards upon those organs which de- pend upon the nervous centres for their vital power. CHAPTER XL SENILE DEGENERATIVE CAUSES OF DISEASE. To all these various classes of disease, divided, so far, in re- spect to origin, into six groups, must be added tliose changes which are specially incident to old age, and which are said to in- dicate the progress of senile decrepitude and decay. Each period of life is marked out as belonging to one or other of four distinct stages of progress. There is a first period extend- ing from infancy to complete adolescence, through a range say of thirty years. There is a second period extending from thirty to forty-five years, which embraces a time that reaches from com- pleted adolescence up to completed manhood. There is a third period extending from forty-five years to about sixty -five, which includes a time when the body has attained what may be called full lifehood, and retains it without much shade of change if the conditions necessary for natural life are fairly observed. Lastly, there is a period prolonged from sixty-five to ninety or even a hundred years, in which the body is passing from completed life- hood into natural decline. The first two of these stages seem to be fixed and ordained by strict rules amongst members of the human family. The two last-named periods are not so fixed, but either of them may be reduced or extended. Some men and women have passed into their declining stage so soon as they have reached perfected life- hood, and die without showing any third or retaining stage at all. Others retain fair perfection of lifehood even up to the seven- tieth year, and decline so slowly that their fourth stage may be extended many years beyond the ordinarj^ duration : these seem, positively, to live a new life, to experience a rejuvenescence under which they may attain to even a hundred years. Throueh all these stas-es there is a certain line of true phvsi- cal change. In the first stage all the organs and parts undergo SENILE DEGENEEATIVE CAUSES OF DISEASE. G37 the enlargement and development which constitutes what is called growth. In this stage the elastic tissne of the elastic mobile organs is brought up to its full range of tension, to as much as it can bear with equality of resistance and with evenness of action. In the second stage the elasticity is maintained, but is not im- posed upon by further force of growth, while all the organs, brought now to their fulness of development, are consolidated and fashioned into working order. In the third stage the perfected organism, though no longer naturally expanding or growing, and no longer possessed of its previous elasticity, is enabled, neverthe- less, to endure a certain long and defined phase of work and movement. It does not truly repair so readily as it did ; does not bear shocks, mechanical or mental, so well as it did ; but still it works on, a good steady, hardy organism, and in some ^^owers of a mental kind is better endowed than" at any previous period of its existence. In the last stage the physical decadence of the organism is the notable fact. In this stage the once elastic fabric lias ceased to be elastic, and affords little resistance or resiliency. The once elastic arterial tubes which recoiled after each stroke of the heart, and by counter-stroke helped on the circulation of the blood, gradually fail. The resilient lungs which, by their elastic fibres, responded to the impulse of the respiratory muscles, gradually fail, so that the emptying of the lungs of their con- tained air is imperfect, and breathing is shortened. Then within the tissues of the relaxed organs new products ceasing, under an impaired nutrition, to be formed, the organs shrink. Then the blood, circulating more languidly, and diminished, is reduced in volume and in vital warmth. Then the brain and nervous struct- ures undergo the physical change called sclerosis. Then, at last, all oi'gans and parts passing gently into inertia, the extinction of life from the peripherj'- or circumference of the body towards its centres, leads to complete arrest of motion, or, as it is said, death. It is in this last stage that the phenomena of the natural dis- ease by which life is terminated is developed. The disease is sometimes located in one organ, sometimes in another, and by the organ most affected the mode of death is commonly recorded. Really, however, when at the full period of life one vital organ fails, so dependent are all the vital organs on each other, they all soon begin to fail with their fellow, and follow it into its deathly decrepitude. From observation founded on this fact came the 638 SEXILE DEGEISTERATIYE CAUSES OF DISEASE. wise saying of one of the shrewdest of philosophers, that old men are '" like ruined towers." They hold up, wonderfully, so long as they hold up together and as one ; but touched at a single part they fall in mass. Because their yital activity is less than it was in earlier times of life, old persons are less liable to be affected by some of the acute diseases that are incident to the early days of vital power. Thus thej are saved from yarious causes of danger. For the same reason, however, they are more exposed to danger when they are attacked with maladies of an acnte character, and sink easily from even slight attacks of acute disease. The period of the year in which the aged most frequently succumb extends from the close of November to the end of April. The period of highest mortality or absolute maximum is January. These are the periods marked by cold and dryness and cold. The period when the mortality from old age or senile decay is the least extends from May to Noyember ; the time of lowest mortality or absolute minimum being from July to October. So soon as the month of X ovember is on the advance mortality fi'om senile decay begins rapidly to rise, an indication that the wave of cold, now setting in, is telling upon the reduced vital powers. The organs of the body which are most frequently points of failure are the lungs, a fact which has led some authorities to conceive that in every case of natural decline the primary failure is from the respiratory surface. A dogmatic statement to such effect is, I think, too absolute. But it must be conceded that as no surface of the body is so directly affected by cold air as the breathing surface of the luno-s, this is the surface which in a large majority of cases is primarily affected. Hence the number of aged people who, during the season of cold, and of cold and damp, sink from bronchitis, acute or chronic, pulmonary congestion, asthma, spasmodic breathing, and other affections of the chest. It often happens OM'ing to this weakness of respiration that aged people going from a warm room, in winter time, to sleep in a bedroom where a fire is not retained during the wliole of the night, are subjected to acute congestion of the lungs as the result of the rapid fall of the temperature of the air they breathe. I have known in my experience several instances in which this sud- den change has been sufficient to cause dissolution during the act of sleep. CHAPTER XII. DEATHS AND CHIEF CAUSES OF DEATH IN ENGLAND AND WALES IN THE YEAR 1880. In order to bring to a full conclusion the part of this work relating to causes of disease, I add, on the suggestion of my dis- tinguished friend, Mr. Edwin Chadwick, C.B., a table construct- ed for me, by Mr. Mundj, of the Registrar-General's Office, of the causes of the mortality of England and Wales in the year 1880. The table thus presented is, in the main, a copy of a similar one constructed by Mr. Chadwick, from the returns of 184Y, an abstract of which table is also added for the purpose of comparing the relative mortalities of two equal periods separated by the span of thirty-three years. On comparing the two years we see that the proportion of deaths from different classes of disease has slightly varied. The zymotic diseases, relatively to total deaths, have decreased in 1880 in the proportion of 3.17 per cent. ; con- sumption has decreased in the proportion of 3.55 per cent. ; dis- eases of the digestive organs in the proportion of 1.08 per cent. On the other hand, diseases of the respiratory organs, irrespective of consumption, have increased 5.61 per cent. ; diseases of the brain, nervous system, and senses, 1.58 per cent. 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Zymotic Diseases Consumption Diseases of the Bespiratoiy Organs Diseases of the Brain, Nerves, and Senses Diseases of the Digestive Organs Accidents or Other Violence Other Causes All Causes Deaths, 1847. 97,924 53,317 51,115 48,574 24,492 12,917 132,638 420,977 Deaths, 18S0. 106,205 48,201 93,992 69,364 25,069 17,490 168,303 Proportion to 100 deaths from all causes. 1847. 1880. 528,624 23.26 12.67 12.14 11.54 5.82 3.07 31.50 100 20.09 9.12 17.78 13.12 4.74 3.31 31.84 100 Note. — The numbers are not strictly comparable owing to slight differ- ences in classification : for instance, Teething was classed with Digestive Organs in 1847, while in 1880 it would come under Other Causes ; Delirium Tremens was classed with Nervous Diseases in 1847, but with Zymotics in 1880. BOOK III. PART THE SECOND. A PEACTICAL SUMMAKY OF PEEVENTIONS OF DISEASE. CHAPTEE I. INTRODUCTORY NOTES. It was stated in the introductory portion of this third book, that, although there were, nominally, over a thousand diseases affecting human kind, the number of diseases which called for special notice might be reduced, practically, to a little over one hundred. If we could prevent, therefore, from ninety to a hundred of the diseases which make up our mortalities, we should compass the prevention of almost the whole field of disease, since we should incidentally learn how to prevent or remove most of the minor diseases, which do not kill, by the same effects of preven- tion. Commencing the study of prevention we may then limit our observations to the comparatively few diseases which are most prevalent and most fatal. In dealing with this limited number of diseases, in respect to the means necessary for their prevention, we may again reduce them to groups according to their causes, because we shall discover, if we simply turn back to the pages of the history of disease, that preventive measures group themselves into natural position by the side of causes. Tlius, to take one example, almost all the class of diseases grouped under the head of zymotic demand similar principles of treatment in relation to their pre- vention. The chapters which are to follow will consist of a series of practical summaries relative to preventive measures. In these, chapters I shall considei- the question of prevention as connected with the varieties of origins and causes of disease, with the object of indicating how those origins and causes may best be averted or stopped altogether. There are three grand agencies to be taken into account in 646 Ij^-teoductoet notes. the numeration of all measures of prevention. I may call tliese the ])ersonal^ the municijxd or local, and the central or govern- Tnental agencies. By the personal I refer to the influence which every individual or person may bring to bear for the prevention of disease in himself, or in those who immediately belong to him. By the municipal or local I mean those agencies for prevention which are brought into action through the instrumentality of local or municipal boards in their localities. By the central I mean those agencies which spring from the central government, and which are intended to apply to the country altogether, to local government, and equally to personal responsibility and authority. Of these three agencies the first is, according to my view, by far the most important. It is so important that if, as an agency, it could be made perfect, all else would sink into mere nominal position, or would, at most, consist of formal administrative la- bor. As, however, it is impossible to secure such personal per- fection, the two other agencies are, perforce, demanded, and of these two the local is in my opinion pre-eminent. The local government of the place is the health of the place. Each place must be ruled into health by those who know, and know best, the wants, the necessities, the feelings, and the fail- ings of each individual centre. To try to make all the separate centres and towns of our land perfect in salubrity by directions and instructions from a central government control is to give up permanent local reform in this direction altogether. There are in a locality sufficient obstacles in overcoming mere local tra- ditions and sympathies to render hopelessly impossible urgent re- form pressed from a distant quarter where there is no local knowledge of sympathies and no sympathy with them. For the local work there must be the local power ; power which the local authority shall be proud to exercise with knowledge and wisdom ; power which shall be in its way competitive, and which shall have the effect of stimulating competition until health, like leaven, has leavened the whole of the national life. At the same time in every country there should, no doubt, be a supplementary governmental or central board. A central board of reference ; a board competent to speak with authoritative ad- vice in general questions ; a board that could arbitrate between conflicting opinions and would be open to be consulted on dis- INTRODUCTORY NOTES. 647 puted points ; a board wliicli, bj its personnel^ would command the respect of the nation, and confer scientific dignity on the nation in the presence of other nations ; and, a board to wliich other nations organizing a national health advancement conld refer. Snch a central board in England, at the seat of govern- ment, would be invaluable. Here, however, its duties should end. It should rule, not govern, be at once the greatest and thie least of the sanitary authorities. It should be a centre exhibiting to the nation and to the world the widest, to the particular locality the narrowest, range of action. Sometimes, in treating on details of prevention, we shall find that all these agencies are required to be brought into operation in order to secure prevention. At other times one only or two may be required ; but in every case the first or personal agency will be demanded. I shall, consequently, in each succeeding chapter take the personal consideration first, and the local and central, when they come into requisition, in the second and third place respectively. CHAPTEK 11. PREVENTION OF HEREDITARY CONSTITUTIONAL DISEASES. I. Peksonal Rules foe Prevention. The prevention of descent of disease by hereditary taint can only be systematically secured from its origin by such measures as shall arrest or check the intermarriage of disease. By most persons it is supposed that this mode of prevention is necessary only for persons of the same kindred. The theory is true and untrue. It is quite true when it applies to the marriage of per- sons of the same family, such as cousins, if the members of that same family are affected with decisive taints of disease, for then the taint is intensified by such marriage should progeny be the result. On the other hand, if the members of a family be per- fectly healthy, and free of taint of disease, marriage taking place among the members of that family, within the legalized limits, instead of being attended with bad results in regard to progeny may be attended with the best results. In other words, mere consanguinity is not the determining cause of descent of disease, and parents who have charge of those who are marriageable, or marriageable people themselves, need not consider consanguinity an objection unless it carries with it constitutional defect. In all cases reasonable people should give no countenance to marriages where there is definite indication of constitutional affection on both sides, even though the constitutional affection shall not be the same on each side ; since some crosses of disease are quite as serious as the double hereditary infliction of the same disease. A reference to the chapter on hereditary causes will make this matter sufficiently clear. PREVENTION OF HEREDITARY DISEASES. 649 Rules for an Expectant Mother . In all cases, whether tendency to hereditary taint be great or small, — it is never, perhaps, actually absent,— special care ought to be taken with women who are about to become mothers. There is no part of the preventive art which calls for more care than this. There is no practice that is more seriously neglected. Amongst the poor we often see women laboring at the hardest tasks, subjected to the most painful annoyances, anxieties, and troubles, up to the very moment wdien the pains of labor are coming on. Amongst the wealthy and well-to-do we see women pursuing occupations and often wearying pleasures, giving way to caprices, or exposing themselves to fatigues, or being subjected to trouble and sorrow, up to the same period. This is all as wi'ong as can be, and when the fact is recalled that during all the period previous to its birth the unborn child is dependent for its life-blood on its mother, the commonest sense not less than the commonest humanity comprehends how everything that tends to reduce the vitality of the mother tends also to reduce the vitality of the offspring, and to render it the more liable to suffer from the effects of hereditary or transmitted taints of disease. For my part I do not know which suffer most, the poor women or the rich women, during these most critical and im- portant periods of their lives ; but, on the whole, I fear the wealthy are the w^orst affected, and that indulgence is more in- jurious than poverty. Amongst both classes certain simple rules should invariably be followed. The diet on which the expectant mother subsists should be of the simplest and least stimulating character. Animal food in tlie way of flesh should not be taken more than twice per day, and always in moderation. Alcoholic drinks and tea should be strictly avoided, the drink diet being made to con- sist of milk, milk and water, cocoa, and similar nutritious and unstimulating fluids. Next to these attentions in respect to diet matters of exercise and rest should be carefully considered. Daily out-door exercise, to the extent of not producing extreme fatigue, is essential. But this should be alternated with the most careful attention to rest. Every night bed should be sought at an early houi-, and never less than nine hours for sleep should be taken. The bedroom 650 PREVENTION OF HEEEDITAEY should be well ventilated and of equable temperature, a temper- ature of 60° Fahr. being a good standard. The bed-clothing should be warm but light, and the bed should be exclusively occupied by the woman herself. In daily life all scenes leading to excitement of mind, emotion, passion, especially passion of fear or anger, should, to the fullest possible extent, be avoided. Influences telling through the mother on the child during the stages of development inflict, I am quite confident, upon the developing child nervous impressions which are never eradicated. The clothing of the expectant mother requires special care, since, under the present system, it is the worst that by any mor- tal ingenuity could be devised. The clothing should be loose, light, warm, and borne entirely from the shoulders ; anything like tight bands or. corsets round the body are equally injurious to mother and to child. Lastly, the expectant mother should, of all persons, be pro- tected from exposure to infectious disease, because, as we are now well aware, such disease may be directly communicated to the unborn. I have reduced these rules to the fewest possible and to the most elementary form, so as to render them plain and easy to every class. They are very simple ; they are entirely natural ; and, being followed, would largely prevent the many dangers incident to hereditary proclivity. Rules for Infancy. The infant, so soon as it is born, should be warmly wrapped up and kept warm. Warmth is essential to its life. It should be washed as soon as possible with warm water and soft flannel. After the first washing, the infant should have a warm bath twice a day, one in the morning and one in the evening. The water should be pleasantly warm to the hand — not hot, but luke- warm. The body should be washed, while in the bath, with a piece of soft flannel, which should be changed for a new piece every week at least. The v/ashing should be conducted gently and rapidly, a little plain soap being used. After the washing, the body should be well dried with a warm soft cloth or towel. The washing should be continued every day, with careful drying and gentle friction. COlSrSTITUTIOTTAL DISEASES. 651 From the first, the dress of the child should fit loosely and easily. Tightness of the dress anywhere is very bad. Tight swathing of the body and limbs by many bands of cloth or flannel, — swathing-bands, — is the worst thing that can be done. It checks free breathing and circulation of the blood, chafes the skin, pinches, and causes want of comfort and rest. The clothing should be light and warm, and it should cover all the body, except the head, face, and hands. Light soft flannel, having a smooth surface, should be put next the skin. The feet should be clothed in warm woollen socks and shoes. The clothing should always be kept as clean as can be, so that it never has a bad smell nor shows patches nor spots of dirt. The body linen of the child should not be m- ashed with soda. So soon as the infant is washed and di-essed, it should be put to the mother's breast. The mother and child both get good from tli]^ plan. If the mother has little milk, the act of putting the child to the breast will tend to cause a flow of milk ; and, if the infant gets milk direct from its mother, it will not require opening medicine. The infant will live best, and ought to live solely, on breast milk for six months ; nine months will not be too long. If the mother fail to supply milk from her own breast, and if there be no wet nurse, the child should be fed with cow's milk diluted with water. One part of pure cow's milk and two parts of water is the best mixture, to which a little sugar, one teaspoon- ful to a quarter of a pint, may be added. As soon as ever it is possible, the infant should have its natural breast milk ; and should that not be quite suflicient in quantity it should be supple- mented with cow's milk, diluted with water as above. It is wrong to give up breast milk because the supply from that source is not enough. The milk gi^en in addition to breast milk should be warmed before it is given as food. As the child gets older, the quantity of cow's milk may be increased and the water lessened. At two months, the cow's milk may be increased to two-thirds, water one-third. At six months, the cow's milk may be used without water. After six months, the infant may begin to be weaned ; but there is no cause for hurry, and if the child is at the breast for nine months it will take no harm. At nine months it should be weaned. 652 PREVENTIO]^ OF HEREDITAEY Weaning should be carried out gradually, and the milk food should be replaced by something similar. The best substitutes are whole meal, wheaten porridge, and oatmeal porridge, with fresh milk. Until the first set of teeth is complete, no other kinds of food are required. The practice of giving infants bits of ani- mal food, animal soups, or puddings is most injurious. Intoxicating drinks of all kinds are most poisonous to infants. Any terms less strong than this, as applied to the drinks, would be under the truth. No such drinks should ever be given, either with or as food. Tea and coffee should never be given to children. After the child has cut all its first teeth it may begin to take light solid food. Good bread, small portions of well-cooked ani- mal food, light custard puddings, and fresh fruits, are the best foods in early life. Under a prudent system, animal flesh may be dispensed with, as well as intoxicating drinks. Oatmeal and wheaten porridge with milk are still the best staple foods. The feeding of children as of infants should be at regular intervals. They should be fed about every three hours in the course of the day. Care should be taken that the infant does not suck its thumb or any solid substance. This practice is bad in two ways. Of a certainty, it causes pain in the stomach, and disturbance of the bowels. It also gives rise to after deformity of the mouth. Nearly all grown-up persons who have their upper front teeth too prom- inent and angular, with a deep hollow in the roof of the mouth, have caused that deformity by sucking the thumb when they were infants, and the deformity is hereditary. The infant should from the first be taught to sleep in its own little bed or cot. In its first days it should be allowed to sleep when it likes, and indeed it may pass three parts of its life in sleep. It should be trained to go to sleep at regular hours at night. Its bed sliould be very soft, so that the little body finds rest on every part. The infant should be put into a warm bed, and be kept warm during sleep. It should not be excluded from the air, but should sleep in a pure warm atmosphere, and be well covered with light warm bed-clothes. The air of the room should always feel com- fortably warm. If a thermometer be used, it should indicate not less than 60° and not more than 65° Fahr. CONSTITUTIONAL DISEASES. 653 All artificial plans and practices of causing sleep are bad. The infant should go direct to its rest. AValking about Avith it, rock- ing it, jogging it, are bad habits. Once taught these habits, it soon fails to go to sleep without them, and they create much dis- turbance of sleep, Avitli dreams and startings, which lead to fever- ishness and fretting the next day. Soothing sirups, laudanum, poppies, and all sleeping drugs are most injurious as means for producing sleep, and should only be used under competent medi- cal advice. They ought to be excluded from the houses of all persons who call themselves respectable, except when wanted, under medical direction. The sleep of infancy should never be disturbed by noises and sudden surprises. It is most hurtful to take up an infant from its quiet repose to show it to strangers, or to amuse it in gas-, candle-, or lamp-light. It is desirable that the sleeping-room or nursery should not only be warm, but quiet, spacious, and well aired. Anything that causes a bad smell should not remain in the room for a moment. The room should never be darkened. The cot may be shaded from direct light, or the light may be shaded from the little sleeper by a curtain ; but the sunlight, when it is present, should always be let into the room. Sunlight cheers, exposes dirt, and purifies the air. The infant should be taken out into the air every day, except when the weather is wet or very cold. It does the infant no harm for it to sleep when it is out of doors, if it be well wrapped up. The exercise out of doors should be long before night, and at times when the weather is most agreeable, not too hot and not too cold. In winter, the infant should go out twice a day if it be possible, once as a matter of course. In summer, it may live out of doors in the best parts of the day. When out of doors, the infant should be well protected from the cold in winter and from the heat in summer. In winter as well as in summer light-colored clothing is best for it. In the summer, its head should specially be shielded from the direct rays of the sun. The infant life should be one of quiet all the day and all the night long. An infant ought never to be exposed to sudden noises and starts. An infant should never be taken into ereat crowds or tumults, nor into public noisy meetings and amusements. Many of the painful impressions which are felt in after life, and which cannot be traced to any direct origin, are inflicted in the 654 PKEVENTION OF HEREDITAKY period of infancy, when the mind receives but does not remember the fact of receiving the impressions. Infants should not be shouted at nor scolded, nor in any way frightened. They suffer intensely from sudden alarms and fears, and may become nervous for life by such injuries. A baby should never be struck nor subjected to any punishment of that kind. It should alwaj-s be made as happy as it can be. Then it is likely to grow up disposed to be blessed with a cheerful dis- position, which will make it happy in itself and a source of happi- ness to all around it. The infant should never be lifted up by its arms, or made to stand just on its toes while partly lifted. It should on no account be placed too early on its feet to stand or to walk. By placing it on its feet too early the child is apt to get bow-legged, and some- times weak or deformed in the back. As a rule the child itself learns, naturally, to acquire the art of standing and walking, and it should be left to itself so to learn. Those who are nursing the young from their own breast, should be kept as free as is possible from anxietj^ and care, and should be encouraged to be all day cheerful and happy. The impressions they make on the child are often life-long. l^ursing women and mothers should be well but not richly fed. They should have four light meals a day, abundance of milk, fresh fruit, and, in fact, generous food. They may take tea and coffee in moderate quantity, but every stimulant of an alcoholic kind, such as ales, stouts, wines, and spirits, should be avoided. Stimu- lants injure the nurse, the mother, the infant. They can be easily substituted by milk, maltine, oatmeal-porridge, and other harmless and truly sustaining foods. Every mother, who is not actually in bad health, should nurse her own child. This is a duty, not to the child merely, but to the mother. It is health to both. Rules for Childhood. The first rule for childhood relates to the feeding. This should be at once simple and efficient. The meals should be at regular hours and at periods of three or, at most, four times a day. Animal food, with the exception of milk, should not be taken more than twice per day, and judicious preference should CONSTITUTIONAL DISEASES. 655 always be given to carefully selected vegetable foods and fruits. The liking of children for fruits is a natural desire, and with care to see that the fruits are clean, ripe,' but not over-ripe, and fresh, this liking should be encouraged. The child should be taught to cease to eat so soon as it feels satisfied. The foods chosen for it should include those which provide for all the animal wants ; colloidal foods, for building up the active structures of the body ; mineral foods, for building up the passive structures or bones; hydro-carbon foods, for supporting the animal warmth ; and water, for supplying the natural fluid food by which all the other foods are carried and distributed. All stimulating beverages, alcoholic drinks in everj^ form, should be strictly avoided. Tea and coffee should also be with- held. The dress in childhood should be warm, light, loose, and should be made to assimilate as nearly as possible, in shape and form, for both sexes. All dresses which compress the growing body ; all dresses which muffle up some portions of the body closely and leave other parts, such as the legs, arms, and breasts, uncovered, are a mistake. The clothing should be so adapted as never to be an encumbrance to the movements of the limbs or to the move- ments of the respiration. It should be carefully adapted to the seasons, on the rules to be described in the next chapter. In childhood there should be free exercise both of body and mind, sufficient exercise without enforcement of it. Every simple bodily exercise which brings into play the muscles of the limbs, which causes the lungs healthily to expand, which encourages free circulation, which entices natural appetite, which keeps all the natural functions in order, and which keeps the mind happy and cheerful, is excellent. Whatever goes beyond this in the way of physical exercise, whatever leads to physical strain, is injurious and provocative of constitutional disease. All mental strain in childhood is exceedingly mischievous in effect. The mind should be left free to grow with the body, and lessons should l)e permitted rather than enforced. Lessons com- municating knowledge should be of the simplest and most practi- cal kind, after the manner of the Froebel or Kindergarten system, in which the mind is educated through all the senses and with pleasurable emotions. In a word, nothing tends more to prevent the development of constitutional disease than the natural and 656 PEEVEISTTION OF HEEEDITAET liealthj development of the nervous system, without strain or worry. The repose of childhood by sleep requires to be carefully tended. During the whole period of childhood, which we may consider to extend to the fifteenth year, ten hours of sleep should be encouraged. Each child should sleep in his or her own bed ; this is a vital point. The bedroom should be well ventilated, pure, light, cheerful, and of equable temperature, 60° Fahr. The bedding should be elastic, so that the body reclines altogether and not on parts of its surface. The bed-coverings should be light, porous, warm, and spotlessly clean. Perfect quiet in the bedroom is essential for the healthy sleep of childhood, since every unnecessary disturbance of sleep is against nature. Children should be very carefully taught to carry out all natu- ral habits with regularity and cleanliness. They should be par- ticularly instructed to attend to the action of the bowels at one particular time each day. They should also be taught the habit- ual practice, common amongst the Jewish people, of ablution afterwards. They should further be brought into the regular habit of the morning bath, so that they may feel that the day has not been properly commenced until the bath has been taken. Connected with morning and evening habits they should be instructed at night to turn their clothes inside out, and lay them in systematic order so that they may be aired during the night, and turned and cleaned previous to dressing on the following morning. The mind during childhood should be kept free from all men- tal impressions of fear and disquietude. Stories of ghosts and such-like absurdities should be kept always from the young. The child should also be held free from excitements springing from details of crime or tragedy of any kind. Lastly, children should be scrupulously protected from ex- posure to the contagious diseases, physical or moral. Their time of life is that in which such contagions act with greatest effect, and numbers of the after physical evils to which they may be lia- ble are called into action by the results of these contagious influ- ences. The vulgar idea, which some persons hold, that children ought to be submitted to contagious diseases because they must, almost of necessity, pass once through the ordeal, is most repre- hensible. CO]SrSTITUTIONAL DISEASES. 657 Rules for Adolescence. All the rules which have been stated as applicable to childhood are, iu the main, equally applicable to the period of adolescence. Some of these, however, require to be particularly enforced, while one or two require to be added. The diet should be as simple and regular as in childhood, and the avoidance of all stimulants should be carried out with equal resolution. It is unfortunately in this period of life that the habit of resorting to alcoholic bev- erages is most frequently acquired, hence the reason why this habit should be specially guarded against. If it be not guarded against, the stimulant, in no sense whatever a necessity, soon begins to be considered as such, and leads to a system of false dependence upon it which becomes one of the most dangerously disposing causes of constitutional affection. In this same period of life another habit is apt to be acquired which should never be acquired. I refer to smoking. Of the bad effects of this habit I have treated at pp. 359-363. The first symptoms induced whilst acquiring this habit ought of them- selves to be sufficient indication, to all wise adolescents, of the evils which spring from it. The same rules which are applicable to physical and mental strain in childhood are applicable at this period. Physical over- strain, mental overstrain, the all but certain producers of consti- tutional mischiefs, should specially be prevented. Every thought- ful person who wishes well for the future of his kindred should oppose with the most resolute determination the competitive freaks and insanities which are now the fashion of the hour. With their utmost energy thoughtful persons should oppose the current cramming system of so-called education, and the extor- tionate examinational aberration which brings the cramming system into existence. The result of extreme mental pressure is already bearing fruit. It is not raising the culture of the na- tion in any sense. It is unfitting manhood and womanhood for good, steady, and progressive work, and it is keeping alive, ac- tively alive, the constitutional proclivities to nervous and mental disease. It is particularly mischievous to young women who are to become the mothers of a future generation. 42 658 PEEVENTION OF HEREDITARY DISEASES. t Rules for Mature Life. For the prevention of development of hereditary diseases in persons of mature age, an adhesion to many of the rules already given are as necessary as in earlier life, while some few others are demanded. Continued temperance in respect to alcohoh is essential, in addition to which other kinds of temperance are called for. Self- possession and mastery over the passions or emotions is, with a mature man or w^oman, one of the choicest safeguards against the inroad of constitutional disease. Freedom from ordinary passion of anger protects both the nervous and vascular systems. Freedom from extreme competitive strife and the worry depend- ent upon it protects largely from two of the constitutional dis- eases to which many persons are predisposed, — tubercular disease and cancer. Freedom from restless worry, excitement, and specu- lation protects in the most signal manner from those premature degenerations of heart, brain, and glandular organs such as the kidneys, which lead to organic death, in so many instances, dur- ing the middle age of man. The reader will observe for himself that the rules for preven- tion against hereditary and constitutional evils are all personal rules, and are such as generally belong to the first, second, and third stages of life. In later stages active proclivities to consti- tutional affection become much modified, and such distinct he- reditary affections as cancer often run a slow and comparatively painless course. No new rules for prevention under these cir- cumstances call for description. CHAPTER III. PREVENTIONS OF ATMOSPHERICAL, METEOROLOGICAL, AND CLIMATIC DISEASE. Personal Rules for Preventions. Rules for the Various Seasons. The first personal rule for preventing diseases from seasonal influences should be based on the facts collected by Mr. Milner, and epitomized at pp. 526-7. It shonld be remembered that the body becomes heavier during the summer months, lighter during the winter months, and that the changes from gain to loss are abrupt, the gain beginning about the end of March, and the loss in September. The practice springing from this knowledge should bear on foods. The proportions of all foods should increase somewhat, in September, and be maintained so as to meet waste up to March. The kind of food that requires to be most increased is that which sustains the animal warmth. Starchy foods, such as potatoes and rice ; fatty foods, such as butter, and animal fats and oils; and saccharine foods, such as common sugars, jams, and honey, may be increased in quantity. On the other hand, with the turn of the month of March such foods may be de- creased, and may be taken in much more moderate quantities during the succeeding months up to September. Owing to the circumstance that during the heat of summer there is very free perspiration and extreme loss of water from the body, there is often great loss of water weight, and the body seems to lose both in substance and weight. The fact leads many to consider that because of the apparent Avasting, excess of food, and of rich food, is called for. This is an entire mistake. In 660 PKEVENTIONS OF ATMOSPHERICAL warmtli tlie body requires less food, though it may require a little more watery drink. In warmtli rich foods are not digested and assimilated, and a great deal of the dyspepsia and bowel derange- ment in the summer season arises from over-feeding, in igno- rance of these facts. Attention to clothing should also be connected with these general changes of season. As September advances, additional clothing should be assumed, and should be fully maintained until the season of waste. It is good practice to continue the warm clothing well into the period of return of the gaining season, and indeed not to make any important change until April has passed away. The warmth obtained by clothes should not be attended by great weight of clothes. The warm winter clothing should be porous and light ; the knitted Shetland woollen clothing is the best example that can be given of what is required. During the sum- mer months the light clothing should also be of porous texture. During the wasting months the hodily exercise should be less severe than in the gaining months, and excessive strains or sudden demands on the bodily powers should be particularly avoided. This same rule extends to Tnental exercises. Both rules are of special importance in regard to the young, and equally in regard to those who have passed the meridian of life. During the wasting period longer hours of sleep and rest are required than in the warmer months when the disposition of the body is to gain in weight. All through the winter season half as much sleep again is necessary compared with what is wanted in summer. Other things being equal, six hours of sleep on mid- summer night are equal to nine on midwinter night. Prolonged hours of sleep, in summer are prejudicial ; short hours of sleep in winter are prejudicial. These rules are peculiarly applicable to the young and to the old. The temperature of the hath should be regarded in respect to season, if any variation be desired. As a general thing, it is good practice to find an agreeable temperature for the body and to keep to that all the year round. But those who like to have a cold bath for a portion of the year should limit that portion to the seasons when the body is naturally gaining weight, the cold bath being very hazardous during the months when the process of waste is in progress. A strong man in the prime of life may bear it for some years and feel a pleasure in the reaction ; but AND CLIMATIC DISEASES. 661 even he is easily cliilled by it when his nervous system is de- pressed, and he is never wise in lioldiiig rigidly to the practice. To the young, the old, and the feeble, and to the members of the female sex at all ages, the practice is an unsafe one. Fi'om May to September the cold bath may be permissible, but as soon as the wasting period begins the temperature of the bath water should be raised, so as not to produce a chill when entering it. Rules for ^jjecial Seasonal Changes. Let it be remembered that there are six special periods char- acterized by special conditions of atmosplieric temperature and moisture ; namely, a first period of damjpness and cold • a second of cold ; a third of dryness and cold ; a fourth of dryness and warmth • a fifth of heat / a sixth of dampness and toarmth. Let it also be remembered that each of these periods is marked by particular diseases. The above rule applies to London in so far as accurate inves- tigation has up to this time been pursued. But probably in most civilized parts of the world a similar division is equally traceable. In the period of dampness and cold, extending in this country from the last week in October to the third week in December, the best preventive rules consist in keeping, as far as possible, in a dry and warm atmosphere ; in excluding moisture from the house, especially from the bedroom ; and in avoiding bodily con- tact with damp clothes and bedding. In this period the body should be kept warmly and lightly clothed, and the feet should be well shod. What is called waterproof clothing is, however, best avoided, except in the form of a very loose cape. A good umbrella is much safer and better than a waterproof. The diet should be suflicient but unstimulating. In the period of cold, extending from the end of December to the third week of February, a period in which throat and chest diseases begin to be easily developed, and in which diseases of the respiratory organs show the greatest mortality, the chief rule is to keep up the animal temperature by good food, and complete avoidance of depressing alcolK^lic drinks, to conserve animal warmth by warm clothing, and to conserve nervous power by tak- ing a full allowance of sleep. These three rules should be rigor- 662 PEEVENTIONS OF ATMOSPHERICAL ously observed by the strongest men if tliey mean to retain their strength, and by the weaker if they mean to retain their life. In the third period, that of dryness and cold, extending from the last week of February to the second week of April, the de- pression of body is greater than at any other time. The condition of dryness and of cold is most exhausting in itself, and caps, if I may so say, the two preceding periods of exhaustion. It is the nervous system now that suffers, and diseases dependent on nervous depression are dominant. The practical rule in this season is to maintain the animal warmth ; to avoid night air ; to avoid excess of every kind ; to avoid great trials of strength, physical and mental ; to live well ; and, to take abundant rest. The lessons of school-children ought to be considerably reduced during this season. In the fourth period, that of dryness and warmth, extending from the third week of April to the fourth week of June, life is beginning to return, and the healthiest season of the year is pre- sented. The practical rules now are gradually to lighten the clothing, to reduce the hours of sleep, to reduce food, and reason- ably to increase work, mentally and bodily. At this time the best work of the year ought to be carried out, in private as well as in public life. In the fifth period, that of heat, extending from the end of June to the end of August, affections of the alimentary canal, bowel complaints, and some aifections of the head have* to be guarded against. The clothing should be light and porous, the hours of sleep reduced to a moderate minimum, and the hours of exhaustive labor of mind and bodj' fairly limited. The most important rule at this season relates to diet. The diet should be moderate in quantity, should be well cooked, should be mainly a cold diet, and should always be composed of fresh food. The greatest care should be taken that the water used as drink should be fresh and pure. Acid and effervescing drinks are inadvisable, and all alcoholic beverages are most pernicious, from being the most common promoters of liver and intestinal disorder. Indulgence in fruit is permissible, so long as it is mod- erate, when the fruits are quite fresh and are neither under nor over ripe. AND CLIMATIC DISEASES. 663 A further important rule in this season is to protect the head from the direct rays of the sun. In sending out infants and cliildren the strictest attention sliould be paid to this precaution. In the period of dampness and warmth, extending through September and three parts of October, a healtliy seasonal time is presented. In this season the simple rules of practice are to avoid damp, and to pm-sue so regular a diet that the danger of in- testinal disturbance, still present, may be avoided. This is a period in which good bodily and mental work can be carried out with facility. It is an excellent period for travel and for recrea- tion out of doors. Rules Irrespective of Seasons. Protection from Damp. In all seasons it is essential to insure protection from damp. Damp beds have always been considered dangerons, and linen that has not been put to the fire to air and take off damp is usually avoided. A great deal more than these measures, which in their way are excellent, calls for attention. The damp house is the source of greatest danger. All precautions should be taken to keep atmospheric damp from the house. The stone or brick work of the building should not be porous, so as to hold moistui-e ; the walls of rooms should not be covered with material that will absorb and hold moisture ; the basement should be perfectly dry, so that from it damp and impure air do not rise into the rooms above. Properly, the basement of every house ought to be raised from the earth underneath by an arch, so that air can flow be- neath it. Cellarage under a house should be well ventilated and kept dry. The roofs and gutters of the house should be made water and damp proof in their relations to the interior of the building. As a certain rule, when moisture streaks the walls and banisters of a house, and looking-glasses are easily dimmed by moisture, the house is unfit for habitation. The soil on which a house is built modifies, naturally, the facility for saving the house from the bad effects of atmospheric moisture. The choice for selection of site should be a porous or gravelly soil, through which the water can percolate rapidlj'^ and make free escape. This may be considered the most perfect site. Houses constructed on clay or impervious soils are unfortunately placed in this respect, but the dangers can be largely prevented 664 PEEVENTIOT^S OF ATMOSPHERICAL by tlioroiigli drainage and by raising the dwellings from the earth. Sites of impervious stony structure are bad. These sites are most difficult to drain, and from the surface of them, Mdth each rise of temperature, the evaporation of M-ater is exceedingly rapid. Thus in cold seasons they are cold and damp, in warm seasons they are warm and damp. The worst site of all is perhaps the undrained, soft, spongy soil on which so many new houses are heedlessly constructed. These houses are never truly dry. It is as if they were built on sponge, and Mr. Chadwick, in denouncing such constructions as causes of many of the diseases which lead to the highest mortali- ties, understates, I believe, rather than overstates the fatal evil. The plan of securing the most complete subsoil drainage for every human habitation is therefore necessary as a precaution against the dangers of atmospheric damp. Trees in and about habitations are good and bad. They are good when they are so placed as to purify the air by the breathing function of their leaves ; when they protect from harsh winds like the east and northeast winds ; and when they afford pro- tection in hot weather from the sun. They are injurious when they surround a place so completely that they shut out the air, prevent escape of moisture, and interfere with the entrance of light. The dead leaves of trees are also a source of danger around a house in the damp and cold season of the year. Trees, consequently, should be so placed in respect to a resi- dence as not to interfere with air, evaporation of moisture, light, or atmospheric purity. Sunlight. As much sunlight as can be obtained should be allowed to en- ter into every room of the dwelling at all hours of the day, and the light should only be subdued when it is painfully strong or oppressive. Sunlight purifies, and is a potent agent for destroy- ing the action of the organic poisons which float in the air. Let a beam of sunlight traverse a room from an opening in a shutter, and if the course of the beam is not filled or made bright with a cloud of specks of dust, the air is comparativelj^ clean. If, on the other hand, the beam is loaded with floating particles, the air is unclean and unfit for healthy respiration, for those particles en- ter the lungs at every breath, interfere with respiration, and are AND CLIMATIC DISEASES. 665 obstructive of circulation. Such particles may carry witli them the organic matters which constitute the virus of the contagious diseases. The electric light might often be used with advantage for testing the purity of the air of a house, a hospital ward, or other places where people live. Freshness of Air. The air admitted into a dwelling-house should always be as pure and as fresh as it can be. Air that is breathed over and over again is devitalized, and in such air there is not only risk of accumulation of the products of combustion, fumes of gas, and odors of decomposing organic substances, but the air itself is de- prived of its full power to vitalize. As a rule, whatever is pro- ducing an unpleasant or oppressive smell, however faint, in a house or in a room, is doing harm to the air of that house or that room, and should be at once removed. Dead flowers, preserved or stuffed animals, remains of food, should never be kept in rooms the air of which is used for the purposes of life. Bed- rooms should of all rooms be free of such impurities ; they should be as free as they can be even of furniture that is unne- cessary, and should never be the respositories of soiled or left-off clothes, or other similar sources of uncleanliness. They cannot be too efficiently ventilated. Preventions in Relation to Climate. Places that are damp are always bad as localities for human habitations. There is no exception to this rule. Some diseases are closely connected with dampness of climate, pulmonary con- sumption especially ; hence the residence of consumptive persons in close and wet valleys is most injurious to them. The same fact applies to those who suifer from the disease rheumatism, and, indirectly, from heart-disease consequent upon the rheumatic affection. The climate that is on the whole best suited to man is one of comparative dryness and warmth. The climate of May and June in this country is therefore the most favorable, and it is a good thing to remember so simple a lesson derived from the calcula- tions of scientific inquirers. To those in England who can afford to take a change of cli- 666 PEEVENTIONS OF ATMOSPHERICAL mate, and feel that they reqinre such change, it is excellent prac- tice for them to observe which of the six climates of England, the damp and cold, the cold, the dry and cold, the dry and warm, the hot, and the damp and warm, is most injurious or most bene- ficial. They can, in this way, find out what seasons of the year require to be avoided, and by reference to technical information as to foreign climates, can discover which climate is the one to be sought for by way of change. There is in the United Kingdom itself a great variety of climate, and by care in selection many persons might find what they want here, who now, with an im- perfect knowledge, go, after w^iat they think they want, to other countries, where many of the conditions of health are less favor- able than those obtainable at home. The question of residence in a valley or on a height, or on the sea-level, is one of much moment. Taking it all round, I believe that the sea-leVel in an open space is the best. It is assumed by some that certain races can bear variations fi'om the sea-level, above it and below it, better than other races, and the Jewish race has been cited as peculiarly favored in this respect. The evidence in proof of this is insufiicient, while it is very strong in favor of the advantage of the sea-level surface. Much of the ben- efit of a sea-voyage, in many cases of disease, depends on the equality of atmospheric pressure, as well as on the purity of the atmosphere. With most persons residence at an elevation of a hundred feet or so above the level of the sea gives a sensation of lightness and activity, and is, no doubt, much preferable to residence below the sea-level. Occasional change from the crowded city or town to the sea- side is, to the vast majority of people, one of the greatest of benefits. By such change the blood is newly aerated, and the lungs, to use a familiar expression, are cleared of the dust and dehf'is of the populous place. I am of opinion that three or four short visits to the sea-side in the year are productive of far more good than one prolonged visit extending over the same time. AND CLIMATIC DISEASES. 667 II. Local and Centeal Preventions of Atmospheeical Causes of Disease. Local sanitary authorities ought to do a great deal for the atmospheres of towns by attending to the proper planting of trees in open places, the introduction of parks and squares, and the immediate removal of all sources of atmospheric impurity. They ought to provide also proper shelters for the protection of those who are, by necessity, engaged in public out-door work, such as cabmen. They ought to provide gymnasia and winter gardens for the poor, and especially for the children of the poor. They ought to protect from the dangers of lightning shock by erecting lightning-conductors on all public buildings. But their first and greatest care should relate to the subsoil drainage of the locality which is under their direction. Everything is literally and prac- tically mere surface work until all the area covei-ed with houses is rendered dry and efficient for carrying away moisture. The Central Government has duties to perform in specially enforcing subsoil drainage, and in giving the local authorities powers to enforce the use of none but proper materials in the con- struction of human dwellings. The Central Government has still another duty before it, that, namely, of legislating more scientifically and determinately for the suppression of noxious exhalations and vapors in large man- ufacturing centres and industries. There is nothing whatever to prevent every industry from being carried on without causing any impurity of air, except the one difficulty of deficient resolution. Science has at command every means of suppressing noxious vapors and of making industry more profitable when the expenses incident to the reformation have been met. It is the duty of the Government to employ science to discover the methods of refor- mation, and to supply standards by which the authorities can in- sist that all work shall be carried on by such standards, until the air of every affected town in the kingdom is freed of atmospheric impurities. CHAPTEE lY. PREVENTIONS OF PARASITICAL DISEASE. Foe the prevention of all tlie parasitical causes of disease there is one sole method, a method which is as effective as it is simple, and that is to be clean ; for the diseases induced by parasitic growths of all kinds, with one or two partial exceptions, are due to uncleanliness. For the prevention of those diseases from parasites which enter the body by the alimentary canal, and which give origin to hyda- tids, tape-worm, and trichinosis, cleanliness in respect to food is the desideratum. For the prevention of diseases, like scabies, from those par- asites which affect the surface of the body,, systematic general ablution is the means required. For the prevention of cutaneous diseases from vegetable para- sites, like the diseases ring- worm and scald-head, protection from contagious influence, sustainment of tlie general health by correct diet and regime, are, in addition to cleanliness, the measures de- manded. In carrying out these preventive measures personal and local authoritative action are both required. I. PERsOiSrAL Rules for Prevention. Personal cleanliness is called for in respect to the cleanliness that should be followed in the preparation of food in every household. Foods are the grand means for the introduction of parasites, and butcher's meat and pork-butcher's meat are the commonest means. All specimens of animal food which present signs of being spotted or speckled should be rejected. If in the flesh small rounded white spots be observed, the meat should be rejected. If connected with a portion of flesh there be minute bladder-like PEEVENTIONS OF PAEASITICAL DISEASE. 669 structures attached, the substance should be rejected. If the meat, especially pork, present what is called a measly appearance, or, as it is sometimes commonly described, " a pepper and salted look," in lines or sections, it should be rejected. If it presents the appearance of anything living in its structure it should be rejected. The greatest care should be taken that all foods, whether ani- mal or vegetable, be thoroughly clean before they go through the process of cooking if they are going to be eaten cooked ; still greater care should be taken with those articles of food of a vege- table kind, such as celery, radishes, onions, and the various kinds' of fruits, which are going to be eaten uncooked. AYith children unclean fi'uits are a constant cause of disease, particularly of that parasitic disease caused by the ascaris vermicularis, or thread- worm. I believe, also, that the large round worm ascaris lum- hricoides is often introduced by fruit. When the intestinal parts of animals are being used as food, as in the case of tripe, too much care cannot be taken in regard to cleanliness. Such foods are very doubtful altogether, but if they are to be utilized it should be with more than ordinary pre- ventive care. The same rule applies to the liver, a structure which is an easy channel, as food, for the propagation of disease among those who subsist upon it. In regard to every kind of animal or vegetable food that may be a means of conveying parasitic forms into the body, there is another rule which should be universally adopted, and that is, to have such food thoroughhj and completely cooJi'ed. Ko animal food ought to be eaten that has not been subjected to the tem- perature of boiling water, that is to say, 212° Fahr. It should be subjected to this temperature through the whole of its struct- ure, whether it be boiled or roasted. It is probable that all the parasitic organic forms are destroyed at this temperature of 212°, and the actual fact of complete boiling is preventive of itself. But roasting when effectually carried out is a still better pre- ventive. Preserved meat, even when the preservation from decompo- sition is perfect, is not a sufficient protection against the intro- duction of parasites, and indeed the parasite of the disease trich- inosis has been more frequently distributed through preserved hams and such kinds of food than by any other means. Pre- 670 PEEVEFTIOlSrS OF PARASITICAL DISEASE. served foods, as well as fresh, require, therefore, to be kept under observation for the sake of prevention of disease. Foods, vegetable or animal, in a state of decomposition ought to be rigorously excluded. The idea that some foods can be taken when they are what is called " high," and when they are charged actually with low forms of animal life, is a fallacy as uncleanly as it is dangerous. Such food, high game, high venison, is al- together out of place at a table surrounded by those who wish to be healthy. For the prevention of those diseases of the cutaneous surface which spring from parasitic forms, such as scabies, two rules are necessary. The first of these is to prevent contact of the healthy with the unhealthy. The second is to maintain perfect cleanliness of body. These rules extend to the prevention of all the living animal forms which move upon the surface of the bod}", or which burrow under the surface. For the prevention of the diseases which spring from the low forms of parasites, such as ring-worm and scald-head, three rules, as suggested already in general terms, are required. The first rule is to prevent contact of the healthy with the affected, a rule which should be rigorously carried out in nurseries and school- rooms whenever any cases of the affections appear. The second rule is to maintain the general health of the young in wdiom these diseases are most common, and who become more than ordi- narily liable to them when, from exposure to close and bad air, indifferent diet, or overwork mental or physical, the vital powers are deteriorated. The third rule is to maintain perfect cleanli- ness of the body. II. Local Attthoritative Rules for Prevention. Local authorities have at command powers which should en- able them to unite their authority with that of personal care for the prevention of the parasitic diseases. These, in fact, are just the diseases which a local authority can control. In every locality local authority ought to have an inspector of animal food, whose duty it should be to see that no part of a car- cass of an animal should enter the market if it present any evi- dence of being tainted with disease. PEEVENTIONS OF PARASITICAL DISEASE. 671 This is a practical fact whicli has been known to the Jewish people for ages past, and has been acted upon by them with the utmost benefit to the health of their community. In the Jewish community there is a certain number of men set apart to act as inspectors of animal food. They attend at the slaughter-houses, and after an animal is slain and dressed they submit it to inspection ; then, unless they put upon it their sign that it is free of disease, which certainly excludes all parasitic dis- ease, it is not permitted to enter a Jewish family. It enters into the families out of the Jewish community, so that we, who are not Jews, actually accept into our bodies food which the Jews have rejected as diseased food. It may be true that the Jewish inspectors are not skilled pathologists ; it may be that they sometimes make mistakes, con- demning as unfit for food what is only seemingly unfit ; but when they err it is on the safe side, and to what extent they reject food which other members of the community accept is shown by com- paring a statement of the number of animals slaughtered for the Jewish community in the London districts, with the numbers that were free from disease and diseased. The facts, collected by Mr. H. Harris, Secretary to the Jewish Ecclesiastical Board, have been supplied to me by Mr. D. Tallerman. Animals inspected in London by the Jewish inspectors yielded the following returns : — Total Oxen 1 ply, which in past days has been a fre- quent source of communication of the zymotic diseases, the milk supply of the place should be most carefully supervised. Cow- 682 PEEVETTTIONS OF ZYMOTIC DISEASES. sheds in the midst of human commmiities, in which cows, like animal machines for producing milk, are kept, perhaps for months together, in partial darkness, dirt, close air, and often without any provision for the separation of healthy from unhealthy animals, should be entirely abolished. Milk supplies, like meat and vege- table supplies, should be under systematic supervision. Provision of Publio Laundries. Each local authority should take care to provide for its dis- trict, or to see that there is provided in it, model laundries and drying-grounds. Double injury springs from the present system of laundries. In the small houses of the poor in which so large an amount of laundry work is going on, the atmosphere is overcharged with moisture, and the poor children of the workers are exposed to many acute diseases, especially to croup, from this cause. That is evil number one. Evil number two is more extended and ex- tensive: it is the danger, always imminent, — from the laundry in which there is no separation of infected from uninfected clothing, and no disinfecting chamber for infected clothing, — of the poi- sons of the infectious diseases being conveyed by clothing into the homes of the healthy, an accident which is easy to accom- plish, and often accomplished. Hospitals for the Infected Sick. For the care of those who are stricken with the zymotic or contagious diseases each local authority should have within its boundaries a small hospital, and if the place be large a series of small hospitals, ready at every moment for the reception of the infected sick from all classes of society, rich as well as poor. Such hospitals sliould be under the control of the local central au- thority, and each should be constructed to receive not more than twenty to thirty sufferers at one time, so that spread of infection by concentration of the sick may not occur. In crowded places these hospitals should, in my opinion, be placed on the same level as the roofs of the houses ; they should be constructed of iron, so that their walls may be purified by the fire brush and all organic matter from the sick instantly destroyed. The hospitals thus planned, and made entirely safe from be- coming sources of danger to the general community, should be in PEEVENTIONS OF ZYMOTIC DISEASES. 683 the midst of the community. First, because it is bad practice to remove the sick long distances ; and, secondly, because every per- son in whose house a case of infectious disease breaks out should be induced, by example, not to have the sufferer taken away a long distance, but removed close at hand to a proper place pro- vided with every means for the most scientific treatment while isolated from the rest of the community. Under this plan every private house would cease to be a centre of infectious disease ; every person accidentally attacked would be removed out of harm's way ; and every person so removed would be placed under the best circumstances to secure recovery. Amongst the poor children suffering from contagious disease, the mere matters of equable temperature and proper feeding in such hospitals would alone sufiice to reduce the mortality from the in- fectious maladies fully one-half what it now is. In connection with this department for the management of the infections sick, the local authority should have a meteoro- logical observatory in order to detect the relation of seasons and of all known atmospherical variations to disease. It should keep curve charts of current diseases after the method introduced by Messrs. Mitchell and Buchan, of the Scottish Meteorological So- ciety. It should instruct its sanitary inspectors to sustain the strictest police observation as to the development of infectious disease in different centres of the community ; and whenever a centre was found to be steadily yielding a number of cases ex- ceeding a certain standard, it should remodel that centre, and if absolutely necessary should carry out to the letter the old Mosaic system of pulling the infected part down and reconstructing it in a condition for health. It should have the most accurate reg- istration of diseases at all times, throughout all the boundaries under its jurisdiction. Under this system every parish would bear its own burden and accept its own responsibility for the retention and management of the infectious cases occurring within its own boundaries. It would have all the special centres of infection in each of its districts thoroughly mapped out, and would know, on a calculation of cases occurring in quinquennial periods, what is the permanent accom- modation required for its infectious sick. The general supervision of this M^ork should be in the hands of the Medical Ofiicer of Health. 684 PEEVENTIOISrS OF ZYMOTIC DISEASES. The nursing, also under the supervision of the Medical Officer of Health, should be carried out by trained nurses, who might be educated to then- work in the Union Infirmaries. The medical attendance should be conducted by a special staff of duly qualified medical men, acting under the Medical Officer of Health, and re- sponsible to the local authority. in. Central AtrTHOBiTATivE Kules foe Prevention. When all that can be done by personal effort is done, and when personal effort is backed by local administrative authority, little remains for a central government to perform. And, as a central government is comparatively powerless in a free country, unless it be acting in accordance with the will of the people, it has but little to do with matters in which the people are ready to act for themselves. On the subject of the prevention of zymotic diseases there are, however, a few rules required which can only be carried out by the central authority. Registration of Disease. The registration of births and deaths which has been going on since 1838 has proved the most valuable record extant of the nature, course, and progress of the zymotic diseases. That ought now to be supplemented by a registration of those diseases, so that we may not only see what those diseases pay over to death, but what health pays over to them. I suggested this work of reo-istration to the Government nearly a quarter of a century ago. I also organized a voluntary plan of such registration, and with over fifty stations, extending in different points of the country from St. Mary's, Scilly, to the Shetland Islands, carried on the plan for some years. The details were placed by me before Sir Benjamin Hall when he was President of the Board of Health, and obtained his strong approval. But the project lapsed, and although it ha,s been carried out in some particular localities, under local authority, it remains yet to be brought into a general scheme in the United Kingdom and to be affiliated with the pres- ent work of the Registrar-General. Through the registrars of births and deaths these returns of PEEVENTIONS OF ZYMOTIC DISEASES. 685 disease should now be collected. A law is required rendering it necessary for every householder to make a return of the conta- gious disease which is present in his house. The return should go regularly to Somerset House, and should be embodied, sys- tematically, in a weekly statement. Collateral returns relating to the meteorology of districts in which the diseases occur, and of epidemic diseases of cattle, domestic animals and plants, should also be collected. From such returns, coupled with complete geological survey of the dis- tricts, we should, in a few years, possess a perfect natural history of the spreading diseases. We should know precisely their modes of origin, their course, and their relations one to another, as well as their mortalities, from which facts we should soon learn how to prevent them altogether. Compulsory Prevention. Yaccination. The compulsory enforcement of measures for preventing dis- ease on what are called prophylactic principles is a subject which has led to the active administration of the Government in regard to one particular disease. Small-pox. The Government enforces vaccination as a prophylactic measure against small-pox. Some years ago that measure w^as made compulsory by Parliament, with the assent of the greater part of the nation that had paid atten- tion to the question involved. Of late years a very powerful opposition to vaccination has been started, and active measures have been taken by many energetic and conscientious men to bring about a repeal of the compulsory act. It is important to place this question in a true and impartial light. There is no doubt from the evidence at command that the disease Cow-pox, which is induced by vaccination, prevents those who have suffered from it from contracting the more severe disease small-pox. Again, there can be no doubt that cow-pox itself, pure and simple, that is, uncomplicated by any accident, is a harmless disease, while small-pox is one of the most serious. As a matter of exchange, therefore, of one disease for another, presum ing that one or other must be had, cow-pox has everything in its favor. Again, admitting that cow-pox is attended by certain accidents, by the introduction into the body of erysipelas, syphilis, and some other diseases, if tlie choice of two evils be an absolute necessity, the balance is all on the side of vaccination. 686 PEEVENTIONS OF ZYMOTIC DISEASES. The next point then which we have to discuss is whether small- pox must exist if cow-pox be not compulsorily enforced ? To understand this question we must consider on what ground vaccination stood when it was first introduced. Yaccination was brought in by Jenner in order to supersede a process called inoculation for small-pox, a process by which small- pox was systematically propagated from one person to another by operation. This began in the early part of the last century, and became so general it may have been considered all but universal. A few years before the close of the century a census was taken of Brighton and of some other towns, as preparatory to a general inoculation of the people. In this way every village and every town, we may almost say every house, became a centre of small- pox, because whei^ever the disease was propagated by inoculation it was also propagated by infection. It was at this period, when the country was saturated with the contagious disease, that Jenner came forward with his antidote, and it is not in any way surprising that by his substitution of a comparatively harmless inoculation for a terribly fatal one, he changed the state of things altogether, and created a triumphant success for himself which no one could dispute. That which remains to be determined is, whether by this suc- cess he merely corrected an egregious blunder in assumed prophy- lactic practice, or whether he went further, and introduced a plan for preventing the natural disease, irrespective of the mischiefs produced by inoculation. The truth lies probably between the two extremes. The most determined opponent of vaccination must acknowledge, if he will be fair, that Jenner, in substituting vaccinia for variola, cow- pox for small-pox, substituted a protective disease against small- pox which in itself was harmless, and which had this indescribable advantage, that the protective disease, unlike small-pox, was not of an infectious or contagious character, except when it was pro- moted for a distinct objeet by a specific operation. The effect of this introduction was, naturally enough, stupen- dous. If inoculation had been given up, small-pox would have continued in the most wide-spread manner, because the disease was everywhere, and every dwelling was so infected with it that nothing short of insusceptibility to the affection by the process of contracting it could be considered as protective, while every per- PEEVENTIONS OF ZYMOTIC DISEASES. 687 son who took tlie disease became another instrument for its prop- agation. In a word, the whole population was obliged to have small-pox, and I remember myself being shown by a relative of mine, who entered the practice of medicine before vaccination was accepted, a large village where every resident in it had, with- out a single exception, been through the small-pox. Vaccination swept this away. It afforded a protection ; it did not afford an infections disease. It checked the universal evil ; it gave time for the general disinfection of the country from small-pox poison. Its good effect was so immense that all secondary evils incident to it were naturally overlooked. So much for the original value of vaccination. It has played a most important part, and has, in all probability, by giving time for general removal of small-pox poison from the homes of the people, brought the suppression of small-pox within the range of sanitary measures alone, without necessitating, for many years longer, the enforcement of vaccination... The opponents of vaccination wish it to be accepted that that time has now come. They direct our attention to Jurin's and Net- tleship's remarkable computations about the mortality of small-pox before the introduction of inoculation, and they urge that the mortality from small-pox of persons who take the disease after vaccination is not greater than that of persons who, in the old times, died from the original small-pox, namely, — 18 per cent. What Jurin said was the following : — {(I) That of all children that are born in England at the time he wrote, 1722, there will at some time die of small-pox one in fourteen. (J) That of persons of all ages taken ill of the natural small- pox, there will die of that distemper one in jive or six, or two in eleven, or just over 18 per cent. ('l be fur- nished without cost to the author. All letters pertaining to the Editorial Department of The Medical News and The American Journal of the Medical Sciences should be addressed to the Editorial Offices, 1004 Walnut Street, Philadelphia. All letters pertaining to the Business Department of these journals should be addresserl exclusively to Henry C. Lea's Son & Co., 706 and 708 Sansom Street, Philadelphia. Henry C. Lea's Son & Co.'s Publications — Dictionaries. DUJV^GLTSOJSr, MOBLBY, M.D., Late Professor of Institutes of Medicine in the Jefferson Medical College of Philadelphia. MEDICAL LEXICON; A Dictionary of Medical Science : Containing a concise explanation of the various Subjects and Terms of Anatomy, Physiology, Pathol- ogy, Hygiene, Therapeutics, Pharmacology, Pharmacy, Surgery, Obstetrics, Medical Juris- prudence and Dentistry, Notices of Climate and of Mineral Waters, Formulas for Officinal, Empirical and Dietetic Preparations, with the Accentuation and Etymology of the Terms, and the French and other Synonymes, so as to constitute a French as well as an English Medical Lexicon. A new edition, tlioroughly revised, and very greatly modified and augmented. P>y Richard J. Dunglison, M. D. In one very large and handsome royal octavo volume of 1139 pages. Cloth, $6.50; leather, raised bands, $7.50; very handsome half Russia, raised bands, $8. The object of the author, from the outset, has not been to make the work a mere lexi- con or dictionary of terms, but to afibrd under each word a condensed view of its various medical relations, and thus to render the work an epitome of the existing condition of medical science. Starting with this view, the immense demand which has existed for the work has enabled him, in repeated revisions, to augment its completeness and usefulness, until at length it has attained the position of a recognized and standard authority wherever the language is spoken. Special pains have been taken in the preparation of the present edition to maintain this enviable reputation. The additions to the vocabulary are more numerous than in any previous revision, and particular attention has been bestowed on the accentuation, which will be found marked on every word. The typographical arrangement has been greatly improved, rendering reference much more easy, and every care has been taken with the mechanical execution. The volume now contains the matter of at least four ordinary octavos. A book of which every American ought to be prouii. When tlie learned author of the work passed away, probably all of us feared lest the book should not maintain its place in the advancing science whose terms it defines. Fortunately, Dr. Richard .1. Dunglison, having assisted his father in the revision of several editions of the work, and having been, therefore, trained in the methods and imbued with the spirit of the book, has been able to edit it as a work of the kind should be edited — to carry it on steadily, without jar or inter- ruptiim, along the gi-ooves of thought it has trav- elled daring its lifetime. To show the magnitude of the task which Dr. Dunglison has assumed and carried through, it is only necessary to state that more than six thousand new subjects have been added in the present edition. — Philadelphia Medical Times, Jan. 3, 1874. About the first book purchased by the medical student is the Medical Dictionary. The lexicon explanatory of technical terms is_simply a -sine qua non. In a science so extensive and with such col- laterals as medicine, it is as much a necessity also to the practising physician. To meet the wants of students and most physicians the dictionary must be condensed while comprehensive, an(i pr.actical while perspicacious. It was because Dunglison's met these indications that it became at once the dictionary of geneial use whei-ever medicine was studied i"n the English Language. In no former revision have the alterations and additions been so great. The chief terms have been set in black letter, while the derivatives follow in small caps; an arrangement which greatly facilitates reference. — Ciacinnnti Lancet and Clinic, .Ian. 10, 1874. As a standard work of reference Dunglison's work has been well known for about forty years, and needs no words of praise on oar part to recom- mend it to the members of the medical, and like- wise of the pharmaceutical, profession. The latter especially are in need of a work which gives ready and reliable information on thousands of subjects and terms which they are liable to encounter la pursuing their daily vocations, bat with which they cannot be expected to be familiar. The work before us fully supplies this want. — American Jour- nal of Pharmacy, Feb. 1874. Particular care has been devoted to derivation and accentuation of terms. With regard to the latter, indeed, the present edition may be consid- ered a complete "Pronouncing Dictionary of Medical Science." It is perhaps the most reliable work published for the busy practitioner, as itcon- tains information upon every medical subject, in a form for ready access, and with a brevity as ad- mirable as it is practical. — Southern Medical Record, Feb. 1874. A valuable dictionary of the terms employed in medicine and the allied sciences, and of the rela- tions of the subjects treated under each head. It well deserves the authority and popularity it has ohin.iue.d.— British Med. Jour., Oct. 81, 1874. Few works of this class exhibit a grander monu- ment of patient research and of scientific lore. — London Lancet, May 1:5, 1875. Dunglison's Dictionary is incalcul.ably valuable, and indispensable to every practitioner of medi- cine, pharmacist and dentist. — Western Lancet, Blarch, 1874. It has the rare merit thatitcertainly has no rival in the English language for accuracy and extent ot references. — London Medical Gazette. JELOBT.YN, JIICHABD D., 31. D. A Dictionary of the Terms Used in Medicine and the Collateral Sciences. Revised, with numerous additions, by Isaac Hays, M. D., late editor of The American Journal of the Medical Sciences. In one large royal 12mo. volume of 520 double-columned pages; Cloth, $1.50; leather, $2.00. It is the best book of definitions we have, and ought always to be upon the student's table — Southern Medical and Sitrgical Journal. BOnWIJLL, G. F., F. B. A. S,, F. C, S,, Lecturer on Natural Science nt Clifton College, England. A Dictionary of Science : Comprising Astronomy, Chemistry, Dynamics, Elec- tricity, Heat, Hydrodynamics, Hydrostatics, Light, Magnetism, Mechanics, Meteorology, Pneumatics, Sound and Stntics. C(nitrihuted l)y J. T. Bottomley, M. A., F. C. S., AVilliara Crookes, F.R.S., F.C.S., Frederick (iiitlirie, B.A., Ph. D., E. A. Proctor, B.A., F.R.A.S., G. F. Rodwell, Editor, diaries Tomlinscm, F.R.S., F.C.S., and Richard Wornell, M.A., B.Sc. Preceded by an Essay on the History of the Physical Sciences. In one handsome octavo volume of 702 pages, with 143 illustrations. Cloth, $5.00. Henry C. Lea's Son & Co.'s Publications — Coiiipends, Anat. HARTSHORJSrE, HEJSTRY, A, M., M, JD., Lately Professor of Hij;/icne in the Vniversitji of Pennsylvania. A Conspectus of the Medical Sciences ; Containing Handbooks on Anatomy, Physiology, Chemistry, Materia Medica, Practice of Medicine, Surgery and Obstetrics, Second edition, tliorouglily revised and greatly improved. In one large royal 12mo. volume of 1028 pages, with 477 illustrations. Cloth, |4.25 ; leather, $5.00. The work is intended as an aid to the medical student, and as such appears to fulfil admirably its o)>ie''t hy its excellent anangement, the lull com- Eiiation of facts, the perspicuity and terseness of mguage, and the clear and instructive illustra- tions. — Anu-ricnn Journai of Plinr»inri/,,Ux\y, 1874. The oliject of this manual is to afford a conven- ient work of reference to students dining the briel moments at their command while in attendance upon medical lectin-es. It is a favorable sign that it h.is been found necessary, in a short space of time, to issue a new and carefully revised edition. The illustrations are very numerous and unusu- ally clear, and each part seems to have received its due share of attention. We can conceive such a work to be useful, not only to students, but to practitioners as well. It reflects credit upon the industry and energy of its able editor. — Boston Blriitcnl and Surnicat Journal. Sept. 3, 1ST4. We can say, with the strictest truth, that it is the best work ol'the kind with which we are acquaint- ed. It embodies in a condensed form all lecent contributions to pi'aetical medicine, and is there- fore useful to every busy practitioner throughout our country, besides being admirably adapted to the use of students of medicine. The book is faithfully and ably executed. — Charleston Medical Journal. Api'il, 1875. STVIJBNTS' SBBIES OF MANUALS. A Series of Fifteen Manuals, for the use of Students and Practitioners of Medicine and Surgery. Tliey will be written by eminent Teachers or Examiners, and will be issued in pocket-size 12mo. volumes of 300-540 pages, richly illustrated and at a low price. The following volumes may now be announced: Klein's Elements of Histology, Pepper's Surrjlcal Pathology, Treves' Surgical Applied Anatomy, Ralfe's Clinical Chemistry, and Clarke and Lockwood's Dissectors^ Manual, {Just ready) ; Power's Human Physiology, {Reculy shortly); Robertson's Physical Physiology, Bruce's Materia Medica and Therw- peutics, Bellamy's Operative Surgery, and Bell's Comparative Physiology and Anatomy, {In active preparation for early publication.) For separate notices see index on last page. JSTBTLL, JOHN, M. I),, and SMITH, F. G., M. ID., Late Surgeon to the Penna. Hospital. Prof, of the Institutes of Med. in the Univ. of Penna. An Analytical Compendium of the Various Branches of Medical Science, for the use and examination of Students. A new edition, revised and improved. In one very large royal 12mo. volume of 974 pages, with 374 woodcuts. Cloth, $4; strongly bound in leather, raised bands, $4.75. LUDLOW, J. L., M, J>., Consulting Physician to the Philadelphia Hospital, etc. A Manual of Examinations upon Anatomy, Physiology, Surgery, Practice of Medicine, Obstetrics, Materia Medica, Chemistry, Pharmacy and Tiierapeutics. To which is added a Medical Formulary. Third edition, thoroughly revised, and greatly extended and enlarged. In one handsome royal 12mo. volume of 816 large pages, with 370 illus- trations. Cloth, $3.25 ; leather, $3.75. The arrangement of this volume in the form of question and answer renders it espe- cially suitable for the office examination of students, and for those preparing for graduation. WILSON, FMASMUS, F, JJ.X A System of Human Anatomy, General and Special. Edited by W. H. ., and HORNEJl, WM. E.,3I.I>,, Emeritus Prof, of Surgery in the Univ. of Penna., etc. Late Prof, of Anat. in the Univ. of Penna. An Anatomical Atlas, Illustrative of the Structure of the Human Body. In one large imperial octavo volume of 200 pages, with 034 beautiful figures. Cloth, $4.50. CLFLAND, JOHN,m7i>.,F.II.S., Professor of Anatomy and Physiology in Qucen''s College, Galivay. A Directory for the Dissection of the Human Body. In one 12mo. volume of 178 pages. Clotii, $1.25. BELLAMY, EDWAUD, F. M. C, S., Senior Assistant-Surgeon to the Charing-Cross Hospital, London. The Student's Guide to Surgical Anatomy: Being a Pe.scription of the most Important Surgical Regions of tbe Iluniau Body, ami intended as an Introduction to Operative Surgery. In one 12mo. voliune of 300 pages, witli 50 illustrations. Clotli, $2.25. HARTSHORXE'S HANDBOOK OK ANATOMY HORNKR'S SPRCIAL ANATOMY AND IIISTOIi- A.\lJ I'HVSIOLOGY. Second edition, revised. OtiY. Kiglitli edition, extensively revised and In one royal 12tno. volume of 310 pages, with 'I'lO moilified. In two octavo voliunos of 1UU7 paged, , woodcuts. Cloth, $1.75. with 32U woodcuts. Cloth, $li.UO. 6 Henry C Lea's Son & Co.'s Publications — Anatomy. ALLBN, ffAMBISOJV, M, D., Professor of Physiology in the University of Pennsylvania. A System of Human Anatomy, Including Its Medical and Surgical Relations. For the use of Practitioners and Students of Medicine. With an intro- ductory Chapter on Histology. By E. O. Shakespeake, M. D., Ophthalmologist to the Philadelphia Hospital. In one large and handsome quarto volume of about 700 double- columned pages, with 380 illustrations on 109 lithographic plates, many of which are in. colors, and about 150 engravings in the text. In six Sections, each in a portfolio. Section I. Histology {Just Beady). Section II. Bones and Joints {Just Ready). Section III. Muscles and Fasciae {Just Ready). Section IV. Arteries, Veins and Lymphatics {Just Ready). Section V. Neryous System {Just Ready). Section VI. Organs of Sense, of Digestion and Genito-Urinary Organs {In Press). Price per Section,. $3.50. For sale by subscription only. Apply to the Publishers. Extract from Introduction. It is the design of this book to present the facts of human anatomy in the manner best suited to the requirements of the student and the practitioner of medicine. The author believes that such a book is needed, inasmuch as no treatise, as far as he knows, contains, in addition to the text descriptive of the subject, a systematic presentation of such anatomical facts as can be applied to practice. A book which will be at once accurate in statement and concise in terms ; which will be an acceptable expression of the present state of the science of anatomy ; which will exclude nothing that can be made applicable to the medical art, and which will thus embrace all of surgical importance, while omitting nothing of value to clinical medicine, — would appear to have an excuse for existence in a country where most surgeons are general practitioners, and where there are few general practitioners who have no interest in surgery. Among other matters, the book will be found to contain an elaborate description of the tissues; an account of the normal development of the body; a section on the nature and varieties of monstrosities ; a section on the method of conducting post-mortem examina- tions ; and a section on the study of the superficies of the body taken as a guide to the position of the deeper structures. These will appear in their appropriate places, duly subordinated to the design of presenting a text essentially anatomical. A book like this is an ideal rarely realized.' It I to the profession, believing that it is suited not is a mine of wealth in the informationit give.s. It only to those of scientific tastes, but that it will be differs from all preceding anatomies in its scope, of use to the practising physician. — Boston Medical and is, we believe, a vast improvement upon them I and Surgical Journal, Jan. 11, 1883. all. The chief novelty about the book, and really ! It has fallen to the lot of the fortunate publish- one of the greatest ueects in anatomy, is the ex- | ers to be able to bring out the best anatomy yet tension of the text to cover not only anatomical \ produced in America, and one which will prove descriptions, but the uses of anatomy in studying j much more useful to the general practitioner than disease. This is done by stating the narrower | the foreign works now accepted as standard. The topographical relations, and also the wider clin- | descriptions are clear, tersely expressed and well ieal relations, of the more remote parts, by giving | up to date. The work, as a whole, .^^hows a great a brief account of the uses of the various organs, : amount of research, and reflects credit upon it& and by quoting eases which illustrate the "local- 1 author. — N.Y.Med. Jour. and Oiisfef. i?er., Nov. 1882. ization of diseased action." The plates are beau- ■ It is to be considered a study of applied anatomy tiful specimens of woi-k by one who long since jn its widest sense— a system'atie presentation of won a deserved reputation as an artist.— T/ie il/edi- ! such anatomical facts as can be applied to the cal News, October 21, 1882. j practice of medicine as well as of surgery. Our The appearance of the book marks an epoch in ! author is concise, accurate and practical in his medical literature. It is the first important work i statements, and succeeds admirably in infusing on human anatomy that has appeared in America and, more than this, its scope is new and original. It is intended to be both descriptive and topograph- ical, .scientific and practical, so that while satisfy- ing the anatomist it will be of value to the practis- ing physician. The illustrations of the bones are very fine. The names of the parts, muscular at- tachments, etc., are printed either on the figure or close })eside, so th.at they are easily recognized. Dr. Allen'streatmentoftne joints is admirable, and the illustrations made from the author's dissec- tions deserve the'highest praise. They are well con- ceived and well executed, handsome artistically and clear anatomically. As the author points out, such a work as lie has undertaken is necessarily an interest into the study of what is generally con- sidered a dry subject. The department of Histol- ogy is treated in a masterly manner, and the ground is travelled over by one thoroughly famil- iar with it. The illustrations are made with great care, and are simply superb. It would be impos- sible, except in a general way, to point out the excellence of the work of the author in the second Section — that devoted to the consideration of the Bones and Joints. There is as much of practical application of anatomical points to the every-day wants of the medical clinician as to those of the operating surgeon. In fact, few general practi- tioners will read the work without afeeling of sur- prised gratification that so many points, concern- encyclopfedic, and the result shows that he has ing which they may never have thought before, brought to it a mind well prepared for the task by | are so well presented for their consideration. It extensive reading, critical judgment and literary i is a work which is destined to be the best of its ability. We can cordially recommend the work | kind in any language.— il/fd/ca/. iJccort/, Nov. 25, '82. CLABKIJ,W,B.,F.ILC.S. & LOCKWOOD^C. B., JF.B.C.S, Demonstrators of Anatomy at St. Bartholomew's Hospital Medical School, London. The Dissector's Manual. In one pocket-size 12mo. volume of 396 pages, with 49 illustrations. Limp cloth, red edges, |1.50. Just ready. See Students' Series of Manuals, page 5. _^ TBEVES, JFBJEBBBICK, F. B. C. S., Senior Demonstrator of Anatomy and Assistant Surrieon at the London Hospital. Applied Anatomy. In one pocket-size 12mo. volume of 540 pages, with 61 illus- trations. Limp cloth, red edges, |2.00. Just ready. See Students' Series of Manuals, page 5. Henry C. Lea's Son & Co.'s Publications — Anatomy. GBAY, HENRY, F, R, S,, Lecturer on Anntomf) at St. George's Hospital, London. Anatomy, Descriptive and Surgical. The Drawings by II. V. Carter, M. D., and Dr. Westmacott. The dissections jointly by the Author and Dr. Carter. With an Introduction on General Anatomy and Development by T. Holjies, M. A., Surgeon to St. George's Hospital. Edited by T. Pickering Pick, F. R. C. S., Surgeon and Lecturer on Anatomy at St. George's Hospital, London, Examiner in Anatomy, Royal College of Surgeons of England. A new American from the tenth enlarged and improved London edition. To which is added the secorul American from the latest English edition of Landmarks, Medical and Surgical, by Luther Holden, F. R. C. S., author of " Human Osteology," " A Manual of Dissections," etc. In one imperial octavo volume of 1023 pages, with 564 large and elaborate engravings on wood. Cloth, $6.00 ; leather, $7.00 ; very handsome half Russia, raised bands, $7.50. Just ready. This work covers a more extended range of subjects than is customary in the ordinary text-books, giving not only the details necessary for the student, but also the application of those details to the practice of medicine and surgery. It thus forms both a guide for the learner and an admirable work of reference for the active practitioner. The engravings form a special feature in the work, many of them being the size of nature, nearly all original, and having the names of the various parts printed on the body of the cut, in place of figures of reference with descriptions at the foot. They clius form a complete and splendid series, which will greatly assist the student in forming a clear idea of Anatomy, and will also serve to refresh the memory of those who may find in the exigencies of practice the necessity of recalling the details of the dissecting-room. Combining, as it does, a complete Atlas of Anatomy with a thorough treatise on systematic, descriptive and applied Anatomy, the work will be found of great service to all physicians who receive students in their offices, relieving both preceptor and pupil of much labor in laying the groundwork of a thorough medical education. Landmarks, Medical and Surgical, by the distinguished Anatomist, Mr. Luther Holden, has been appended to the present edition as it was to the previous one. This work gives in a clear, condensed and systematic way all the information by which the practitioner can determine from the external surface of the body the position of internal parts. Thus complete, the work, it is believed, will furnish all the assistance that can be rendered by type and illustration in anatomical study. There is probably no work used so universally by physicians and medical students as this one. It is deserving of the confidence that they repose in it. If the present edition is compared with that issued two years ago, one will readily see how much it has been improved in that time. Many pages have been added to the text, especially in those parts that treat of histology, and many new cuts have been introduced and old ones modified. — Journal of the American Medical Association, Sept. 1, 1883. This well-known work comes to us as the latest American from the tenth English edition. As its title indicates, it has passed through many hands and has received many additions and revisions. X The work is not susceptible of more improvement. Taking it all in all, its size, manner of make-up, its character and illustrations, its general accur- acy of description, its practical aim, and its per- spicuity of style, it is the Anatomy best adapted to the wants of the student and practitioner. — Medical Record, Sept. 15, 188:}. Also for sale separate — SOLD EN, LTITHER, F. R. C S., Surgeon to St. Bartholomew's and the Foundling Hospitals, London. Landmarks, Medical and Surgical. Second American from the latest revised English edition, with additions by W. W. Keen, M. D., Professor of Artistic Anatomy in the Pennsylvania Academy of the Fine Arts, formerly Lecturer on Anatomy in the Phila- delphia School of Anatomy. In one handsome 12mo. volume of 148 pages. Cloth, $1.00. almost to learn it by heart. It teaches diagnosis by external examination, ocular and palpable, of the body, with such anatomical and physiological facts as directly bear on the subject, it is eminently the student's and young practitioner's book. — Phy- sician and Surgeon, Nov. 18S1. This little book is all that can be desired within its scope, and its contents will be found simply in- valuable to the young surgeon or physician, since they bring before him sucli data as he requires at .every examination of a patient. It is written in language so clear and concise that one ought JDALTON, JOHN C^M, D., Professor of Phi/siologi/ in the College of Phi/sicians and Surgeons, New York. The Topographical Anatomy of the Brain. In one very liandsome quarto volume of about 200 pages of descriptive text. Illustrated with forty-nine life-size photo- graphic illustrations of Brain Sections, with a like numl)er of outline exi)lanatory plates, as well as many carefully-executed woodcuts through tlie text. In press. ELLIS, GEORGE VINER, Emeritus Professor of Anatonui in Unirersiti/ College, London. Demonstrations of Anatomy. Being a Guide to tiie Knowledge of the Human Body by Dissection. From the eighth ancl revised I^ondon edition. In one very handsome octavo volume of 716 pages, with 249 illustrations. Clotii, $4.25; leather, $5.25. Ellis' Demonstrations is the favorite text-book special line. The descriptions are cleat, and the of the English student of anatomy. In passing methods of pursuing anatomical investigaticms are through eight editions it has been so revised and given with such detail that the boolc is honestly adapted to the needs of the student that it would entitled to its natne. — St. Louis Clinical Record, seem that it had almost reached perfection in this June, 1S7'J. 8 Henry C. Lea's Son & Co.'s Publications — Physiology. J) ALTON, JOHN C, M. D,, Professor of Physiology in the College of Physicians and Surgeons, New York, etc. A Treatise on Human Physiology. Designed for the use of Students and Practitioners of Medicine. Seventh edition, thoroughly revised and rewritten. In one very handsome octavo vokime of 722 pages, with 252 beautiful engravings on wood. Cloth, $5.00 ; leather, $6.00 ; very handsome half Eussia, raised bands, §6.50. The merits of Professor Dalton's text-book, his i pi-evious one, and will tend to keep the profession smooth and pleasing stjHe, the remarkable clear- j posted as to the most recent additions to our ness of his descriptions, which leave not a chapter obscure, his cautious judgment and the general correctness of his facts, are perfectly known. They have made his text-book the one most familiar to American students. — Med. Pecord, March 4, 1882. Certainly no physiological work has ever issued from the press that presented its subject-matter in a clearer and more attractive light. Almost every page bears evidence of the exhaustive revision that has taken place. The material is placed in a more compact form, yet its deliglitful charm is re- tained, and no subject is thrown into obscurity. Altogether this edition is far in advance of any physiological knowledge. — Michigan Medical News, April, 1882. One can scarcely open a college catalogue that does not have mention of Dalton's Physiology as the recommended text or consultation-book. For American students we would unreservedly recom- mend the edition of Dr. Dalton's work now before us. Let it suffice to state that revisions have been made to such an extent as to bring the volume as fully up to the present state of physiological knowl- edge as it is practicable for any author of a book to do. — Virginia Medical Monthly, July, 1882. FOSTER, MICSAJEL, 31, !>., F. It. S., Professor of Physiology in Cambridge University, England. Text-Book of Physiology. Second American from the third English edition. Edited, with extensive notes and additions, by Edward T. Reichert, M. D., late Demonstrator of Experimental Therapeutics in the University of Pennsylvania. In one handsome royal 12mo. volume of 999 pages, with 259 illust. Cloth, $3.25 ; leather, $3.75. A more compact and scientific work on physiol- ogy has never been published, and we believe our- selves not to be mistaken in asserting that it has now been introduced into every medical college In wliich the English language is spoken. This work conforms to the latest researches into zoology and comparative anatomy, and takes into consid- eration the late discoveries in physiological chem- istrj' and the experiments in localization of Ferrier and others. The airangement followed is such as to render the whole subject lucid and well con- nected in its various parts. — Chicago Medical Jour- nal and Examiner, August, 1882. Dr. Mic'iiael Foster's Manual of Physiology has been translated into the German, with a preface, by Professor Kiihne. Kiihne points out in his preface that the abundant material, in spite of the moderate size, is not condensed to systeAiatic shortness, but the whole is related in a narrative style. Further on he writes: "Togive tostndents arid physicians a book which is not intended merely fur reference, but which, by its flowing, lively style, invites the reader to go through it, is always useful, especially when the contents, in- cluding numei-oiis matters in a state of active dis- cussion in which physiology is now so rich, in- struct with truth and calm irnpartiality. Such the author has preserved throughout." The tiansla- tion of it into German is a well-merited compli- ment, since Germany is the especial home of pliysiology, and its literature isat)undantly rich in te.xt-books, monographs and periodicals on physi- ology.— xlmerican Med. Bi- Weekly, June IS, 1881. FOWFB, SENRY, 31. B., F. M. C. S., Examiner in Physiology, Royal College of Surgeons of England. Human Physiology. Shortly. See Students' Series of Manuals, page 5. ROBEBTSON, J. 3IcGREGOR, 31. A., 31. B., Muirhead Demonstrator of Physiology, University of Glasgow. Physical Physiology. In active preparation. See Students' Series of Manuals, page 5. BELL, F. JEFFREY, 31. A., Professor of Comparative Anatomy at King's College, London. Comparative Physiology and Anatomy. In active preparation for early publication. See Students' Series of Manuals, page 5. CARFEJSTER, WM. B., 3L D., F. R. S., F. G, S., A L. S., Registrar to the University of London, etc. Principles of Human Physiology. Edited by Henry Power, M. B., Lond., F.E. C. S., Examiner in Natural Sciences, University of Oxford. A new American from the eighth revised and enlarged edition, with notes and additions by Francis G. Smith, M. D., late Professor of tlie Institutes of Medicine in tiie University of Pennsylvania. In one very large and Inindsome octavo volume of 1083 jiages, with two plates and 373 illus- trations. Cloth, $5.50 ; leather, $6.50 ; half Russia, $7. The editors have, with their additions to the i tion. We have been agreeably surpiised to find only work on physiology in our language that, in the vohmie so coniplcte in regard to the struclui-e the fullest sense of the wor\!t- EARF. With a preface by D. F. Condik, JI. D., and e.xplanations of scientific words. In one small 12mo. volume of 178 pages. Cloth, GO cents. LEH.MANN'S MANUAL OF CHEMICAL PHYS- liiLdtiY. Tianslrtted from the German, with notes ami .additions, bv J. {'iik.rton JIokuis, M. D. In one octavo volume'of 327 pages, with 41 illus- trations. Cloth,.$2.25. Henry C. Lea's Son & Co.'s Publications — Chemistry. ATTFIBLD, JOHN, JPh. D., Professor of Practical Clicmistri/ to the Pharmaceutical Society of Chreat Britain, etc. Chemistry, General, Medical and Pharmaceutical ; Including the Cliem- istry of the U. S. Pharmacopoeia. A Manual of the General Principles of the Science, and their Application to Medicine and Pharmacy. A new American, from the tenth English edition, specially revised by the Author. In one handsome royal 12mo. volume of 723 pages, with 87 illustrations. Cloth, $2.50 ; leather, $3.00. Just ready. From the Author's Preface to the Tenth Edition. This manual is intended as a systematic exponent of the general trntlis of chemistry, but is written mainly for the pupils, assistants and principals engaged in medicine and pharmacy. It will be found equally useful as a reading-ljook or as a text- book, while its comprehensive Index, cc^ntaining eight thousand references, will fit the work for after- consultation in the course of business or professional practice. Introductory pages are devoted to a few leading properties of the elements. The consideration in detail of the relations of tlie elementary and compound radicals follows, synthetical and analyt- ical bearings being pointed out, and attention frequently directed to connecting or underlying truths or general principles. The chemistry of substances naturally associated in vegetables and animals is next considered. Practical toxicology, and the chemical as well as microscopical characters of morbid urine, urinary sediments and calculi, are then given. The concluding sections form a laboratory -guide to the chemical and physical study of quantitative analysis. Tlie work now includes the whole of the chemistry of the recently published United States Pharmacopoeia, and nearly all the chemistry of the British and Indian Pharmacopoeias. BLOXAM, CHABLES i.. Professor of Chemistry in King's College, London. Chemistry, Inorganic and Organic. New American from the fifth Lon- don edition, thoroughly revised and much improved. In one very handsome octavo volume of 727 pages, with 292 illustrations. Cloth, $3.75 ; leather, $4.75. Just ready. This work is designed to give a clear and simple description of the elements and their principal compounds, both inorganic and organic, and also of the chemical principles in- volved in the most important bi'anches of manufacture. It will thus serve as a convenient text-book for the student of general or medical chemistry, and as a work of reference for those engaged in the arts and manufactures. The author has aimed to render the termi- nology and mathematics of chemistry as simple as possible, and to increase the vividness of the text by the inti'oduction of experiments with illustrations of apparatus. The table of contents has been arranged to serve the purpose of an abstract, by which the student may examine himself upon each paragraph of the book, and the Index includes cross- references to the most important formulas. The American edition has been passed through the press subject to the closest scrutiny, with the result of eliminating numerous errors which occur in the English sheets. Though this edition contains as much matter as its predecessor, the publishers are pleased to have been able to make a reduction even from the former low price. MEMSEN, IRA, M. D., JPh. 2>., Professor of Chemistry in the Johns Hopkins University, Baltimore. Principles of Theoretical Chemistry, with special reference to the Constitu- tion of Chemical Compounds. Second and revised edition. In one handsome royal 12mo. volume of 240 pages. Cloth, $1.75. Ju-si ready. From the Author's Preface to the Second Edition. The book lias been thonjughly revised, and much of it has been entirely rewritten. The principal ciianges will be found in the chapters on valence and constitution. These have been materially changed, anl, I believe, much improved. A short chapter on the physical methods for determining the constitution of chemical compounds has been added. FOWNES, GEORGE, Ph. B. A Manual of Elementary Chemistry; Theoretical and Practical. Revised and corrected Ijy IIexky W.vtts, B. A., F. K. S., Editor of A Dictionary of Chemistry, etc. A new American from the twelfth and enlarged London edition. Edited by Robert Bridges, M. D. In one large royal 12mo. volume of 1031 pages, with 177 illustrations on wood and a colored plate. Cloth, $2.75 ; leather, $3.25. The book opens witli a treatise on Cliemical Phy-iics, inchiding He.at, Li(;lit, Mai^netiwrn and Electricity. These 8iU)jects are treated clearly and hrieHy, bnt enough is given to eiiaMe the stu- dent to cornprpjiend the fants and laws of Chemis- try proper. It is the fashion of late years to omit the-'e topics from worivs on chemistry, hut their omissi III is not to be commended. As was required by tlie great ad \'an:;e in tlie science of (Jhemistry of late years, the chapter on the Oeneral Principles of Chemical Philosophy has been entirely rewrit- ten. The latest views on I'lquivalents, Quautiva- lence, et^., are clearly and fully set forth. This last edition is a great improvement upon its prede- ces-iors, which is saying not a little of a book that has rea'.hed its twelfth edition. — Oliio Medical Re- eorder, Oct. 1878. Wohler's Outlines of Organic Chemistry. Edited by Fittig. Translated by Ira Remsen, M. D., Ph. D. In one Timo. volume of 550 pages. Cloth, $3. 10 Henry C. Lea's Son & Co.'s Publications — Chemistry. HOFFMAJSW, F., A.3I., JPh.J)., & FOWEB, F.B., Fh.D., Public Analyst to the State of New York. Prof, of Anal. Chem., in Phil. Coll. of Pharmacy. A Manual of Cheraical Analysis, as applied to the Examination of Medicinal Chemicals and their Prepai-ations. Being a Guide for the Determination of their Identity and Quality, and for the Detection of Impurities and Adulterations. For the use of Pharmacists, Physicians, Druggists and Manufacturing Chemists, and Pharmaceutical and Medical Students. Third edition, entirely rewritten and much enlarged. In one very handsome octavo volume of 621 pages, with 179 illustrations. Cloth, $4.25. Ju&t ready. We congratulate the author on the appearance of the third editionof this work, published for the first time in tliis country also. It is admirable and the information it undertakes to supply is both extensive and trustworthy. The selection of pro- cesses for determining the purity of the substan- ces of which it treats is excellent and tne descrip- tion of them singularly explicit. Moreover, it is exceptionally free from typographical errors. We have no hesitation in recommending it to those •who are engaged either in the manufacture or the testing of medicinal chemicals. — Lotidon Pharma-. ceutical Journal and Transactions, 1883. Viewed in regard to its general aims as well as to the manner in which they have been carried out, the work will be found as complete as can well be desired. The descriptions of operations are full without being redundant, so that the tyro can easily understana them and practise the processes successfully; at the same time the details are not given with such minuteness and prolixity as to become wearisome alike to the adept and the stu- dent. A work is thus presented well adapted as a book of reference for practical use, and calculated to impart such information as in each particular case may be useful or required witiin the limit of its objects. — American Journal of Phar., Rlay, 1883. This work has undergone a very considerable change since the first edition appeared in 1873; in its present form it is a marked improvement on the earlier editions. The authors are to be congratulated on the manner in which they have rem'bdelled the work ; in its present form it is sure to prove a valuable aid in the practice of pharmaceutical chemistry.— io/iJ. Chemist, and Druggist, June 15, 1883. In one 12mo. volume WATTS, HEWRY, B. A.i F. B. S. Author of "A Dictionary of Chemistry," etc. A Manual of Physical and Inorganic Chemistry. of 500 pages with 150 illustrations. In jj?-e.s.s. CLOWES, FBANK, B. Sc, London, Senior Science- Master at the High School, Newcastle-under-Ly7ne, etc. An Elementary Treatise on Practical Chemistry and Qualitative Inorganic Analysis. Specially adapted for use in the Laboratories of Schools and Colleges and by Beginners. Second American from the third and revised English edition. . In one very handsome royal 12mo. volume of 372 pages, with 47 illustrations. Cloth, $2.50. The chief object of the author of the present work was to furnish one which was sufficiently elemen- tary in the description of apparatuses, chemicals, modes of experimentation, etc., so as to "reduce to a minimum the amount of assistance required from a teacher." It is a generally recognized fact that one of the most serious hindrances to the utility of many of the smaller text-books is the too great conciseness of the language employed, whicli renders it unintelligible to the primary student unless supplemented by copious verbal explana- tions from the teacher. The Elementary Treatise of Dr. Clowes, examined with reference to the above claims, is found to be a great improvement on other elementary works. A student who care- fully reads this text will scarcely need the assist- ance of a tutor in following out any of the ex- periments described. — Va. Med. Monthly, Ap., 1881. BALFE, CHABLES H., M. B., F, B. C. B., Assistant Physician at the London Hospital. Clinical Chemistry. In one pocket-size 12mo. volume of 314 pages, with 16 illustrations. Limp cloth, red edges, $1.50. This little text- book opens with a short and able sketch of the constituents of the animal body, and of the chemical reactions of its chief organic and inorganic components. Then follows a chapter on the blood, chyle and lymph, in which the chemistry of these fluids is ably and successfully See Students' Series of Manuals, page 5. dealt with. The short epitome of the toxic condi- tions of the blood is also mo.'^t instructive. This little Clinical Chemistry will be very useful to stu- dents, as it contains rnueh valuable information in a small compass. — British Medical Journal Novem- ber 24, 1883. CLASSEN, ALEXANBEB, Professor in the Royal Polytechnic School, Aix-la-Chapelle. Elementary Quantitative Analysis. Translated, with notes and additions, by Edgar F. Smith, Ph. D., Assistant Professor of Chemistry in the Towne Scientilic School, University of Pennsylvania. In one handsome royal 12mo. volume of 324 pages, with 36 illustrations. Cloth, $2.00. and then advancing to the analj;sis of minerals and such products as are met with in applied chemis- try. It is an indispensable book for students in It is probably the best manual of an elementary nature extant, insomuch as its methods are the best. It teaches by examples, commencing with single determinations, followed by separations, chemistry.— i?osion Journal of Chemistry, Oct. 1878. GBEEWE, WLLLLA3I H., M, B., Demonstrator of Chemistry in the Medical Department of the University of Pennsylvania. A Manual of Medical Chemistry. For the use of Students. Based upon Bow- man's Medical Chemistry. In one r2mo. volume of 310 pages, with 74 illus. Cloth, $1.75. It is a concise manual of three hundred pages, I the recognition of compounds due to pathological giving an excellent summary of the best methods conditions. The detection of poisons is treated of analyzing the liquids and solids of the body, both with suftieient fulness for the purpose of thestu- forthe estimation of their normal constituents and | dent or pra,ctitioBei:— Boston Jl. of Chem., June, '80. A MANUAL OF QUALITATIVE ANALYSIS. I London edition. In one royal 12mo. volume, with By Robert Galloway, F. C. S. From the sixth [ illustrations. Preparing. Henry C. Lea's Son & Co.'s Publications — Phariu., Mat. Med. 11 JPARRISH, EJDWARI), Lnte Prdfcssor of the Tlicory and Practice of Pharmacy in the Philadelphia College of Pharmacy. A Treatise on Pharmacy : designed as a Text-book for the Student, and as a Guide for the Phj'sician and riuirniaceutist. With many Formulae and Prescri])tions. Fiftli edition, thorouglily revised, l)y Thojias S. ^Vjegaxd, Pli. G. In one liandsonie •octavo vohmie of 1093 pages, with 2")0 illustrations. Cloth, So; leatlier, §6. Just ready. From the Preface to the Fifth Edition. A new eilition of ^Ir. Par risli's standard work has been rendered an imperative necessity, not only by tl)L' late revision of tlie U. S. Pharmacopteia, l)ut also by the great advance in chemical and pharmaceutical .science within the last decade. The changes thus required liave rendered the task of the editor l)y no means light, and have considerably increased the size of the volume, in spite of earnest efforts at condensation and the omission of all obsolete matter. The new prejKirations of tlie Pharmacojxx'ia have been introduced, to- gether with its tests for chemical and officinal compounds, and its system of parts by weight in place of definite quantities. The entire chemical section has been reari-anged in con- formity with the jjresent views of that science, and tlie subject of testing, both qualitative and quantitative, has l:)een rendered as complete as the scope of the work would i)ermit and the wants of students are likely to require. All general jiharmaceutical and chemical pro- cesses have been arranged in a separate part, thus facilitating reference and avoiding repetition, while special ajiparatus for particular classes of j^reparations has been placed under those classes. The syllabi, which proved so valuable a feature of previous editions, and on wliich Professor Maisch bestowed so much care, have Ijeen retained; many of them have l)een rewritten and new ones introduced. All new remedies of interest have been added, and in the chapter on elixirs some new formulfe of much popularity liave been given. The editor need only add that he has spared no labor or care in the hope of ren- dering tlie work as acceiitable as it has hitherto been to the student and the pharmaceutist. JIEB3IAWJS, Dr. X., Professor of Pliysiology in the University of Zurich. Experiraental Pharmacology. A Handbook of Methods for Determining the Physiological Actions of Drugs. Translated, with the Author's permission, and with extensive additions, by Kobert Meade Smith, M. D., Demonstrator of Physiology in tlie University of Pennsylvania. In one handsome 12mo. volume of 199 pages, with 32 illustrations. Cloth, §1.50. Just ready. The selection of animals and their management, > liehold experimental and clinical _ experience the patli.i of elimination and changes of poisons ■ firmly and inseparably united. Il is a reliable, in the body, the explanation of the symptoms pro- j concise and practical vade mecum for the time- duced tiy poisons, alterations in tissue, in the re- | pressed worlcer in the laboratory. — New Orleans productive function and in temperature, action on Medical and Surqical Journal, May, 1883. muscles and in nerves, anatomical and chemical This manual is for the piu-pose of instructing changes produced by poisons, all are successively , those who are engaged in the study of the physio- passed in review in a practical instructive fashion, logical actions of drugs— the modus operandi of which speaks well for both the author and the | proceeding. It teaches what instruments are nec- translutor. The book is deserving of an eneo- essary, and how to make use of them. It is just mium as a correct exponent of the spirit and ; tlie work for one engaged in original research, tendencies of modern pharmacological research, and will be found very valuable to all physicians. After closely perusing tlie pages, all laden to over- j for there is- in it a large amount of plivsiologlcal flowing with the rich -.st facts of physiological in- information that is not to be found iii ordinary vestigation, and after following the astounding \ works on physiology. The translator lias added progress of toxic pharmacology as revealed by the j very considerably to the work. The little work is author, we feel that we are fast approaching the ! worthy of the study of all students of phvsiology. realization of that Utopian dream in which we ; — Cincinnati Medical News, Blareh, lS8:i. MAISCH, JOHN M, JPhar. 1)., I'rofritsar of j\lateria Medica and Bo/am/ in tlie Pliiladclpliia Collef/e of Pliarinnei/. A Manual of Organic Materia Medica; Being a Guide to Materia Medica of the \'egetable and Animal Kingdoms. For tlie use of Students, Druggists, Pharmacists and Pliysicians. New edition. In one lianrlsoine royal 12uio. volume. Preparing. A few notices of the jirevious edition are appended. A book evidently written for a purpose, and not , The above manual, by a well-known authority in simply fur the purpose of writing a booli. it is this department and one of the authors of the comfii-eliensive, inasmuch as it refers to all, or , National iJiHpensatory, \ii nwovU fovwUichstudenta nearly all, that is of essential value in organic ma- ' of pharmacy should he grateful. The subject is teria medica, clear and siinpio in its style, concise, unk in which the beginner needs the guidance of since it would be difficult to find in it a snpertiuous a good classification in order to avoid the l)ewil- word, and yet suflficiently ex|)licit to satisfy the dei-nienl wliich fnllows the attempt to grasp a sub- most critical. The text is freely illustrated with ject having so many details. 'I'his condition the woodcuts, which cannot fail to be" valuable in famil- hook fulfils, the classification adopted being a sim- larizing students with the physical, microscopic : pie and practical^ one; the notice of each drug is and macroscopic appearance of drugs. — Chicai/o nrief and clear,' non-essentials being omitted. — Mediint Journal and Kxainuirr, Aug. issu. ' i Boston Mrd. and Sur;/. Journal, .Jan. U), 188:i. GRIFFITH, ROBERT EGLESFJEL/), M. I). A Universal Formulary, containing tiic .Mctliotis of Preparing and Adminis- tering OtHcintd and otbcr .Midiciiu-s. Tlic wlioic adapted to Physicians and Pilar maceut- ists. Tiiird edition, tiiorniiglily revised,. witb numerous additions, by .loiiN M. Maisch, Phar. D., Professor of Materia Medica and Botany in tiie Philadelphia College of P harmacy. In one octavo volume of 77") Jiage.s, witli 38 illustrations. Cloth, $4.50; leather, $5.50, 12 Henry C. Lea's Son & Co.'s Publications — Mat. Med., Therap. STILLJE, A,, M.n.^LL.D., <& MAISCH, J. M., JPJiar. D., Professor of the Theory and Practice of Prof of Mat. Med. and Botany in Phila. Medicine and of Clinical Medicine in the Ct/llege of Pharmaci/, Scc\i/ to the, Anieri- University of Pennsylvania. - can Pharmaceutical Association. The National Dispensatory : Containing the Natural History, Chemistry, Phar- macy, Actions and Uses of Medicines, including those recognized in the Pharmacopoeias of the United States, Great Britain and Germany, with numerous references to the French Codex. Third edition, thoroughly revised and greatly enlarged. In one magnificent imperial octavo volume of about 1600 pages, with several hundred fine engravings. In press. The publishers have much pleasure in announcing to the Medical and Pharmaceutical Professions tliat a new edition of this important work is in press, and that it will appear in the shortest time consistent with the care requisite for printing a work of immense detail, where absolute accuracy is of such supreme importance. Besides its revision on the basis of the U. S. Pharmacopoeia of 1880, it will include all the advances made in its department during the period elapsed since the preparation of that work. To this end all recent medical and i^harmaceutical literature, both domestic and foreign, has been thor- oughly sifted, and everything that is new and important has been introduced, together with the results of original investigations. To accord with the new Pharmacopoeia the officinal formulae are given in parts by weight, but in every instance, for the sake of con- venience, the same proportions are also expressed in ordinary weights and measures. The Therapeutical Index has been enlarged so that it contains about 8000 references, arranged under an alphabetical list of diseases, thus placing at the disposal of the practitioner, in the most convenient manner, the vast stores of therapeutical knowledge constantly needed in his daily practice. The work may therefore be justly regarded as a complete Encyclo- paedia of Materia Medica and Therapeutics, including 1883. The exhaustion of two very large editions of The National Dispensatory since 1879 is the most conclusive testimony as to the necessity which demanded its preparation and to the admirable manner in which that duty has been performed. In this revision the authors have sought to add to its usefulness by including everything properly coming within its scope which can be of use to the physician or pharmacist and at the same time by the utmost conciseness and by the omission of all obsolete matter to prevent undue increase in the size of the volume. No care will be spared by the publishers to render its typographical execution worthy of its wide reputation and universal use as the standard authority. A notice of the previous edition is appended. must admit that the authors have labored faith- fully and with success in maintaining the high chaiac'ter of their work as a compendium meeting the requirements of tlie day, to which one can safelv turn in quest of tlie latest information eon- The authors have embraced the opportunity offered for a thorough revision of the whole work, striving to include within it all that might have been omitted in the former edition,andall that has newly appeared of sufficient importance during the time of its collaboration and the short inter- val elapsed since the previous publication. After having gone carefully through the volume, we cerning everytliing worthy of notice in connection with Pfiarmacy, Materia Medica and Therapeutics. — Am. Jour, of Pharmacy, Nov. 1S79. DUJAHJDIN-BEAUMBTZ, Member of the Academy of Medicine, Physician to the Hdpital St. Antoine, Paris. Dictionary of Therapeutics, Materia Medica, Pharmacology, Tox- icology and Mineral Waters. Translated with notes and additions. Preparing. BBUNTOJ^, T, LAUBER, M. I),, Lecturer on Materia Medica and Therapeutics at St. Bartholomew'' s Hospital, etc. A Manual of Materia Medica and Therapeutics, including tlie Pharmacy, the Physiological Action and the Therapeutical Uses of Drugs. In one handsome octavO' volume. In press. BRUCE, J. MITCHELL, 31. !>., F. B. C. P. Materia Medica and Therapeutics. In active preparation for early publication^ See Students' Series of Manuals, page 5. STILLE, ALFBED, M, D., LL. JD., Professor of Theory and Practice of Med. and of Clinical Med. in the Univ. of Penna. Therapeutics and Materia Medica. A Systematic Treatise on the Action and Uses of Medicinal Agents, including their Description and History. Fourth edition, revised and enlarged. In two large and liandsome octavo volumes, containing 1936 pages. Cloth, $10.00; leather, $12.00; very handsome litdf Russia, raised bands, $13!^00. multitude of its citations and the fulness of its research into clinical histories.and we nuist assign it a place in the physician's liltrary; not, indeed. The rapid exhaustion of three editions and the universal favor with which the work has been re- ceived by the medical profession are sufficient proof of Its excellence as a repertory of practical and useful information for the physician. The edition before us fully sustains this verdict. — American Journal of Pharmacy, Feb. 1875. We can hardly admit that it has a rival in the as fully representingthe present state of knowledge in pharmacodynamics, but as by far the most com- plete treatise upon the clinical and practical side of the question. — Boston Medical and Sui-gical Jour- nal, Nov. 6, 1874. Henry C. Lea's Son & Co.'s Publications — Therap., Pathol., Histol. 13 FABQVHARSOJS^, ROBERT, 31. D., Lecturer on Materia Medica at St. Marifs Hospital Medical School. A Guide to Therapeutics and Materia Medica. Third American edition, Bpecially revised by the Author. Enlarged and adapted to the U. S. Pharmacopa-ia by Frank Woodbury, M. D. In one handsome 12mo. vohime of 524 pages. Clotli, $2.25. the disease in whieli observers (wlio are nearlv al- Dr. Farquharson's Therapeutics is constructed upon a plan wliieli brings before the reader all the essential points with reference to the properties of drugs. It impresses these upon him in such away as to enable him to take a clear view of the actions of medicines and the disordered conditions in which they must prove useful. The double-col- umned pages — one side containing the I'ccognized physiological action of the medicine, and the other ways mentioned) have obtained from it good re- sults — make a very good arrangement. Tlie early chapter containing rules for prescribing is excel- lent. We have mucli pleasure in once more diaw- ing attention to this valuable and well-digested book, and predict for it a continued successful ca- reer. — Canada Med. and Surg. Journal, Dec. 1882. WOOJDHEAD, G. SIMS, M. JD., F. R. C. P. E., Demonstrator of Pathology in the Vnivcrsity of Edinburgh. Practical Pathology. A Manual for Students and Practitioners. In one very beautiful octavo volume of 497 pages, with 136 exquisitelv colored illustrations. Cloth, $6.00. Just ready. GREEW, T. HENRY, M. JD, Lecturer on Pathologii and Morbid Anntumy at Charing-Cross Hospital Medical School, etc. Pathology and Morbid Anatomy. Fifth American from the sixth enlarged and revised English edition. In one very handsome octavo volume of about 350 pages, with about 150 fine engravings. In press. COATS, JOSEPH, M. J)., F. F. P. S., Pathologist to the Glasgow TFesiern Infirmary. A Treatise on Pathology. In one with 339 beautiful illustrations. Cloth, $5.50 The work before us treats the subject of Path- ology more extensively than it is usually treated in similar worlcs. Medical students as well as physicians, who desire a work for study or refer- ence, that treats the subjects in the various de- partments in a very thorough manner, but without proli.xity, will certainly give this one the prefer- ence to any with which we are acquainted. It sets forth tlie most recent discoveries, exhibits, in an interesting manner, the changes from a normal very handsome octavo volume of 829 pages ; leather, $6.50. Just ready. condition effected in structures by disease, and points out the charaetei-istics of various morbid agencies, so that they can be easily recognized. But, not limited to morbid anatomy,it explains lully how the functions of organs are disturbed by abnormal conditions. Tliere is nothing belonging to its de- partment of medicine that is not as fully elucidated as our present knowledge will admit. — Cincinnati Medical News, Oct. 1883. CORNIL, v., and RAJSIHCER, L., Prof, in the Faculty of Med. of Paris. Prof, in the College of France. A Manual of Pathological Histology. Translated, with notes and additions, by E. O. Shakespeare, M. D., Pathologist and Ophthalmic Surgeon to Philadelphia Hospital, and by J. Henry C. Simes, M. D., Demonstrator of Pathological Histology in the University of Pennsylvania. In one very handsome octavo volume of 800 pages, with 360 illustrations. Cloth, $5.50 ; leather, $6.50 ; half Russia, raised bands, $7. We have no hesitation in cordially recommend- ing the translation of Cornil and Ranvier's " Patho- logical Histology" as the best work of the kind in any language, and as giving to its readers a trust- worthy guide in obtaining a broad and solid basis for the appreciation of the practical bearings of pathological anatomy. — .inierican Journal oj the MetUcal Sciences, April, 1880. One of the most complete volumes on patholog- ical histology we have ever seen. The plan of study embraced within its pages is essentially practical. Normal tissues are discussed, and aftei' their thor- ough demonstration we are able to compare any pathological change which has occiu-ied in them. Thus side by side physiological and pathological anatomy go hand m hand, atfording that best of all processes in dcmonsti-ations, comparison. The admirable arrangementof the work att'ords facility in the study of any part of the human economy. — New Orleans Medical and Surgical Journal, J une,1882. KLEIN, E., M. D., F. R. S., Joint Lecturer on General Anat. and Phys., in the Med. School of St. Bartholomew's Hoi>p. London Elements of Histology. In one handsome pocket size r2uio. volume of 360 pages, with 181 illustrations. Liuip cloth, red edges, $1.50. Just ready. {See Students' Series of Manuals, page 5.) Although an elementary work, it is by no mean.s superficial or incomplete^ for the author presents in concise language nearly all tlie fundamental facts regarding the microscopic structure of tissues. The illustrations are numerous and excellent. We commend Dr. Klein's Elements most heartily to the student. — Medical Rrconl, Dec. 1, 188:!. This little volume, originally intended by its able author as a manual for medical students, contain.s much valuable information, systematically ar- ranged, that will be acceptable to the general practitioner. It gives a graphic and lucid descrip- tion of every tissue and organ in the himian body and, while small in size, it is full to overflowing, with important facts in regai'd to these multiform and complex structures. Wcknow of no book of its size that will prove of greater valiu> to medical students and practitioners of Medicine. — Tht Southern Practitioner, Nov. 1883. SCHAFER'S PRACTICAL HISTOLOGY. Being an Introduction to the Use of the Microscope. In one handsome royal 12mo. volume of 308 pages, with lo illustrations. GLUGE'S ATLAS OF PATHOLOGICAL HISTOL- OGY. Tianslated, with notes and additions, by Joseph Leidv, M. D. In one volume, very large imperial quarto, with 320 copper-plate figures, plain and colored, and descriptive letter-press. Cloth, 84.00. 14 Henry C. Lea's Son & Co.'s Publications — Practice of Med. FLINT, ATISTIJSr, M. D., Prof, of ike. Principles and Practice of Med. and of Clin. Med. in Bellevue Hospital Medical College, N. Y. A Treatise on the Principles and Practice of Medicine. Designed for the use of Students and Practitioners of Medicine. AVith an Appendix on the Eesearches of Koch, and their bearing on tlie Etiology, Pathology, Diagnosis and Treatment of Phthisis. Fifth edition, entirely rewritten and much improved. In one large and closely-printed octavo volum'e of IIGO pages. Cloth, $5.50; leather, §6.50; very hand- some half Russia, raised bands, $7. Just ready. Koch's discovery of the bacillus of tubercle gives promise of being the greatest boon ever conferred by science on humanity, surpassing even vaccination iio^its benefits to mankind. In the appendix to his work. Professor Flint deals with the subject from a practical standpoint, discussing its bearings (m the etiology, pathology, diagnosis, prog- nosis and treatment of pulmonary phthisis. Thus enlarged and completed, this standard T\ork will be more tlian ever a necessity to the physician who duly appreciates the re- sponsibility of his calling. We cannot conehide thip notice without express- i not merely a new edition. In making these altera- ans our admiration for this volume, which is eer- iainly one of the standard text-books on medicine ; and we may safely affirm that, taken altogether, it -exhibits a fuller and wider acquaintance with re- ■cent pathological inquiry than any similar work witli uhich we are acquainted, whilst at the same ■time it shows its author to be possessed of the rare faculties of clear exposition, tlioughtful discrimi- nation and sound judgment. — London Lancet, July 23, 1881. Jn a word, we do not know of any similar work wliieli is at once so elaborate and so concise, so full and yet so accui'ate, or which in everj^ part leaves wpon the mind tlie impression of its being the pro- duct of an author richly stored with the fruits of «linical observation, and an adept in the art of con- veying them clearly and attractively to others. — American Journal of Medical iSciencejs, April, 1881. Flint's Treatise is the work of an accomplished Siospitai physician, and is remarkable for its mas- terly descriptions of disease. It is a work on clin tions, Flint openly confesses that he has not been too careful to maintain a character for consistency, but has endeavored to give his reader his more matured, and, as he believes, more truthful views, careless of any discrepancy between them and those he formerly advanced. Flint is right; only in this way could' he produce a work worthy of be- ing looked upon as a standard. — Edi nbii rghMedical Journal, June, 1882. This work is so widely known and accepted as the best American text-book of the practice of medicine that it would seem hardly worth while to give this, the fifth edition, anything more than a passing notice. But even the imost cursory exami- nation shows that it is, practicalh', much more than a revised edition; it is, in fact, rather a new work throughout. This treatise will undoubtedly continue to hold the first place in the estimation of American physicians and students. No one of our medical writers approaches Professor Flint in clearness of diction, breadth of view, and, what we aeai medicine embodying the experience of a [ regard of transcendent importance, rational esti Bifetime. It has been carefully brought up to the I mate of the value of remedial agents. It is thor- present day, and the additions and alterations liave j oughly practical, therefore pre-eminently tlie hook Sieen so great tliat it is virtually a new work, and i for Arnerican readers. — St. Louis Clin. 7?ef.,Mar. '81. MARTSHOBJSfE, HEJSBY, 31. J>., Latebj Professor of Hi/giene in the University of Pennsi/lvania. Essentials of the Principles and Practice of Medicine. -\ Handbook for Students and Practitioners. Fifth edition, thoroughly revised and rewritten. In one handsome royal 12mo. volume of 669 pages, with 144 illustrations. Cloth, .$2.75; half i)()und, $3.00.' The author of this book seems to have spared no ] papers, etc. We cannot but admit that there is a pains to bring it up to the modern standpoint, for j wonderful amount of information contained in this as we tiu'n over its pages we find many subjects j work, and that it is one of the best of its kind that we have seen. — Glasgow 3Iedical Journal, 'Sow If^Si. An indispensable book. No work ever exhibited a better average of actual practical treatment than this one; and probably not one writer in our day had a better opportunity than Dr. Hartshorne for condensing all the views of eminent practitioners into a 1-imo. The numerous illustrations will be very useful to students especiallj^. Tliese essen- tials, as the name suggests, are not intended to supersede the text-books of Flint and Bartholow, but they are the most valu.able in affording the means to see at a glance the whole literature of any disease, and the most valuable treatment. — Chicago antroduc^d which have only lately l)een brought ?^iefore the profession. Certainly amongst books of ats cUiss it deserves and has obtained a good posi- tion. On the whole it is a careful and conscien- tious piece of work, and may be commended. — London Lancet, June 24, 1882. Within the compass of (300 pages it treats of the Jiistory of medicine, general pathology, genei-al ssyniptornatology, and physical diagnosis (including laryngosctope, ophthalmoscope, etc.), general ther- apeutics, nosology, and special patluilogy and prac- tice. With such a wide range, condensation is, of course, a necessity ; but the author has endeavored to make up for this by copious references to original i Medical Journal and Examiner, April, 188 BMISTOWJE, JOHN SYJER, M, D., F. JR. C. F., Plii/sician and Joint Lecturer on Medicine at St. Thomas' Hospital. A Treatise on the Practice of Medicine. vSecond American edition, revised by the Autlior. Edited, with additions, by Jasies H. Hutchinson, ]\I.D., physician to the Pennsylvania Hospital. In one handsome octavo volinne of 1085 pages, with ilbistrations. Cloth, $5.00; leather, $6.00; very handsome half Russia, raised bands, S6.50. author in following the latest growth of medical science. — Boston Medical and Surgical Journal, Feb. 1880. The reader will find every conceivable subject connected with the praclice-of medicine ably pre- sented, in a style at once clear, interesting and concise. The additions made bv Dr. Hutchinson The .second edition of this excellent work, like the first, has received the benefit of r>r. Hutchin- son's annotations, by which tlie phases of disease which are peculiar to this country are indicated, and thus a treatise which was intended for British practitioners and students is made more practically useful on this side of the water. We see no reason to modify the high opinion previously expressed with regard to Dr. Bristowe's work, except by add- ong our appreciation of the careful labors of the are appropriate and practical, and greatly add to its usefulness to American readers. — Buffnlc Med- ical and Snrgiral Journal, March, 1880. Henry C. Lea's Son & Co.'s Publications — Practice of Med. 15 HEYJVOZnS, J. MUSSELL, 31. J>., Professor of the Principles and Practice of Medicine in University C'uUene, London. A System of Medicine. With notes and additions by Henry Hartsiuvhxe^ A. M., M. D., late Professor of Hygiene in the University of Pennsylvania. Tn tiuoe large and handsome octavo volumes, containing 3056 double-columned pages, with ol7 illustra- tions. Price per volume, cloth, $5.00 ; sheep, $G.OO ; very handsome half Russia, raised hand.s, $6.50. Per set, cloth, $15 ; sheep, $18 ; half Russia, $19.50. Sold only by t^ubscription. Volume I. Contains General Diseases and Diseases of the NEiivous System. Volume II. Contains Diseases of Respiratory and Circulatory Systems. Volume III. Contains Diseases of the Digestive, Blood-Glandular, Urinary, Re- ■ productive and Cutaneous Systems. Reynolds' System of Medicine, recently completed, has acquired, since the lii-st ap- pearance of the first volume, the well-deserved reputation of being the work in whicU modern British medicine is pi-esented in its fidlest and most practical form. This coulcE scarce be otherwise in view of the fact that it is the result of the collal. oration of the lead- ing minds of the profession, each subject being treated by some gentleman who is regardeil as its highest authority. All the leading schools in Great Britain have contributed their best men, in geneioiis rivalry, to build up this monument of medical science. That a work conceived in such a spirit and carried out under such auspices should prove an indis- pensable treasury of facts and experience, suited to the daily wants of the practitioner, was inevitable; and the success which it has enjoyed in England, and the reputation which it has acquired on this side of the Atlantic, have sealed it with the aj>probation of the two pre-eminently practical nations. Its large size and high price having kept it beyond the reach of many practitioners in this country who desire to possess it, a desuand has arisen for an edition at a price which shall render it accessible to all. To meet this demand the present edition has been under- taken. The five volumes and five thousand pages of the original have, by the ust- of a smaller type and double columns, been compressed into three volumes of over three thousand pages, clearly and handsomely printed, and offered at a price which rendere it ■ one of the cheapest works ever presented to the American profession. But not only is the American edition more convenient and lower priced than the Eng- lish ; it is also better and more complete. Some years having elapsed since the a})pearance of a portion of the work, additions were required to bring up the subjects to the existing con- dition of science. Some diseases, also, which are comparatively unimportant in England, require more elaborate treatment to adapt the articles devoted to them to the wants of the American physician ; and there are points on which the received practice in this country ■ differs from that adopted abroad. The supplying of these deficiencies has been undertakers by Henry Hartshorne, M. D., late Professor of Hygiene in the University of Pennsyl- vania, who has endeavored to render the work ftdly up to the day, and as useful to the American physician as it has proved to be to his English brethren. The number of illus- trations has also been largely increased, and no effort spared to render the typographical execution unexceptionable in every respect. so i!oncise and thorough, and withal so lucid an(J trustwoithy. In tliat branch of medicine in wlueli the rank and file of the profession are mainly in- terested, viz., the practical part, therapeutics, Rey- nolds, without intending any invidious com parison^ stands pre-eminent. The tlierapeuticsof the Kng- lish corre.spond more closely than tlio.se of any- other eounti-y with those of this country, and th» American editor of Reynolds' has lirouglit this branch up to the most advanced American stand- ard.— Af/c/iif/a/i Medical News, Feb. 15, ISSO. Tliese three volumes are a whole library in and of themselves. As w., Senior Physician to and late Lect. on Principles and Practice of Med. at Ouy's Hospital, London. On the Diseases of the Abdomen ; Comprising tho.se of the Stomach, and other parts of the Alimentary Canal, (Esophagus, C'secum, Intestines and Peritoneum. Second American from third enlarged and revised P^nglish edition. In one liandsi)me octavo volume of 554 pages, with illustrations. Cloth, $3.50. B.\RLOW'S MANUAL OF THE PRACTICE OF ! ACUTE DISEASES. In one octavo volume of MEDICINE. With additions by D. F. Condie, M . D. 1 vol. Svo., pp. G03. Cloth, 82.50. TODD'S CLINICAL LECTURES ON CERTAIN .320 pages. Cloth, S2.50. HOLLAND'S MEDICAL NOTES AND REFLEO- TIONS. 1 vol. 8vo., pp. 49,"}. Clotli, 83.50. 18 Henry C. Lea's Son & Co.'s Publications — Throat, Livuigs, etc. SBILJEB, CAJRL, M. D., Lecturer on Laryngoscopij in the Uaicersitij of Pennsylvania. A Handbook of Diagnosis and Treatment of Diseases of the Throat, Nose and Naso-Pharynx. Second edition. In one handsome royal 12mo. volume of 294 pages, Asdth 77 illustrations. C'lotli, 81.75. Just ready. Dr. Seller's book is a clear, concise, practical I Dr. Sailer's treatise contains all the essentials of exposition of the subject, such as onlj' a ma.*ter of the knowledge of the important localities corn- it could have written. It is better suited to the wants of advanced students and j'oung physicians than any other at present in the hands of the pro- fession. — American Practitioner, Aue, 1883. pressed into a small space and put together by one of the ablest of American specialists. To stu- dents and others this book can be recommended as one of the best and most generally useful. — Canada Medical and Surgical Journal, July, 1883. BROWJST:, LBj^JSOX, F. M. a S., Edui., Senior Surgeon to the Central London Throat and Ear Hospital, etc. The Throat and its Diseases. Second American from the second English edi- tion, thoroughly revised. With 100 typical illustrations in colors and 50 wood engravings, designed and executed by the Author. In one very handsome imperial octavo volume of about 350 pages. Preparing. FLIJS^T, AJJSTIJS', M. D., Professor of the Principles and Practice of MedAcine in Bellevue Hospital Medical College, N. Y. A Manual of Auscultation and Percussion ; Of the Physical Diagnosis of Diseases of the Lungs and Heart, and of Thoracic Aneurism. Third edition. In one hand- some Toyal 12mo. volume of 2-10 pages. Cloth, §1.63. Just ready. This practical and justh' popular manual is con- j termined by analysis, and as based particularly on veniently divided into eight eliapters, and the | the variations in the intensity, pitch and quality student "is gradually led up from a general con- [ of sounds; to impress the facts upon the student sideration of piiysical signs in health'and disease ; and reader that the significance of physical signs to the differential diagnosis of diseased conditions relates to certain physical conditions, and tiiat by a knowledge of these physical signs. As in his ! close study of the physical conditions in health courses of practical instruction, so in this book ] and disease is a sine qua non of success in both the author's plan is to simplify the suhiect as | diagnosis and treatment. — The Medical News, much as possible; to consider the distinguishing i April 28, 1883. characteristics of different physical signs as de- i By the Same Author. Physical Exploration of the Lungs by Means of Auscultation and Percussion. Three lectures delivered before the Philadelphia County Medical Society, 1882-83. In one handsome small 12mo. volume of 83 pages. Cloth, $1.00. By the Same Author. A Practical Treatise on the Physical Exploration of the Chest and the Diagnosis of Diseases Affecting the Respiratory Organs. Second and revised edition. In one handsome octavo volume of 591 pages. Cloth, S4.50. By the Same Author, Phthisis: Its Morbid Anatomy, Etiology, Symptomatic Events and Complications, Fatality and Prognosis, Treatment and Physical Diag- nosis ; In a series of Clinical Studies. In one handsome octavo volume of 442 pages. Cloth, 13.50. By the Same Author. A Practical Treatise on the Diagnosis, Pathology and Treatment of Diseases of the Heart. Second revised and enlarged edition. In one octavo volume of 550 pages, with a plate. Cloth, §4. GJKOSS, S. !>., M.n,, LL,J)., D.C.Z. Ojoon.. LL.J). Cantab. A Practical Treatise on Foreign Bodies in the Air-passages. In one octavo volume of 452 pages, with 59 illustrations. Cloth, $2.75. FULLER ON DISEASES OF THE LUNGS AND ' STOKES' LECTURES ON FEVER. Edited by AIR-FASSAGES. Their Pathology, Physical Di- 1 John William Moore, M. D., F. K. Q. C. P. In agnosis. Symptoms and Treatment. From the' one octavo volume of 280 pages. Cloth, §2.00. second and revised English edition In one TREATISE ON FEVER. By Robert D. Lyons. octavo volume of 47.-> pages. Cloth, «3.o0. K. c. C. In one 8vo. vol. of 3^ pp. Cloth, S2.25: ''^:^^^^^}^\^^!S'^^- : I^ECrURES ON THE STUDY OF FEVER^^y valence in various Countries. Second and revised -^^ "'-'I'S"^; .M- D-. Y' ri Jh «:> '^o edition. In one l2mo. vol., pp. 108. Cloth, §1.25. I volume ol 308 pages. Cloth, S2.50. WILLIAMS ON PUL.MONARY CONSUMPTION; j LA ROCHE ON YELLOW FEVER, considered in its Nature, Varieties and Treatment. With an ! its Historical, Pathological, Etiological and analysis of one thousand cases to exemplify its ] Therapeutical Relations. In two large and hand- duration. In one 8vo. vol. of 303 pp. Cloth, $2.50. I some octavo volumes of 1468 pp. Cloth, S7.00. SMITH ON CONSUMPTION; its Early andReme- | PAVY'S TREATISE ON THE FUNCTION OF Dl- dial lie Stages. 1 vol. 8vo., pp. 253. S2.25. ' GESTION ; its Disorders and their Treatment. LA ROCHE ON PNEUMONIA. 1 vol. 8vo. of 490 I From the second London edition. InoueocUwo pages. Cloth, Srs.OO. \ volume of 238 pages. Cloth, S2.00. WALSHE ON THE DISEASES OF THE HEART ! CHAMBERS' MANUAL OF DIET AND REGIMEN ANDGRE.Vr VESSELS. Third American edi- '■ IN HEALTH AND SICKNESS. In one hand- tion. In 1 vol. 8vo., 416 pp. Cloth, S3.00. some octavo volume of 302 pp. Cloth, 82.75. Henry C. Lea's Son & Co.'s Publications — Nerv. andMent.Dis.,etc. 19 JTAMIZTOW, ALLAJSr 3IcLAJSrB, M. D., Attending Plu/sician at the Hospital for Epihptirs and Paralytics, BUickwelVs Island, .V. 1'., and at the Out- Patients' Department of the JS'cw York Hospital. Nervous Diseases ; Their Description and Treatment. Second edition, thoroughly revised and rewritten, hi one handsome octavo volume of 598 pages, with 72 illustrations. Cloth, l?4. AVeare j;lad to welcome a second edition of so use- ful a work as this, in which Dr. Hamilton lias suc- ceeded in condensing into convenient limits the most important of the recent developments in re- gard to diseases of the nervous system. Of recent years nervous pathology has attained to such im- portance as to necessitate very careful description in special works, and among these this volume must takealiigh place. This volume is on the whole e.xcellent, and is d ivoid of that spirit of plagiarism which we have unforrunately seen too much of in certain recent Englisli works on nervous diseases. —Edinburgh JMedi'caL Journal, May, 1S82. W'hen the firstedition of this good book appeared we gave it our emphatic endorsement, and the present edition enhances our appreciation of the book and its author aS" a safe guide to studetits of clinical neurology. One of the Ijest and most critical of EuglisTi neurological journals, B7-ain,ha,s characterized this book as the best of its kind in any language, which is a handsome endorsement from an e.xalted source. The improvements in the new edition, and the additions to it, will justify its purchase even by those who possess the old. — Alienist and Neurologist, April, 1882. The book is made up of plain and practical de- scriptions of the chief disorders of the nervous system, with interesting discussions of pathological points and very sensible views as to treatnaent. It is a book which the general practitioner will find of great value.— A'. 1 . il/ed. Jour., Sept. 1882. The author's aim is to write a treatise on Nervous Diseases which is both concise and practical, while it is, at the same time, sufficiently comprehensive. We have pleasure in bearing testimony to the fact that his efforts have been crowned with success. The various diseases have been well described, the directions as to how to arrive at a correct diag- nosis are very clear, and tlie hints in treatment are plain, practical and sound. Such a book should be considered a necessity in every medical library, as the ailments described are among the most common that come under observation in the every day work of the general physician. To him, there- fore, we recommend it with pleasure; in fact, we rrwiy go further and say that, all things considered, it is for his purpose the best work of the kind now available. — Canada Jour. Med. Sciences, April, 1882. This work is well adapted to the wants of the general practitioner, for whom it seems to have been especially written. It is a thoroughly prac- tical book, the careful study of which will render the diagnosis of nervous affections the more easy, and their treatment more successful. The book is very useful as a reference work to the busy prac- titioner, to whom we can recommend it. — Medical and Surgical Reporter, .Jan. 21, 1882. CLOUSTOJS^ TH03IAS S., 31. J>., F. M. C. P., X. JR. C. S., Lecturer on Mental Discn.'^cs in the Unircrsiti/ of Edinburgh. Clinical Lectures on Mental Diseases. "With an Appendix, containing an Exhaustive Summarv ol' the Laws in puree in the United States upon tlie Commit- ment and Confinement of the Insane. By CiiAiiLEs F. Folsom, M. I)., Assistant Pro- fessor of Mental Diseases, Medical De]iartment of Harvard University. New edition. In one handsome octavo volume of about (iUO jiages, illustrated with woodcuts and eiglit litliographic plates, four of which are beautifully colored. In pv«.s. JPLAYFAIB, W. S., 31. J)., F. J?. C. F. The Systematic Treatnient_ of Nerve Prostration and Hysteria. In one handsome small 12mo. volume of 97 pages. Cloth, $1.00. Just ready. The hook is well worth perusal, and will repay | cise. — IScu) Orleans Medical and Surgical Jmirnal, anyone for the time spent in its careful study, iii- | May, 1883. ., asmucli as it will lead to a better understanding of ! The treatment of.>nerve prostration ef^pounded the management of those hefesnoirs of the physi- I and illut^trated bj' Dr. Playfair is a therapeutic cian. nerve prostration and hysteria. Details are \ method of exceeding practical importance. Dr. Playfair gives all the credit of the introduction of this treatment to the ])rofessjf)n to our distin- guished i-ountryman, ]>r. Weir Mitchell. No other inctiind h;is ever produced results ciunpar- able to ■\Iitcheli's and Playfair's in these maladies. — Louisrilltt Medical Kcus, .April V, 188:;. giv't-n of the manner of carrying out the treatment, to which are added the histories of a niimhHr of cases illustrative of the method and its results. An appendix contains a description of the method of performing massage, which is clear and con- 311TCHFLL, S. WFIB, 31. F>., Phiisifinn to Orthoprr.dic Iln.spital anil the liifiriaaru for Diseases of the Nervous S;/stem, Phila., etc. Lectures on Diseases of the Nervous System; Especially in Women. Second edition. In one very jiandsome ]2mo. volume of about 2o0 j)ages. Preparing. TIKE, nAXIFL HACK, 31. n., Joint Author of The Manual of P.<;ichnhriiral Medi 'inr, <■/,: Illustrations of the Influence of the Mind iipon the Body in Health and Disease. Designed to illustrate the Action of tiic Imagination. iS'ew edition. Thnrouglily rcvisfd and iH'writtcn. In one liandsoiiie octavo volume. //( prr.'is. BLAKnFOFI), G. FIFLDING, 31. />., F. II. C. F., Lecturer on Psiirhological :\[c'liciur at thr SrIionI of St. O'eorgrs Hospital, London. Insanity and its Treatment: Lectures (m the Treatment, Medical and Legal, of Insane Patients. With a Summary of the l>aws in force in tlie United States on the (,"on- finement of the Insane, by I.s.\Ac Kay, M. D. In one very handsome octavo volume. CLINICAL ORSERVATIdN.S ON FUNCTION.AL NEKVors DISORDERS, by V. Haxt.kikm. .Iont.s, M. D. Second American edition. In one hand- some- octavo volume of :M0 pages. Cloth, $:{.2.'i. 20 Henry C. Lea's Son & Co.'s Publications — Surgery. GMOSSf S. D., M, D.f XX. X>., X>. C, X. Oxon., XX. X>. Cantah.f Emeritus Professor of Surgery in the Jefferson Medical College of Philadelphia. A System of Surgery: Pathological, Diagnostic, Therapeutic and Operative. Sixth edition, thoroughly revised and greatly improved. In two large and beautifully- printed imperial octavo volumes containing 2382 pages, illustrated by 1623 engravings. Strongly bound in leather, raised bands, $15 ; half Eussia, raised bands, $16. Tlie work as a whole needs no commendation. : fully maintains the reputation the work has ae- Many years ago it earned for itself the enviable rep- , quired.^ Itjias become a complete and systematic utation of the leading American woi-k on snrgerj', ' ' '" -^ --.■ and it is still capable of maintaining that standard. The reason for this need only be mentioned to be appreciated. The anthor lias always been calm and judicious in his statements, has based his con- elusions on much study and personal experience, has been able to grasp his siujject in its entirety, and, above all, has conscientiouslj' adhered to truth and fact, weighing the evidence, pro and con, accordingly. A considerable amount of new material has been introduced, and altogether the distinguished author lias reason to be satisfied that he has placed the work fully abreast of the state of our knowledge. — Med. Eecord, Nov. 18, 1882. We have purposely abstained from comment or criticism of the book before us. It lias formerly been noticed more than once in our columns, and it is enough now to remark that the present edition book of reference alilce for the student and the practitioner. — The London Lancet, Jan. 27, 1883. We regard Gross' System of Surgery not only a» a singularly rich storehouse of scientific inl'orma- tion, but as marking an epoch in the literary his- tory of surgery. The present edition has received the most careful revision at the hands of the emi- nent author himself, assisted in various instances by able specialists in. various branches. All depart- ments of the vast and ever-increasing literature of the science have been drawn upon for their most recent expressions. The late advances made in surgical practice have been carefully noted, such as the recent developments of Listerism and the improvements in gynfecological operations. In every respect the work reflects lasting credit on American medical literature. — Medical andSurgical Reporter. Nov. 11, 1882. ASSHUBST, JOHK, Jr., M. X)., Professor of Clinical Surgery, Univ. of Penna., Surgeon to the Episcopal Hospital, Philadelphia. The Principles and Practice of Surgery. Third edition, enlarged and re- vised. In one large and handsome octavo volume of 1060 pages, with 555 illustrations.. Cloth, |6 ; leather, $7; very handsome half Eussia, raised bands, $7.50. Dr. Ashhurst's Surgery is a condensed treatise covering the whole domain of tlie science in one manageable volume. The present edition has had a thorough revision. The novelties in surgical practice and the recent observations in surgical science have been incorporated, but the size of the volume has not been materially increased. The author's arrangement is perspicuous, and his " a condensed but comprehensive description ot the modes of practice now generallj' employed in the treatment of surgical affections, with a plain exposition of the principles upon which these modes of practice are based." In this he has so- well succeeded that it will be a surprise to the reader to know how much practical knowledge ex- tending over such a wide range of research is eom- language correct and clear. An excellent index i pressed in a volume of this size. This feature ot closes the work, and on the whole we consider it tlie best system of surgery in one volume which could be named as the product of an American author. — Medical and Surgical Reporter, Oct. 28, '82. The author, long known as a thorough student of surgery, and one of the most accomplished scholars in the country, aims to give in this work the work must be its best claim for continued popularity with students and practitioners. In fact, in tHis respect it is without an equal in any language. In the present edition many novelties in surgical practice are introduced, many modifi- cations of previous statements made, and several new illustrations added. — Med. Rec, Nov. 18, 1882» GIBKET, F. B., M, B. Surgeon to the Orthopccdic Hospital, New York, etc. Orthopaedic Surgery. For the use of Practitioners and Students, some octavo volume, profusely illustrated. Preparing. In one hand- BOBBBTS, JOBTJV B., A. M., M. B., Lecturer on Anatomy and on Operative Surgery at the Pliiladelphia School of Anatomy. The Principles and Practice of Surgery. For the use of Students and Practitioners of Medicine and Surgery. In one very handsome octavo volume of about 500 pages, with many illustrations. Preparing. BEBBBB, A. J., M. B., M. S., F. B, C, S., Surgeon and Lecturer at St. Mary's Hospital, London. Surgical Pathology. In one pocket-size 12mo. volume of 511 pages, with 81 illustrations. Limp clotli, red edges, §1.50. Just ready. See Students^ Series of Manuals, page 5, This work on Surgical Pathology is certainly a "jewel" of a book, not only for students, but also as a work of reference for practitioners. Though 80 small that it can easily be carried in the pocket for reference, yet it is quite full and explicit in its details. The student who is preparing for final examination will keep it about him all tlie time. — Cincinnati Medical News, November, 1883. BELLA3IY, BDWABD, F. B. C. S. Operative Surgery. In active preparation. See Student^ Sei^ies of 3fanvxils, ■page 5. STIMSON, ZEWIS A., B, A,, M. X>., P7o/. of Pathol. Anat. at the Univ. of the City of New York, Surgeon and Curator to Bellevue Hosp. A Manual of Operative Surgery. In one very handsome royal 12mo. volume of 477 pages, with 332 illustrations. Cloth, $2.50. Henry C. Lea's Son & Co.'s Publications — Surgery. 21 BRYANT, TH03IAS, F. M. C. S., Sur(/eon to Guy's Hospital, London. The Practice of Surgery. Third American from the tliird and revised English edition. Thorouglily revised and much improved, by John B. Roberts, A. M., M. D., Lecturer on Anatomy and Operative Surgery in the Philadelphia Academy of Surgery. In one large and very handsome imperial octavo volume of 10U9 pages, with 735 illustra- tions. Cloth, $6.50; leather, 17.50; vei-y handsome half Kussia, raised bands, $8.00. Without freighting liis bool; with multiplied de- | plans of treatment, etc., to make the siu'geon who- tails and wearying desci-iptions of allied methods of proeedure, lie is ample enough for reference on all the departments of surgery, not omitting such strict specialties as dental, ophthalmic, military, ortliopiedic and gynpecnlogieal surgery. Some of these chapters are written by specialists in these respective branches, and all are amply sufficient for anyone not himself aiming at special practice. The l;\hors of the American editor deserve un- qualified praise. His additions to the author's te.xt are numerous, judicious and germane. They add very distinctly to the value ol the original treatise, and give a more equitable illustration of the part taken by American surgeons than the author was able to do. — Medical and Surgical Re- porter, Feb. 12, 1881. It is the best of all the one-volume works on sur- gery of i-ecent date for the oixlinai-y surgeon, con- taining enough of pathology, accurate description of surgical diseases and injuries, well-devised follows the text successful in his diagnosis and- treatment in any case in which success can be se- cured, according to the present state of the sur- gical art. — Vrrginin Medical Monthlt), May, 1881. It is a work especially adapted to the wants of students and practitioners. It affords instruction' in sufficient detail for a fidl understanding of sur- gical principles and the treatment of surgical dis- eases. It embraces in its scope all the disease.^ that are recognized as belonging to surgery, and all traumatic injuries. In discussing these it has seemed to be the aim of the author rather to pre- sent the student with practical information, and that alone, than to burden his memory with the views of different writers, however distinguished they might have been. In this edition the whole work has been carefully revised, much of it has been rewritten, and important additions have been made to almost every chapter. — Cincinnati Medical News, Jan. 1881. EJRICHSBN, JOHN JE., F. B, S,, F. It. C. .S^., Professor of Surgery in University College, London, etc. The Science and Art of Surgery ; Being a Treatise on Surgical Injuries, Dis- eases and Operations. Specially revised by the Author from the eighth and enlarged English edition. In two large and beautiful octavo volumes of about 2000 pages, illus- trated with about 900 engravinas on wood. Preparing. A few notices of the previous edition are appended. His polished, clear style, his freedom from pre- not only in this country, but in Great Britain. judiee and liobbies, his unsurpassed grasp of his subject and vast clinical experience, qualify him admirably to write a model text-book. When we wish, at the least cost of time, to learn the mfist of a topic in surgery, we turn, by preference, to his work. It is a pleasure, therefore, to see that the appreciation of it is general. — Medical and Surgical Reporter, Feb. 2, 1878. For the past twenty years Erichsen's Surgery has maintained its place as the leading text-book, That it is able to hold its ground is abundantly proven by the thoroughness with which the pres- ent edition has Vjeen revised, and by the large amount of valuable material that has been added. Aside from this, one hundred and fifty new illus- trations have teen inserted, including quite a number of microscopical appearances of patholo- gical processes. So marked is this change for the etter that the work almost appears as an entirely- new one. — Medical Record, Feb. 23, 1878. ESMABCH, Br. FBIFBBICH, Professor of Surgery at the University of Kiel, etc. Early Aid in Injuries and Accidents. Five Ambulance Lectures. Trans- lated by H. R. H. Princess Christian. In one handsome small 12mo. volume of 109' pages, with 24 illustrations. Cloth, 75 cents. Just ready. Tfie excellent little handbook by Dr. Esmarch may be referred to by all for clear, safe and practi- cal directions and instructions for rendering the right kind of aid until the doctor arrives, in the event of the numerous injuries that are liable to happen in a family or neighborhood in the circum- stances of daily life. The manual is earnestly andjusf ly commended for its excellence and clear- ness, and especially for the minuteness and e.xtent of its practical details. — Harpers' Magazine, Aug., 1883. The course of instruction is divided into five sections or lectures. The first, or introductory lecture, gives a brief account of tho structure and organization of the human body, illustrated by clear, suitable diagrams. The second teaches how- to give judicious help in ordinary injurie.s — contu- sions, wounds, hsemorrhage and poisoned wounds. The third treats of first aid in cases of fracture and of dislocations, in sprains and in burns. Next, the methods of affording first treatment in cases of frost-bite, of drowning, of suffocation, of loss of consciousness and of poisoning are described; and the fifth lecture teaches how injured persons may he most safely and easily transuorted to their homes, to a medical man, or to a hospital. The illustrations in the book are clear and good. — Medi- cal Times and Gazette, Nov. 4, 1882. BBUITT, BOBEBT, M. B. C. S., etc. The Principles and Practice of Modern Surgery. From the eiglith London edition. In one 8vo. volume of 687 pages, witli 432 illus. Clotli, $4; leatlier, $5. SARGENT ON BANDAGING AND OTHER OPERA- TIONS OF MINOR SURGERY. New edition, with a Chapter on military surgery. One 12mo. volume of .•iS3 pages, with 187 cuts. Cloth, Sl.7.'). MILLER'S PRINCIPLES OF SURGERY. Fourth American from the third Edinburgh edition. In one 8vo. vol. of (188 pages, with 340 illustrations. Cloth, 8:i.7r.. MILLER'S PRACTICE OF SURGERY. Fourth anil revised American from the last Edinburgh edition. In one large 8vo. vol. of G82 pages, with 364 illustrations. Cloth, ^i.lh. PIRRIE'S PRINCIPLES AND PRACTICE OF SURGERY. Edited by John Neu.i,, M. D. In one 8v(). vol. of 784 pp. with 31(i illus. Cloth, 83.75 COOPER'S LECTURES ON THE PRINCIPLES AND PRA(n"ICE OF SURGERY. In one 8vo. vol. of 7on and ofiered an opportunity to subscribe. The authors of the original English edition are | easy reaeli of American surgeon.« a worl? whioh has men of the front ranli in England, and Dr. Pacl^ard been received with such universal favor on the has been fortunate in securing as his American ! other side of the Atlantic as Holmes' System of coadjutors such men as Bartholovv, Hvde, Hunt, i Surgery. In the list of English contributors to the Conner, Stimson, Blorton, Hodgen, Jewell and their colleagues. As a whole, .the work will be solid and sul:)stantial, and a valuable addition to the library of any medical man. It is more wieldly and more useful tlian the English edition, and with its companion work — "Reynolds' System of Medi- cine" — will well represent the present state of our science. One who is familiar with those two works will be fairly well furnished head-wise and hand- wise.— r/?,e Medical A'etvs, Jan. 7, 1882, first volume we find the names of such well-known surgeons as Sir James Paget, Simon, Savory, Oal-,, le&der, Barclay, and others equally distinguished;, while among' the American revisers we recog- nize men of no less celebrity. With regard to the mechanical execution of the work, neither pains nor money seem to have been spared by the pub- lishers. — Med. and Surg. JJeportcr, Sept. 14, I.S8L In the revision of the work for the ,Amei-ican edition not only has provision l)een made for a m,- 1 • T T • 1 i. J I recognition of the advances made in our knowledge This work is ovelopcedic m character, and every- ^ .- , ; j^, ^ ^ publi.'ation, subject IS treated in an exhaustive manner. It is ^ f ^ pi4sentation of the variations in especially designed for a reference book, which practice which characterize American surgery and every practising surgeon should have under hand ^i^tj^ ^^jgi, j^ f,„m that of (ireat Britain. The in eases which require more than ordinary knowl- ^^ j S pleasure in eom- edse.-Chicago Med. Journ. and Ream., Feb. 188'2. ^^nding to the notice of our readers as an eney- Great credit is due to the American editor and clopsedia of surgical knowledge and practice. — his co-laborers for revising and bringing within | St. Lnitis Cottrier of Medicine, Nov. ISSl. HOLMES, TI3IOTHY, M. A, Surgery, Its Principles and Practice. In one handsome octavo volume of 968 pages, with 411 illustrations. Cloth, $6.00; leather, $7.00; half Russia, $7.50. Mr. Holmes is a surgeon of largo and varied ex- I It will be found a most excellent epitome of sur- perience, and one of the best known, nnd perliaps gery by the general practitioner who has not the the most brilliant writer upon surgical subjects in I time to give attention to more minute and extend- Englarid. It is a book for stnd(»nts — and an adini- 1 ed works, and to the medical student. In fact, we rable one — and for the busy general practitioner. ; know of no one we can more cordially recom- Itwill give a student all thcknowledge needed to mend. The author has succeeded well in giv- passa rigid exiimination. The book fairly justifies ling a plain and practical account of each surgical the high expi'ctations that wen^ formed of if. Its | injury and disease, and of the treatment which is style is clear and forcible, even brilliant at times, < most commonly advisable. It will no doubt be- aiid the conciseness needed to bring it within its j come a popular work in the profession, and ospe- proper limits has not impaired its i'm-cc and dis- ' cially as a text-book.— Cinci/i. Med. News, April, tinctness,— ,V, )", Med, Record, Ajiril 11, isV'i, l.sTC. Henry C. Lea's Son & Co.'s Publications— Frac?» Disloc, Oplithal. 23 Professor of Patholoqical Anatomy at the University bf the Oitfi of N-ew TorT;, Surgeon and Curator to Bellevue Hospital, Surgeon, to the Preshyierian Hospital, Neioiark, etc. A Practical Treatise on Fractures. In one very handsome octavo volume of 598 pages, with 3(30 beautiful illustrations. Cloth, $4.75 ; le-ather, $5.75. Just ready . The author lias given to tlie medical profession in this treatise on fractures what is likely to be- come a standard work on the subject. It is certainly not surpassed by any work written in the English, or, for that matter, any other language. Perfectly conversant with the American, English, French and German medical literature, the author tells us in a short, concise and comprehensive manner, all that is known about his subject. There is nothing scanty or superficial about it, as iu most other treatises; on the contrary, everything is thorough. The chapters on repair of fractures and their treat>- ment show him not only to be a profound student, but likewise a practical surgeon and j athoiogist. His mode of treatment of the ditt'erent fractures is eminently sound and piactical. We consider this work one of the best on fractures ; and it will be welcomed not only as a text-book, but also by the surgeon in full practice. — N. O. Medical a7ui Sur- gical Journal, March, 1883. HAMILTON, FHAJSTK H., M. D., LL. !>., Surgeon to Bellevue Hospital, S'ew York. A Practical Treatise on Fractures and Dislocations. Sixth edition, thoroughly revised and much improved. In one very handsome octavo volume of 909 pages, with 352 illustrations. Cloth, $5.50 ; leatlier, $6.50; half Kussia, raised bands, $7.00. work in his own or any language on fractures and dislocations. — Lond. Med. Times and Gaz. Nov. lii, "81. The work as a whole is one of the very tew medical books of American origin that are every- where accorded a standard character, its sub- ject-matter unavoidably comes home to every general pi'actitioner as a branch of our art in which he cannot attord t(j neglect the fullest and most practical information of such a character as it and it alone furnishes.— iV. Y. Med. Jour., March, '81. The only complete work on its subject in the English tongue, and indeed it may now be said to be the only work of its kind in any tongue. It would require an exceedingly critical examination to detect in it any particulars in which it might be improved. The work is a mon- ument to .\morican surgery, and will long serve to keep green the memoi-y of its venerable author. — Mir.ldgan Medical News, Nov.. 10, 1881. Dr. Hamilton is the author of the best modern WJEZZS, J. SOJELBEBG, F. B. C, S., Professor of Opltt.halmologt/ in King's College Hospital, London, etc. A Treatise on Diseases of the Eye. Fourth American from tlie third London edition. Thoroughly revised, with copious additions, by Charles S. Bull, M.D., Surgeon and Pathologist to the New York Eye and Ear Infirmary. In one large and verj' hand- some octavo volume of 822 pages, with 257 illustrations on Avood, six colored plates, and selections from the Test-types of Jaeger and Snellen. Cloth, $5.00 ; leather, $t).00 ; very handsome half Russia, raised bands, $6.50. Just ready. The present edition appears in less than three years since the publication of the last American edition, and yet, from the numerous recent inves- tigations that have been made in this branch of medicine, many changes and additions have been required to meet the present scope of knowledge upon this suVjjeet. A critical examination at once shows the fidelity and thoroughness with which the editor has accomplished his part of the work. The illustrations throughout are good. This edi- tion can be recommended to all as a complete treatise on diseases of the eye, than which proba- bly none better exists. — Medical Record, Aug. 18, '83. This magnificent work is par excellence the standard work of the times on the important sub- jects of which it treats. It is absolutely necessary for the physician to have an acquaintance with the pathology and therapeutics of the eye. From no source can he more accurately derive this needed knowledge than from the volume before us. — Medical and Surgical Reporter, August 4, ISS:!. NETTLBSHIB, EBWABB, F. B. C. S., Ophthalmic Surg, aiul Led. on Ophth. Surg, at St. Thomas'' Hospital, London. The Student's Guide to Diseases of the Eye. New edition. With a chap- ter on the Detection of Color-Blindness, by William Thomson, M. D., Ophthalmologist to the Jefferson Medical College. In one royal r2mo. volume of 416 pages, witli 138 illustrations. Clotli, $2.00. Jiist ready. This admirable guide bids fair to become the favorite text-book on ophthalmic surgery with stu- dents and general practitioners. It bears thi'ough- outthe imprint of sound judgment combined with vast experience. The illustrations aie numerous and well chosen. This book, within the short com- pass of about400 pages, contains a lucid exposition of the modern aspect of ophthalmic science. — Medical Record, June 23, 1883. This work is essentially a student's manual of ophthalmology, and the fovor with which it has been received shows its real value and the appre- ciation by the pi'ofession of its intrinsic merits. Dr. Thomson has added a, Chapter on Color-Blind- ness, on which subject his extensive investigation!* are well known, with this valuable addition the book becomes the most valuable guide to diseruses of the eye yet published. We commend it to the notice of students of nu>dicine, and to such prac- titioners as desire a condensed treatise on a clans of diseases which are frequently met vvitli in daily practice. — Buffalo Med. atul Surg. Journ., May, 1883. BBO JVWB, BDGAB A,, Surgeon to the Liverpool Eijc and Ear Infirmnrg ami to the Dispensary for Skin Diseases. How to Use the Ophthalmoscope. Heing IClementary Instructions in Oph- thalmoscopy, arranged for the use of Students. In one small royal 12mo. volume of 116 pages, with 35 illustrations. Cloth, $1.00. LAWSON ON IN.IURIES TO THE EYE, ORBIT AND EYELIDS: Their Immediate and Remote Effects. 8 vo., 404 pp., '.n illus. Cloth, $3.r)0. LAURENCE AND M()(tN'S HANDY HOOK OF ■ OPHTHALMIC SURGKRY, for the u.se of Prac- titioner."*. Second edition. In one octavo vol- iHTie of •-'27 pages, with 05 illust. Cloth, $-J.75. CARTER'S PRACTICAL TREATISE ON DLS RAS- ES OF THE EYE. Edited by John Giikkn. M.D. In one handsome octavo volume. 24 Henry C. Lea's Son & Co.'s Publications — Otol., Dent.,Urm. Dis. JPOLITZEM, AT) AM, Imperial- Royal Prof, of Aural Therap. in the Univ. of Vienna. A Text-Book of the Ear and its Diseases. Translated, at the Author's re- quest, by James Patterson Casselt.s, M. D., M. E. C. S. In one handsome octavo vol- ume of 800 pages, with 257 original illustrations. Cloth, $5.50. Jusi ready. Professor Politzer's well-known reputation as one of the first authorities on diseases of the ear will lead the reader to expect something more than an ordinary text-book in a work that bears his name, and he will not be disappointed. The anatomy, physiology, pathology, therapeutics and bibli- ography of the ear are so ably and thoroughly pre- sented, thathe who has carefully readthis imposing volume can feel sure that very little of interest or value in the past or present of aural surgery has escaped him. — Ain. Jour, of the Med. Sciences, J \ily, 1883. The work itself we do not hesitate to pronounce the best upon the subject of aural diseases which has ever appeared, systematic without being too diffuse on obsolete subjects, and eminently prac- tical in every sense. The anatomical descriptions of each separate division of the ear are admirable, and profusely illustrated by woodcuts. Tliey are followed immediately by the physiology of the section, and this again by the pathological phy.si- ology, an arrangement which serves to keep up the interest of the student by showing the direct ap- plication of what has preceded to the study of dis- ease. The whole work can be recommended as a reliable guide to the student, and an efficient aid to the practitioner in his treatment. — Boston Med- cat and Surgical Journal, June 7, 1883. BURWBTT, CHARLES H., A, M., M, D., Aural Surg, to the Presh. Hasp., Surgeon-in-charge of the Infir.for Dis. of the Ear, Philadelphia. The Ear, Its Anatomy, Physiology and Diseases. A Practical Treatise for the use of Medical Students and Practitioners. In one handsome octavo volume of 619 pages, with 87 illustrations. Cloth, $4.50 ; leather, $5.50 ; half Kussia, raised bands, $6.00. The medical profession will welcome this new prinreps in our language. To the specialist the work on otology, which pi-esents clearly and con- work is of the highest value, and his sense of grati- cisely its present aspect, whilst clearly imlicatiiig tudeto Dr. Burnett will, we hope, be proportionate the direction in wliieh further researches can be mtheamountoJbenefit he can obtain from thecare- most profitably carried on. Dr. Hurtiett has pi'o- ful study of the book and a constant reference to its duced a work which, as a text-book, stands facile \ trustworthy pages. — Edinburgh Med. Jour. Aug. '78. COLEMAN, A., L. M. C. JP., F. B. C, S., Exam. L. 1>. S., Senior Dent. Surg, and Led. on Dent. Surg, at St. Bartholomeiv^s Hosp. and the Dent. Hasp., London. A Manual of Dental Surgery and Pathology. Thoroughly revised and adapted to the use of American Students, by Thomas C. Stellwagen, M. A., M. D., D. D. S., Prof, of Physiology at tlie Philadelphia Dental College. In one handsome octavo volume of 412 pages, with 331 illustrations. Cloth, $3.25. deserves a place in the library of every dentist. —Dental Cosmos, May, 1882. It should be in the possession of every practi- tioner in this country. The part devoted to first and second dentition and irregularities in the per- manent teeth is fully worth the price. In fact, price should not be considered in purchasing such a work. If the money put into some of our so-called standard text-books could be converted into such publications as this, much good would result. — Southern Dental Journal, May, 1882. This volume deserves to rank among the most important of recent contributions to dental litera- ture. Mr. Coleman has presented his methods of pi-actice, for the most pa)-t, in a plain and concise manner, and the work of the American editor has been conscientiously performed. He has evidently labored to present his convictions of the best modes of practice for the instruction of those commenc- ing a professional career, and he has faithfully en- deavored to teach to others all that he has acquired by his own observation and experience. The book GROSS, s. n., M. n., ll, d., n. C. i., etc. A Practical Treatise on the Diseases, Injuries and Malformations of the Urinary Bladder, the Prostate Gland and the Urethra. Tliird edition, thoroughly revised by Samuel W. Gross, M. D., Surgeon to the Philadelphia Hospital. In one octavo volume of 574 pages, with 170 illustrations. Cloth, $4.50. For reference and genera! information, the phy- sician or surgeon can find no work that meets their necessities more thoroughly than this, a revised edition of an excellent treatise. Replete with hand- some illustrations and good ideas, it has the unu- sual advantage of being easily comprehended by the reasonable and practical manner in which the various subjects are systematized and arranged. — Atlanta Medical Journal, Oct. 187li. ROBERTS, WILLIAM, M. B., Lecturer on Medicine in the Manchester School of Medicine, etc. A Practical Treatise on Urinary and Renal Diseases, including Uri- nary Deposits. Fourth American from the fourth London edition. Illustrated by numerous engravings. In one large and handsome octavo volume. Preparing. TiiOMBSo:sr, sir hejsrt, Surgeon and Professor of Clinical Surgery to University College Hospital, London. Lectures on Diseases of the Urinary Organs. Second American from the third English edition. In one 8vo. volume of 203 pp., with 25 illustrations. Cloth, $2.25. By the Same Author. On the Pathology and Treatment of Stricture of the Urethra and istulse. From tlie third English edition. In one volume of 359 pages, with Cloth, $3.50. Urinary Pistulse 47 cuts and 3 plates. BASHAM on renal DISEASES: A Clinical Guide to their Diagnosis and Treatment. In one 12mo. vol. of 304 pages, with 21 illustrationa Cloth, 82.00. Henry C. Lea's Son & Cu.'s Publications — Venereal Dis., etc. 25 BUMSTEAD, F. J,, and 31. I)., LL. ID,, Late Professor of Venereal Diseases at the t'otteiie of Physicians and Surgeons, New York, etc. TAYLOR, jR. TF., A. M., 31. n., Surgeon to Chariti/ Hospital, New York, Prof, of Venereal' and Skin Diseases in the University of Verrnont, Prcs. of the Am. Dermatoloijical Ass'n. The Pathology and Treatment of Venereal Diseases. Including the results of recent investigations upon the subject. Fifth edition, revised and largely re- written, by Dr. Taylor. In one large and handsome octavo volume of about 898 pages witli lo'J "illustrations, and thirteen cliromo-lithographic ligures. Cloth, $4.75; leather, $5.75; very handsome half Kussia, ?6.2o. From the Preface to the Fifth Edition. In this edition I have carefully revised the text, and, when necessary, liave changed and modilied it, and making additions where required, 1 have endeavoi-ed to bring it up to our present state of knowledge in all particulars. Mudi new matter will be found re- lating to lhera[)eutics, and in tlie chapter on the treatment of syphilis a new adjuvant is spoken of. The subjects of the inoculation of animals with syphilis and the bacillus-origin of the disease, which are at present attracting much attention, have been included in this edition, and a chapter on sypiiilis and marriage has been apjjended.^ I am able to give to my readers two pages of cliromo-lithographic drawings, including thirteen figures representing the chief venereal lesions, which I am convinced will be a great aid in the study of these affections. No work has been published upon this subject I fifth edition has been prepared by Dr. Taylor alone, that has attauied to as high a standard as an an- i Much new matter will be found relating to thera- thorityas tliis has. Ricord, Vidal, Signumd and I peuties. Tlie worlc has been brought tally up to others, held ranli as authorities in venereal atfec- i the present slate of linowledge, and will undoubt- tions, but the works of none of them were so ediy continue to be the principal authority on generally quoted and esteemed as tliis one. The | venereal diseases for a long time. COBNIL, v., Professor to the Faculty of Medicine of Paris, and Physician to the Lourcine Hospital. Syphilis, its Morbid Anatomy, Diagnosis and Treatment. Specially revised by the Author, and translated with notes and additions by J. Henry C. Simes, M. D., Demonstrator of Pathological Histology in the University of Pennsylvania, and J. William White, M. D., Lecturer on Venereal Diseases and Demonstrator of Surgery in the University of Pennsylvania. In one handsome octavo volume of 461 pages, with 84 very beautiful illustrations. Cloth, $3.75. Just ready. Tlie anatomical and histological characters of the hard and soft sore are admirably described. The multiform ciUiUieous manifestations of the disease are dealt with histologically in a masterly way, as we should indeed expect tiiem to be, and the accompsmying illustrations are e.xecuted carefully and well. The various nervous lesions which are the recognized outcome of tlie syphilitic dyscrasia ai'e treated with care and consideration. Syphilitic epilep.sy, paralysis, cerebral syphilis and locomotor ata.xia are subjects full of interest; and nowhere in the whole volume is the clinical experience of the author or the wide acquaintance of tlie translators with medical literature more evident. Tiie anat- omy, the histology, the pathology and the clinical leatures of . syphilis are represented in this work in their best, most practical and most instructive form, and no one will rise from its perusal without the fceling'that his grasp of the wide and impor- tant subject on whicli it treats is a stronger and surer one. — The London Practitioner, Jan. 1882. GBOSS, SAMUEL W., A. M., M. !>., Professor of the Principles of Surgery and of Clinical Surgery in the Jefferson Medical College. A Practical Treatise on Impotence, Sterility, and Allied Disorders of the Male Sexual Organs. Second edition, thorouglily revised. In one very hand- some octavo volume of 168 pages, with 16 illustrations. Cloth, $1.50. Just ready. This worlv will derive value from the high stand- ing of its author, aside from the fact of its passing so rapidly into its second edition. This is, indeed, a book that every physician will be glad to place in his libi'ary, to be reaii with profit to himself, and with incalculable benefit to his patient. Be- sides the subjects embra'^ed in the title, which are treated of in their various forms and degrees, speimatorrhcea and prostatorrhoea are also fully considered. The worli is thoroughly practical in charactei', and will be especially useful to the general practitioner. — Medical Record, Aug. 18, 1883. • The author of this monograph is a man of posi- tive convictions and vigorous style. This is justi- fied iiy his experience and by his study, which has gone liand in hand with liis experience. In regard to the various organic and functional disorders of the male geneiative apparatus, he lias liad ex- ceptional opportunities for obseivatinn, and his boolc shows that he has not neglected to compare his own views with those of other authors. The result is a work which can be safely reconi mended to both piiysicians and surgeons as a guide in the treatment of the disturbances it refers to. It is tlie best treatise on the subject with which we are acquainted. — The Medical News, Sept. 1, 1883. CXJLLEBIEB, A., & BU3ISTEAD, F. J., 31. JX, LL.T>., Surgeon to the Hopital du Midi. Lnle Professor of Venereal Diseases ill the College of Physiciana and Surgeons, New York. An Atlas of Venereal Diseases. Translated and edited by Freeman J. Bum- STEAi>, M.D. In one imjjcriid 4to. volume of 328 pages, double-columns, with 26 plates, containing about 150 ligures, bciiutifully colored, many of tiiom the size of life. Strongly bound in cloth, $17.00. A specimen of the plates and text sent by mail, on receipt of 25 cts. HILL ON SYPHILIS AND LOCAL CONTAfilorS I FORMS OF LOCAL DISEASE AFFECTING DISORDERS. In one8vo vol. of 47!) p. Cloth, S:i.25. PRINCIPALLY THE ORGANS OF GENER.\- LEE'S LECTURES ON SYPHILIS AND SUME | TION. In one 8vo. vol. of 'Mii pages. Cloth, $2.25. 26 Henry C. Lea's Son & Co.'s Publications — Diseases of Skin. HYDE, J. NEVUS'S, A, M., M. 2)., Professor of Dermatology ami Venereal Diseases in Rush Medical College, Chicago. A Practical Treatise on Diseases of the Skin. For the use of Students and Practitioners. In one handsome octavo vohime of 570 pages, with 66 beautiful and elab- orate illustrations. Cloth, $4.25 ; leather, $5.25. Just ready. The author has given the student and praeti- by his detailed descriptions of therapeutic meas- tioner a worli admirably adapted to the wants of each. We can heartily corhmend tlie book as a valuable addition to our literature and a reliable guide to students and practitioners in their studies and practice. — A7n. Journ. of Med. Sci., July, 1883. Especially to be praised are the practical sug- gestions as to what may be called the common- sense treatment of eczema. It is quite impossible to exaggerate the judiciousness with which the formulae for the external treatment of eczema are selected, and what is of equal importance, the full and clear instructions for their \ise.— London Medi- cal Times and Gazette, July 28, 1883. The work of Dr. Hyde will be awarded a high po.sition. The student of medicine will find it peculiarly adapted to his wants. Notwitlistanding the extent of the subject to which it is devoted, yet it is limited to a single and not very large vol- ume, without omitti'rig a proper discussion of the topics. The conciseness of the volume, and the setting forth of only what can be held as facts will also make it acceptable to general practitioners, who have not the time to give attention to discus- sions or unsettled points, however interesting such discussions might be. — Cincinnati Medical JSTews, Feb. 1883. The aim of the author has been to present to his readers a work not only expounding the most modern conceptions of his subject, but presenting what is of standard value. He has more especially devoted its pages to the treatment of disease, and ures h,as adapted them to the needs of the physi- cian in active practice. In dealing with these questions the author leaves nothing to the pre- sumed knowledge of the reader, but enters thor- oughly into the most minute description, so that one is not only told what should be done under given conditions but how to do it as well. It is therefore in the best sense "a practical treatise." That it is comprehensive, a glance at the index will show. — Maryland Medical Journal, July 7, 1883. Professor Hyde has long been known as one of tVie most intelligent and enthusiastic representa- tives of dermatology in the west. His numerous contributions to the literature of this specialty have gained for him a favorable recognition as a careful, conscientious and original observer. The remarkable advances made in our knowledge of diseases of the skin, especially from the stand- point of pathological histology and improved methods of treatment, necessitate a revision of the older text-books at siiort intervals in order to bring them up to the standard demanded by the march of science. This last contribution of Dr., Hyde is an effort in this direction. He has atr tempted, as he informs us,., Physician to the Skin Department of University College, London. Handbook of Skin Diseases; for Students and Practitioners. Second Ameri- can edition. In one 12mo. volume of 353 pages, with plates. Cloth, $2.25. Henry C. Leas Son & Co.'s Publications — Dis. of Women. 27 AN AMBRICAJSf SYSTEM OF GYNMCOLOGY. A System of Gynaecology, in Ti'eatises by Various Authors. In two handsnine octavo volumes , riclily illusti'ated. fn artire preparation. LIST OF CONTRIBUTORS. FOKDYCE BARKER, I\I. D., CIL\RLES C.VRROLL LEE, M. I).. ROBERT B.VTTEY, M. D., WILLIAM T. LUSK, M. D., SAMUEL C. BUSEY, M. D., MATTHEW D. MANN, M. D., HENRY F. CABIPBELL, M. D.. ROBERT B. MAURY, M. D., BENJAMIN F. DAWSON, M. D., C D. PALMER. M. D., WILLIAJI GOODELL, M. D., WILLIAM M. POLK, M. D., HENRY F. GARRIGUES, M. D., THADDEUS A. REAMY, M. D., SAMUEL W. GROSS, M. D., A. U. ROCKWELL, M. D., JAMES B. HUNTER, M. I)., ALBERT H. SJHTH, M. D., WILLIAM T. HOWARD, M. D., R. STANSBUEY SUTTON, A. M., M. D , A. REEVES JACKSON, BI. D., T. GAILLARD THOMAS, M. D., EDW^VRD W. JENKS, M. D., CHARLES S. AVARD, M. D., WILLIAM U. WELCH, M.D. TH03IAS, T. GAILLARD, M. D,, Professor of Diiea.^ct; of Women in the College of Phi/sicians and Surgeons, JX. Y. A Practical Treatise on the Diseases of Women. Fifth edition, tliorouglily revised and rewritten. In one large and handsome octavo volume of 810 pages, with 266 illustrations. Cloth, $5.00 ; leather, $6.00 ; very handsome half Eussia, raised bands, |6.50. The words which follow "fifth edition" are in | vious one. As a book of reference for the busy this case no mere formal announcement. The ! practitioner it is unequalled. — Boston Medical arid alterations and additions which have been made are | Surgical Journal, April 7, 18S0. both numerous and important. The attraction: It has been enlarged and carefully revised. It is and the permanent character of this book lie in a condensed encyclopedia of gyntecologieal medi- the clearness and truth of the clinical descriptions I cine. The style of arrangement, the masterly of diseases; the fertility of the author in thei'a- , manner in which each subject is treated, and the peutic resources and tlie fulnes.s with which the I honest convictions derived from probably the details of treatment are described; the definite : largest clinical experience in that specialty of any character of the teaching; and last, but not least, I in this country, all serve to commend it in the the evident candor which pervades it. We would i highest terms to the practitioner. — Nashville Jour. also particularize the fulness with which the his- ] of Med. and Surg., Jan. 18S1. tory of the .subject is gone into, which makes the | That the previous editions of the treatise of Dr. book additionally interesting and gives it value as ; Thomas were thought worthy of translation into a work of reference.— Xo?!do)j Medical Times and | German, French, Italian and Spanish, is enough Gazette, July 30, 1881. [ to give it the stamp of genuine merit. At home it The determination of the author to keep his j has made its way into the library of every obstet- book foremost in the rank of works on gynsecology ; rician and gynfecologist as a safe guide to practice, is most gratifying. Recognizing the fact that this i No small number of additions have been made to can only be accomplished by frequent and thor- i the present edition to make it correspond to re- ougn revision, he has spared "no pains to make the j cent improvements in treatment. — Pacific Medical present edition more desirable even than the pre- I and Surgical Journal, Jan. 18S1. BLUS, ARTMUM W., M. J>., Lo7id., F.R. C.I*., 31. B. C.S., Assist. Obstetric Physician to Middlesex Hospital,- late Physician to Eritisli Lying-in Hospital. The Diseases of Women. Including their Pathology, Causation, Symptoms, Diagnosis and Treatment. A Manual for Students and Practitioners. In one handsome octavo volume of 576 pages, with 148 illustrations. Cloth, $3.00 ; leather, $4.00. It is a pleasure to read a book so thoroiighly The greatest pains have been taken with the good as this one. The special qualities which are conspicuous are thoroughness in covering the whole ground, clearness of description and con- ciseness of statement. Another marked feature of the Vjook is the attention paid to the details of many minor surgical operations and procedures, as, for instance, the use of tents, application of leeches, and use of hot water injections. These sections relating to treatment. A liberal selection of remedies is given for each morbid condition, the strength, mode of application and other details being fully explained. The descriptions of gynte- cological manipulations and operations are full, clear and practical. Much care has also been be- stowed on the parts of the book which deal with diagnosis — we note especially the pages dealing are among the more common methods of treat- I with the differentiation, one from another, of the ment, and yet very little is said about them in many of the text-books. The hook is one to be warmly recommended especially to students and general practitioner.*, who need a conci.se but com- plete /eswmp of the wliole subject. Specialists, too, will find many useful hints in its pages. — Boston Med. and Surq. Journ., March 2, 1882. different kinds of abdominal tumors. The prac- titioner will therefore find in this book the kind of knowledge he most needs in lii.s daily work, and he will be pleased with the clearness and fulness of the information there given. — The Practilion&r, Feb. 1882. BARNES, ROBERT, 31. B., F. R. C. P., Obstetric Pliysician to St. Thiyinns' Hospital, London, etc. A Clinical Exposition of the Medical and Surgical Diseases of Women. In one liandsome octavo voliune, witli numerous illustrations. New edition. Preparing. CMABWICK, JA3IES R., A. 31., M. B. A Manual of the Diseases Peculiar to Women. In oiu' iiand.some royal 12mo. vohnne, with illustrations. VrepariiKj. WEST, CHARLES, M. B. Lectures on the Diseases of Women. Third American from the thin! lyon- don edition. In one octavo volume of 543 pages. Clolli, $3.75; leailier, $4.75. 28 Henb-tO. Lea's Son & Co.'s Publications — Dis. of Women, Md. E3I3IBT, THOMAS ADDIS, M. D., LL. D., Surgeon to the Woman's Hospital, Xeiv York, etc. The Principles and Practice of Gynaecology ; For the use of Students and Practitioners of Medicine. Second edition. Tliorouglily revised. In one large and very handsome octavo volume ot 879 pages, with 133 illustrations. Cloth, $5.00 ; leather, $6.00 ; very handsome half Eussia, $6.50. No gj^nffieologieal treatise has appeared which ceived more attention than in America. It is, contains an equal amount of original and useful then, with a feeling of pleasure that we welcome a matter; nor does tlie medical and :o. AND OTHER DISEASES PECULIAR TO WO- MEN. In oiieSvo. vol. of-ki4 p.ages. Cloth, S-J.-W. MEIGS ON THK NATURK, .SIGNS AND TREAT- MENT OF CHILDBED FEVER. In one 8vo, -CHURCHILL ON THE PUERPERAL FEVER 1 volume of 34G pages. Cloth, $2.00. Henry C. Lea's Son & Co.'s Publications — Midwifery. 29 BLAYFAIR, W. S., 31. D., F. M. C. J>., Professor of Obstetric Medicine in King's College, London, etc. A Treatise on the Science and Practice of Midwifery, Tliird American •edition, revised by the Author. Edited, with additions, by Egbert P. Harris, M. D. In one handsome octavo volume of 659 pages, with 183 illustrations. Cloth, $4 ; leather ■f 5 ; half Russia, $5.50. The medical profession has now the opportunity ' elioose Playfair's. It is of convenient size, but of adding to their stock of standard medical works ] what is of chief importance, its treatment of tlie various subjects is concise and plain. While the discussions and descriptions are sutticientlv elabo- rate to render a very intelligible idea of th'em, yet all details not necessary for a full un., Obstetric Physician to St. Thomas' Hospital, London. A Manual of Midwifery for Midwives and Medical Students. In one royal 12m(). volume of 197 pages, with 50 illustrations. Cloth, $1.25. JPARRY, JOHN S., 31. 2)., Obstetriann to the Philadelphia Hospital, Vice-President of the Obstet. Society of Philadelphia. Extra - Uterine Pregnancy: Its Clinical HLstory, Diagnosis, Prognosis and Treatment. In one handsome octavo volume of 272 pages. Cloth, $2.50. TANNER, TH03rAS HAWKES, 31. T>. On the Signs and Diseases of Pregnancy. First American from tlie second Engiisli edition. In one iiandsome octavo volume of 490 pages, with 4 colored plates and 16 woodcuts. Cloth, $4.25. WINCKEL, F. A Complete Treatise on the Pathology and Treatment of Childbed. For Students and Practitioners. Translated, willi tlie consent of the .Viithor, from the second German edition, bv James Read Chadwick, M. D. In one octavo volume of 484 pages. Clotli, $4.00. 30 Henry C. Lea's Son & Co.'s Publications — Midwfy., Bis. Cliildn. LEISHMAN, WILLIAM, M. D., Regius Professor of Midwifery in the Universitij of Glasgow, etc. A System of Midwifery, Including the Diseases of Pregnancy and the Puerperal State. Third American edition, revised by the Author, witli additions by John S. Pakry, M. D., Obstetrician to the Philadelphia Hospital, etc. In one large and very handsome octavo volume of 740 pages, with 205 illustrations. Cloth, $4.50 ; leather, $5.50 ; very handsome half Russia, raised bands, «)6.00. The author is broad in his teachings, and dis- ; preparation of the present edition the author has cusses briefly the comparative anatomy of the pel- vis and the .mobility of the pelvic articulations. The second chapter is devoted especially to the study of the pelvis, while in the tliird the female organs of generation are introduced. The structure and development of the ovum are admirably described. Then follow chapters upon the various subjects embraced in the study of mid- wifery. The descriptions throughout the work are plain and pleasing. It is sufficient to state that in this, the last editign of this well-known work, every recent advancement in this field has been brought forward. — Physician and Surgeon, Jan. 1880. We gladly welcome the new edition of this ex- cellent text-book of midwifery. The former edi- tions have been most favorably received by the profession on both sides of the Atlantic. In the made such alterations as the progress of obstetri- cal science seems to require, and we cannot but admire the ability with whieli the task has been performed. We consider it an admirable text- book for students during their attendance upon lectures, and have great pleasure in recnmmend- ing it. As an exponent of the midwifery of the present day it has no superior in the English lan- guage. — Canada Lancet, Jan. 1880. To the American student the work before us mustprove admirably adapted. Complete in all its parts, essentially modern in its teachings, and with demonstrations noted for clearness and precision, it will gain in favoi and be recognized as a work of standard merit. The work cannot fail to be popular and is cordially recommended. — N. 0. Med. and Surg. Journ., Blarch, 1880. SMITH, J. LEWIS, M. D., Clinical Professor of Diseases of Children in the Bellevue Hospital Medical College, iV^. }'. A Complete Practical Treatise on the Diseases of Children. Fifth edition, thoroughly revised and rewritten. In one handsome octavo volume of 836 pages, with illustrations. Cloth, $4.50 ; leather, $5.50 ; very handsome half Russia, raised bands, $6. This is one of itie oest books on the subject with j which we have met and one that has given us j satisfaction on every occasion on which we have ' consulted it, either as to diagnosis or treatment. It is now in its fifth edition and in its present form is a very adequate representation of the subject it treats of as at present understood. The important subject of infant hygiene is fully dealt with in the early portion of the book. The great bulk of the work is appropriately devoted to the diseases of infancy and childhood. We would recommend any one in need of information on the subject to procure tlie work and form his own opinion on it, which we venture to say will be a favorable one.— Dublin Journal of Medical Science, March, 18S3. There is no booli published on the subjects of which this one treats that is its equal in value to the physician. While he has said just enough to impart the information desired by general practi- tioners on such questions as etiology, pathology, prognosis, etc., he has devoted more attention to the diagnosis and treatment of the ailments which he so accurately describes; and such information is exactly what is wanted by the vast majority of " family physicians."— Va. Med. Monthly, Feb. 1882. It is a pleasure to peruse such a vt^ork as the one before us, and as reviewers we have but one diffi- culty — there is but little to find fault with. The author understands what he writes about from a practical acquaintance with tlie diseases incident to infancy and childhood, and also thoroughly comprehends their pathology and therapeutics. The work is full of original and practical remarks which will be particularly acceptable to tlie student and young physician ; but at the same time we can with' great sincerity commend it to the notice of the profession in general. — Edinb. Med. Jl.. May, '82. KEATIWG, JOSWM., M. D., Lecturer on the Diseases of Children at the University of Pennsylvania, etc. The Mother's Guide in the Management and Feeding of Infants. one handsome 12mo. volume of 118 pages. Cloth, $1.00. In Works like this one will aid the physician im- mensely, for it saves the time he is constantly giv- ing liis patients in instructing them on the sub- jects here dwelt upon so thoroughly and prac- tically. Dr. Keating has written a practical book, has carefully avoided unnecessary repetition, and successfully instructed the mother in such details of the treatment of her child as devolve upon her. He has studiously omitted giving prescriptions, and instructs the mother when to call upon the doctor, as his duties are totally distinct from hers. — American Journal of Obstetrics, October, 1881. Dr. Keating has IvCpt clear of the common fault of works of this sort, viz., mi.xing the duties of the mother with those proper to the doctor. There is the ring of common sense in tlie remarlss about the employment of a wet-nurse,'about the proper food for a nursing mother, about the tonic effects of a bath, about the perambulator verstcs the nurses' arms, and on many other subjects concerning which the critic might say, "surely thi.s is obvi- ous," but which experience teaches us are exactly the things needed to be insisted upon, with the rich as well as the poor. — London Lancet, January, 28 1882. A book small in size, written in pleasant style, in language which can be readily understood by any mother, and eminently practical and safe; in fact a book for which we have been waiting a long time, and which we can most lieartily reoomniend to mothers as the book on this subject. — IVeio York Medical Journal and Obstetrical Review, Feb. 1882. WEST, CHARLES, 31. D., Physician to the Hospital for Sick Children, London, etc. Lectures on the Diseases of Infancy and Childhood. Fifth American from the sixth revised and enlarged English edition. In one large and liandsome octavo volume of 686 pages. Cloth, $4.50 ; leather, $5.50. By the Same Author. On Some Disorders of the Nervous System in Childhood. 12mo. volume of 127 pages. Cloth, $1.00. la one small CONDIE'S PRACTICAL TREATISE ON THE DISEASES OF CHILDREN. Sixth edition, re- vised and augmented. In one octavo volume of 779 pages. Cloth, $5.25 ; leather, $e.25. Henrv C. Lea's Son & Co.'s Publications — Med. Juris., Miscel. 31 TIDY, CHARLES 3IEY3IOTT, M. B., F. C S., Professor of Cliemistry and oj Forensic Medicine aiui Public Health at the London Hoapital, etc. Legal Medicine. Volume IE. Legitimacy and Paternity, Pregnane}^, Abor- tion, Rai)e, Indecent Exposure, Sodomy, Bestiality, Live Birth, Infanticide, vVsphyxia, Drowning, Hanging, Strangulation, Suflbcation. Making a very handsome imperial oc- tavo volume of 529 pages. Cloth, $6.00; leather, $7.00. Just ready. VOLUME I. Containing 664 imperial octavo pages, with two beautiful, colored plates. Cldth, S6.00 ; leather, §7.00. Recently issued. He whose inclinations or necessities lead him to I The fact that the very numerous illustrative cases assume the functions of a medical jurist wants a are drawn from many sources, and are not limited, book encyclopaedic in character, in wliich he may ! as in Casper's Handbook, to the author's own ex- be reasonably sure of finding medico-legal topics perience, and the additional fact that they are discussed wih judicial fairness, with sufficient brought down to a very recent date, give them, completeness, and with due attention to the most for purposes of reference, a very obvious value. — recent advances in medical science. Mr. Tidy's Boston Medical and Surgical Journal, Feb. 8, 188.3. work bids fair to meet this need satisfactorily. | TAYLOR, ALFRED S., M. D., Lecturer on Medical Jurisprudence and Chemistry in Guy's Hospital, London. A Manual of Medical Jurisprudence. Eighth American from the tenth Lon- don edition, thoroughly revised and rewritten. Edited by John J. Reese, M. D., Professor of Medical Jurisprudence and Toxicology in the University of Pennsylvania. In one large octavo volume of 937 pages, with 70 illustrations. Cloth, $5.00 ; leather, $6.00 ; half Russia, raised bands, $G.50. The American editions of this standard manual ] only have to seek for laudatory terms. — American. have for a long time laid claim to the attention of j Journal of the Medical Sciences, .Jan. 1881. •the profession in this country; and the eighth comes before us as embodying the latest thoughts and emendations of Dr. Taylor upon the suljject to which he devoted his life with an assiduity and success which made him facile princeps among English writers on medical jurisprudence. Both the author and the book have made a marli too deep to be affected by criticism, whether it be censure or praise. In this case, however, we should This celebrated work has been the standard au- thority in its department for thirty-seven years, both in England and America, in both tlie profes- sions which, it concerns, and it is improbable that it will be superseded in many years. The work is simply indispensable to every physician, and nearly so to every liberally-educated' lawyer, and we heartily commend the present edition to both pro- fessions. — Albany Law Journal, March 20, 1881. By the Same Author, The Principles and Practice of Medical Jurisprudence. Third edition. In two handsome octavo volumes, containing 1416 pages, with 188 illustrations. Cloth, $10 ; leather, $12. Just ready. The revision of the third edition of this standard work has been most happily con- fided to a gentleman who was during fourteen years the colleague of the author, and who therefore is thoroughly conversant with the methods of thought which have everywhere gained for the book an exalted position as a work of reference. In its present form the work is the most complete exposition of Forensic Medicine in the English language. books of its class. Including within its purview. Taylor's Treatise at the hands of Dr. Stevenson has tindergone a diminution of bulk with an in- crease of mass. This edition only asserts with stronger reason the allowed claims of the late Dr. Taylor's work to the first position among English as the subject does, something from every divi- sion of medical science, this exhaustive treatise will ever remain an invaluable collection of data. — Neiv York Medical Journal, Dec. 1, 1883. By the Same Author. Poisons in Relation to Medical Jurisprudence and Medicine. Third American, from the third and revised English edition. In one large octavo volume of 788 pages. Cloth, $5.50 ; leather, $6.50, LEA, HENRY C. Superstition and Force : Essays on The "Wager of Law, The Wager of Battle, The Ordeal and Torture. Third revised and enlarged edition. In one handsome royal 12mo. volume of 552 pages. Cloth, $2.50. should not he most carefully studied ; and however well versed the reader miiy be in the science of jurisprudence, he will find much in INIr. Lea's vol- ume of which he was previously ignorant. The book is a valuable addition to the literature of so- cial science. — Westminster Review, Jan. 1880. This valuable work is in reality a history of civ- ilization as interpreted by the progress of jurispru- dence. . . In "Superstition and I'orce" we have a iper philosophic survey of tlie long period intei-vening between primitive bai-barity and civilized enlight- enment. There is not a chapter in the work that By the Same Author. Studies in Church History. The Rise of the Tem.poral Power — Ben- efit of Clergy — Excommunication, octavo volume of 605 pages. Cloth, $2.50. Theauthor i.s pre-eminently ascholar. He takes up every topic allied with the leading theme, and traces it out to the minutest detail with a wealth of knowledge and impartiality of treatment that compel admiration. The amoimt of information compressed into the book is extraordinary. In no -other single volume is the development of the New edition. In one very handsome royal Juat ready. primitive church traced with so much clearness, and with so definite a perception of complex or conflicting sources. The fifty pages on the growth of the pa])acy, for instance, are admirable for con- cisene.ss and freedom from prejudice. — Boston Ti-aveller, May 3, 1883. 32 Henry C. Lea's Son & Co.'s Medical and Surgical Publications. INDEX TO CATALOGUE. American Journal of the Medical Sciences American System of Gynaecology . Allen's Anatomy *Astihurst's Surgery . Asli well on Diseases of Women Attfield's Chemistry Barlow's Practice of Medicine Barnes' Midwifery *Barnes on Diseases of Women Barnes' System of Obstetric Medicine Bartholow on Electricity Basham on Kenal Diseases . Bell's Comparative Physiology and Anatomy Bellamy's Operative Surgery Bellamy's Surgical Anatomy Blandford on Insanity Bloxam's Chemistry . Bowman's Practical Chemistry *Brislowe's Practice of Medicme . Browne on the Ophthalmoscope . Browne on the Throat Bruce's Materia Medica and Therapeutics Brunton's Materia Medica and Therajjeutics *Bryani's Practice of Surgery *Bumstead on Venereal Diseases . *Burnett on the Ear .... Carpenter on the Use and Abuse of Alcohol *Carpenter's Human Physiology . Carter on the Eye .... Century of American Medicine Chadwiclv on Diseases of Women . Chambers on Diet and Regimen Cliurchill on Puerperal Fever Clarke and Lockwood's Dissectors' Manual Classen's Quantitative Analysis Cleland's Dissector .... Clouslon on Insanity .... Clowes' Practical Chemistry Coals' Pathology .... Coleman's Dental Surgery . Condie on Diseases of Children Cooper's Lectures on Surgerj' *Cornil and Ranvier's Pathological Histology Coruil on Sypliilis .... Cullerier's Atlas of Venereal Diseases *Dalton's Human Physiology Dalton's Topograpliical Anatomy of the Brain Davis' Clinical Lectures Druitt's Modern Surgery Dujardiu-Beaumetz's Therapeutics Duncan on Diseases of Women *Dunglison's Medical Dictionary . Edis on Diseases of Women . Ellis' Demonstrations of Anatomy *Emmet's Gynaecology *Erichsen's S.ystem of Surgery Esniarch's Early Aid in Injuries and Accid'ts Farquharson's Therapeutics and Mat. Med. Fenwlcls's Medical Diagnosis Finlayson's Clinical Diagnosis Flint "on Auscultation and Percussion Flint on Phthisis .... Flint on Puysical Exploration of the Lungs Flint on Respiratory Organs Flint on the Heart .... *Flint's Clinical Medicine Flint's Essays . . . . ' *Flint's Practice of Medicine Foster's Physiology .... *Fothergill s Handbook of Treatment . Fownes' Elementary Chemistry Fox on Diseases of the Skin . Fuller on the Lungs and Air Passages . Galloway's Analysis .... Gibne.v's Orthoptedic Surgery Gibson's Surgery .... Gluge's Patliological Histology, by Leidy *tirav's Anatomy ..... Greeiie's Medical Chemistry . Green's Pathology and Morbid Anatomy Grillith's Universal Formulary Gross on Foreign Bodies in Air-Passages Gross on Impotence and Sterility . Gross on Urinary Organs *Gross' System of Surgery . Gusserow on Uterine Tumors G>-necological Transactions . Habershon on the Abdomen *Hamiltoti on Fractures and Dislocations Hamilton on Nervous Diseases Hartsliorne's Anatomy and Physiology . Haitsliorne's Conspectus of the Med. Sciences Harlslioriie's Essentials of Medicine Ilerniann's Experimental Pharmacology Killier's Handbook of Skin Diseases Hill on Syphilis ..... PAGE. 2 27 6 20 28 9 17 29 Hoblj'n's Medical Dictionary Hodge on Women .... Hodge's Obstetrics .... Hoffmann and Power's Chemical Analysis Holden's Landmarks .... Holland's Medical Notes and Reflections *Holmes' Surgery .... *Holmes' System of Surgery Horner's Anatomy and Histology Hudson on Fever . . ' . Hyde on the Diseases of the Skin . Jones (C. Handheld) on Nervous Disorders Keating on Infants .... King's Manual of Obstetrics . Klein's Histology .... La Roche on Pneumonia, Malaria, etc. . La Roche on Yellow Fever . Laurence and Moon's Ophthalmic Surgery Lawson on the Ej'e, Orbit and Eyelid Lea's Studies in Church History Lea's Superstition and Force Lee on Syphilis ..... Lehnianh's Chemical Physiology . *Leishman's Midwifery Ludlow's Manual of Examinations Lyons on Fever ..... McGregor's Physical Physiology . Maisch's Organic Materia Medica . Medical News ..... Meigs on Childbed Fever Miller's Practice of Surgery . Miller's Principles of Surgery Mitchell's Nervous Diseases of Women . Morris on Skin Diseases Neill and Smith's Compendium of Med. Sci. Nettleship on Diseases of the Eye . *Parrish's Practical Pharmacy Parry on Extra-Uterine Pregnancy Parvin's Midwifery .... Pavy on Digestion and its Disorders Pepper's Surgical Pathology Pirrie's System of Surgery Playfair on Nerve Prostration and Hysteria *Plaj'fair's Midwifery .... Politzer on the Ear and its Diseases Power's Human Physiology . Ralfe's Clinical Chemistry Ramsbotham on Parturition Remsen's Theoretical Chemistry . *Reynolds' System of Medicine Richardson's"^Preventive Medicine Roberts on Urinary Diseases Roberts' Principles and Practice of Surgery Rod well's Dictionary of Science Sargent's Minor and Military Surgery Schiifer's Histology .... Seller on the Throat, Nose and Naso-Pharynx Skey's Operative Surgery Slade on Diphtheria . . . . Smith (Edward) on Consumption . Smith (H. H.) and Horner's Anatomical Atlas *Smith (J. Lewis) on Children *Stille & Maisch's National Dispensatory *Stillri's Therapeutics and Materia Medica Stimson on Fractures .... Stimson's Operative Surgery Stokes on Fever ..... Students' Series of Manuals . Sturges' Clinical Medicine Tanner on Signs and Diseases of Pregnancy Tanner's Manual of Clinical Medicine Tarnier and Chantreuil's Obstetrics Taylor on Poisons .... *Taylor's Medical Jurisprudence . Taylor's Prin. and Prac. of Med. Jurisprudence *Thomas on Diseases of Women Thompson on Stricture Thompson on Urinary Organs Tidy's Legal Medicine .... Todd on Acute Diseases Treves' Applied Anatomy Tuke on the Influence of Mind on the Body Walshe on the Heart .... Watson's Practice of Physic . Watts' Physical and Inorganic Chemistry *WelIs on the Eye .... West on Diseases of Children West on Disea?ei of Women West on Nervous Disorders of Children . Williams on Consumption . Wilson's Handbook of Cutaneous Medicine Wilson's Human Anatomy . Winkel on Pathol, and Treatment of Childbed Wiihler's Organic Chemistry Woodbury's Practice of Medicine . Woodhead's Practical Pathology . PAGE. 4 Books marked * are also bound in half Russia. HENRY C. LEA'S SON & CO., Philadelpliia. \l.