Minor maladies and their treatment

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MINOB MALADIES AND THEIB TEEATMENT.

First Edition, October 1906

Reprinted, February 1907
Second Edition, March 1908

Reprinted, June 1909
Third Edition, February 1913
Fourth Edition, January igtg
Reprinted, September iqi8
January, 1920

MINOR MALADIES

AND

THEIR TREATMENT

BY

LEONARD WILLIAMS, M.D.

PHYSICIAN TO THE fRENCH HOSPITAL

FOURTH EDITION

TORONTO '

THE MACMILLAN COMPANY OF CANADA, LTD.
1918

M HOMI

Printed in Great Britain

PREFACE TO FOURTH EDITION.

All medical works are egotistical; either furtively
or frankly. If the matter is not coloured by the
author's experience, if it be not presented in the
form in which it emerges from the mill of his own
brain, the result is a compilation which, though it
may have some value in classifying facts, must
nevertheless always fail in the more important
direction of suggesting ideas. Orthodoxy is an
easy comforting thing, but it is very confining.
Heterodoxy, which in medicine is synonymous with
progress, is a difficult and dangerous thing, but
it is very interesting; often, it is even amusing.
This book is entirely egotistical, and it is in many
respects heterodox. It was first published in 1906;
in each succeeding edition very considerable altera-
tions have been introduced; the present one em-
bodies changes greater in number and more con-
siderable in importance than any of the others.
The section on Constipation has been entirely
rewritten; the chapter on Change of Air has dis-
appeared, to be replaced by one on Minor Glandular
Insufficiencies ; and a small chapter on Old Age has
been added.

y

vi PREFACE TO FOURTH EDITION

WTien I was first qualified, I went into general
practice. I soon found that though moderately
well equipped in the diagnosis and treatment of
diseases which I seldom encountered, I was dis-
concertingly ignorant in those matters about which
I was most frequently consulted. Pneumonia I
knew, and Rheumatic Fever, and Typhoid; I was
so well acquainted with Phthisis that I confidently
recognized it in every trivial cough; and, so well
versed was I in heart-murmurs that I was prepared
to discover them and treat them — with a combina-
tion of digitaUs and words of serious warning — even
when they had no real significance. With know-
ledge concerning Tabes, Tumours, and Trematodes
I was full to overflowing; but I soon realized that
I knew very little about a common Cold, less about
ordinary Indigestion, and nothing at all about the
rheumatic conditions. My knowledge of the subject
of Personal Hygiene consisted in attributing to
flannel all kinds of virtues, and to fresh air all
manner of vices. In this dilemma I searched for
a book which would lighten my darkness; but I
found it not. I then determined that if time and
circumstance should ever give me the opportunity
of writing such a book, those of my juniors who
found themselves in the same predicament should
not want for such help as I might be able to afford
them. The opportunity came about twelve years
later, when I forsook the drive of a busy general
practice for the comparative calm of consulting work.

rilEFACE TO FOURTH EDITION. vii

Such of my experiences as I deemed of value in
tliis connection (many of them were gained by
si feting at the feet of elderly practitioners) first
materialized in the form of some lectures and demon-
strations which I gave at the Medical Graduates'
College and Polyclinic in 1904'. These were after-
wards published, chiefly in the Cli7iical Journal
and the Medica} Press and Circular. When
they were being put into book form they were
supplemented by matter which had been incor-
porated in articles which had appeared in The
Lancet, The Practitioner^ and other periodicals.
In each fresh edition this process of laying under
contribution portions of my writings which had
appeared elsewhere has been steadily persevered
with. I am pleased here to record my apprecia-
tion of the facilities afforded me by the editors of
these periodicals for this form of plagiarism, and to
express my thanks to the proprietors of works of
less evanescent character, the Oxford Medical
PubUcations in particular, for allowing me to repro-
duce here portions of what was written primarily
for them.

In rereading the proofs of the matter which has
been left practically untouched since it first appeared
in print, I have been forced to recognize that much
of it is in reality once more in the crucible, not so
much in detail as in principle. In therapeutics
we often adopt measures merely because we know
by experience that they succeed. An explanation

viii PREFACE TO FOURTH EDITION.

of the modus operandi comes later, and the coiTect
explanation often much later still. Many of the
subjects which I treated with dogmatism ten years
ago have, in the interval, been subjected to fresher
and fiercer lights which, in the future, may modify
our present estimates, and may even change t'lem
beyond recognition. To wiite a medical book,
however modest its aims, and to keep your hand
conscientiously upon it, is to reahze fully the first
essential to the dignity and progress of medicine—
namely, the ruthless cultivation of the open mind.
To the contracting cerebral arteries of the seniors
must be attributed the inadequate prestige of the
profession in the body poHtic ; it is with the juniors
to redress the balance, by persisting in a divine
discontent with present imperfections, and by
pursuing with diligence the kind of heterodoxy
which consists in a reasoned receptivity to new
ideas. This is not to extol the excited welcome
which I have too often seen extended to new thera
peutic fashions. Those which are in my mind had
no change in outlook to warrant them. It is ex-
perience alone which brings discrimination, but it
is a safe rule which bids us receive with cai«5ion new
methods which are not based upon fresh ideas.
The substitution of a synthetic drug for a vegetable,
in the treatment of a disease whose pathology is
obscure, may succeed in the wholly laudable object
of giving greater relief from symptoms, but we
must not delude ourselves into believing that science

PREFACE TO FOURTH EDITION. ix

is thereby advanced. And it is, as a rule, precisely
those who are most eager to follow new fashions who
are jnost impervious to fresh ideas. It is an easy
tiling to prescribe a drug, but it is not an easy thing
to readjust your outlook. The man who discovers
a new drug — ^like Maclagan and his sahcylates — is
acclaimed as a deliverer; the man who preaches
a new gospel, as Lister, Arbuthnot Lane, or George
Gould, is despised by his contemporaries and stoned
by his elders.

In so far as this book can pretend to be anything
higher than an ephemeral practical aid to every-
day practice, the larger claim would rest on the
fact that in successive editions it has endeavoured
to reflect the current of thought which is moving
opinion among those who are really progressive.
The ultimate object of medical science is prevention,
not cure. The ultimate aim of any curative system
is to influence a morbid process while it is still in a
stage where skilful interference will do permanent
good. Sir James Mackenzie is fond of insisting that
our present methods of investigation are not suffi-
ciently directed towards the discovery of disease
in its earUer stages, that we are content impotently
to contemplate the fuU-blown, whereas we ought
to search for buds and tendencies. In this criticism
I see much justice, and I believe that the serious
study of what are called minor maladies will in this
way lead to the prevention or forestalling of many
serious diseases. Still more earnestly do I believe

X PREFACE TO FOURTH EDITION.

fcliat the study of the whole field of the Internal
Secretions will enable us to detect and correct
morbid tendencies with a degree of success which
has been denied to the older methods. The microbe
— ^the seed — has ruled the immediate past; the future
is with the soil, the endocrine glands.

LEONARD WILLIAMS.

128, Harley Street, W. 1,
January 1, 1918.

CONTENTS.

CIIAPTBR

I. GOLDS, COUGHS, AND SORB THROATS

FA6E
1

n. INDIGESTION - - - - . - 63

in. CONSTIPATION, DIARRHCEA, VOMITING, AND GIDDINESS 95

IV. RHEUMATISM, NEURALGIA, HEADACHE

V. GOUTINESS
VI. MINOR GLANDULAR INSUFFICIENCIES
Vn. GENERAL HEALTH
Vm. OLD AGE . - •

IX. SOME DRUGS, AND THBIB USE3
X; INSANITY > • .

EfTDEZ • • «

U4

187
243
277
310
322
366

387

MINOK MALADIES AND THEIE
TEEATMENT.

CHAPTER L

COLDS, COUaHS, AND SORE THROATS.

The inflammatory conditions which are liable to
affect the upper air-passages are usually attributed
to inclement weather, and the elements, such as damp,
cold, and chill, of which such weather is composed.
This is a view which is no longer tenable. These
inflammatory conditions we now know to be due to
the same causes as those which produce inflammation
in other mucous membranes — namely, irritation and
microbic invasion. There is no doubt that these
affections are more prevalent during inclement
weather, and although we may admit that the in-
clemency, by lowering the resisting powers, may, in
some cases and in some degree, contribute towards
the microbic invasion, it is evident that other and
more important factors must also be in operation.
These other factors are provided by the deficient

1

2 MINOR MALADIES.

ventilation of houses, public buildings and con-
veyances, which immediately ensues when the weather
becomes cold or otherwise disagreeable. Windows
and doors, which in summer-time are always kept
open, are closed in winter, with the result that patho-
genic germs are in the latter season allowed oppor-
tunities for exercising their effects which are denied
to them in the warmer weather. Moreover, in the
summer, people spend much more time out of doors,
and are consequently less exposed to the activities of
the germs, which, as we know, are more readily killed
by sunshine and fresh air than by any other means.
Colds, coughs, and associated conditions are due,
therefore, not to damp and chill, but to microbic
invasion. The surest method of avoiding them is to
cultivate efficient ventilation, and the most certain
method of encouraging them is to tolerate impurity
of atmosphere.

The association of * chills ' with these conditions is
very old, and until comparatively recently these
* chills' were regarded as the cause of the malady.
Most people now realize that this is not the case.
The feelings of chilliness which so often occur at the
outset of these complaints are not, as is so often
erroneously believed, the cause of the symptoms —
they are the primary manifestations of the malady,
the sign which proclaims the success of the microbic
invasion. The person who * caught a chill ' and sub-
sequently developed a sore throat was, although ho
failed to realize the fact, already infected when he

COLDS, COUGHS, AND SORE THROATS. 3

experienced his chilly sensations. It is necessary to
insist upon this view, because the laity cling with
great pertinacity to the chill theory, with the result
that fresh air, instead of being esteemed as a curative
and prophylactic agent, is regarded as the deadliest
enemy of the human race, and great vigilance is
consequently exercised in excluding it by every
possible means from houses, public rooms, and public
conveyances, l/ntil people become more enlightened,
' colds ' and their congeners will continue to afflict
them with quite unnecessary frequency.

The commonest of all disorders is the catarrh
affecting the naso-pharynx, the larynx, or the larger
bronchial tubes, which is known as a COMMON COLD.
For reasons which have just been considered, the
term * cold,' as applied to this condition, is peculiarly
unfortunate ; for not only does it lend support to a
mistaken view of the cause of the malady, but it
tends to obscure what should always be realized
in connection with it — namely, that it is infectious.
It is a well-recognised fact that colds are very liable
to pass from one member of a household to another,
which means that they are epidemic in character,
and, being epidemic, they must necessarily be caused
by bacterial infection. This fact supplies us not
only with an obvious means of avoiding them, but
it points unmistakably to the proper way of treating
them. The infection induces inflammatory action,
and in ordinary people the inflammation begins
in the nose. In those who, from adenoids or nasal

4 MINOR MALADIES.

obstruction, habitually breathe through their mouths,
it may begin lower down in the air-passages ; but
whenever it begins at a site which can be reached
by nasal douching or gargling, it is, if taken in time,
a very easy matter to abort a cold. This is done by
the simple expedient of washing the microbes out of
the part with an antiseptic solution, used both as a
gargle and a nasal douche.

It is curious to observe how few people know how
to use a nasal douche. There are several patterns
on the market, all of which have merits ; but the one
which I prefer, because I am better acquainted with
it than with any other, is called the Bermingham
Nasal Douche.^ It is employed as follows :

Having filled the douche with the necessary fluid,
the index-finger is kept on the air inlet, and the nozzle
placed well inside the nostril. With the head thrown
well back and to one side, the operator then raises the
finger, and if the point of the nozzle is not too
tightly pressed against the mucous membrane, the
fluid will flow into the nostril. What becomes of it
then depends upon one thing, and one thing only. If
the mouth is kept widely open, and the patient goes on
breathing, the fluid will flow out of the other nostril ;
if the mouth is kept closed, the fluid will find its way
into the oesophagus, the ear, or the larynx, giving rise
to efiects which are always disagreeable, sometimes
alarming, and, in the case of the ear, occasionally
very serious. The instruction to keep the mouth open
* That sold as Dr. Woakes' Irrigator is also very good.

COLDS, COUGHS, AND SORE THROATS. 5

should, therefore, always be dwelt upon. If the fluid
does not flow out of the douche at all, the nozzle
must be withdrawn slightly.

With regard to the fluid to be used, St. Clair
Thomson insists upon the importance of the following
three points : The solution should be warm— that is,
not below 100° Fahr. ; it should be alkaline by
reaction, and should be isotonic with the blood plasma.
If it is of lower specific gravity than the plasma,
there will be painful ex osmosis from the pituitary
surface; if of higher specific gravity, there will be
equally painful endosmosis. In either case the patient
will complain of disagreeable and occasionally even of
agonizing drawing sensations in the nose. Of prepara-
tions which fulfil these conditions, the most elegant
and agreeable is that which is sold under the name of
Glyco-Thymoline, whose active principle is a salicylate.
It has, however, the demerit of being rather ex-
pensive. A good substitute is the following :

R. Sodii bicarb. \ ,

Sodii biborat. j

Sodii benzoat. gr. \

Encalyptol ^^

Menthol S^- ^

Aqnam ... ... ... ... ad 5i.

Solve et misce. Sig. : To be used frequently.

The following is also agreeable and efficacious i

Hazeline tnxx.

Borax gr. v.

Glycerine "iv.

Water m. to Si.

6 MINOR MALADIES.

These solutions should also be used as gargles, so
that the infective material may be flushed as rapidly
£is possible from all accessible parts of the upper air-
passages.

By no means the least of the merits of this method
of dealing with a nasal catarrh is, that should the
catarrh be the first stage of an attack of whooping-
cough, we are adopting the measures best calculated
to cut short the attack, to provide against the spread
of infection, and to prevent the occurrence of the
sequelse to which this disease owes its gravity. So
effectual, indeed, is nasal douching in the treatment of
this malady, even when delayed until the whoop is
established, that to neglect to advise, and even to
insist upon it, is in the judgment of many to under-
take a very grave and a wholly unjustifiable responsi-
bility. An excellent formula^ for this purpose, which
is substantially the same as that which used to be
known as Dobell's Solution, is :

Br. Sodii bicarb. \

Sodii biborat./ RSgr.xxx.

Listerini 5ii.

Glycerini 3vi.

Aquam ad 01.

M. Sig. : To be used frequently.

When the catarrh commences lower down in the
air-passages — e.g,, in the larynx — the local abortive
treatment is not so easy of application, ai^d is

* Annals of OjphtJialmology cmd Otology^ vol. v., No. <L

COLDS, COUGHS, AND SORE THROATS. 7

consequently not always so successful. Nevertheless,
it should always be tried and persevered with, because
its effects cannot be other than beneficial. Th**.
means to this end which I have found most successful
consist in the use of oils, such as eucalyptus, well
vaporized or atomized in a suitable apparatus, and
inhaled vigorously and frequently both through mouth
and nose.

The atomizers on the market are numerous; that
sold by Messrs. Oppenheimer under the name of
the Universal Vaporizer is convenient, efficient,
and comparatively inexpensive. The compound sold
by the same firm under the name of Neboline No. 1,
consisting of eucalyptus, menthol, and Scotch pine, is
very agreeable; it is, however, expensive. A useful
substitute is as follows :

Oil of eucalyptus

... iiixx.-xl.

Menthol

... gr. x.-3i.

Liquid paraffin

... to5ii.

Dissolve and mix.

Either ingredient may be used alone. Oil of
eucalyptus is stimulating, though less so than thymol
(of which 5 grains may be used in place of either
of the above, and dissolved by heat). Menthol is
sedative generally, but it is liable to excite lachryma-
tion in some people.

Aqueous solutions in the form of sprays may also
be used, but they are less efficacious than the
oleaginous. The following are useful formulae :

Pot. permang

... gr.i

Sodii chlorid

... gr. V.

Aquam

... ad 51

Solve et misco.

8 MINOR MALADIES

^. Sodii bicarb. I .-^ ^^

Sodii biborat. J

Acid, carbol. lev ... tn,^

Glycerini tiixx.

Aquam ad gi.

Misce. Mitte 5iv.

Sig. : Spray freely through the nostrils into the throat every

four hours, or oftener, using Bogers' No. 1 spray.

R.

Whether the solution employed be aqueous or oily,
the patient must be instructed to draw a sharp, deep
breath each time the air-bulb of the atomizer is com-
pressed. In this way the medicament will reach the
larynx and the larger tubes.

In addition to these local measures it is desirable
to increase the powers of resistance to microbic
activity — first, by sending the patient to bed, and
secondly, by freeing the primse vise. This is best
done by a mild purgative and a hot bath, or, better
still, a hot wet pack. If, in addition to the local
symptoms, there should be evidence of constitutional
disturbance, such as headache and a slight elevation
in temperature, then a single nocturnal dose of opium
is invaluable. The form which I prefer is liq. opii
sedativus, and of this at least 20 drops should be
given. In influenza, taken early enough, I regard
opium as almost specific, but even in common colds
its efiect in soothing the inflamed mucous membrane

COLDS, COUGHS, AND SORE THROA^rS. 9

and in calming the irritated nervous system is most
helpful. As a general tonic after a cold, nothing in
my experience has proved so useful as quinine ; and
when giving quinine, it is always better to prescribe
it in fluid form, and preferably as an effervescing
mixture.

Br. Qnin. sulph gr. iiss.

Acid, citric gr- x. .

Aquam ad 5ss.

M. Sig. : The A mixture.

E. Potass, bicarb gr. x.

Ammon. carb gr. iiss.

Syr. simpl 3i.

Aquam ad 5i«

M. Sig. : A tablespoonful of the A mixture to be added to two
tablespoonfuls of this mixture and taken during effervescence.

Quinine in powder is not only capricious in its
behaviour, but, as compared to a solution, it is much
more liable to upset the stomach. When dissolved
in hydrobromic acid, the drug is comparatively
tasteless.

When once the inflammatory process is in full
swing, the microbic activity is at an end. We can
no longer expect any benefit by killing the organisms ;
it is only their irritative effect upon the air-passages
that we can hope to influence. And if we wish our
interference, in a process which is by nature self-
terminating, to be really beneficial, we must not lose
sight of the time-honoured division of expectorants
into soothing and stimulating. If we stimulate the

10 MINOR MALADIES.

mucosa in the congestive period, the only effect
which we can logically expect to produce is that of
increasing the patient's sufferings ; and, similarly, if
during the stage of free secretion we soothe the
mucosa, the only reward for our activities will be a
tardy and prolonged convalescence. When, therefore,
the complaint is of rawness and a sensation of con-
striction either in the throat or behind the sternum,
when the cough is hard, and accompanied at most by
some slight mucus, when the skin is harsh and dry
and the tongue coated, the only proper treatment
consists in soothing, or, as they are very properly
called, depressing expectorants. A very old com-
bination and a very excellent one is as follows ?

Vin. antiinon.\
Vin. ipecac. /

aamx

Spts. EBther. nitrosi ...

taixx.

Liq. ammon. acetat

3ii.

Syr. liinonis

5i.

Mist, amygdal

ad5i.

M. Sig. : Every four hours, or, if the distress is great,
half the quantity every two hours.

This is a time-honoured prescription, to whose
efficacy in reheving congestion and promoting secretion
several generations of practical therapists have borne
grateful and willing testimony. There is one counter-
indication to the use of such a mixture to which it
would seem necessary to direct special attention,
and that is the existence of any valvular disease
of the heart in the patient for whom it is proposed
to prescribe it. I have known at least one fatal

COLDS, COUGHS, AND SORE THROATS. 11

result to ensue from neglect of this very obvious
precaution. Ipecacuanha and antimony, be it
remembered, are both very powerful cardiac depres-
sants, and if we are careless enough to give them
to a patient with an organ which is already labour-
ing under mechanical disadvantages, we must not
be surprised if by so doing we provide the proverbial
last straw in the heart's burden. When a com-
plication of this nature confronts the practitioner, he
must content himself with, relieving the congestion
by such means as poultices, hot packs, and purga-
tives, reserving his drug remedies for the relief of any
symptoms which may be caused by the state of the
heart. I must not be understood to imply, however,
that such means as those just indicated should be ex-
clusively reserved for cases in which valvular disease
is present. On the contrary, a purgative and a hot
wet pack are to be regarded as the very best sub-
sidiary means of combating the condition, whether the
intention be to abort an attack or to guide the
inflammation to a rapid conclusion.

When the congestion is relieved and freedom
of the secretion is established, then, and not until
then, is the time for those stimulating measures
which many people erroneously prescribe at the outset.
As a good example of an expectorant mixture of this
class, let me recall one which is as time-honoured as
that which I have just quoted ; it is as follows :

12 MINOR MALADIES.

1^. Ammon. carb gr. ▼.

Tr. camph. co ^xx.

Syr. scillae tjixxx.

Syr. tolu. 3i.

Inf. senegaB ad gi.

M. Sig. : Every four hours.

It is well to remember that squill upsets the
stomach in many cases, so that where this organ is
weak this ingredient is better omitted.

When the muco-purulent exudation is mainly
tracheal, such a mixture may fail to give the neces-
sary relief. In such cases cubebs usually acts very
promptly. It is the main ingredient in a much-
advertised remedy. Twenty grains of the powder in
a cachet three times a day is a very convenient form
for its administration.

In connection with these catarrhal conditions, of
which cough is such a prominent symptom, it will be
convenient to glance briefly at some of the other
CAUSES OF COUGH. We will leave out of consideration
those coughs for which a cause is found as soon as the
chest is examined — such, for example, as those which
arise in the lungs and pleura from phthisis, pneumonia,
pleurisy — and those which accompany tumours,
aneurisms, and other gross cardio- vascular changes.
Nor need such obvious causes as whooping-cough and
measles detain us, for it is essentially the coughs
which seem to own no relationship which give rise to
difficulty. In the presence of such a cough in a child,
it is well to remember two very potent but frequently

COLDS, COUGHS, AND SORE THROATS. 13

overlooked causes : the one is a collection of cerumen
in the ear, and the other is nasal or postnasal
obstruction. Cerumen, of course, is very liable to
collect in the ears of adults, but in them it more often
gives rise to giddiness than to cough, whereas in
childhood giddiness is seldom complained of, and
cough is common. The removal, by the simple
expedient of syringing the ears, of a troublesome
cough which has caused anxiety and annoyance to a
household for some time, is a proceeding which is
highly calculated to increase the reputation of the
man who does it and to injure the reputation of him
who neglects it.

So far as concerns nasal and postnasal obstruction,
there can be no doubt that, though the former is often
overlooked, the degree and importance of the latter are
very generally exaggerated. Where there is any ob-
struction in the nose itself to the free passage of air,
that obstruction should be removed as soon as possible
by operative measures. This is also true of gross
obstruction caused by adenoids, but it is to be
remembered that mild degrees of these vegetations
are very rapidly and very effectually removed by
pulmonary exercises, and that with the removal of the
adenoids the cough vanishes. It is well for a young
practitioner to remember that suggestions of the
tonsillotome and its congeners do not awaken in
private patients the same acquiescent indifference
which may be relied upon in those of the hospital
class, and that a reputation for a too -ready appeal to

14 MINOR MALADIES.

operative measures is one which it is prudent to
avoid. The very simple details of chest exercises or
pulmonary gymnastics should, therefore, be mastered
in order that they may be explained to parents and
intelligent nurses.^

A cough is sometimes excited by a relaxed ana
elongated uvula, and such a cause should be suspected
if the fits of coughing seem to be provoked by the
recumbent posture. A relaxed uvula seldom arises
independently; it is usually a part of a general
relaxation of the neighbouring structures, secondary
to nasal or postnasal obstruction or other cause,
and may be treated symptomatically by an astringent
gargle such as the following :

K. Alumlnis ... gr. x.

Glycerini 5i«

Inf. rosse acid ad 5L

M. Ft. garg. Sig. : To be used frequently.

Or, the parts may be painted at suitable intervals with
glycerine of tannin, or with a mixture of equal parts of
liq. ferri perchlor. and glycerine. This local treat-
ment should be supplemented by measures directed to
the removal of the cause, which is very often gouty
or rheumatic. A brisk mercurial cathartic is always
helpful.

When the uvula, in addition to being relaxed, is
also oedematous, it should be seized at the point by a -
pair of forceps, drawn into the mouth and freely
* Harry Campbell : ' Respiratory Exercises in the Treatment
of Disease ' (H. K. Lewis).

COLDS, COUGHS, AND SORE THROATS. 15

scarified with a sharp knife. Such a proceeding is
very simple, is almost painless, and the relief which
it gives is instant and complete. The occurrence of
such an oedema, however, even when it has been
successfully dealt with by the above means, should
never be lightly regarded ; for although the majority
of cases terminate favourably in a short time,
especially when the underlying cause is discovered
and treated, in a certain proportion of them the
oedema progresses downwards until the glottis is
involved. Such a complication, according to Sir
Felix Semon, may be suspected if the ordinary
redness of a relaxed throat presents a bluish tinge,
or if the element of dysphagia is out of proportion
to the amount of inflammation present. The patient
in such circumstances should be carefully watched,
and the friends warned of the possible danger. A
mixture containing TT\^xx. of liq. ferri perchlor. and
TT] X. of liq. hydrarg. perchlor. to 3 ounces of water
should be given, preceded by a brisk cathartic, and
preparations be made either for intubation of the
larynx or for the performance of tracheotomy on the
occurrence of urgent symptoms.

A cough which presents very distinctive features
is that which is associated with chronic irritation
either in the larynx or trachea. The irritation often
amounts to nothing more serious than a relaxed
and slightly catarrhal mucosa, the aftermath of a
bronchitis or an attack of influenza. The latter is
especially liable to give rise to it, but it may occur

16 MINOR MALADIES.

independently of any obvious cause, and is then
usually the result of anxiety, worry, and overwork.
It is more common in relaxing climates, and is
aggravated by dull, damp weather. Such a cough
may be more or less present throughout the day,
but it is, especially in the morning and at night,
liable to energetic exacerbations. The amount of
matter voided is very small in proportion to the
violent efforts which its expulsion seems to entail, and
consists mainly of colourless glairy mucus. During the
paroxysms the patient's face becomes congested, and
so rapid are the expulsive efforts that he is unable to
inspire. A climax is often reached by a spasm of the
diaphragm, which causes retching or even vomiting.

Having regard to these facts, it is not surprising
that such a cough is frequently mistaken for whooping-
cough, its resemblance to which is further borne out
by its obstinacy to ordinary cough- mixtures. If it is
remembered that a cough of this kind is essentially a
manifestation of debility, there should be no difficulty
in affording speedy relief. Perhaps the best remedy
of all is a complete holiday in some really bracing
climate, such as that of Margate and the other stations
on the east coast. This, however, may be out of the
question, so that it is well to consider other means.

As a measure for allaying the cough, an acid
in combination with glycerine is very useful, and
one of the best acids for the purpose is the acid
phosphor, dil., of which 25 to 30 minims should
be given to the drachm of glycerine in an ounce

COLDS, COUGHS, AND SORE THROATS. 17

of water three times a day. To such a mixture
the addition of about 2 grains of quinine and 4
minims of tr. nux vom. will be found helpful in
relieving the relaxed state of the mucosa, which
is the real cause of the trouble. Gargles are of
very little service in this condition — they are, indeed,
quite useless — but lozenges are most valuable. That
which I have found most effective is the Krameria
lozenge. It is not very unpleasant, and it certainly
helps to restore tone to the affected parts. Patients
should be warned in connection with this lozenge
that it is not meant to be sucked. It should be
allowed to remain between the teeth and the cheek,
and to dissolve slowly of its own accord, otherwise
its activities will be expended upon the oesophagus,
and the larynx remain altogether uninfluenced.
There is another warning in connection with lozenges
of all sorts of which it is well to remind patients,
namely, that they should be taken out of the mouth
if there is any immediate prospect of sleep; for
during sleep, not alone a solution of its ingredients,
but the whole lozenge, might easily find its way into
the larynx, with disastrous consequences.

If such measures fail to relieve the cough, there need
be no hesitation in adding as a temporary expedient,
say 10 minims of nepenthe to each dose of the above
mixture. Heroin (^ to | grain) is most valuable.

The coughs which arise in association with gastric,
hepatic, and intestinal derangements are to some
extent characteristic. They are generally loud, short,

18 MINOR MALADIES.

and frequent, and do not result even in the discharge
of mucus ; that is to say, they express a reflex and
not a direct irritation. Their treatment is necessarily
bound up with the discovery and efficient manage-
ment of the original cause. More often than not this
will be found to be chronic constipation ; it may turn
out to be intestinal worms, inactivity of the liver,
gastric dilatation, or some lesion even more serious ;
the important point to remember being that, apart
from aneurism, a cough which is persistent,
obtrusive, and futile, generally has its cause not
above, but below the diaphragm.

Another kind of cough which is associated with
gastric derangements is that which is typically seen
in alcoholics. In its main features this cough may
resemble closely that just described as laryngeal and
due to debility; indeed, alcoholics very frequently
have a huskiness due to relaxed vocal cords, but the
existence of the chronic poisoning is generally easy
to detect, and its detection not only prevents any
misapprehension as to cause, but points unmistakably
the right line of 'treatment.

Having mentioned Injliuenza, it seems fitting that
I should say a word or two in connection with it.
It may begin as a minor malady, but it is very apt
to become the reverse. If the illness be taken in
time, and the patient sent to bed until the tempera-
ture and other obtrusive symptoms have subsided,
the disease is easily kept within the category of
minor conditions ; but if it is allowed to obtain a

COLDS, COUGHS, AND SORE THROATS. 19

* hold ' of the patient, so as to give dangerous sequelae
an opportunity of developing, then influenza is liable
to be one of the deadliest of diseases. I know of no
condition in the presence of which I feel less hopeful
than a pneumonia which is secondary to influenza —
a complication which supervenes most frequently,
one might almost say exclusively, in cases where the
primary condition has been regarded as a passing
matter which should not interfere with the ordinary
affairs of life. The necessity for early recognition
and prompt treatment of these cases, even when slight,
is further emphasized by the fact that when they
are allowed to be * ambulatory ' the subsequent
depression is always much more pronounced and of
infinitely longer duration than when they are taken
in time and suitably treated.

It is not that there is, nowadays, any tendency either
to overlook influenza or to belittle it when present.
The difficulty is, indeed, in exactly the opposite direc-
tion, for it is quite certain that many conditions are
constantly labelled * Influenza ' which are no more due
to the Pfeiffer bacillus than they are due to the
Bacillus typhosus. Since about 1890, ' influenza ' has
become a sort of diagnostic rubbish-heap on to which
is cast every febrile state which cannot with certainty
be referred elsewhere. There is really no reason for
this, because the Pfeiffer bacillus is as characteristic as
the Klebs-Loeffler or any other whose presence is
regarded as distinctive of a certain disease, so that a
positive diagnosis of so highly infectious a condition

20 MINOR MALADIES.

should not be made without the confirmatory evidence
which the presence of the bacillus affords. It is, of
course, often exceedingly difficult to be certain as to
the exact nature of a febrile condition at first, or
even subsequent, visits, but there is no excuse for
seeking to overcome the difficulty by idly attaching a
label, which, though it may be satisfying, is wrong.
It is much better to be frank in such matters ; the
practitioner who is straightforward always commands
more confidence and greater respect than the one who
poses as omniscient.

The presence of real influenza may always be
suspected from the sudden onset of symptoms with a
high temperature. The symptoms may vary in
degree and in kind (thoy are divided into nervous,
respiratory, and gastro-intestinal), and their severity
is not often great, but when they appear suddenly —
so suddenly as to suggest a blow from an unseen hand
— then the probability is that they are influenzal
in origin. Occasionally, of course, the symptoms
themselves are overwhelming in their severity — so
overwhelming, in fact, as to convert a strong, healthy
man into a prostrate mass of aches and pains in less
than five minutes. The temperature at the onset is
often high, reaching 105° F. or over, but it may
be quite low, and even, according to some, subnormal
from the first. Typical cases in an epidemic are by no
means difficult of diagnosis, but atypical cases, especi-
ally where they are sporadic, should always be referred
to the bacteriologist before a positive opinion is given.

COLDS, COUGHS, AND SORE THROATS. 21

If the disease is seen at its onset, the patient ought
to be sent to bed at once, and kept there until the
temperature has fallen to normal and the attendant
discomforts have ceased. There is nothing which
hastens this end so much as an initial dose of opium.
I was first made acquainted with its merits about the
time of the 1890 epidemic by a note in one of the
journals by Sir Samuel Wilks, who told how, accord-
ing to his diary. Prince Napoleon had been cured by
such a dose, which had been prescribed by Corvisart.
Since that time I have appealed to it on many
occasions, and, if in a sufficiently early stage, never in
vain. It is, however, necessary to give a full dose,
say 20 to 30 minims, of liq. opii sed., if the beneficial
effect is to result. This eflect shows itself, as a rule,
in a remarkably short space of time, and consists in
the disappearance of the pains and the production of
deep and refreshing sleep. So much impressed have
I been with this line of treatment that I have learned
to regard opium almost in the light of a specific
against the Pfeiffer bacillus. That it should relieve
the pains and soothe the irritated nervous system is
not on general principles surprising, but that it should
effect its purpose so rapidly, so completely, and so
permanently, points to some action other than the
ordinary effect of the drug, and is highly suggestive of
some specific influence (see p. 52).

When the acute stage is past, quinine seems to
be the most useful drug. It appears to render the
subsequent depression loss profound and of shorter

22 MINOR MALADIES.

duration. In connection with this depression, it is
well to remember that it is often intensified by
excessive and injudicious feeding. The * keeping-up'
regime, which is so commonly prescribed during this
stage, is regarded by the anxious friends as the height
of therapeutic wisdom, but in reality it is liable to
be quite the reverse. The system is very apt to
become overloaded with efiete matters, and the
poisons have in consequence fewer opportunities for
escape. The best thing to do with such a patient is
to see that the food is simple and nutritious, contain-
ing a little meat and some alcohol in the form of
a well- matured wine, and to arrange for a complete
holiday at the seaside as soon as possible. The
locality chosen must depend, among other things,
upon the time of year and the type of the attack, but
bracing climates are as a rule strongly indicated.

The next subject to be considered is that of
SOEE THROAT. There are, of course, several kinds
of sore throat, and I wish it could be said that the
degree to which specialism in this department has
attained had been productive of any corresponding
degree of precise knowledge as to their varieties
and causation. To the plain man, where it does
not mean scarlet fever or some similar condition,
in which accompanying symptoms are present to clear
the issue, sore throat spells tonsillitis ; and with
regard to a tonsillitis, the first point to decide is
whether or not it is diphtherial. In these days of
bacteriological investigation and antitoxin treatment,

COLDS, COUGHS, AND SORE THROATS. 23

the question may not seem to present the same im-
portance as it did in the days when we were still
without such assistance. But bacteriological investi-
gation takes time, and reliable antitoxin is not always
easy to procure, so that it is well to be prepared with
a plan of campaign which leaves such luxuries out
of account.

Speaking as one who has had more than his
fair share of experience in diphtheria, I may say
that I know of no condition which, in its slighter
forms, at any rate, is more difficult of diagnosis. It
is, even now, no uncommon thing for a sore throat
which has been dismissed as a passing matter tardily
to vindicate its true character by a legacy of alarming
and even fatal paralysis. Apart altogether, there-
fore, from the question of preventing the spread of
infection — a question whose importance and urgency
cannot be too strongly insisted upon — it is essential
that we should not, if we can help it, fail to recognise
a case of diphtheria when we see it. Now, there are
two aids to diagnosis which, partly, perhaps, on
account of the luxury of the bacteriological short-
cut, seem to be falling into increasing disuse, of
which, for this reason, and as being easy of per-
formance and capable of yielding information of the
utmost value, it is well that we should remind our-
selves. The one is the state of the knee-jerks, the
other the state of the urine. It is generally known,
perhaps, that in diphtheria the knee-jerks are liable
to disappear, and that albumin is often present in

U MINOR MALADIES.

tlie urine. But it does not seem to be sufiBciently
realized that these phenomena, when they do occur,
occur early, sometimes very early, in the disease, and
that it is therefore our bounden duty to look for them
in every case of sore throat, however slight, which
presents itself to our notice.

Now, let us suppose that we have detected such a
case, and that a considerable amount of precious time
must necessarily elapse before any reliable antitoxin
can be obtained. What are we to do ? Taking the
ordinary precautions as to isolation, etc., for granted,
the first thing to do is to give the patient a mixture
containing biniodide of mercury. Before the days of
antitoxin I had learned to have so much confidence
in this drug that I came to regard the occurrence
of a case ot diphtheria with something very nearly
approaching to equanimity. The biniodide is in-
soluble in water, though freely soluble in the presence
of an excess of iodide of potassium. The following
is a convenient way of prescribing it ;

Br.

In such a mixture a double decomposition takes
place between the two salts, and the amount of result-
ing biniodide is rather less than the original amount
of perchloride, so that each ounce contains rather
less than | grain. The ordinary tablespoonful is,

Hydrarg. perchlor. ...

...

... gr.i

Potass, iodid.

...

... gr. ixx.

Glycerini

...

... 3ii.

Aquam

...

... ad Sviii.

COLDS, COUGHS, AND SORE THROATS. 25

therefore, a perfectly safe dose for an adult; and if its
effects are carefully watched, it may be frequently
repeated. The glycerine is added with the view
of causing the mixture to adhere to some extent
to the fauces, and of thus securing a local as well as
a constitutional effect. The biniodide of mercury as
a bactericide is four times as powerful as the per-
chloride, and it has no tendency, as the perchloride
has, to throw down an inert albuminate when brought
into contact with the tissues. Whether for these
reasons, or because it is especially inimical to the
Klebs-Loeffler bacillus, in the same way that nitrate
of silver is especially inimical to the gonococcus,
there can be no doubt that, antitoxin apart, Hglj is
a far more effective weapon in combating diphtheria
than any drug, inhalation, or pigment which has
ever been introduced.

In severe cases of diphtheria, whether or not
antitoxin be available, an early appeal should be made
to strychnine, preferably by subcutaneous injection.
This drug is believed to present a direct physiological
antidote to the action of the toxins, by stimulating the
very centres which the toxins tend to depress. Now,
in a bad case, the toxins are being manufactured in
large quantities, so that to be efficacious the drug
must be vigorously pushed. The ordinary dose of
tV to -^jj grain is quite useless even in the case of
children. If the effects are watched, it will be found
perfectly safe to give yV ^^ A grain four times a
day for three or four days, and those who have not

26 * MINOR MALADIES.

tried it will be surprised to find how well it is
tolerated. Strychnine is also infinitely the best drug
for the treatment of diphtheritic paralysis. It is then
best given by the mouth in combination with liq.
ferri perchlor. (vide formula on p. 29).

When we come to consider the forms of tonsillitis
other than diphtheritic, I have to confess to an
absence of settled convictions. That tonsillitis * may
be, and often is, a manifestation of true articular
rheumatism, giving rise to endocarditis and causing
valvular disease of the heart ; that it may, on the
other hand, own no such relationship, and, even after
repeated attacks, be followed by no such consequences ;
that under the name of * septic throat ' it is very
properly recognised as due to bad drainage ; that not
infrequently, especially in autumn, it seems to
become epidemic ; and that, finally, it often arises
under circumstances so ill defined that it is forced to
herd with a motley company of congeners and aliens
in that enormous pigeon-hole labelled ' Chills ' — these
and perhaps some other facts are familiar to us, but
connection and co-relation between them there is
none. Fortunately, however, the aspect of the matter
which we are considering — namely, the mere utili-
tarian one of treatment — is but little affected by our
ignorance, but before we discuss that question it is
desirable to emphasize one point in the diagnosis.

1 'Tonsillitis' and 'quinsy' are terms which are frequently
confused. Tonsillitis means an inflammation of the tonsil itself,
-^hereas quinsy signifies a peritonsiUar inilammatiou which
frequently leads to abscess formation.

COLDS, COUGHS, AND SORE THROATS. 27

There is, as I have said, nothing in the state of the
throat itself to help us to determine whether a tonsil-
litis is, or is not, of rheumatic origin, and as the settle-
ment of this question is of paramount importance to
the patient, it cannot be too strongly insisted that
a careful examination of the state of the heart should
be as much a matter of routine in a case of tonsillitis
as it is in chorea or articular rheumatism. And in
examining the heart, the feature to which particular
attention should be directed is its size. The detection
of any signs of dilatation, especially of the right
heart, is of the utmost importance, for it enables us
to deal with the condition while it is still amenable to
treatment. If we wait until a murmur has declared
itself, the time for effective interference may be
already gone. With some people the examination
of the heart is comprised in the use of the stetho-
scope ; but auscultation is in reality far less important
than percussion, and he who wishes to detect the
earliest signs of impending mischief will do well to
bear in mind that most excellent clinical rule, * Eyes
first, fingers next, ears last.*

In the matter of the treatment of a tonsillitis, the
first point of importance to be observed is the degree
of the accompanying fever. If this is slight, the fact
should give rise to a strong suspicion of the case
being diphtheritic, and steps should immediately bo
taken to settle the diagnosis by bacteriological
examination. In most illnesses a moderate elevation
of temperature means a moderate degree of anxiety.

28 MINOR MALADIES.

but sore throat provides a notable exception to this
very obvious rule, which ought always to be borne in
mind, not only because of diphtheria, but also because
some, at any rate, of the worst septic throats are often
attended by a quite insignificant amount of fever.

If the temperature is high, which in most cases
of tonsilUtis, other than diphtheritic, it usually
is, the tincture of aconite has an excellent effect.
When the thermometer registers 105° F. in a patient
in whom we need not fear a certain amount of cardiac
depression, tincture of aconite, in doses of 6 minims
every four hours, or, better still (where its effects can be
watched), in drop doses hourly for a few hours, will
bring down the temperature rapidly, and will confer a
degree of comfort on the patient which is really
remarkable. And the higher the temperature, the
greater is the confidence with which the drug may be
prescribed. If a tonsillitis is taken early enough, it is
quite possible to abort it by means of aconite alone. I
have learned, however, not to depend on aconite
alone. I find that it acts better, or, at any rate, that
its action is not impaired by the presence in the
mixture of other drugs directed against the local and
constitutional aspects of the case. For instance,
where the case is unquestionably rheumatic in origin,
apart from the salicylates, upon whose importance I
need not dwell, I have found guaiacum to be a most
trustworthy remedy, and, in spite of the inelegance of
the resulting mixture, I can fully recommend this
formula :

COLDS, COUGHS, AND SORE THROATS. 29

]^. Potass, chlorat ... ... gr. i.

Tr. aconiti niv.

Tr. guaiao. ammon 3i.

Mucilag. acacise nxx.

Aquam ad 51.

M. Sig. : Every four hours.

As soon as the temperature has fallen the aconite
should be discontinued; but the other ingredients,
the chlorate of potassium and the guaiacum, may be
persevered with for some time.

When a sore throat is neither diphtheritic nor
rheumatic, it is always safe to treat it as due to some
septic influence, and the treatment of such conditions
is one of the most satisfactory things in all thera-
peutics. The following mixture, with such slight
variations as special circumstances may suggest, con-
stitutes what the advertisements of quack medicines
describe as a sovereign remedy, one of the very few
with which I am acquainted :

c. Tr. aconiti

•••

miL-v.

Potass, chlorat.

••«

gr.v.

Liq. ferri perchlor.

...

ttixx.

Liq. hydrarg. perchlor.

...

mx.

Liq. strychninsB

...

mv.

Glycerini

...

5ii.

Aq. chlorof

...

ad 5ss.

M. Sig. : Every four hours, or, better still, half the quantity
every two hours, at any rate until the temperature falls.

As in the case of the previous mixture, the aconite
should be stopped as soon as the temperature sub-
sides, and the other ingredients continued until the
local conditions in the throat are satisfactory.

30 MINOR MALADIES.

, This prescription owes its efficacy to its antiseptic
powers. Few people seem to realize that liq. ferri
perchlor. is, when taken internally, a bactericide of the
utmost value. It was no doubt originally suggested in
sore throat because of its astringency, but this attribute
would not even partially explain its almost magical
effects in a tonsillitis of septic origin. The liq.
hydrarg. perchlor. is added with the view of account-
ing for any cocci which may escape the attention of
the iron salt, and the glycerine to enable the mixture
to remain longer in contact with the fauces than it
would otherwise do. Strychnine, in addition to being
a general tonic, appears to have an antiseptic effect
in most cases of septic sore throat, and it is, therefore,
always well to include it. Chlorate of potassium is
given more as a matter of routine than anything else.
It has a reputation in inflammatory states of the
pharynx, and if it does no good, it certainly does no
harm. Treated with an initial purgative of a few
grains of calomel, and by perseverance with this
mixture, a tonsillitis which is neither diphtheritic nor
rheumatic will yield completely in an astonishingly
short space of time.

In the matter of the taking of temperatures, not
only in cases of sore throat, but in all cases, there is
a word of warning to which I should like to direct
attention. It has been proved that the temperature
in the mouth is very materially influenced by many
comparatively insignificant conditions which are
purely local to the moiith itself. Thus hot fluids

COLDS, COUGHS, AND SORE THROATS. 31

such as tea will raise the temperature two or even
three degrees, and maintain this elevation for two
hours or more. Food of any sort will also raise the
temperature, though to a slighter degree, and cold
fluids will depress it. The moral of this is that we
should never be satisfied with a temperature which
has been taken in the mouth. This is, of course,
infinitely the most convenient place in which to take
it, especially in a person fully dressed, but we do well
to /emember that a record so obtained is very un-
reliable under all circumstances, and that it is con-
spicuously so when any portion of the buccal or
pharyngeal mucous membrane is inflamed.

There is a condition which, as it is often described
as a FEVERISH COLD, it is as well to notice here.
It is, indeed, known to fame by various names. The
scientifically-minded call it 'febricula,* those who
seek to be impressive describe it as a * chill on the
liver,' while everyone is very liable to mistake it for
influenza. It consists of a general feeling of malaise,
with pains in the back and limbs, accompanied by a
temperature which may ascend in forty-eight hours
to 102° F. or over. It may be distinguished from
influenza by its comparatively gradual onset, by the
fact that the pains, though severe, are aggravated by
movement and are always worse at night, by the
comparative absence of other symptoms, and by its
very rapid defervescence under suitable treatment.
The condition has nothing to do with cold ; it is as a
rule connected with the gouty diathesis even in young

82 MINOR MALADIES.

people, and is essentially a myalgia or 'muscular
rheumatism * distributed over a wide area.^ If it is
seen early enough — that is, before the temperature has
risen above 100° F. — a hot wet pack (vide p. 204)
will probably cut it short. The prima8 vise should be
cleared, and aspirin given in doses of 10 to 15 grains
every three hours until the symptoms subside. In
people who are otherwise healthy I have often
known a single dose of 20 grains of aspirin to remove
all symptoms in a few hours. It is important to
recognise this condition, because the mistake of con-
fusing it, as is now so often done, with influenza
creates very unnecessary alarm in the patient's
household and amongst his friends. Moreover, the
condition being allied to goutiness, a wrong diagnosis
of influenza will almost certainly lead to a disastrous
line of after-treatment. The prostration which follows
even mild attacks of real influenza suggests a tonic
and stimulating regime, whereas the after- manage-
ment of febricula should be directed to prevent a
recurrence by combating the gouty tendency which
predisposes to the condition. The person who has
had influenza 'fourteen times in the last three
months' has probably never had influenza at all.
The attacks have been due to febricula, and their
constant recurrence has been the result of a wrong
diagnosis, and its logical outcome, mistaken treatment
In a great many of these so-called influenzal attacks
the real cause is toxaemia of gastro-intestinal origin
arising from abuse of meat foods, alcohol and tobacco,
» See Chapter IV.

COLDS, COUGHS, AND SOllE THROATS. 33

leading to high arterial tension, a question which is
discussed in the chapter on Goutiness.

Sore throats of septic origin are occasionally over-
looked. Where the invasion is severe and the con-
stitutional symptoms are consequently pronounced,
the local discomfort is apt to be lost sight of; the
patient does not mention the throat, and its condition
is therefore not investigated. The high temperature
being thus the only objective sign, the case is liable
to be regarded as one of typhoid, a watching policy
is pursued, and no improvement results. It is there-
fore a good rule to examine the throat carefully in
every case where a high temperature is not due to
some obvious cause.

In cases where there is reason to suspect typhoid,
there is one simple diagnostic point which, when
present, is very helpful. It is that in this disease,
though the temperature is usually very high, the
pulse may be low, the one registering, say, 104*° F. and
the other from 70 to 80. In cases of undoubted
typhoid a rapid pulse ia of evil prognostic omea

A CONSTANT SUCCESSION OF COLDS occurring in
the same person should never be lightly regarded.
The recent impetus which has been given to the study
of tuberculosis has resulted in the bringing to light of
various signs and symptoms which indicate a condi-
tion of what is called pretuberculosis — a condition,
that is, in which, although there may be nothing

which permits of a positive diagnosis, there arenever-

3

34 MINOR MALADIES.

theless indications of suflScient importance to warrant
grave suspicion. The lime has now gone by when,
before commencing treatment, we used to wait in
prayerful patience until there was an involvement of
the pulmonary area so definite as to be accessible to
ordinary percussion and auscultation. We now
realize that to wait for the classical signs of phthisis
is to allow the period to slip by in which treatment is
most likely to be effective. Phthisis is, no doubt,
under favourable circumstances, a very curable
disease ; but the condition precedent to its ready
curability is its detection in its earliest — that is, its
pretuberculous — stage.

The stigmata which may be said to reveal the exist-
ence of this stage are, like a constant succession of
colds, for the most part, individually so unimportant
that they are properly regarded as minor conditions ;
it is only the association of several or many of them
which confers upon them their gravity. They would
seem, therefore, to deserve more than a passing
notice.

In common with all other toxic agents, the poison
of tubercle has certain physiological effects. Of
these, one of the most important and far-reaching
is its relaxing effect upon the peripheral vessels.
When it is borne in mind that the tuberculous toxin
is initially above all things a powerful vaso-dilator, it
becomes comparatively easy to understand and recall
many of the phenomena of pretuberculosis which
otherwise seem disjointed and obscure.

COLDS, COUGHS, AND SORE THROATS. 35

Directly consequent upon this vaso-dilation is the
important symptom of tachycardia. What is true of
most of the other symptoms to which, in this connec-
tion, reference will be made is very conspicuously true
of tachycardia — namely, that it is by no means always
present. In cases of demonstrable tuberculous lesions it
is, of course, a prominent and constant symptom, but
in the very earliest stages there are frequently no signs
of hoart-hurry. Nevertheless, an unduly rapid pulse in
an otherwise seemingly healthy person should always
suggest tuberculous infection as its cause. A grave
error is often committed in attributing such a tachy-
cardia in young men to excessive tobacco-smoking.

Another symptom which is directly due to the vaso-
dilation caused by the poison is albuminuria. A
good deal of very unnecessary, and, I may add,
scarcely justifiable, alarm is occasioned to patients and
their friends by the unduly narrow view which is
commonly taken of the significance of this symptom ;
for albuminuria, it seems necessary to insist, is a
symptom, and nothing more than a symptom; and it
is as absurd to regard it as synonymous with kidney
disease as it would be ridiculous to consider epistaxis
as synonymous with typhoid fever. Albumin will
appear in the urine if the kidneys are in any degree
passively congested. A widespread vaso-dilation will
readily cause this passive congestion, especially if the
patient be going about in the ordinary way — if, that
is, he is for the most part in the erect posture. This

36 MINOR MALADIES.

is a phenomenon with which we are all familiar in
the cyclical or postural albuminuria of adolescents, a
condition which has been attributed to many causes,
and has in numberless instances been made the occa-
sion of solemn head- shakings, but which is in reality
due simply to a want of tone in the muscular coats of
the peripheral vessels, giving rise to passive conges-
tion in the renal area. Owing to the vaao-dilative
effect of the poison, this passive congestion is very
liable to occur in early tuberculosis. It is not, of
course, suggested that all those who present the
phenomenon of cyclical or postural albuminuria are
necessarily pretuberculous, but I am distinctly of
opinion that the discovery of albumin in the urine of
an adolescent, which has not been voided immediately
after exercise, is a sign which should lead to a very
minute examination for other evidences of tuberculous
invasion. Collier of Oxford and others have con-
clusively shown that albumin in the urine of young
men soon after exercise is not only without morbid
significance, but that it may even be regarded as a
normal sequence of severe muscular exertion.

Another symptom of early tuberculosis in the causa-
tion of which vaso-dilation may reasonably be con-
sidered to bear some part is dyspepsia. Dyspepsia,
especially of the asthenic type, is due to a faulty
adjustment between the blood-pressures in the local
areas. A widespread vaso-dilation disturbs the
normal balance, and tends to deprive the gastric

COLDS, COUGHS, AND SORE THROATS. 37

area of that increment of blood which for the pur-
poses of the digestive process is essential to it. The
dyspeptic symptoms which so commonly forerun the
ebullition of definite tuberculosis, more especially of
the lung, are thus easy to understand. The difficulty
consists in the fact that we are so liable to forget
their true significance. Such a dyspepsia may be
accompanied either by diarrhoea or constipation, but
in the earliest stages constipation is much the more
common of the two.

Two other signs, which may be included under the
head of results of vaso-dilation — namely, mental
hebetude and muscular debility — are, of course, by no
means peculiar to tuberculosis; but, like others, their
presence — especially their continued presence — in
young people, without obvious cause, goes to swell
the number of points upon which a superstructure of
reasonable suspicion may be erected. The majority of
lethargic children who are punished for indolence at
school, when they are not the subjects of eyestrain or
nasal obstruction, owe their lack of energy and want
of comprehension to the relaxing effects of the tuber-
culous toxin; and a large number of adults who are
idly labelled * neurasthenic ' undoubtedly owe their
nervous exhaustion to the early inroads of the
bacillus.

Among the many causes which give rise to suppres-
eion of the menses the action of the poison of tubercle
should not be forgotten. This is another symptom

38 MINOR MALADIES.

which is duo directly to its vaso- dilative power.
Menstruation is effected by the dilation of the pelvic
vessels coincidently with a contraction of the other
systemic arteries. If the contraction of these arteries
is prevented, as by nitrite of amyl or trinitrine, the
menstrual flow does not appear. The poison of
tubercle acts in the same way, though less power-
fully, and hence it is that amenorrhcea is so common
a precursor of obvious tuberculous mischief.

The second physiological effect of the tuberculous
toxin under which, in our efforts to generalize, we
may group some of the phenomena of the very early
stages, is irritation of the nervous system. The most
important member of this group is certainly pyrexia.
The fever of tuberculosis is one of the most interesting
features of this complex disease. It is, as a rule,
slight, sometimes so slight as to escape the notice of
all but the most meticulous observer, and, although
it is almost invariably present, it is usually only at
night that it is to be detected. By no means infre-
quently it follows in the wake of a pyrexia due to
some obvious and well-recognized cause, and seeks, as
it were, to conceal its real significance by masquerad-
ing as a continuance of this initial complaint. But
perhaps the most characteristic feature about the
fever of tubercle is its persistence. We have all been
taught to suspect the operations of the bacillus
typhosus in a case where malaise and a temperature
represent the only departures from the normal. It

COLDS, COUGHS, AND SORE THROATS. 39

does not reduce the value of such advice to recall the
saying of the late Dr. Moxon, of Guy's Hospital, to
the effect that if a candidate at an examination failed
to include tubercle among the causes of continued
fever, he always referred him to his studies. Among
the many negations and ambiguities of this evasive
and protean disease we have, then, this positive and
unequivocal sign to aid us : that fever, whether it be
of the intermittent, remittent, or hectic type, especi-
ally if the rise be slight and present only in the after-
noon between the hours of 2 p.m. and 6 p.m., which
persists beyond the allotted span of recognisable
fevers, is in all human probability tuberculous in
origin.

It is, however, necessary to remember that a tem-
perature of 99° F. to 99'6° F. is not uncommon from
2 to 8 p.m. for three or four days before a perfectly
normal menstrual period. Moreover, Kingston Fowler
says that the only form of pyrexia which can be
regarded as pathognomonic of tubercle is that in
which the morning temperature is higher than the
evening reading. A subnormal temperature when
persistent and most pronounced in the evening is
generally due to thyroid insufficiency.

To an undue irritability of the nervous system we
may, I presume, attribute the psychical charac-
teristics of most pre tuberculous persons. The
sufferers from gross lesions are notoriously, unduly,
and even pathetically optimistic in their mental out-

40 MINOR MALADIES.

look, but such is seldom the attitude of the pre-
tuberculous. The atmosphere surrounding the latter
can only be described by the French word difficile.
It is not that they are necessarily aggressive, though
they sometimes are, but they present a conspicuous
absence of what Matthew Arnold used to describe as
* sweet reasonableness.' They are passive resisters to
any suggestions for their welfare, and they are apt to
try the tact and patience of the physician more
severely and more obstinately even than people who
are definitely insane. A change of manner and dis-
position in this rather indefinite direction, more
especially when associated with other signs, consti-
tutes confirmatory evidence of very anxious omen.

Very considerable importance is attached in France
to a sign of pretuberculosis, which is presumably the
direct outcome of irritation of the nervous system, of
which in this country we hear very little — namely, an
exalted sexual appetite. The toxin of tubercle would
seem, especially in young men, to exercise a very
decided aphrodisiac influence, and our French friends
contend that in the many cases in which the disease
appears to supervene as a fitting nemesis upon a
licentious adolescence, the real truth lies in the fact
that when the unfortunate patient embarked upon
his immoral career he was already the subject of
tuberculous invasion — that it was, in fact, the action
of the toxin which impelled him to the unbridled
gratification of his passions. This view of the matter

COLDS, COUGHS, AND SORE THROATS. 41

is well worthy of serious consideration among people
like ourselves, in whom an unduly literal interpreta-
tion of the Old Testament teaching has begotten a
belief in the direct intervention of Providence for the
immediate physical punishment of moral transgres-
sion.

Trousseau was the originator of the saying, which
has been attributed to many physicians since his
time, that an ancemia which does not yield to iron is
probably due to tubercle. It would be difficult to
overestimate the value of the practical lesson which
this saying is intended to convey. The form of
anaemia to which it refers is, of course, a general
anaemia : in young girls we should call it chlorosis*
An examination of the blood reveals nothing which
serves to distinguish it from chlorosis, but it is of
paramount importance that it should be so dis-
tinguished, and that as soon as possible. There is
also a local anaemia, which, as being more common, is
of even greater importance than this general anaemia,
and of which, in our search for the stigmata of pre-
tuberculosis, we do well to remind ourselves. This is
the anaemia of the soft palate with which throat
specialists are familiar in all cases of laryngeal tuber-
culosis. Now, this is a symptom which frequently
occurs quite independently of a general anaemia, and
independently also of definite laryngeal tuberculosis ;
it is, in fact, a valuable sign of pretuberculosis, and
one which from its ease of recognition should always

42 MINOR MALADIES.

be looked for. It seems hardly necessary to point out
that in the other two classical chronic diseases —
namely, gout and syphilis — the soft palate, instead of
being ischaemic and insensitive, is almost invariably
injected and irritable. The pretuberculous throat
supports a laryngeal mirror with equanimity ; the
gouty or syphilitic throat will often refuse to tolerate
it Until cocaine has been liberally applied.

In connection v/itli the throat there is another
matter to which it seems pertinent here to refer, and
that is the significance of functional aphcmia. This
is commonly and very authoritatively described as
one of the stigmata of hysteria, but it is now being
invested with a fresh importance, inasmuch as it is
confidently regarded as one of the very earliest
manifestations of pretuberculosis. I have no experi-
ence which enables me to confirm this view, but the
quarter from which it emanates entitles it to every
respect and consideration.^

Among the symptoms of pretuberculosis the exact
meaning of which still await explanation the occur-
rence of dyspnoea is probably the most important
The dyspncea of the fully-developed or active pul-
monary lesion requires, of course, no explanation ;

* Soon after the above was first published {Polyclinic,^
October, 1907), Dr. Fleming Browne wrote to tell me of a
patient, now definitely phthisical, whom he had first seen six
months previously with complete aphonia. The throat specialist
who was consulted assured him that it was purely functional.
The voice soon returned, and this was followed at a short
interval by the development of demonstrable phthi:.4s.

COI.DS, COUGHS, AND SORE THROATS. 43

but it should be remembered that breathlessness due
to a tuberculous cause is by no means confined to the
later stages of the disease, nor is it even a special
attribute of pulmonary invasion. There is a dyspnoea
which is apt to appear in the very earliest stages of
tubercle, and it is just as likely to herald abdominal
or intracranial mischief as the more classical phthisis.
There is nothing characteristic about it except that
the most careful examination of the heart and lungs
fails to afford any explanation of its meaning. It is
to be distinguished from the dyspnoea of slight effort,
which is so suggestive of functional high arterial
tension,^ only by the observation of concomitant
signs. In tuberculosis there will probably be present
some of the other stigmata with which this section
deals, and the patient will generally be young. In
the arterial condition there will be the accentuated
second sound at the aortic base, and the patient will
generally be at least middle-aged. There is also the
sphygmomanometer to aid us; for whereas high
blood-pressure from vaso-constriction is the essence
of the one condition, low blood-pressure from vaso-
dilation is characteristic of tubercle, even in its
earliest stages. It has been well said that a per-
sistent dyspnoea which cannot positively be assigned
to a definite cause is almost certainly tubercu-
lous.

» See p. 220.

44 MINOR MALADIES.

In weighing the evidence for and against tho
presence of tuberculosis in any particular case, the
importance of the condition of the bronchial glands
cannot be overestimated. They constitute the first
line of defence where the primary infection comes by
way of the air-passages, so that they tend to show a
very early reaction to any disturbing influence. It is
unfortunately impossible to examine these glands
during life, and they may therefore attain to a
considerable size before they hoist signals of distress.
There are, nevertheless, two signs for which it is our
duty to search whenever there is any suggestion of
tuberculous involvement. One of these is slight
paresis of a vocal cord. Generally, but not in-
variably, it is the left cord which is thus affected,
for the same reason that it is affected in aneurism —
namely, on account of the anatomical disposition of
the left recurrent laryngeal nerve. In a few cases,
however, it is, for some unexplained reason, the right
cord alone which is affected. The other symptom is
also associated in our minds with aneurism, and is
doubtless due to pressure upon the sympathetic —
namely, inequality of the pupils. This sign, like
many of the others which we have been considering,
can only be regarded as tending to confirm a suspicion
otherwise aroused, more especially as it is undoubtedly
present in many people who are perfectly healthy.

A history of a constant succession of colds, to which
reference has already been made, is very suggestive of

COLDS, COUGHS, AND SORE THROATS. 45

early tuberculosis. This fact is now very generally
accepted, but it is unfortunately as generally mis-
interpreted. It does not mean, as is commonly sup-
posed, that the person is originally or hereditarily
unusually susceptible to the influence of the bacillus,
but it indicates that the patient is living in unwhole-
some surroundings, which depress his vitality and
render him a ready prey to microbic invasion. Such
are the people who wear flannel next their skins ; who
in fine weather make a virtue of sleeping with the
window ' a little bit open at the top '; who know that
they are in a * draught * because it makes them
sneeze — who, in short, live thoroughly unwholesome,
coddling lives, and thus cultivate within themselves
an atmosphere, both physical and moral, in which the
bacillus flourishes and multiplies exceedingly. A
constant succession of colds, therefore, has this degree
of pretuberculous importance — that it implies a mode
of life in which all aerial microbes are afforded abun-
dant opportunities, with the result that the soil is
suitably prepared for the reception of the bacillus of
tubercle whenever the latter should think fit to
advance. To * live cleanly/ so far as the air-passages
are concerned, is not only to avoid tubercle, but to
avoid also the constant catarrhal attacks which are
ignorantly attributed to draughts and chills.

It has now been taught for some years that pleurisy
is a tuberculous manifestation. I should be very
sorry indeed to think that all pleurisies were of that

46 MINOR MALADIES.

nature, and I am quite convinced that it is not so.
It is nevertheless right that we should regard a
person who has had a definite pleural effusion with a
certain amount of anxiety. There is, however, one
form of pleural effusion which is to be regarded with
very special anxiety, and that is the form which
comes on without pain, fever, cough, or any of the
other signs which usually proclaim the onset. The
patient feels unwell rather than positively ill ; his
only complaint is dyspnoea ; but when his chest is
examined, one pleura is found to be full of fluid.
This stealthy form of pleural effusion may follow
some definite pulmonary disease, or it may occur
independently of any previous illness. It is perhaps
rare, but when it does occur, it almost invariably
connotes tuberculosis. When we do meet with it,
therefore, we do well to treat it with all the circum-
spection which its true inwardness demands.

When suspicions have once been aroused, it is, of
course, our duty to institute a minute search for any-
thing by which they may be confirmed. The lungs
should be examined for weak breathing, especially at
the bases ; for harsh or cog-wheel breathing, especially
at the apices ; and the possible presence of enlarged
lymphatic glands, more especially in the neck and
axillaB, should engage our attention. The details of
these matters are carefully reviewed in most of the
text- books, so that they need not be considered
here.

COLDS, COUGHS, AND SORE THROATS. 47

An accessory diagnostic aid which has the double
merit of helpfulness and ease of application is the
ulnar reflex} The patient's forearm is bared and the
arm placed in the flexed position, with all the muscles,
especially those of the fingers, fully relaxed. If a pin
be now sharply drawn along the whole length of the
ulnar side of the forearm from elbow to wrist, in most
tuberculous cases the abductor minimi digiti will
contract, and cause a distinct reflex wrinkling of the
hypothenar eminence. This response of the abductor
minimi digiti, while it cannot be called pathogno-
monic of tuberculosis, may nevertheless be regarded
as confirmatory evidence of the strongest description.
It is very seldom present in conditions other than
tuberculosis, but is by no means always present in
cases which are undoubtedly tuberculous. The re-
sponse has seemed to me to be more readily elicited
in those accustomed to use the small muscles of the
hand, and very difficult to obtain in those who are
engaged chiefly in coarse employment. Like many
other valuable signs, there is doubtless a certain
degree of ambiguity in connection with it. When it
speaks, within certain limits it speaks true ; but when
it does not speak, we must not allow ourselves to be
lulled by its silence into any false sense of security.

When all the clinical methods have been exhausted
we can, when still in doubt, carry our appeal into
other, though not necessarily higher, courts. It is

^ Phipps Institute, second Annual Report. Dr. J. J. Gal-
braith (Fractitioner^ June, 1907).

48 MINOR MALADIES.

scarcely necessary to mention an examination of the
sputum for the presence of bacilli, because the
importance of such a procedure, if overlooked by the
medical man, is sure to be remembered by the patient
or one of his friends. At the stage which we are now
considering, however, it is only right to say that such
an examination would almost certainly prove negative.

A laboratory method which is more likely to give
positive information is that of estimating the opsonic
index. It is, of course, by no means always possible
to avail ourselves of the great advantage of this means
of diagnosis, but where it is possible it should always
be resorted to.

There remain two methods to be considered, the
one of which comes to us from Germany and the
other from France. The first is von Pirquet's * cuti-
reaction,' which is obtained by vaccinating the skin
with a 1 per cent, solution of tubercuHn. In a healthy
person this produces no effect, but in the tuberculous,
the vaccinated area becomes red, swollen, and occa-
sionally pustulous, within twenty-four hours, return-
ing to normal again in from five to ten days. This
method is very valuable in children under ten years
of age. In adults it is apt to be misleading, for the
reason that in the majority of persons over ten years
of age a more or less positive reaction is said to
ensue. The second is the plan advocated by Pro-
fessor Calmette, of Lille. A drop of a 1 per cent.
solution of dried tuberculin is placed in the patient's

COLDS, COUGHS, AND SORE THROATS. 49

eye. In a healthy person no reaction ensues, but in
the tuberculous there follows the *ophthalmo-reaction'
— that is, an acute catarrhal conjunctivitis. The
objection to this method is that the conjunctivitis is
apt to be so acute as to endanger the eye itself. Very
serious results have been reported in several cases.

ADDITIONAL FORMULA
Nasal Washes.

Lotions intended for cleansing the nose may be used
as simple hand-washes, or placed in a nasal douche,
irrigator, or spray. The nasal douche of any
apparatus on the siphon principle is to be avoided,
the great and continuous pressure exerted rendering
its use dangerous. A very simple method is to
sniff the lotion from the palm of the hand or from a
shallow cup or bowl up through the nose, letting it
pass well into the throat and returning it through
the mouth. This should be practised before rather
than after meals, as it may excite retching or even
vomiting. About an ounce and a half of solution
should be used at each time, and it should be
employed comfortably warm (about 100° F.). The
use of a nasal irrigator should, however, where
possible, always be substituted for the above.

A spray may also be used, but it is not nearly so
effective as a douche. An instrument giving as
coarse a spray as possible should be chosen.

4

50 MINOR MALADIES.

The following formulae have stood the test of time }

1^, Sodii bicarb. ...

Sodii biborat. ...

Acid. carboL ...

Sacch. alb

Aquam

M. et solve. Detergent.

^. Tr. benzoin, co.

Sodii biborat

Sacoh. alb

Aquam

M. Sedative.

Seiglo^s steam spray producer is a very useful
apparatus when a warm spray is preferred. Used
in this apparatus, the following was a favourite
combination of the late Mr. Arthur Durham's in the
treatment of * hospital throats ' :

9.

gr. iii.

gr. iil

gr.i.

gr. V.

ad5i.

ITlV.

gr. V.

gr. V.

adSi.

Boracis

... 3i8s.

Acid, boric

... gr. xl.

Tr. iodi

... 3ss.

Liq. morph. hydrochl.

... 51.

Glycerine

... 5i.

Aquam

... adgviii.

M.

This may be used for ten minutes every hour,
and will be found very soothing.

Gargles.

About half a fluid ounce should be taken in the
mouth for each act of gargling, and this should be

' See Pharmacopoeia of the Hospital for Diseases of the Throat.

COLDS, COUGHS, AND SORE THROATS. 51

repeated four times on each occasion. Gargles should
be used about every four hours.

9. Potas. chlorat gr. xii.

Sodii bicarb gr. vi.

Potas. bicarb gr* vi.

Aquam ad 5i.

M. Ft. garg. Detergent and sedative.

]^. Eesorcin gr. x.

Aquam ad 5i<

M. Ft. garg. Antiseptic

The following is a useful snuff :

Br. Menthol gr. viii

lodol gr. Ixxx.

Acid, boric gr. co.

Sacch. alb ^.

M. Sig. : To be used as a snu£^

Cough Mixtures.

To allay Tickling Cough,

^. Tr. camph. co 5ii.

Oxymel scillss ^u.

Syr. tolu. 311.

Glycerin. 3ii.

M. Dose : 1 drachm.

B^. Heroin gr. i.

Acid, hydrocyanic, dil. itlxxx,

Oxymel scillae 3ii.

Syr. limonis 5ii.

Aquam - ad 51.

Dose : 1 teaspoonful.
An exceptionally agreeable mixture is that sold by
Ferris and Company of Bristol under the name of
syr. poctoralis rub.

52 MINOR MALADIES.

A useful lozenge is :

^ Menthol gr. |

Pulv. glycyrrhiz8B gr. ii.

M. Ft. ' nigroid.'

Influenza.

Dr. J. C. Boss, of Manchester, writing In the Lancet
(November 8, 1906), speaks in the highest terms of the effect
of the oil of Ceylon cinnamon bark in the treatment of this con-
dition. The earher the treatment is commenced, the more
satisfactory are the results ; but, however late in the disease the
oil is administered, it never fails to do good. It allays the sub-
jective sensations, rapidly reduces the fever, and prevents
sequelae. Twelve drops of the oil in a wineglassful of water are
given immediately, and the dose is repeated in an hour. Two
hours after the second dose 10 drops are administered, and then
10 drops every two hours until the temperature falls to normal.
After this 10 drops are given three times a day for three days.
Other writers appear to have had equally favourable results
from this line of treatment, which seems well worth a triaL

Chronic Bronchitis.

In the treatment of the chronic winter cough of the aged,
attended by copious expectoration, Sir Eichard Douglas Powell *
recommends the following :

9- Liq. picis aromat. (Bell) ... 3ii

Glycerini ... ... ... 5iv.

Ext. liq. glycyrrhizee... ... 5iss.

Spts. ammon. aromat. ... 5iv. to 3vi

Tr. cardam. co. ... ... 5iv. to 3vi.

Aq. chloroform. ... ... ad S^ili*

M. Sig. : A sixth part thrice daily.

* ' Senile Bespiratory Disorders,' The Hospital^ December 7,
1907.

CHAPTER IL
INDIGESTION.

I INTEND in this chapter to confine myself to the
consideration of those forms of dyspepsia which are
not of organic origin. The dyspepsias which arise in
association with cancer, with ulcer, with hepatic and
renal cirrhosis, with pulmonary tuberculosis, and
other forms of structural disease, are exhaustively
considered in the text-books, whereas the purely
functional dyspepsias — the dyspepsias, that is, whose
symptoms are due to such faults as those of secretion
and motihty — though far more frequently encountered
in daily practice, are not so considered. These cases
occur in people who are for the most part otherwise
healthy, who are impatient of the disabilities and dis-
comforts which the malady imposes upon them, and
who are impatient also of anything short of prompt
and complete rehef. Their successful treatment is,
therefore, a matter of considerable importance.

To this end our first care must be to learn to
classify them properly. In view of the multiplicity
of qualifying and would-be distinctive adjectives

Yfh'ich are generally found in connection with the

6a

64 MINOR MALADIES.

term * dyspepsia,' this would not at first seem to
be a simple matter. In quite a recent text-book
the varieties of gastric indigestion are given as
follows : atonic, gouty, renal, irritative, flatulent,
and acid ; and reference to other text-books would in
all probability reveal several more. But, in that they
suggest essential distinctions, these terms are in
reality misleading. It is better, therefore, to discard
them altogether and to classify functional dyspepsias
under two heads only — the sthenic and the asthenic.
These two present distinct and definite clinical types,
with different pathology, different symptomatology,
and very different treatment. All else is chaff and
dust, which let the wind blow whither it listeth.

But before we proceed to the details of this
classification, it is necessary to consider briefly the
main facts of gastric digestion in the light of the
researches of Pawlow and others, which have recently
been admirably crystallized in a short paper by
Dr. Langdon Brown.^

We know that the masticated and insalivated food
passes from the mouth along the oesophagus into the
stomach, where it is acted upon by pepsin and HCl,
and the arresting feature in connection with the
above-mentioned researches is the prominent part
which, in their light, must henceforth be assigned
to the action of HCl. It used formerly to be
believed that pepsin was the predominant partner

* * On the national Treatment of Gastric Disorders,' Practi-
tioner, October, 1904.

INDIGESTION. 65

in this association; it is now recognised that HCl
is of infinitely more importance. The presence of
the acid is essential to the activity of the ferment,
and if HCl is not present in sufficient degree, no
conversion of the food can possibly take place. The
mass becomes a mere mechanical irritant to the
mucosa, and excites only the outpouring of alkaline
mucus. This in its turn surrounds the mass and
renders its permeation by the digestive fluids still
more difficult. But this is not all HCl, which is
thus seen to be necessary to gastric digestion, is by
the above-mentioned researches shown to be necessary
also to pancreatic digestion. * Bayliss and Starling
have shown that the hydrochloric acid of gastric
juice acts on the prosecretin stored in the intestinal
mucosa to form secretin, a specific stimulant to the
flow of pancreatic juice. . . . Therefore, if there is
not a due secretion of acid, pancreatic digestion is
impossible.*

Now, we know that the functions of the pancreas
include the digestion of fats and the elaboration of
such of the carbohydrates as have escaped digestion
by the saliva, so that it is evident that the absence of
a proper quantity of HCl in the gastric process entails
serious effects not only upon the digestion of proteids,
but upon the digestion of all the proximate principles
of food, proteids, carbohydrates, and fats. It is
therefore impossible to overestimate the importance
of the presence in full force of this constituent of the
gastric juice.

56 MINOR MALADIES.

Let us now look at the other side of the picture,
and consider for a moment what happens when the
hydrochloric acid, instead of being deficient, is ex-
cessive in quantity — a state of matters which, as we
shall see presently, may be the result of various
causes. In the normal person no more gastric juice
is secreted at any individual meal than is necessary
to the digestion of that meal, so that in a certain
time after the meal is finished the secretion slows off
and eventually ceases.^ If the stomach supplies too
much juice, or if the supply is continued beyond the
limits of the digestive requirement, the food-mass
becomes too acid to be allowed into the duodenum.
The pyloric sphincter therefore contracts and pre-
vents the passage of the food out of the stomach
until the bile and pancreatic juices are present in
quantities sufficient to neutralize its acidity. This
may take some hours, and the gastric mucosa and
nerve-endings are, during the interval, subjected to
continual irritation, which varies, of course, in degree,
according to the amount of acid present in excess.

Now, it is possible to bring all cases of functional
dyspepsia under these two heads — those in which
hydrochloric acid is deficient and those in which it is
excessive. And, first, it is necessary to remember
that the causa causans of the dyspepsia is the same
in both — that is, the retention of food in the stomach
long after that viscus ought to have finished with it.
In both cases the mass becomes a species of foreign
* Vide Starling, Crooniaa Lectures, 1905.

INDIGESTION. 57

body, giving rise directly to pain, the outpouring of
mucus, and the development of flatulence ; and indi-
rectly to languor, sleeplessness, and irritability of
temper. These symptoms, then, are common to both
classes, and indicate merely that we have a dyspepsia
to deal with. They are liable to be present in any
and every case of indigestion, and consequently they
afford no assistance in classification.

As bearing on this fact, it is well to remember that
there is a line of treatment which, in so far as it is
successful at all, is equally successful in both. This
is the practice of giving alkalies before meals. Alka-
lies were originally given before meals on the sup-
position that they excited the flow of hydrochloric
acid and pepsin in the stomach. As the practice
gave relief to a very large number of dyspeptics, the
supposition was held to be correct until the researches
already referred to conclusively proved that, so far
from promoting the flow of gastric juice, the alkalies
very materially retard it.

How, then, are we to explain the benefits which
have admittedly followed the practice of prescribing
alkalies in all forms of dyspepsia? In the light of
what we have already seen as to the mechanism
of dyspepsia, the explanation is not very far to seek.
The mass which tarries in the stomach (whether
the tarrying be the result of too little hydro-
chloric acid or of too much) sets up an irritation,
which in its turn provokes the outpouring of mucus
and the development of flatulence, the evil efiects of

58 MINOR MALADIES.

which are still present when the time for the next
meal has arrived. If, however, just before that meal
is taken — say half an hour before — wo put into the
stomach a draught of water containing an alkali, we
are applying lavage to that stomach — we are washing
it out with a solution which is of all others the best
calculated to remove the sticky mucus which is
adhering to its walls and occluding the mouths of
the secreting glands.

Herein, then, resides the efficacy of the practice of
giving alkalies before meals — the organ is relieved
not only of the mucus, but also of the undigested
residue of the last meal, and is thereby cleansed and
prepared for the reception of the next. And, as 1
have said, it matters nothing in this connection which
form of dyspepsia we are dealing with, for in both
there are undesirable matters to be removed, and in
the treatment of both, a clean stomach for each meal
is a great desideratum.

One practical point emerges from these considera-
tions, namely, that if our desire is to wash out the
stomach, we should see to it that the fluid is not
stinted. The alkali — say 10 grains of sodium
bicarbonate — should therefore be dissolved in, or
immediately followed by, a full half-pint of water,
preferably hot.

In one other respect, and in one other only, is it
unnecessary, from the point of view of treatment, to
distinguish between the two forms of dyspepsia — I
mean the freeing of the primao viae. Above aU

INDIGESTION. 59

things, let the state of the bowels engage the most
serious attention. The presence of constipation will
obscure every issue and nullify every therapeutic
effort. The best initial measure is undoubtedly a
dose of calomel. This drug is not only a purgative,
but it is also the very best of all intestinal antiseptics.
Further, the excretory function of the skin should not
be despised. It is too large a question to be discussed
here, but there are many facts which point to the
conclusion that some of the more obscure phenomena
of indigestion are to be explained by assuming that
defective cutaneous activity reacts in a special
manner upon the gastric secretions. Be this as it
may, a hot bath or a hot wet pack at the onset of
treatment will often make all the difference between
prompt and tardy relief.

Now how are we to distinguish between these
two forms of dyspepsia, the sthenic and the asthenic ?
There are certain marked differences both in the
type of patient and in the nature of the symptoms
which cannot fail to strike the careful observer.
The sthenic form occurs in people who seem other-
wise to be in robust health — people who are
for the most part strong, active, and energetic,
and who are seldom teetotallers. The asthenic
form appears in weakly, nervous, convalescent, or
overworked persons who may be teetotallers, but
who are generally tea- drinkers. The one is essen-
tially an active, positive, the other a passive
negative, type ; and the distinctions between the

60 MINOR MALADIES.

symptoms are in consonance with these characteristics.
The sthenic tongue is firm and generally furred ; the
asthenic is flabby, frequently indented at the edges,
and generally clean and glazed. The sthenic pulse is
slow and full, the asthenic quick and feeble. The
sthenic appetite is voracious and ever present; the
asthenic is weak, capricious, and often absent. In
the sthenic, the discomfort consists of a sense of
epigastric fulness ; in the asthenic, it consists of
actual pain in the epigastrium striking through
between the scapulae. In the sthenic, a full meal
relieves the symptoms ; in the asthenic, it aggravates
them. In the sthenic, the mental state is one of
irritability ; in the asthenic, it is one of depression.
But perhaps the most striking, as it is certainly the
most diagnostic, distinction is presented by the period
of onset of the symptoms. This in the sthenic is
delayed until towards the end of the digestive
process — that is, from four to five hours after a full
meal ; whereas in the asthenic the discomfort, always
more or less present, becomes acute within half an
hour of the ingestion of food.

There is one symptom which is often mentioned
in connection with dyspepsias of all sorts which,
nevertheless, occurs only in the sthenic form —
namely, heartburn. It is by no means always
present, but when it is there can be no shadow of
doubt as to the class to which the case belongs. The
same may be said of pyrosis or the gushing of alkaline
fluid from the mouth. This fluid is in reality saliva

INDIGESTION. 61

of a rather higher alkalinity than normal, and its
secretion represents an effort on the part of Nature to
relieve the symptoms by introducing an alkali into
the stomach. It only occurs in very severe cases, but
when it does occur the diagnosis is no longer in
doubt.

The matter of differentiation is not, however,
always so easy as the above distinctions would seem
to indicate. It must be remembered that we are
dealing almost exclusively with subjective phenomena;
that not all patients are intelligent, and that most
dyspeptics tend to exaggerate their symptoms. , But,
fortunately, where, after due consideration, a doubt
does remain in our minds as to whether we are
dealing with a sthenic or an asthenic case, it is
speedily set at rest by the results of treatment. For,
as will be readily understood from the essential
features of the two conditions, what will relieve the
one will tend to aggravate the other. If, for example,
we give a dose of HCl to a patient suffering from
sthenic dyspepsia, we thereby increase the amount of
the offending material, and add conspicuously to his
miseries; and, similarly, if to a stomach which is
crying aloud for HCl we respond by administering
an alkali, our interference can have but one effect —
that, namely, of aggravating the existing mischief.
This refers, of course, to medicines given after meals.

As I have already pointed out, medicines given
before meals have the effect of washing out the
stomach, but they exercise no influence whatever

62 MINOR MALADIES.

either upon the secretion of gastric juice or upon the
digestion of the food itself. Effectually to treat either
form of dyspepsia, then, it is necessary to rely
absolutely upon the action of the drugs which are
introduced into the stomach after the meal is taken.

Let us now take a case of STHENIC DYSPEPSIA,
and see how it should be treated. We will assume the
patient to be a man of middle age who has at one
time been fond of athletics, but who has been obliged
by business exigencies to give them up, who is
capable, hard-working, and energetic. He complains
of epigastric discomfort after food, flatulent eructa-
tions, and mental irritability. The symptoms are not
pronounced until some time has elapsed after a meal ;
indeed, he not infrequently associates them with the
period before a meal, and may attribute them to
hunger, a theory which obtains support from the fact
that a feeling of * sinking ' in the epigastrium is often
present, and that he is always better immediately
after he has fully satisfied his rather vigorous appetite.
He dines at 7.30 p.m., and is very often awakened
between four and five in the morning with heartburn,
pyrosis, sneezing, hiccoughing, asthmatic attacks or
other troubles, which, however, rapidly subside as
soon as he is able to * disperse the wind ' of which his
stomach appears to be full.

In the daytime he is liable to suffer so much from
palpitation that he feels sure there must be something
wrong with his heart.

The first thin<? to be done with such a man is to

INDIGESTION. 63

clear his primsB vise. He should be given a dose of
calomel (remembering that those of dark complexion
bear this drug better than those who are fair) ; he
should be ordered a turkish bath, an electric light
bath, or an ordinary hot bath, and induced, if possible,
to take some daily exercise in the open air, or at least
at the open window. The unwisdom of wearing
wool or flannel^ next his skin should be explained to
him, and he should be enjoined to masticate his food
adequately. These and other warnings suggested
by the special circumstances of the case must be
emphasized, but the great, the paramount, the urgent
need in such a patient is for an antacid to be taken
either as soon as his symptoms commence, or, if
possible, immediately before their onset.

The antacid which is most popular is the bicarbonate
of sodium, but this salt is an antacid pure and simple,
and is possessed of no sedative properties. It also
has the disadvantage, especially where flatulence is
troublesome, of increasing the amount of gas in the
stomach. What is required is an antacid agent
which is free from this objection, which at the same
time is possessed of sedative properties. Such an
agent is bismuth. There have been many differences
of opinion regarding the merits of this drug, even
so great an authority as Sir William Roberts going
so far as to deny that it was an antacid at all.
Sir Lauder Brunton, Dr. Burney Yeo, and other
authorities, however, appear to esteem it very highly,
» See Chapter VII.

64 MINOR MALADIES.

and this view is supported by most of those who have
made a systematic trial of its action. The disappoint-
ments attending its use in suitable cases have been
almost certainly due to its employment in insuflficient
quantities. The ordinary B.P. doses are utterly
useless ; the minimum which I employ is : of the
subnitrate 25 grains (B.P. 5-20), and of the liq.
bismutL ammon. cit. (B.P. 30-60) 2 drachms.

It is these two preparations which I have learned
to appreciate most highly. The subnitrate may be
given either in cachet form, or suspended in a
mixture. When prescribing it as a cachet I generally
combine it with that excellent sedative, oxalate of
cerium (whose B.P. dose of 2 grains is also ridiculously
inadequate), thus :

Bismuth subniL

•.• ...

•••

gr.

rxv.

Cerii oialat.

...

gr-

X.

M. Sig.:

Ter die post cib.

If, as is not infrequently the case, the patient has a
gouty tendency, it is well to add 5 grains, or a little
more, of pulv. guaiaci to each cachet, but it not
infrequently happens that the ' little more ' is found
to produce griping, purging, or both. Another drug
which might be added to such a cachet is bicarbonate
of sodium. It increases the alkalinity, but it increases
also the bulk of the cachet and the quantity of gas in
the stomach.

Although the subnitrate is frequently prescribed in
a mixture (20 grains of the salt to 20 jgrrains of pulv.

INDIGESTION. 65

tragacanth. co.), it is not wise to do so. The
carbonate acts nearly as well, and does not tend to
decompose as the subnitrate does. On no account
should the subnitrate be placed in a mixture with
bicarbonate of sodium. The decomposition of the
former leads to CO2 being evolved from the latter,
and explosions are apt to occur.

If it is desired to give bismuth in a fluid form, the
liq. bismuth, ammon. cit. should be used. I am in
the habit of combining it (as in the cachet) with a
sedative — i.e., hydrocyanic acid — thus ;

li. Liq. bismuth, ammon. cit. 1 -- ,^..

Syr. prum virg. j
Aquam ad 5i.

Misce.

This makes an agreeable and palatable mixture ;
but if, with a view of correcting any gouty tendency,
we add, say, 3ss. tr. guaiaci ammon., we must
remember to suspend the latter in 40 grains of
mucilage of acacia, and even then the mixture will
be deprived of its elegance. There is no objection to
adding bicarbonate of sodium to this combination,
but there is really no necessity to do so, for it is
already sufficiently alkaline.

Now, whichever form is decided upon, the cachet or
the mixture, th(3 important point to remember is that
the proper time for its administration is some time after
food. The length of time which should be allowed to
elapse between the meal and the taking of the remedy
depends, of course, upon the size of the meal, k full

CO MINOR MALADIES.

meal will take five hours to digest, and will use up
a great deal of HCl. A light meal, especially if it be
poor in proteids, will use up very little acid — that is
why sthenic dyspepsia is so much more common after
light meals — and the surplus will want neutralizing
relatively soon. It will want neutralizing sooner
after breakfast than after luncheon, and sooner after
tea than either. After a full dinner the symptoms
frequently do not shov/ themselves until about
4 or 5 a.m., and may then, in addition to pyrosis
and heartburn, take the far more obscure forms of
hiccoughing, sneezing, asthmatic, and even anginal
attacks. The tendency of any symptoms, however
little connected with the stomach they may at first
sight appear, to recur regularly at 4 or 5 a.m. should
give rise to a suspicion that dyspepsia is at the root
of the mischief.

It is probable that much of the success which has
attended the practice of giving alkalies before meals
has been due to the fact that the period immediately
preceding one meal is the period which witnesses the
close of the digestion of the last — the period, that is, in
which there is surplus acid waiting to be neutralized.
However that may be, there can be no doubt that the
administration of alkalies, and especiall}^ of bismuth,
at a suitable interval after food, offers a means of
relief in sthenic cases which is practically unfailing,
and I would go so far as to say that if relief is not
obtained by such means, then the case is certainly
not a dyspepsia of the class under consideration.

INDIGESTION. 67

A lino of treatmont suggested, or at any rate
recommended, by Sir William Eoberts is that of
prescribing lozenges to be sucked by the patient as
soon as the symptoms have developed. Lozenges have
the advantage of portability, and the sucking of them
insures that the superfluous acid in the stomach
shall be neutralized by its physiological antidote,
namely, saliva. It is curious to note that the saliva
secreted during a sthenic dyspeptic attack is hyper-
alkaline. It is as if Nature herself were suggesting
the best means of curing the condition, for not only
is the reaction enhanced, but the amount of the fluid
is markedly increased in those attacks which the
presence of pyrosis and coryza proclaim to be of
more than usual severity.

The lozenge which Sir W. Roberts prefers is the
trochis. bismuth, of the B.P., which contains 3 J grains
of chalk and 2 J grains of carbonate of magnesia ; but,
true to his disbelief in bismuth, he suggests that this
ingredient should be omitted. However, so long as the
lozenge is not acid, it probably matters little of what
it is composed. The efficacy of this line of treatment
resides in the use which is very properly made of the
alkaline saliva in neutralizing the offending acid.
Even the mechanical irritation of a clean pebble
carried in the mouth is useful in this direction,
and patients should be told to remember it in the
presence of an attack where no alkalies are at hand.

There is a point in prophylaxis which ought always
to bo brought to the notice of a sthenic dyspeptic.

C8 MINOR MALADIES.

The source of the muriatic acid present in the gastric
juice is believed to be common salt; patients
should, therefore, be told to eschew salted meats, and
be warned to relinquish the habit of adding chloride
of sodium to their food. It is merely a habit, and
few have any difficulty in relinquishing it. If the
supply of the raw material is checked, the over-
production of the manufactured article will cease.

And this consideration carries another lesson, which
is this : The natural mineral waters which are so
largely imported into this country have justly earned
for themselves a great reputation in the treatment of
chronic and occasional constipation. As nearly all
these waters contain chloride of sodium, and some of
them in very large quantities, it is inadvisable to
recommend them to patients whose constipation is
associated with sthenic dyspepsia. To relieve the
difficulty in such cases recourse must be had to other
means. Cascara is very serviceable, but I prefer either
of the following, given three times daily before meals,
followed by a glass of hot water ;

B. Sodii siilphat. gr. xxx.

Sodii bicarb gr. x,

Tr. nucis vom. triv.

Ess. menth. pip. ... ... ... mi.

Inf. gent. CO ad 5i.

IM.

R. Magnes. sulphat gr. xxx.

Magnes. carb. gr. 2C

Tr. nucis vom. ... 'iv.

£88. mentli. pip iriii.

Inf. cascarilliB ad 5i.

INDIGESTION. 69

Either of these mixtures takes the place of that
containing sodium bicarbonate suggested above for
* lavage ' of the stomach, and if persevered with, may
be relied upon to dispose of the constipation.

Among those who suffer from sthenic dyspepsia,
there are a very large number of people (mostly
maiden ladies and widows) who are persuaded that
they want * supporting,' that their condition is due
to debility, and that large and frequent meals are
essential to their continued existence. Their miseries
towards the end of digestion, and the prompt relief
which is afforded by another meal, lend an amount of
support to this view which no skill in the art of
persuasion is in some cases sufficient to combat. If
the real state of affairs is pointed out to them, they
write the doctor down as an unsympathetic person,
who is devoid both of perception and therapeutic
instinct. Nevertheless, the attempt should always be
made, for it is better to lose a patient than to share
in the responsibility for the arterio-sclerosis and other
serious manifestations which sooner or later provide a
fitting Nemesis for these misguided people.

And this leads me to say that mistakes in differ-
entiating between the two kinds of dyspepsia generally
take the form of diagnosing as an asthenic case one
which is in reality a sthenic case. Patients who
pity themselves readily dwell upon the weakness
which they feel, and, believing their symptoms to be
due to debility, seek, by graphic and heartrending
descriptions, to persuade the doctor to the same view.

70 MINOR MALADIES.

This is a pitfall against which it is very necessary
that we should bo on our guard. When there is any
doubt about the nature of the case, it should
be treated as if it was sthenic, by the exhibition of
alkalies and sedatives. The reason for this is that
alkalies and sedatives, though they may do an
asthenic case no good, will certainly not aggravate
the symptoms; whereas acids given to a sthenic
dyspeptic immediately give rise to an acute exacerba-
tion of all the troubles from which he was previously
suffering.

There is one other point to remember in this con-
nection, and that is the futility of treating sthenic
dyspepsia by any remedies directed to the stomach
alone until we are quite certain that the cause of all
the trouble does not lie in the transverse colon.
When we recall the anatomical relations of this
portion of the large intestine to the great curvature
of the stomach, it is not diflQcult to believe that an
irritation which has its source in the one will be
readily communicated to the other; and I have
repeatedly found, clinically, that a dyspepsia of the
sthenic type, which had resisted every combination
of alkali and sedative, responded promptly to calomel
and an enema properly administered.

Sir William Roberts divided the dyspepsia of
substantially healthy people into the atonic form and
the irritative or acid form, which is practically the
same classification as that which is here advocated.
Of the latter form he writes fully and instructively ;

INDIGESTION. 71

but with the bias natural, perhaps, to one who
has suffered much from one form, he dismisses the
other, the atonic, in a few words as scarcely meriting
the name of dyspepsia. From this view, and from
the theory which would confine the term * irritative ' to
either form, I must express my dissent. Atonic or
asthenic dyspepsia — the dyspepsia, that is, whose
essential condition is a deficiency of HCl in the
gastric juice — is an exceedingly common condition,
more especially among the working classes and among
neurotic people of all classes ; and the symptoms
which such cases have in common with sthenic
dyspepsia, the discomfort and the flatulence — albeit
brought about in the one case by excess of acid and
in the other by the presence of undigested food — are
due to precisely the same condition, namely, an
irritable state of the gastric mucosa.^

This element of irritation which the two forms
have in common is important because failure U
appreciate it seems to lie at the root of much of the
confusion which prevails on the subject. Where the
symptoms of the two forms seem to overlap, they do
so on account of this factor and its results, and when
this is clearly understood the difficulties disappear.

Let us now look at a typical case of ASTHENIC
DYSPEPSIA, and consider how it should be treated.
The causes which may produce the condition are

^ I purposely refrain from any discussion of the fermentation
theory, for even if there be any truth in this theory, which I
doubt, it cannot affect the above considerations.

72 MINOR MALADIES.

numerous, and some of them are remote. Setting
aside those which are obvious, such as convalescence
from acute disease, it is well to remember that any-
thing which gives rise to a constant leakage of
nervous force is peculiarly liable to set up an asthenic
dyspepsia. Such conditions as worry, uncongenial
surroundings, nasal obstruction, and errors of refrac-
tion are among the most frequent, and it is safe to
say that they are precisely those which are most
commonly overlooked.

Let us, then, take as our type a married but child-
less woman of thirty, who is not exactly unhappy,
but who has no definite object in life. She is lacka-
daisical rather than melancholy, with a dull com-
plexion and spare frame. Her tongue is clean, but
pale and flabby, and some of her teeth are defective
She complains of a dull pain in the chest, which
passes through to the back. The pain is always
more or less present, but every meal, no matter
whether it be large or small, intensifies it. She has
very little appetite as a rule; though occasionally,
when she forces herself to eat, it seems to improve
after she has taken a few mouthfuls. She sufifers
from flatulence and palpitation, and is generally very
constipated. Medicines may relieve the constipation,
but they generally leave the discomfort and the
flatulence unafiected. On examining her abdomen,
we may find a movable kidney on the right side,
and the muscles in the anterior abdominal wall will
be found to be badly developed. She takes very

INDIGESTION. 73

Httlo exercise, and protests that she never feels up
to it.

The treatment of such a case is not difficult.
Having freed the primse vise and attended to
the other details already mentioned as suitable to
both forms of the malady, we turn to the measures
of active treatment. Having regard to what we
know to be the essential condition in this case —
namely, deficiency of HCl in the gastric juice — the
first indication is, clearly, to supply the deficiency.
And in doing so we must be careful to give doses
large enough to effect our purpose. The ordinary
B.P. dose of rn^x. is altogether inadequate ; the
minimum dose which I employ is TT|^xxv. This it
is well to combine with strychnia and pepsin, as in
the following :

R. Acid. mur. dil nixxv.

Liq. strychnin. ... .„ ... v\y.
Glyc. pepsin 3i.

Aq. menth. pip. ad gss.

M. Sig. : Thrice daily immediately after food.

To such a mixture may be added other drugs
which the nature of the case may seem to demand.
Quinine hydrochlorate, liq. ferri mur., liq. morph.
mur., and liq. arsen. hydrochlor., are all of them
preparations which are frequently of great assistance
in such cases, and all of them are quite compatible,
not only with each other, but also with the other
ingredients in the mixture. The most useful of them
is perhaps the morphia salt. In cases of long

74 MINOR MAIjVDIES.

standing, where the element of irritation is conse-
quently very pronounced, the addition of vo^x. of the
liq. morph. hydrochlor. is invaluable. It soothes the
mucosa and enables it to tolerate the stimulating
effects of the HCl and strychnine, which in its absence
are liable to cause so much local disturbance as to
bring the patient back wi^.h the complaint that each
dose of the medicine aggravates her sufferings. It is
scarcely necessary to dwell upon the great importance
of deleting this ingredient from the prescription as
soon as there is any prospect of doing so with
impunity.

For the constipation, which is generally so pro-
minent a feature in asthenic dyspepsia, the use of the
natural mineral waters is not only unobjectionable — it
is strongly indicated. The presence in them of
common salt, which we have seen to be a contra-
indication in sthenic dyspepsia, is here an advan-
tage. Most of those waters are best taken in the
morning (fasting), and their effect is enhanced by the
association with each dose of a tumblerful of hot
water.

Such are the broad lines on which most cases of
functional dyspepsia should be approached. But
even in uncomplicated cases it is more easy to make
mistakes than the facts as above stated would lead
one to expect.

It not infrequently happens that where there is a
serious difficulty in coming to a conclusion as to
whether the case is one of sthenic dyspepsia or its

INDIGESTION. 75

opposite, it eventually turns out to be one which
cannot, properly speaking, be placed in either category,
but is due to some underlying cause which must be
discovered and removed before either acid or alkali
will have the desired effect. A large percentage of
these aberrant cases are the result of causes which,
for the want of a better term, we must call nervous
or neurotic. Common instances are afforded by men
on the Stock Exchange who lead strenuous and even
exhausting lives, who are exposed to periods of de-
pression, varied by sudden volcanic explosions of
excitement and panic, in whom the philosophic calm
so necessary to good digestion is hardly ever obtain-
able except at a foreign health-resort, where tele-
phones cease from troubling and * markets ' are at
rest. An instance drawn from another, though
scarcely less familiar, sphere is presented by a young
lady who once consulted me, with all the signs of
asthenic dyspepsia, with this notable point of dis-
similarity from the typical picture, that her acid
symptoms began to trouble her as soon as the food
obtained access to her stomach. The ordinary pre-
scriptions of bismuth, soda, and hydrocyanic acid, in
combination with laxatives, produced no result, and
so at her third visit I got her mother out of the room
and demanded to know the nature of the silent sorrow
which I felt certain she was nourishing. It soon
emerged in the shape of a secret engagement, which,
should it leak out, would set the whole family by the
ears. The combination of 15 grains of bromide of

76 MINOR MALADIES.

potassium and 2 minims of Fowler's solution in
water three times a day after food, coupled with a
little worldly-wise advice, cured that dyspepsia in a
few days.

One of the most common causes of aberrant
dyspepsias is that which, for some extraordinary
reason, is the one most commonly overlooked. So
common is it, indeed, that one feels almost ashamed
to mention it. I mean dental caries. The teaching
of the schools — and I say this without any implied
reflection — tends to the too exclusive cultivation of the
obscure in diagnosis and the heroic in treatment, with
the sad result that the obvious and common sensicaJ
become overlooked. Thus it happens that patients
are suspected to be suffering from cancer, gastric
ulcer, oesophageal stricture, hepatic, pancreatic, and
even splenic, disease, when a few visits to a competent
dentist will cause the disappearance of all their
symptoms. We talk glibly of the gastro-intestinal
toxins and their nefarious consequences, but we
appear to think of them as lurking, brigand-like, in
the inaccessible rugce of the small intestine, when
their real habitat is the commonplace cave of a decay-
ing molar. That * washing in Jordan ' should never
be a popular proceeding with patients is comprehen-
sible, because patients are generally in an epic mood ;
but why doctors should avoid it as a prescription is
less obvious. That the avoidance frequently impairs
professional credit is a matter of common experience.
Another condition which is very closely associated

INDIGESTION. 77

with intractable dyspepsias is nasal obstruction. No
one can pretend that a nasal obstruction due to ade-
noids is now in danger of being overlooked. The
very reverse is indeed the case, for adenoids are
diagnosed, and even operated upon, in cases when
they do not and never have existed. But that is by
the way. Nasal obstruction may be due to causes
other than adenoids, and such obstruction is a very
common provoker or maintainer of a dyspepsia which
fails to conform to either of the two regular types,
and remains obstinate to treatment by their appro-
priate remedies. Such was the case with a man
whom I have known for many years, energetic, hard-
working, capable, who at unequal intervals suffered
from attacks of what both he and I agreed to call
* gouty dyspepsia.' It was distinctly of the sthenic
type, and the worst discomforts connected with it
scarcely ever failed to yield to bismuth and soda.
Nevertheless, even when taking the medicine he was
seldom entirely free from flatulence, eructations,
heartburn, and constipation. The enemy was always
on his flank, to fall upon him unmercifully should he
commit any dietetic indiscretion, or in the event of
any extra pressure of work, and on the occasion of
any mental anxiety. Matters continued thus for
several years until he was married. Not long after
that event he came to see me with one of the usual
attacks, and told me incidentally that his wife com-
plained that he not infrequently snored, and that, in
connection with this complaint on her part, he had

78 MINOR MALADIES.

himself noticed that he alwaj^s awoke with his mouth
open. I then, for the first time, tested his nasal air-
way, and found that it was practically blocked on the
right side by a combination of spurs and a deviated
septum. Since this condition was relieved, now over
two years ago, he has never had any return of his
trouble, or, if he has, it has been so slight in degree
as to be readily amenable to ordinary treatment.
This may seem an inconclusive story, but both he and
I are quite convinced that the cause of his former
troubles was the obstruction in his nose, an opinion
which on my part is very strongly supported by other
cases of a similar kind.

But if nasal obstruction is a common cause of
obstinate digestive troubles, an even commoner cause is
to be found in uncorrected errors of refraction. These
errors give rise to eye-strain, and eye-strain in its turn
provokes disturbances which are by no means limited
to the eyes or their neighbourhood. The teaching of
too many of the schools is to the effjct that unless a
person with a slight error of refraction complains of
definite symptoms, then it is a work of supererogation
to correct it. Such advice might be sound if all the
symptoms of eye-strain were easily recognisable as
such; but they are not. A person who is the sub-
ject of eye-strain may suffer from symptoms which
neither he himself nor the vast majority of doctors
would dream of referring to his vision.^ It is begin-

^ See Ernest Clarke, *The Medical Aspect of Eye- Strain,'
Clinical Journal, October 4, 1005.

INDIGESTION. 79

ning to be recognisod, perhaps, that headaches, supra-
orbital and other local neuralgias, may be caused by
visual defects, but it is seldom even admitted that
dyspeptic troubles and many obscure and indefinable,
but very persistent, miseries, which are either care-
lessly or ignorantly labelled neurotic, neurasthenic,
or hysterical, may be due to the same cause. This
attitude is not altogether surprising when we remember
that, in order to produce these results, it is essential
that the defect should be slight in degree ; should be
one, that is, which the patient himself, by contracting
his ciliary muscle, can adequately correct. The
grosser errors do not cause these symptoms, for the
reason that no amount of ciliary contraction being
sufficient to correct them, no effort is ever made. In
the lesser degrees the effort, being successful, is not
only made, but is maintained during the whole of the
waking hours. It is this maintenance of muscular
effort which is the crux of the whole situation, for
the ceaseless and illegitimate contraction of the ciliary
muscle means an equally ceaseless and illegitimate
expenditure of nervous energy. The * electric power '
intended for the motors in the various organs is all
monopolized by the visual. There seems nothing to
determine which of these organs will be the first to
cry out that it is being starved of its due amount of
nervous energy, and much of the trouble arises from
the fact that its cry is almost invariably misunder-
stood and misinterpreted. In the case of the stomach
the responsibility is generally placed upon the diet.

80 MINOR MALADIES.

which is pared and whittled both in quantity and
quaHty until the fare of King Nebuchadnezzar may
seem generous in comparison ; while the organ itself
is now soothed with papaveric caresses, and anon
chastised with Chilian scorpions, in the vain hope that
it may thus be induced to make bricks without straw ;
for unless the nervous energy or the motive power,
or whatever else it may be termed, is prevented from
leaking out through the crevice of that minor refrac-
tive error, the stomach will be deprived of its due
share of this energy, with the result that symptoms
in very sooth, though symptoms of an aberrant and
baffling type, will continue to afflict the unfortunate
possessor of the organ, in spite of acid and alkali, and
in spite, too, of their all too common and ridiculous
association in the same mixture.

So impressed have I been during the last ten years
with this aspect of obstinate dyspepsias, that I now
never fail to satisfy m3^self, at any rate in the case of
a town-dweller, and more especially in the case of a
town- dweller of over forty years of age, that an error
of refraction is not at least a contributory cause in
the case of troublesome indigestion which resists the
ordinary remedies. If it is true, as I believe it to be,
that the dentist cures more cases of indigestion than
the physician, it is equally true that in the same
direction the refractionist is more potent than the
therapist.

A great many dyspepsias which are confidently
<issigned to the rubbish heap labelled * neurotic ' are

INDIGESTION. 81

due to vaso-motor disturbances, and may thus be hold
to justify the label. The disturbance may take the
form of an undue vaso-dilatation leading to a sub-
normal blood-pressure, or to the opposite condition
of undue vaso-constriction, causing a supernormal
blood-pressure. It may, of course, be the result of
faulty distributions of pressure, for which errors of
vascular tone are not primarily or even mainly
responsible, as in the case of mitral disease. It is
scarcely necessary to refer to such cases, because the
person who fails to examine the heart in a case of
dyspepsia will fail to examine it in a case of chorea,
and is diagnostically past praying for. It is the
vascular disturbances which own no such obvious
cause which give rise to difficulties. In the case of
undue general vaso-dilatation the viodus operandi is
not difficult to follow. The patient is, so to speak,
living under the constant influence of nitrite of amyl ;
his peripheral arteries are relaxed, and there is thus
less blood available for the work of the internal
organs. Consequently the appeal for more blood for
digestive work on the part of the stomach is very
inadequately responded to, and symptoms arise whose
severity is in direct ratio with the degree of general
vaso-dilatatioii. A dyspepsia which is due to this
state of matters may always be relieved by causing
the patient to assume the recumbent posture im-
mediately after a meal, but it can only be cured by
removing the cause of the general vaso-dilatation.
The opposite condition of unduly high blood-

6

82 MINOR MALADIES.

pressure frequently, if not invariably, carries a gastric
disturbance of some kind in its train. The causation
of high blood-pressure in some, at any rate, of its
aspects, is still a matter of speculation, but there
seems no escape from the conclusion that it may be,
and frequently is, due to endogenous toxins. These
toxins would seem in the majority of cases to act
slowly — so slowly, that the existence of the high
pressure is not even suspected until it has left its
inexorable mark upon the arteries in some important
organ, whose resulting degeneration has produced
the symptoms from which the patient seeks relief.
Here, then, is another, and by no means the least
weighty, of the possibilities which should engage our
attention where we have an aberrant dyspepsia to
deal with. The use of the manometer is becoming
more general every day, and such cases will therefore
be overlooked with decreasing frequency, to the credit
of the profession and to the satisfaction of the patients.
Of the dyspepsias which result from high blood-
pressure, the best instance is probably that which
may be drawn from a consideration of what occurs at
the menopause. The process of menstruation must
be regarded as an excretory process, so that the com-
mencement of the climacteric marks as a rule the
commencement of a period of insufficient excretion.
Add to this the consideration that the internal secre-
tion of the ovary is believed, on sufficient grounds, to
be both vaso-dilator and a toxin destroyer, and it is
not surprising to find that at the * gloaming of life,' as

INDIGESTION. 83

the French poetically call it (Vdge crdpusculaire), the
blood distribution becomes deranged. The derange-
ment shows itself as an elevation, which is always
definite, and is not infrequently sufficiently alarming
to warrant very active interference. For reasons into
which it is impossible to enter here, this rise of
pressure exercises a particularly unfavourable effect
upon the vessels in the splanchnic area, and of these
vessels it is, as one would expect, the gastric which
show the greatest disturbance, with the result that
dyspepsia, almost invariably of the sthenic type, is
one of the commonest of the manifestations of the
menopause. Any attempt to treat such a dyspepsia
without very special attention to the state of the
blood-pressure is to court certain failure, and in order
to reduce that pressure we must bear in mind the
above-mentioned factors in its causation.

The fact that an excretory organ has been lost, and
that its absence is not yet compensated for, will
suggest gentle stimulation of the other emunctories,
of which the skin is in this connection by no means
the least important. The absence of the internal
secretion may be met by giving ovarian extract by
the mouth, a procedure which I believe to be of the
greatest benefit. Ichthyol in 5 -grain pills is also
useful, and is perhaps the best of all drugs for com-
bating the vague subjective discomforts which are
apt to appear at this time. When the blood-pressure
is really high — i.e., over 200 mm. Hg — and the above
means fail to reduce it, I never hesitate to recommend

84 MINOR MALADIES.

venesection. This little operation has in several
cases within my knowledge been the means of a
'miraculous' cure of very troublesome climacteric
dyspepsias.

I feel that I must not leave this question without a
reference to a form of dyspepsia which is associated
with the menopause, but which has none of the
characters of that just noticed. The processes peculiar
to the climacteric affect different women differently,
but they seldom fail to produce an instability of the
nervous system, which in extreme cases proceeds to
definite insanity. Short of this, one of the forms
which it assumes is an abnormal craving for sedatives,
and if the craving is satisfied there is very apt to
ensue an irritable condition of the stomach, which
gives rise to symptoms of indigestion. The sedative
usually employed is, of course, alcohol, with regard
to which it is necessary to remember that its excessive
devotees fly to it, not as a stimulant, but as a narcotic,
and that it is narcotic only when taken in doses large
enough to act as an irritant on the gastric mucosa.
There is a great deal of secret drinking at the time of
the menopause, even among those who up to that
period have been strictly temperate, so that the
possibility of such a factor being at work in produc-
ing or maintaining a dyspepsia should not be for-
gotten.

There is a condition which some, at any rate, of
the manifestations of sthenic dyspepsia are liable
very closely to simulate, and to which it therefore

INDIGESTION. 85

seems desirable briefly to refer — namely, angina
pectoris. Where sthenic dyspepsia is associated, as
it not infreq^uently is, with some degree of gastric
dilatation, symptoms resembling true angina are by
no means uncommon. I have already referred to
the fact that attacks of sneezing, dyspnoea, and the
like, are in these cases very liable to occur in the
early hours of the morning, and I have pointed out
that these attacks are due to the irritation produced
primarily by the excess of acid present at the end of
digestion.

Now, it is not difficult to understand how the
consequent flatulent distension of a somewhat dilated
stomach will cause serious mechanical embarrassment
to the heart, nor that, as a result, symptoms should
ensue which are very suggestive of true angina. Add
to this the fact that the patient frequently brings a
history of pain in the chest, evoked by exertion,
which radiates down the arms, and the suspicion
of angina is necessarily deepened. It is important
to remember, therefore, that all these symptoms are
entirely compatible with functional gastric disturb-
ance ; and to prevent unnecessary alarm to the patient
and his friends, it is well to avoid all mention of the
more serious condition until the less serious can be
excluded.

There are some facts which may aid us in
arriving at a conclusion upon this point, which is
liable to present difficulties not only because of the
general resemblance between the symptoms, but also

86 MINOR MALADIES.

because an attack of flatulence may be the starting-
point of the first of a series of true anginal seizures.
In the first place, then, it may be said that the con-
stant presence of palpitation in association with the
attacks is against the suspicion of angina and in
favour of simple dyspepsia. In favour of dyspepsia,
also, is the regular occurrence of the attacks in the
early hours of the morning. When inquiry elicits
that the pain on exertion occurs always after a meal
and never when the stomach is empty, the fear of
angina may be allowed to recede, and it may be
dismissed altogether if an antacid taken at a suitable
interval after meals is successful in preventing the
attacks.

The occurrence of such symptoms, however, even
when they are quite definitely dyspeptic in origin,
should not be too lightly regarded. They are often
associated with giddiness and other phenomena which
occasion alarm to patients, and if the cardio- vascular
condition be carefully examined, as it should always
be, it is very seldom found to be in an entirely
satisfactory condition. Setting aside the heart
itself, whose state, when it is affected at all, is
variable, and is always secondary to the changes
which are present in the arterioles and capillaries,
it is necessary to examine carefully into the state of
the arteries. These will generally — one may say
always — be found in a state of high tension, and the
treatment of the dyspepsia by means of antacids will
bo only temporarily successful unless means be adopted

INDIGESTION. 87

to insure that the intravascular pressure be perman-
ently reduced. In order to reduce this pressure it
is necessary to realize the nature of its cause. In
nine cases out of ten this is the presence of toxins
circulating in the blood. The toxins, by irritating
the vessel walls, cause constriction of the muscular
coats, and blood-pressure is at once increased. The
real nature of the toxins which may give rise to this
state of matters is not yet understood; but in the
cases under consideration — those, namely, of sthenic
dyspepsia — they are generally, if not invariably, the
result of excessive meat-eating.

The first thing to do, then, is to impress upon the
patient the necessity for abstention fcom meat foods ;
and the older the patient, and the more sedentary his
mode of life, the more urgent does this necessity
become. A general reduction of intake, in quantity
as well as quality, is usually very desirable, and, in
my experience, the meal which may be attacked with
the best prospect of success is that which is taken at
or about midday. This should consist of milk, eggs,
cheese, fruit, and vegetables — of anything, in fact,
which has not been killed — and it should be free
from alcohol. So far as the meat at the evening
meal is concerned, it is well to insist that it should
be boiled, because it has been shown that boiled
meats are much less liable to increase arterial tension
than those which are otherwise treated.

To insure the adequate excretion of such toxins as
may already be present, the bowels, skin, and kidneys

88 MINOR MALADIES.

must be stimulated. Mercury is the best agent to
employ for the first of these purposes. About a graie
of calomel should be given every night for a week,
followed each morning by a saline, and the saline
should be continued for at least a week longer,
iurkish and hot-air baths are useful for cutaneous
stimulation, especiall}'- where they are combined with
or followed by efficient massage. Even the ordinary
hot bath, properly administered, is by no means
without its value in this connection. For the
stimulation of the kidneys the salts of potassium
are to be preferred, and of these the iodide and the
citrate are the best. Ten grains of the citrate with
5 grains of the iodide should be added to the mixture
of bismuth above prescribed, and the patient should
be directed to drink freely of Evian water between
meals. Another excellent renal evacuant is theo-
bromine.

The importance of these measures resides in the
fact that a sthenic dyspepsia which is accompanied by
high arterial tension is but a symptom of an under-
lying condition whose continuance is fraught with the
utmost gravity to the patient. There is, as a rule, no
difficulty in curing the dyspepsia ; but if we allow our-
selves to rest satisfied with such an achievement, and
shut our eyes to the possibilities of dangers ahead —
dangers such as granular kidney and general arterio-
sclerosis, which are two among many of the logical
issues of sustained high arterial tension — the patient
will have good cause to regret the promptitude

INDIGESTION. 89

and completeness of the relief from his dyspepsia which
ho has obtained at our hands. This is the condition
to which the term ' gouty dyspepsia ' has been applied,
and if we use the term to denote a dyspepsia of the
sthenic type, which is merely a manifestation of a
general condition of goutiness, which general con-
dition demands our attention even more urgently than
the dyspepsia, then the term is altogether unobjection-
able. There is, however, very little advantage to be
gained from the multiplication of adjectives.

Symptoms are often confidently attributed to
dyspepsia which are in reality due to ovarian
irHtation, The dyspepsia is generally of the
asthenic type, and is usually accompanied by
nausea, frequently by vomiting, which may be very
persistent, and occasionally by haematemesis. When
a dyspepsia in a young woman proves intractable to
the ordinary remedies, the probability is great that
the cause will be found in the ovarian region. To the
seeing eye there is something very characteristic in
the appearance of one who is suffering in this way.
The appearance does not lend itself to verbal descrip-
tion, but, when once observed, it is not easily for-
gotten. Undue brightness of the conjunctivae in a
person whose temperature is normal is very suggestive
of pelvic disturbance, but this by no means exhausts
the elements of which the ' ovarian ' look is composed.
If the existence of this possible cause of an indigestion
be borne in mind, it is easy to verify our suspicions.
Palpation over the ovarian regions will elicit tender-

90 MINOR MALADIES.

ness, sometimes very extreme, on one or both sides.
The best treatment consists in the repeated applica-
tion of small blisters over the congested viscus, com-
bined with free purgation and the exhibition of
bromide of potassium. This kind of dyspepsia is
frequently referred to as * nervous * or * neurotic'
It is not, of course, a dyspepsia at all. It is due to
causes local to the pelvic organs, and unless these
causes, which not infrequently comprise leucorrhcea
and menstrual disturbances, are suitably treated, the
remedies offered to the stomach will be wholly
ineffectual.

There are two symptoms commonly associated with
dyspepsia which, from the discomfort to which they
may give rise, it is often necessary to treat during the
interval which may have to elapse before their cause
can be removed : the one is flatulence, the other is
hiccough.

FLATULENCE may be either gastric or intestinal.
The former is said to be due to fermentation in
the stomach itself. Although there is good reason
to believe that this is not the case, there is no
doubt that the symptom is one which is nearly
always present in every case of gastric derangement,
from whatever cause arising. It may, on the other
hand, be a pure neurosis, and is frequently provoked
by worry and anxiety. In neurotic subjects and
in mouth-breathers (as in the subjects of adenoids
and deviations of the nasal septum) it is due to^
the swallowing of air. When this symptom is so

INDIGESTION. 91

obtrusive as to demand treatment apart from its
underlying cause, there are three remedies which
can usually be trusted.

To those who believe in the fermentation theory,
carbolic acid, 2 grains, made into a pill with 1 grain
each of liquorice powder and powdered althea, and
given three times daily, will probably appeal, and
it certainly is often very helpful. In the form of
sulphocarbolate of sodium (10 to 15 grains) the
same remedy may be added to mixtures prescribed
for the relief of the complaint which causes the
flatulence. The sodium salt sometimes acts better
than the pure acid.

An old and very reliable remedy is charcoal.
This should be given in doses of at least a drachm
three times daily. The drug which has seemed to
me to be most trustworthy, however, is terebene:
10 or 15 drops may be put upon a lump of sugar for
the patient to suck, or the same quantity may
bo given in a capsule three or four times a day.
Whether by checking fermentation or by some other
action, it is certain that few remedies possess so much
power in relieving the distressing eructations to
which some dyspeptics are liable.

Where the flatulence is intestinal, the treatment
should be directed towards increasing peristalsis by
means of nux vomica and belladonna. The condition
is generally associated with atony, and care should be
taken not to administer drugs, such as magnesium
sulphate, which increase the fluid contents of the bowel
without increasing peristalsis, unless the muscular

92 MINOR MALADIES.

action is simultaneously reinforced either by drugs
or massage.

Of all the remedies directed to the relief of
this condition, nothing has seemed to me to compare
with oil of cajuput. It should be given in doses of
2 minims, and may be combined in a pill with extract of
gentian, or, when dissolved in a few drops of spirit, it
can be added to any mixture. In the flatulence
which is so liable to develop after operations in the
neighbourhood of the rectum this remedy is in-
valuable.

HICCOUGH is due to a sudden more or less violent
contraction of the diaphragm, and may be produced
by irritation, either in the immediate vicinity of the
muscle or reflexly from a distance. An attack may
last for a few minutes only or it may be protracted
over several hours, and it may recur at intervals for
weeks, or even months. It is a common symptom of
dyspepsia, more especially of sthenic dyspepsia ; but
it may also be due to organic affections of the stomach
and intestines, such as carcinoma, and to hepatic
disease, or appendicitis. It is a frequent accompani-
ment of the tympanites of typhoid fever. It may be
excited reflexly by organic disease of the nervous
system, such as meningitis, hydrocephalus, and intra-
cranial tumours. In functional diseases it is common ;
hysteria, sudden shocks, and acute emotions providing
a great many instances. It is not altogether un-
known in epilepsy, and may occur in chorea.
Certain constitutional conditions, especially gout,
diabetes, gouty nephritis, and alcoholism iaeem to

INDIGESTION. 93

create a strong predisposition to its development.
So much ifl this the case that the absence of other
obvious cause should lead one to suspect the operation
of such an agent.

Hiccough is very often associated with pregnancy,
and it may complicate Graves' disease or Addison's
disease. When it appears in a person who is
seriously ill, especially if it becomes persistent, it
is a sign of evil omen, and should lead us to be
very guarded in prognosis. Its most obvious
mechanical cause is pressure on the phrenic nerve
within the thorax, a condition which is most likely to
be produced by dilatation of the aorta, pericarditis,
or new growths.

Persistent hiccough, from whatever cause arising, is
very distressing, not only to the patient, but to those
around him, and it is necessary to allay it as soon
as possible. Various means to this end have been
suggested from time to time, including medicines
to be taken by the mouth and applications of a
stimulating nature to the epigastrium. Of the latter,
warmth and small mustard-plasters are occasionally
useful, and skilfully applied massage is frequently so.
Of internal remedies, the best seems to be nitro-
glycerine in doses of jijj of a grain upwards. It seems
to act better when given in tablets than in the form
of liq. trinitrini (2-5 minims), though I have used the
latter with success. In either case the dose should be
small and frequently repeated. Oil of turpentine is
highly recommended by some. It should be given in
doses of 10 minims mixed with mist, amygdal.

94 MINOR MALADIES.

Ext. ergot, liquid in drachm doses, frequently
repeated, has been very successful in some cases, and
is always worth a trial where other things fail. It is
generally conceded that morphia, chloral, bromide of
potassium, and even the inhalation of chloroform, are
useless. Ether by the mouth, however, sometimes
proves effectual. Traction on the tongue will some-
times produce the desired effect. Forcible holding of
the breath in deep expiration is useful in slight
cases, as is drinking a glass of water with both ears
and nostrils closed. Of all these means, however,
nitro-glycerine is the most likely to be successful.

Musk (5 to 10 grains) in a pill with liquorice may
also be tried. It is well spoken of by many, the only
objection to its use being its great expense,

ADDITIONAL FORMULJE.
Alkaline Mixture (Byrom Bramwell).

9. Potass, bicarb.) ^...

Sodii bicarb, j

Spts. ammon. co 5iv.

Tr. rhei 3ii.

Inf. calumbse ad 5vi.

M. Sig. : 5ss. in water, thrice daily, a quarter of
an hour before food.

Mixture for Flatulence.

9. Menthol gr. J

Spts. ammon. co.] ^.

Spts. chlorof. [ ^^^•

M. Sig. : One teaspoonful in water when required

CHAPTER III.

CONSTIPATION, DIARRHCEA, VOMITING, AND
GIDDINESS.

CONSTIPATION may be described as inadequate dis-
charge of the contents of the lower bowel ; a definition
which assumes, of course, that there is material in
the lower bowel which is improperly retained. This
is a fact which seems to require emphasizing, for the
reason that the term constipation is often made to
include infrequent defsecation in people with whom
such infrequency is habitual and normal. It is well
to remember that the amount of faeces represents
the excess of material consumed over what it
is possible for the economy to utilize, and that
consequently, if people took no more food than was
necessary to their continued existence, the amount of
faeces would be practically nil. There are persons—
not very forceful persons perhaps, but still perfectly
healthy persons — who are very spare eaters, and who
are, in addition, very careful eaters, in the sense that
their food is thoroughly masticated, whose bowels do
not act more than once a week. If we were to gauge

the matter only by the standard of the practice of the

95

S6 MINOR MALADIES.

vast majority, this would seem absurdly and even
dangerously inadequate, and yet the infrequency of
the discharge in such cases, as being in consonance
with the small amount of intake, must be regarded
as natural to the physiological working of the
individual, and, as such, not lightly to be interfered
with. These people are, however, not ordinary people,
and th ough it is wise to remember not only their
existence, but also the physiological lesson of which
they present living examples, it would be foolish to
accept them as a standard by which to measure the
practice of the majority.

The ordinary individual does not regard his diet
from the standpoint of mere existence; he likes a
balance on the right side, and is consequently in the
habit of eating more, both in quality and quantity,
than his system can possibly make use of. The excess
in quality supplies him with a stimulant which he
enjoys, which, indeed, he may even find necessary
to the accomplishment of his daily work ; the excess
in quantity is a mere accident, as it were, a con-
comitant of the excess in quality, which he takes
because it is part and parcel of the things he likes.
This excess in quantity consists of what has been
called ballast — material, that is, which he cannot
digest, because it is indigestible by nature, material
such as vegetable fibre and other constituents of food
over which the digestive ferments exercise no dis-
solving influence. It is of the excess in quantity
thus constituted that the fajces are for the most par

CONSTIPATION, DIAKKHCEA, ETC. 97

composed. Some of the excess in quality — a portion
that is, of the material which is by nature digestible —
also enters into their composition, especially when that
excess is very conspicuous ; but the discharged matter,
as a rule, consists of material which has escaped
digestion, not because the digestive organs are at
fault, but because the material itself is insusceptible
of solution and conversion into chyle. It is the
inadequate discharge of this material which consti-
tutes the condition which we are now considering.

It will be convenient to spend a moment in tracing
the course of the excess in quality, and to inquire
what becomes of the soluble material which is con-
sumed, even though it is not wanted and cannot be
utilized. Some of it doubtless becomes entangled
in the indigestible residue, and under favourable
conditions is harmlessly discharged. The greater
portion, however, is metabolized and ultimately finds
its way into the blood. Nature's processes being
essentially thrifty, the excess is not immediately
thrown away; it is stored for use on a rainy day, as
it were, and is deposited as adipose tissue in various
parts of the body. There is reason to believe that
the process of this manufacture of fat, at any rate
after a certain quantity has been deposited, is
attended by by-products which exercise a very
deleterious influence on the economy, and give rise
to gouty, rheumatic, and kindred manifestations.
The bearing of this upon the subject of constipation
is this : that not only the original excess itself, but

7

98 MINOR MALADIES.

also the by-products, have infinitely less chance of
escape if the faeces are unduly retained.

Constipation may be either occasional or habitual.
The former is seldom important, except in so far as it
tends to lead to the latter, and this it does more often
on account of its injudicious treatment than for any
reason inherent in the condition itself. From the
fact that there are so many remedies for it on the
market, which are always given an extended trial
before recourse is had to medical advice, occasional
constipation is a matter about which a doctor is not
often consulted. He may, however, be consulted
about conditions which are directly due to a loaded
rectum, though the cause is unsuspected by the
patient. Diarrhoea is one of these, haemorrhoids is
another ; but perhaps the most common are un-
defined digestive disturbances. It is also well to
remember that a loaded rectum may be the deter-
mining cause of an asthmatic attack, a hysterical fit,
an epileptic seizure, or of some even more obscure
reflex manifestation, and that the nervous instability
which these things denote will remain obdurate to
treatment unless the simple, but easily overlooked,
cause be removed.

Three remedies stand pre-eminent in the treatment
of occasional constipation of this sort, and with
regard to them, it is well to state at once, that
their use in habitual constipation is as futile and
injurious as their employment in occasional constipa-
tion is desirable and successful. The first is castor

CONSTIPATION, DIARKHGEA, ETC. 99

oil, the second calomel, and the third a soap-
and-water enema. Castor oil is a simple aperient,
which generally acts without griping and may safely
be given to people of all ages. The great drawback to
its use is its nauseous taste, to overcome which various
so-called tasteless oils have been placed on the market.
With regard to these, it must be remembered that, to
be efficacious, very much larger doses are necessary
than in the case of the ordinary oil, and that none of
them is quite tasteless. In order to avoid the taste,
in so far as it is possible to do so, the dose of the
ordinary oil should be given in milk, with which the
rim of the glass has previously been wetted. If in
the drinking care is exercised not to allow the oil to
come into contact with the teeth — if, that is to say,
the dose is 'tossed off' — the unpleasant taste is slight
and transitory. Ringer says that a mixture con-
sisting of castor oil, i ounce; fresh mucilage of
acacia, 3 drachms ; distilled water, 5 drachms ; with,
say, 3 drops of oil of peppermint, has very little
taste.

Calomel is rightly considered the best purgative we
possess, mainly because, in addition to being a purga-
tive, it is an intestinal antiseptic of the highest value.
The mistake which is commonly made in connection
with it is that of giving it in large doses — i.e., 2-5
grains. It effects its purpose much more satis-
factorily if given in quite small doses, say J or J
grain, repeated every four hours until the bowels
act, la this way it remains much longer in tha

100 MINOR MALADIES.

intestinal canal, and its antiseptic properties have
therefore an opportunity of exercising their beneficent
efifects. The importance of these properties in the
treatment of occasional constipation does not seem to
be realized ; people appear to imagine that purgation
is of itself an antiseptic measure. Such it may be,
but very often it is the reverse. Faeces which remain
a long time in contact with the colon become quies-
cent, but as soon as they are disturbed by a purgative
their toxins are set free, and unless the purgative con-
tains the means of counteracting the effect of these
toxins, it may do a great deal of harm. Calomel being
the most reliable of all intestinal antiseptics, and a
hepatic stimulant to boot, it is infinitely the best
agent for occasional purgation. As a rule, it is
advisable to follow an evening dose of calomel with a
morning dose of aperient water.

Where it is desired to wash out the lower bowel
without unduly stimulating the small intestine, or
where the object is to hasten the action of a purgative
given by the mouth, a soap-and-water enema is an
excellent measure. For reasons just referred to,
however, it is always well to add an antiseptic to the
enema, and one of the best for this purpose is oil
of eucalyptus, 4 or 5 drops of which should be well
agitated with the soap and water before administra-
tion.

There is one practical point in the giving of an
enema to which I should like to direct attention.
Everyone knows that the fluid should be about

CONSTIPATION, DIARRHCEA, ETC. 101

100° F., and everyone is aware that the success of the
operation depends upon its being performed very
slowly ; but very few seem to realize either that the
nozzle of the ordinary syringe is about the worst that
could have been devised for its purpose, or that a very
efficient substitute is very readily obtainable. The
ordinary nozzle is too short, so that, in order to
prevent the regurgitation of fluid, the disc which
separates the nozzle from the tube has to be firmly
pressed against the anus, a process which may give rise
to considerable pain. This nozzle should, therefore,
be removed, and an ordinary No. 12 gum-elastic male
catheter be put in its place. The bone rim at the
end of the catheter is almost an exact fit for the
rubber of the syringe, and will retain its place without
wire or cord. The catheter thus attached, when
warmed and oiled, makes an admirable nozzle. It is
introduced without pain, it reaches well up to the
sigmoid flexure, and, if the patient's pelvis is elevated,
as it should be, the fluid shows no tendency to
regurgitate.

So much, then, for occasional constipation. We
now pass to tho consideration of the far more im-
portant subject of habitual constipation. Of this
condition I would like to affirm at the outset that
it is in the vast majority of people a malady which
is eminently and easily curable, provided that it has
not been long enough in existence to cause gross
alteration in the anatomical relations of the parts,
and the persistence of this alteration by the forma-

102 MINOR MALADIES.

tion of adhesions, kinks, and bands. It is not, as
a rule, until middle age is reached that chronic con-
stipation becomes incurable by medicinal means.
And, although it is one of the commonest and most
curable of maladies, it is, unfortunately, true that
it is the one that is least often cured; that it is
allowed to remain one of the chief scourges of our
present civihzation, vying even with alcohol and
syphilis in the multiplicity of its consequences and
their magnitude. That it can be made to rank with
the two latter is due to the fact that, like them, it
supplies a toxin to the blood, which so befouls all
the tissues as to render them suitable breeding-
grounds for all kinds of microbes. The poison wears
down the normal defences and allows the enemies
to enter, to flourish, and abundantly to multiply.

Why it is that civilized man should be a consti-
pated animal is a question that requires answering.
And the answer is not, in truth, very far to seek.
It is this: Civilized man eats too much, thinks too
much, and sits too much. Also, he uses a water-
closet. Uncivilized man hunted his food, and thus
justified its consumption. He frequently fasted,
either actually or relatively. The hunting kept his
abdominal muscles in good order ; and he slept, as a
child sleeps, prone and fatigued. Civilization, not
altogether devoid of advantages, is, physiologically,
full of drawbacks. The control of the lower centres
by the higher is essential to social life ; it is the pivot
round which the community revolves, and the dis-

CONSTIPATION, DIARRHCEA, ETC. 108

gusting act of defseeation is very properly the first
to be brought under the iron heel of propriety.

Very early in the life of the child the control
centres are invoked, and defseeation, which, in
strictest physiology, should occur after each meal —
that is, at least thrice daily — is severely battened
down until it reaches the level of a grudging diurnal
concession to lower things. Then come social,
scholastic, and other exigencies; the control is still
further developed, until at length the control attains
such complete mastery that the tail restrains the
whole dog. That is the foundation; the super-
structure erects itself.

This hypertrophic development of the control
mechanism is the cause of all the trouble. In very
early days, when the child is still on the level of the
pot de chambre, he is discouraged from using it too
frequently. Then he is promoted to the water-
closet, to poise himself on the seat of which is all
the more an acrobatic feat to him because his
instinct tells him that to fall backwards into that
seemingly bottomless pit would be the end of all
things. Then come the school-days, and the neces-
sity for regulating and still further controlling the
excretory act. Boys are not encouraged to void
their excreta, and girls are often positively dis-
couraged. * You must not give way to those feel-
ings; you must learn to control them.' Alas ! she
proves all too apt a pupil. The control attains not
only to mastery, but to despotism ; and the healthy,

104 MINOR MALADIES.

clean-skinned adolescent rapidly becomes the sour-
smelling and sour-tempered adult.

If peradventure such a victim ot custom and les
covenances should at this point come in contact with
a medical man who has not been impervious to the
gospel according to Arbuthnot Lane, he may still
find salvation. But even so, with reason and good
advice to guide him, in comparison with the savage
he finds himself handicapped. Many a time and
oft he would like to, but cannot ; letting * I dare
not ' wait upon * I would ' ; and even when he can,
he is still surrounded by enemies. The chief of
these is the modern water-closet. Savage man per-
force adopts the crouching attitude, normal and
necessary to complete emptying of the lower bowel,
and he has only to turn round to assure himself
that the bowel is indeed empty, that the tribute of
the descending colon is really sufficient to lighten
the burden of the day's work, and that he is, so to
speak, a free man. The beneficent psychic effect
produced by the sight of a generous stool cannot be
overestimated. It turns a melancholy man into a
joyous one; it makes the timid courageous and the
lazy energetic. Now, the modern water-closet, for
all its sanitary perfection vis-a-vis the community,
is grossly defective vis-d-vis the individual, because
it deprives him of the mental stimulus of the up-
lifting vision afforded by the result of his peristaltic
labours. Nor is this its only crime. That its
fathomless depth should deprive man of the satis-

CONSTIPATION, DIARRHOEA, ETC. 105

faction of ocular appreciation is bad, but it is almost
worse that its height from the ground should para-
lyze his abdominal muscles. These muscles are
little enough exercised by sedentary man, but when
seated on the ordinary everyday water-closet, he
could not exercise them even if he would. A chair
or a tall footstool may find him salvation by raising
his knees, but if the basin itself were properly con-
structed, these adventitious and easily neglected
aids would not be necessary. The Jennings, the
Doultons, and the other practical sanitarians who
have placed this generation under real obligations,
should extend their energies to the standardization
of a rational and physiological closet.

And what, in this connection, is meant by the term
* a sufficient evacuation ' ? The reply to this question
given by a sergeant to a medical officer is worthy of
record. ' What do you mean by a good rear ? '
The answer was prompt. ' Twice round the pan and
pointed at both ends.' Such, no doubt, represents
an occasionally attainable ideal to the man who
pays his homage to Cloacina but once a day. But
the man who knows, has an ideal at once more
attainable and more workable : he solicits the goddess
at least twice daily, and, careful though he be of the
nature of his matutinal offering, it is to the vesper-
tinal that he attaches the major importance. Then,
freed from the press and distress which pursue him
by day, he learns to lay his willing latria leisurely,
leniently, and lavishly at her gracious feet.

10(5 MINOR MALADIES.

On the question of the mechanism of normal de-
faecation, Professor Arthur Keith shed a flood of
much - needed light in his Cavendish Lecture.^
Therein he showed that the intestinal tract has
several ' bundles ' in many ways comparable to the
bundles in the wall of the heart which originate the
rhythmical contractions of that organ. The matter
is best stated in Professor Keith's own words : * In
passing along the alimentary tract food is propelled
through a series of zones or segments, each furnished
with its own pacemaker and its own rhythmical con-
tractions. In the heart we find two such zones, an
auricular and a ventricular ; in the normal heart the
sino-auricular node is the master pacemaker. But
a block or imperfection in conduction may occur
between the two zones of the heart, with the result
that "back-pressure" — a venous stasis — is produced.
Now, seeing the similarity between the cardiac
and alimentary motor mechanisms, we do not
seem overpresumptuous if we suppose that irregu-
larities may occur in the nodal and conducting
system of the alimentary canal — irregularities of
the same kind as are known to occur in the heart.
When such irregularities or blocks do occur, we
should expect to find them at the points where one
rhythmical zone or area passes into the succeeding
zone. That is exactly what we do find. We find
a block where the oesophagus joins the stomach;
we find another where the gastric zone ends and the
* Medical Press a/nd Circula/r^ July 28, 1916.

CONSTIPATION, DIARRHCEA, ETC. 107

duodenal begins ; we find it where the duodenal zone
passes into the jejunal, and where the jejuno-iliac
passes into the ileo-colic. We find a block may
occur at any point of passage from a lower to a
higher rhythm. At several of these junctional
points sphincters are situated, and I do not deny
that the mechanism of such sphincters may become
disordered and cause alimentary stasis, but it will
probably be found that a disturbance in the action
of a sphincter is secondary to a disturbance in the
excitability and action of the whole rhythmical zone
or segment to which it belongs.

' Further, it is clear that to obtain an orderly
propulsion of the food along the whole length of the
alimentary canal those various rhythmical zones
must be closely co-ordinated in their action, and
there is a growing body of evidence, both experi-
mental and clinical, that points to a very close co-
ordination by means of a complicated system of
reflexes. Disturbance in any one segment upsets
the rhythm in all the segments. Bayliss and Star-
ling observed that distension of the duodenum in-
hibited the action of the ileum; surgeons are fami-
liar with the fact that a duodenal disturbance upsets
the rhythm of the stomach. From the facts already
mentioned it is easy to see that disturbance in the
excitability and rhythm of the pacemaker of the
cfiecum will be reflected to the lower ileum. One
can understand, on the hypothesis I place before
you, how stasis in the great bowel may be followed

108 MINOR MALADIES.

by ileal stasis, duodenal or gastric stasis, or how a
disturbance of the conductivity or excitability of
any of the rhythmical zone may ultimately give rise
to stasis in all.*

The pathology of the physiological position thus
expounded is supplied by Sir William Arbuthnot
Lane in his book on ' Chronic Intestinal Stasis,'^ a
work which should be carefully studied by anyone
who desires to have clear ideas on this all-important
question. Briefly stated, the sequence of events is
as follows: The erect posture of man, which tends
to displace the abdominal viscera downwards and
backwards into the true pelvis, in perfectly normal
conditions is counterbalanced or compensated by
the prone position during sleep, which tends to
return these same viscera upwards and forwards,
away from the true pelvis. Thus, the drainage,
which is impeded during the day, becomes free and
active during the night. If the counterb^».3ance or
compensation should fail from any cause, st'ch as
a faulty position during repose, changes occur.
These changes, originally designed for the purpose
of maintaining the viscera in their places, ultimately
reach such a point of development as to defeat their
own ends. By the kinking of the tube and the con-
sequent narrowing of its lumen, what was intended
as a support becomes an obstruction, much as a
lead pipe may be seen to kink over its narrow bracket
when exposed to heat. The accompanying diagram,
» Adlard and Sons, 1915.

CONSTIPATION, DIARRHOEA, ETC. 109

reproduced from Sir William Arbuthnot Lane's
book, shows very clearly the end-results of the pro-

07 p.

cess which he describes in detail. I say end-results
advisedly, for it must be borne in mind that the
complete monstrosity which the diagram represents

110 MINOR MALADIES.

usually takes about forty years to develop. The
physician is concerned with the matter at a very
much earlier stage, and it is entirely due to the bril-
liant pioneer work of Sir William Arbuthnot Lane
— work for which his own and future generations
cannot sufficiently honour him — that we are in a
position to forestall and prevent the banding and
kinking which impose such untold and such protean
miseries upon their victims.

Inasmuch as our ideas of the normal are neces-
sarily based upon the majority, and inasmuch as
intestinal stasis, in some degree, is a condition which
afflicts the vast majority, it is no wonder that its
symptoms and physical signs escaped recognition-
until Sir William Arbuthnot Lane came with clear
vision to rescue humanity from its own cesspool.
There are people, and they are many, and most of
them are unconscious delinquents, who hoard their
faeces as a miser hoards his gold. A certain amount
is daily and laboriously given to the world, but, in
comparison to what remains behind, the amount is
mean, physiologically insufficient, and therapeuti-
cally ineffectual. When young, these people carry
their avarice upon their earthy, oily, and pimply
faces. In middle age they become anaemic, scant
of breath, exiguous of shin, and abdominally opu-
lent. Old age they never reach; or, reaching it,
they afford examples of the slippered, petulant
pantaloon whom Shakespeare has rendered classical.
Methodical but persistent intestinal drainage has

I

CONSTIPATION, DIARRHCEA, ETC. Ill

now become a rule for him who has eyes to see, ears
to hear, and a nose to smell withal. Intestinal
stasis was not, it is true, invented by Arbuthnot
Lane, for it was known to Galen and Celsus, but he
rediscovered it, and his originality and fearlessness
have imposed its cure as a necessary condition pre-
cedent to all other cures. The therapist who now
neglects it, thus proclaims his own sad stasis in
matters scientific.

It is but a slight exaggeration to declare that every
chronic disease is a symptom of chronic constipa-
tion. It is no exaggeration whatever to say that
chronic constipation is at least a contributory cause
in all chronic disease. At the back of the microbe
there is to be bought the cause of the microbe, and
this cause in every case is the state of the soil which
permits him to flourish. Such a state of soil is
described as a chronic auto-intoxication, which is
only another way of saying that the drainage system
is defective. And when the drainage system is de-
fective to the point of there being a cesspool under
the floor of the gastric dining-room, the powers of
resistance are so reduced that the microbe comes
and takes possession with easy and stupefying as-
surance. There are many diseases about which long
articles and even large volumes have been written
— pyorrhoea alveolaris and rheumatoid arthritis, for
example — and many dyscrasias — the gouty, the
glandular, the acid, and the migrainous, to wit — ■
which are no more than symptoms of chronic intes-

112 MINOR MALADIES.

tinal stasis. The percolations from the cesspool
have permeated the soil, and the whole carcase
becomes inhabited by the fauna and flora of de-
composition and disease. The particular members
of these hostile groups which are destined to lead
the invasion, and the particular points selected for
their ultimate development, are decided by considera-
tions which are at present beyond us.

This general result, the toxsemic, of chronic con-
stipation is not sufficiently insisted upon. The
symptoms usually cited are correct enough in their
way, but they are too local and too topical, and
therefore too singular. The earthy complexion, the
cold extremities, the subfsecal odour of the axillae,
the emaciation, the general malaise. Lane's cystic
breast, and the like, are very real manifestations of
the poisoning, but it is to be remembered that the
same poisoning forms the foundation upon which
actual diseases are built. Such are rheumatoid and
other forms of arthritis; exophthalmic and other
forms of goitre ; ' borderland ' and other functional
nervous manifestations; menstrual disturbances and
various gynaecological conditions; and others too
numerous to mention. The existence of a chronic
disease should thus create a suspicion in our minds
that its existence and continuance are rendered
possible by insufficient intestinal drainage. The
individual symptoms just referred to will always
help in this direction; but even in connection with
tliese it must be remembered that they must be

CONSTIPATION, DIARRHCEA, ETC. 113

looked for; none are so salient but that they easily
escape the superficial observer.

From the foregoing it follows that in treating
chronic constipation we are treating not only a
toxic blood state, but we are also treating many so-
called diseases, and that many so-called diseases
cannot be satisfactorily treated unless and until the
constipation and the consequent blood state have
been successfully dealt with. This does not mean
that the said diseases do not require any additional
form of treatment for the alleviation of the symptoms
which form the complex of each. They do. But it
does mean that unless the constipation and the
toxaemia are removed, treatment directed to the
more obvious 'manifestations will be attended by a
very fleeting improvement. The textbook thera-
peutics of such diseases generally includes the phrase
' attend to the general health.' This should be ex-
tended so as to read * attend to the general health
and especially to the intestinal drainage.'

Thus, in the treatment of intestinal stasis there
are two main indications. The first is to discover
and remove the cause of the stasis; the second, to
nullify the toxaemia. The first is a problem which
in the present state of our knowledge is surrounded
by very considerable difficulties. We do not know
enough to enable us to act with certainty and pre-
cision. We know very little about Professor Keith's
intestinal ' motors.' We know that they exist, but
we do not know what actuates them ; still less do we

8

114 MINOR MALADIES.

know what throws them out of gear. We know
how Lane's * kinks ' and the ' controlling appendix *
act in producing intestinal stasis, but we do not
know why they themselves are produced. The
method of their mechanical production has been
shown us, and shown us in a manner so lucid and
convincing that the dullest may see and believe;
but the predispositions which lead to this mechanism
still lie hidden in a closely sealed book.

Nevertheless, we have some empirical knowledge
of the action of drugs in the treatment of constipa-
tion, which, when applied with judgment, insight,
and some accessories, enables us to do a great deal
to fulfil the two main indications. The question of
the second indication, the nuUification of the toxae-
mia, is one to which but very scant courtesy was
paid until it engaged the attention of the vaccinat-
ing bacteriologist. If this eager truth-seeker has
done little else of value, he has at any rate taught
us not only the real importance of, but the possi-
bility of attaining to, something in the nature of
relative intestinal cleanliness. That this may be
assured by means less complicated than the prepar-
ing and inserting of vaccines, does not detract from
the merit of the vaccinator. Of these means one
of the best is the regular exhibition of paraffin oil.
The oil is said to be a laxative, which no doubt it
sometimes is, but its beneficial effects upon the whole
organism can scarcely be due to its very moderate
power in this direction. Exactly how it behaves is

CONSTIPATION, DIARRHCEA, ETC. 115

not easy to say, but it probably prevents the larjj:o
intestine from absorbing undesirable matters by
blocking the mouths of the glands ; and, by dissolv-
ing and carrying off toxins, both liquid and gaseous,
it reinforces the natural defences against toxic in-
vasion.

Paraffin oil should be as viscid as is consistent
with the fluid form — that is to say, it should have
a specific gravity as near 0*890 as possible. The
pure oil is quite tasteless. There are, however, some
people who object to its consistency; in these cases
there is no objection to combining it with other
substances, such as malt, so as to form a powder,
or emulsifying it with acacia, which is done in some
deservedly popular preparations. To combine it
with active drugs such as iron or the iodides is a
mistake. No good is gained, and the issue is ob-
scured. In connection with paraffin there are two
warnings which should be laid to heart. The first
is that if it passes through the intestines so as to
reach the outer world in a form still recognizable as
paraffin oil, the fact must be taken as an indication
either that the dose is excessive, or, what is more
frequent, that the oil is insinuating its way past
an obstruction which it is unable to move onwards.
In the one case the dose must be decreased; in the
other a purgative, such as calomel, is necessary.
The second warning refers to the power as a solvent
which the oil possesses, a power which necessitates
caution in prescribing it together with other drugs.

116 MINOR MALADIES.

One of these is thymol, which, from the fact that it
is a very good intestinal antiseptic, might easily be
prescribed to be taken in conjunction with the oil
if this warning were not heeded. The symptoms of
thymol-poisoning, thus induced by a very moderate
dose, are very unpleasant and alarming. A warn-
ing of another kind in connection with paraffin is
one which should always be given to a patient who
is about to take it for the first time. It is that
paraffin oil leaks through the anal aperture often in
such quantities as to soil the linen and even the
outer garments, without the victim being cognizant
of its passage. Omission to issue this warning has
been known to bring the patient back to the pre-
scriber with a burning fire on her lips and a dress-
maker's bill in her hand.

There are several drugs whose claim to act as
intestinal disinfectants is generally admitted, and
there are many more whose obscure but beneficial
effect upon the organism generally is probably due
to an underlying disinfectant power either in the
intestines themselves or in the blood-stream. Of
the latter, quinine may be taken as example. Of
the former, thymol has already been mentioned.
Thymol is an intestinal antiseptic of undoubted
potency, which, if certain precautions are observed,
may be given in much larger doses than those sug-
gested by the Pharmacopoeia (J to 4 grains). Inas-
much as it is very soluble, not only in paraffin oil, but
in castor oil, olive oil, and oil of turpentine, these oils

CONSTIPATION, DIARRHOEA, ETC. 117

should not be given at the same time as the thymol.
It is also very soluble in alcohol, ether, and chloro-
form, so that mixtures which contain these should
be avoided. If these facts are borne in mind, thy-
mol in powder, enclosed in a capsule, which may
advantageously be keratinized, can safely be given
in 10-grain doses, twice or even three times daily.
Thus given, it acts not only as a disinfectant of the
intestinal canal, but as a very powerful deodorant
of the fseces. To do any real good it must be given
over long periods of time, say a month or six
weeks.

The salicylates, especially in the form of salol
(salicylic ester of phenyl), quinine salicylate, and
bismuth salicylate, have a considerable reputation
with some physicians as efficient intestinal antisep-
tics. I cannot, however, share in the enthusiasm
which is sometimes expressed for them. In my
hands their results have been disappointing. The
same may be said of beta-naphthol, of which many
speak in high praise ; it has never succeeded in con-
vincing me of its efficacy. With its cousin-germane,
benzo-naphthol, prepared by the action of benzoyl
chloride on beta-naphthol, it is far otherwise. I
regard this drug as second to none in its power of
disinfecting the intestinal tract and the blood-
stream. It may be given in doses of 10 to 15 grains
three times daily as a tabloid (grs. v.), or in a cachet.
Unlike thj'^mol, no special caution is necessary in
prescribing it; and unlike beta-naphthol itself, it

118 MINOR MALADIES.

docs not seem to have any tendency, when given
over long periods, to derange the kidneys.

One of the best of the intestinal disinfectants is
mercury, but as mercury in all its forms is something
more than a disinfectant, its use is necessarily
limited by its chief physiological effects; it is con-
sequently outside the present category.

In the objection which is sometimes urged against
chemical intestinal disinfectants it must be admitted
that there is much force. The objection points out
that an efficient bactericide will kill not only the
enemy microbes, but those friendly ones upon whose
beneficent activities Metchnikoff insisted with such
curious results. This is a very pertinent criticism,
which it would be more easy than it is to dismiss as
mere theory, if the results of our present antiseptic
therapy were always clinically satisfactory. In
certain cases these chemical disinfectants succeed
admirably, but in others they fail, and their failure
reminds us that the real intestinal antiseptic is to
be found in the intestine itself. If we could but
evoke an increased activity of the natural defences,
the necessity for such aids as thymol and benzo-
naphthol would disappear. Attempts are already
being made in this direction by administering
' secretin ' and other hormones. It is still too early
to write with confidence on the measure of success
which is to be expected from such endeavours, but
the principle is undoubtedly sound. I have had
some experience with a preparation known as

CONSTIPATION, DIARRHCEA, ETC. 119

Secretogen (G. W. Carnrick), and the results have so
far seemed to justify the hopes which led to its
introduction. It appears to stimulate the gastro-
intestinal tract to more vigorous function, and thus
to lessen the toxeemia. It seems well worth a
trial in cases where the poisoning has led to loss of
appetite and digestive disturbance.

We pass now to the consideration of the measures
at our disposal for overcoming the stasis itself.
Amongst the most important of these is the ensuring
of proper support for the abdominal viscera, by
toning and if necessary re-educating the muscles
which form the anterior abdominal wall. It is not
necessary here to consider the matter further than
by saying that massage and properly directed exer-
cises are capable of doing a great deal of good in
this direction. Mechanical supports are very useful
adjuncts even to well-developed abdominal muscles,
especially after middle age, but the supports should
be conceived on sound anatomical principles and
carefully executed so as really to fit the individual
patient. A great many of the abdominal belts upon
the market are worse than useless, inasmuch as, by
constricting the area above the umbilicus, they en-
courage the viscera in that fatal descent into the
pelvis which is so surely productive of kinks and
bands. Many a good corsetiere is capable of making
a well - fitting abdominal support, the so-called
straight-fronted stays being very serviceable to this
end. Messrs. Walton and Curtis, of 8, Old Caven-

120 MINOR MALADIES,

dish Street, make an excellent contrivance for tlii^
purpose, the original lines of which were, I believe,
suggested by Sir Arbuthnot Lane himself.

In so far as our knowledge permits, we should base
our application of purgatives upon ascertainable
facts. It is, for example, desirable to find out which
of Keith's intestinal motors is at fault, and if possible
to stimulate that particular one without overstimu-
lating and thus fatiguing the others. In all pro-
bability it is this fatigue of overstimulated motors
to which we refer when we speak of a purgative —
e.g., castor oil — which leaves * after-constipation.*
It is too often assumed that the evil effects of stasis
are due solely to absorption from the large intestine,
an erroneous assumption which dictated the heroic
lavage of the colon which is known as the Plom-
bieres treatment. I am very far from saying that
such treatment is undesirable. I believe, on the
contrary, that in cases where the stasis is really in
the colon, it is capable of doing a great deal of good,
especially as a measure preparatory to treatment
at once more sustained and more gentle. That the
stasis is often, perhaps most often, in the small in-
testine is obvious both from a study of Lane's kinks
and the consideration of Keith's motors. In the
bismuth meal and the radiograph we are now
fortunately possessed of a certain means of diag-
nosis on this very important point, and where such
means are available they should always be appealed
to. The two thinofs which have most retarded the

CONSTIPATION, DIARRHOEA, ETC. 121

scientific study of chronic constipation are the uni-
versahty of the ailment and the superficial ease with
which it may temporarily be overcome.

We do not yet know enough about Keith's motors
and the causes which disorder them to enable us to
deal effectively with their derangement, but we do
know that certain drugs affect certain areas by pre-
ference. Mercury, podophyllin, and euonymin, for
example, exercise their influence mainly in the
duodenum ; the sulphates of sodium and magnesium
are active primarily in the ileum; colocynth chiefly
in the large intestine; and aloes almost exclusively
in the rectum. Most of the other purgatives which
we employ — for example, cascara, rhubarb, and
jalap — afl^ect more than one area, and a great many
produce their results as stimulants of the whole
gastro-intestinal tract, bringing all or most of the
motors within their influence. It is a curious and
senseless and wholly unscientific parrot-cry which
invests nux vomica with any power as a purgative.

The search for a drug which will at once relieve
constipation and abolish a tendency thereto is like
the search for the elixir of life or the philosopher's
stone. A little consideration will show that such a
drug does not and cannot exist. For under what
euphemism soever their real effect may be concealed,
whether they be called aperients, laxatives, hydro-
gogues, purgatives, cathartics, cholagogues, or what
not, every one of them is essentially an irritant
poison with a selective action on the alimentary

122 MINOR MALADIES.

tract or some part thereof, which, when taken
habitually, provokes the production of antibodies
which will ultimately more or less completely nullify
its action. The discovery of cascara gave some
encouragement to the futile search for an ideal drug,
but anyone with any real experience of its properties
must realize that its merit resides solely in the fact
that it produces antibodies more slowly and less
vigorously than most others. In the long-run the
antibodies are duly evoked, and the dose of cascara
must be increased. Until further investigation
succeeds in throwing more light upon the whole
question, we are thus reduced to handling such
aperients as we possess, so that no one of them is
employed to the point of producing its antibodies.
This means that in the treatment of chronic con-
stipation, in addition to paraffin oil and benzo-
naphthol, we must ring the changes on various
laxative drugs. It is my own practice to give a
list of seven, one for each day in the week, with
strict injunctions to the patient that, vary them as
he will, he is not to take any one for more than two
days in succession. In otherwise healthy adults
my list always includes cascara, one mercurial and one
saline; in children, aloin; in old people, belladonna.
A very good pill which figures in most of my lists
is one of whose composition I am ignorant — Pil.
Savonneuse (Boissy).

In the matter of salines, it is to be remembered
that these are less irritant than most other laxatives,

CONSTIPATION, DIARRHCEA, ETC. 123

and are much less likely to evote the neutralizing
anti-bodies. They act by attracting fluid into the
intestine, and thus aid in flushing out the back-
waters. SaHnes have thus many advantages over
most other laxatives. The disappearance from the
market of the Austrian and German natural aperient
waters at first caused some difficulty. British firms
have now, however, filled the gap by the introduction
of suitable substitutes. I can speak well of Tonalka
and of Apwa.

|In combating the deeply rooted prejudice against
the habitual taking of laxatives, begotten of the
excesses of our forefathers, the profession of to-day
has a long and fetubborn furrow to plough. Nothing
is more common than for patients to object to any
treatment suggested for chronic constipation on the
grounds that they do not want to get into the habit
of taking drugs. That is academically a praise-
worthy attitude, the reply to which is that it is
much better to take drugs than to be a walking cess-
pool. The most difficult people to persuade are
those who are satisfied with a small but perfectly
regular daily motion. They will not believe that
there is a residue, the absorption of whose toxins is
the cause of the symptoms arising in diverse places,
most of them remote from the abdomen. Until the
profession succeeds in overcoming these prejudices
and obstinacies, the most potent cause of what may
be called out-patient maladies will continue to
flourish with destructive security.

lU MINOR MALADIES.

DIAEEHCEA.— The first thing we have to re-
member about this condition is that, except in
children, it cannot be regarded as a disease per se.
In the latter it must always be regarded as much
more than merely symptomatic, and as in them tho
condition is Hable to assume an aspect of the highest
importance and the utmost gravity, which is ade-
quately dealt with in most textbooks, I do not pro-
pose to refer to it, beyond caUing attention to a
very masterly presentation of the subject to be
found in Dr. Edmund Cautlcy's work on the
"Diseases of Infants and Children."^ The same
author contributed a pajDcr entitled " Summer
Diarrhoea " to the Medical Press and Circular, wliich
appeared on July 14, 1915, and is one of the most
practical and helpful papers I remember to have
read upon a very common and Httle understood
malady. In view of the latter-day campaign for
the preservation of infant and child life, it behoves
the medical man to be thoroughly well equipped in
the treatment of such diseases as show a high infant
mortahty. Summer diarrhoea is one of these. It
requires very prompt and thoroughly instructed treat-
ment, with the details of which the young practitioner
Bhould make himself quite f amihar. This is the more
necessary because he will frequently encounter very
decided opposition from ignorant mothers and nurses
who are quite unable to appreciate the necessity for
the measures which must be insisted on.
» London, Shaw and Sons, Fetter Lane,

CONSTIPATION, DIARRHCEA, ETC. 125

Diarrhoea in the adult, except where it means
typhoid, dysentery, or some equally obvious condition,
spells intestinal irritation. And in connection with this
irritation we have to remember that what will irritate
one person will fail to produce any effect upon another
— or, for that matter, upon the same person under
different conditions. The diarrhoea of the neurotic or
neurasthenic person, for example, is an instance of
the result of very minute stimuli upon a sensitive
organism, and the proper way of treating it is not by
attempts to remove the irritation, but by lessening the
reactive power of the individual. There are a good
many people who go about in mortal dread of being
'taken short' ^t inconvenient times and places —
e.g., in church, or on a long railway journey ; and
their nervousness under such conditions supplies the
stimulus necessary for the production of the very
condition which they dread. In such cases the
exhibition of the bromides and other measures,
physical and moral, calculated to strengthen the
nervous equilibrium, constitutes the proper line of
treatment. Astringents, especially opiates, should be
avoided.

Diarrhoea may be salutary. This is worth remem-
bering, especially in view of the fact that the condition
is, to say the least of it, very inconvenient, and that
the subjects of it are consequently very insistent in
demanding relief. It is salutary when, as in alcoholism
and kidney disease, the bowels are called upon to do
more of the excretory work of the body than legiti-

126 MINOR M4LADIES.

mately falls to their share. When such a state of
matters is to be suspected the right treatment
consists in calling upon the other emunctories,
especially the skin, to undertake their share of the
burden, and by suitable diet to lessen as much as
possible the manufacture of the offending material.
A hot bath — hot enough, that is, to produce free dia-
phoresis— is an expedient which is too much neglected
in the treatment of this condition. The warmth is
very giateful to the patient, and the diaphoresis
helps to relieve the work of the intestines. In this
way the diarrhoea is checked, while the discharge of
the offending material is not interfered with.

The commonest cause of diarrhoea, however, is the
presence of irritating matter in the intestinal canal
itself. Here the condition is not salutary, because it is
as a rule futile. The irritant, whatever may be its
nature, produces increased peristalsis below the point
at which it is situated, so that the resulting diarrhoea
tends to exhaust the patient, without in any way
contributing to the removal of the cause. In such
cases, which constitute the vast majority of those
with which we have to deal, an efficient evacuant
(say i ounce to 1 ounce of castor oil) which will
act on the intestine from above the site of the
irritant should be given at once. It seems needful to
dwell upon the necessity for this, because I find that
diarrhoea is so often treated by astringents without
any preliminary evacuant — a procedure which is as
unscientific as it is useless. Slight looseness of the

CONSTIPATION, DIARRHCEA, ETC. UJ

bowels may, of course, occasionally be successfully so
treated ; but we must remember that household
remedies have invariably been tried before a case of
diarrhoea reaches a doctor, and that household
remedies consist of astringents. To neglect the
evacuant, therefore, is to do wrong both scientifically
and tactically; the only effects of so doing are to
prolong the sufferings of the patient and to bring
discredit upon the practitioner.

When the bowels have been cleared of the offending
matter, astringents may be given with every con-
fidence. In these it is generally wise to include opium,
always supposing, of course, that the kidneys are in a
healthy conditipn. Opium not only assists the action
of the astringents, but it affords rest to the bowel and
soothes the irritated nervous system. The combina-
tion which I have found most efficacious for this
purpose is as follows :

Tr. opu

... ...

... i»ix.

Sp. ammon. co. ...

•.«

... itixxx

Ess. menth. pip. ...

.♦. ...

... tnxx.

Tr. catechu

... ...

... 3i.

Aquam

...

... ad§i.

M. Sig.: Ev-

ery

four hours.

Preceded by a dose of castor oil and a hot bath,
I have never known this mixture to fail in affording
relief in diarrhoea when the condition was caused
by a simple as opposed to a specific irritant. Diet
is, of course, an important matter in guiding the
malady to a satisfactory conclusion, but the dietetic

128 MINOR MALADIES.

management consists more in the application of
rational general principles than in the prescription of
any particular regime. It is advisable to remind the
patient that food, when well masticated and insalivated,
leaves very little for the irritated intestines to do,
and that the more thorough these processes are the
more quickly will the irritation subside. Milk is
probably the best food for those with whom it agrees.
For those who cannot take milk, fish, poultry, and
meat, as less liable to give rise to fermentation, are
better than farinaceous foods.

Diarrhoea is apt to appear as an early event in two
complaints, of whose existence it is occasionally neces-
sary to remind ourselves — namely. Graves' disease
and Addison's disease. The latter is not very com-
mon, perhaps, but when it does occur it is well for
all parties that it should be recognised early. To
this end it should always present itself as a possible
explanation of what may appear to be an ordinary
attack of diarrhoea. The same is true of Graves'
disease. This is far more common than Addison's
disease, and as its only other symptom may be
tachycardia, we should be on our guard against
dismissing as a little * intestinal irritation ' a case
which may ultimately progress to thyroid enlarge-
ment and exophthalmos. Tannigen (di-acetyl-tannin)
is a good symptomatic astringent. It should be
given in a cachet (10 grains) three times a day.

Fissure of the anus and stricture of the rectum
often lead to diarrhoea by causing accumulation of

CONSTIPATION, DIARRHCEA, ETC. 129

feces. Persistent diarrhoea in a person over forty
should always lead to a careful examination of tho
rectum, as malignant disease is, under such circum-
stances, probably the commonest of all causes.

A group of symptoms variously designated, but now
usually recognised under the title of mucous colitiSf
may bo associated either with constipation or diar-
rhoea. As a rule, the one alternates with the other,
but it is generally the diarrhoea which brings tho
patient under observation. There is always mucus in
the stools, sometimes in very large quantities, and it
is occasionally sufficiently organized to resemble shreds
of membrane (muco-membranous colitis). Not infre-
quently blood 'is also present. The diarrhoea, which
is accompanied by a considerable degree of pain, is
unaffected by the ordinary remedies, and leads
rapidly to emaciation and the development of symp-
toms of * nervousness.' So much is this the case that
mucous colitis has been considered a morbid entity,
and has been described as a neurosis. Against this
facile view of the matter and the mistaken therapy
which is its logical outcome, it seems necessary to
enter a warning. Lockhart Mummery has shown*
that mucous colitis is merely a symptom ; that it may
be due to a great variety of causes, amongst which
may be mentioned malignant disease, ulcers,
adhesions, retroflexed uterus, and the apparently
ubiquitous and inevitable appendicitis. The symp-
tom may, however, be due to a simple catarrhal

^ ' The Causes of Colitis ' {Lancet, June 16, 1907).

9

130 MINOR MALADIES.

inflammation of the large intestine, more especially
of the region of the sigmoid flexure (resembling the
catarrhal inflammation so commonly observed in the
upper air-passages), which has been induced by the
chronic irritation of masses of undischarged faecal
matter. When due to such a condition, the treat-
ment is both simple and efficacious, and, like that of
bronchial catarrhs, it consists in the application first
of sedatives and subsequently of astringents. The
best way of applying sedation is to irrigate the bowel
with the best lucca oil. Inferior oils are useless,
because they act as irritants instead of sedatives.
The oil, previously warmed, should be introduced
very slowly by a douche (not by a syringe) with a
catheter nozzle (see p. 101). The patient lies on his
right side, with the hips well raised and all his muscles
relaxed ; the douche- can is placed at a moderate
elevation (not more than 2 feet above the level of the
anus), and the oil is allowed to flow gently in. The
degree of inflammatory catarrh can to some extent be
gauged by the length of time during which the
patient is able to retain the pint of fluid thus intro-
duced. At first he may wish to return it at once, but
he must be encouraged to bear with it. As improve-
ment sets in, the irritability of the mucosa lessens,
and the oil is easily retained for several hours at a
time. When tolerance is established to the point of
permitting the retention of the oil for ten hours,
which generally occurs in the course of a week, an
astringent fluid, such as argyrol (1 per cent.) or

CONSTIPATION, DIARRHOEA, ETC. 131

potassium permanganate (1 in 2,000) may be substi-
tuted, after which complete subsidence of the symp-
toms quickly follows. It is needless to say that
during this treatment the patient should be confined
to bed ; nor should it be necessary to emphasize the
necessity for the utmost patience and skill in securing
that the injected fluid shall irrigate the whole length
of the large intestine. If this line of treatment does
not succeed in affording prompt and permanent relief,
it is practically certain that the colitis is due to some
cause more serious than a simple inflammatory
catarrh of the mucosa. An examination by means of
the sigmoidoscope should therefore be advised,

VOMITING, X like diarrhoea, usually appears as a
symptom of some definite underlying morbid con-
dition; but, like diarrhoea, it also occurs as an
apparently separate clinical entity, for which no
cause can be discovered beyond an undue irritability
either of the stomach itself or of the vomiting centre
in the brain. It is a common symptom of gastric
disorders, and in searching for a cause, one's thoughts
naturally turn primarily towards the stomach. It
should always be remembered, however, that there are
two serious conditions with which it is often asso-
ciated, and whose existence is liable to be overlooked
if we make the mistake of considering too exclusively
the gastric origin of the symptom : one is intracranial
disease, the other is renal disease. In both these
conditions the sickness may easily be the only obvious
symptom, and, unless we make it a rule always to

132 MLNOR MALADIES. ,

examine the urine and the fundus oculi in every case
of vomiting for which no obvious explanation is forth-
coming, we lay ourselves open to the risk of very
grave errors of diagnosis.

Cerebral vomiting is generally accompanied by
headache and optic neuritis, and careful search for
physical signs in the nervous system will nearly
always bring to light some other facts which point
to its true origin. It is a common and very dis-
astrous mistake to label as hysterical, sickness which
is due to some serious intracranial lesion. Vomiting
does, of course, occur in hysteria, but, then, hysterical
or * functional ' manifestations are of very frequent
occurrence in almost all intracranial conditions, so
that it is never safe to make a diagnosis of hysteria
until structural disease can be positively excluded.
In children vomiting is commonly an early event in
meningitis.

Vomiting may be the first event to call attention
to the existence of kidney disease, and negligence to
examine the urine may thus be fraught with very
serious consequences ; for if we do not realize that
the sickness is of renal origin, not only shall we fail
to treat the disease by appropriate means, but in our
endeavours to stop the vomiting we may have re-
course to measures, such as the giving of morphia
which may actually militate against recovery. More-
over, it is well to remember that absence of albumin
does not necessarily exclude the possibility of disease
of the kidneys. In nephritis, of the chronic inter-

CONSTIPATION, DIARRHCEA, ETC. 133

stitial type especially, albumin may be absent, so
that evidences of renal trouble must be sought for
by examination of the heart and arterial system — the
former for hypertrophy of the left ventricle, the
latter for arterio-sclerosis.

Other common causes of vomiting are hernia,
pregnancy, whooping-cough, and phthisis. It is,
of course, of the utmost importance to bear the
existence of these factors in mind, so that they may
be examined for. Our mistakes are less often due to
ignorance than to the forgetfulness or negligence
begotten of hurry. A form of vomiting which is
characteristic enough to lead one immediately to
suspect its true cause is that which heralds the
invasion of an acute specific disease. Here the
sickness is not accompanied either by nausea or
retching, but the contents of the stomach are sud-
denly, completely, and unexpectedly expelled without
pain or discomfort. Except where an emetic has
been given, this kind of sickness is very suggestive
of the onset of an acute fever of some sort.

The vomiting which occurs in association with the
condition variously called sick headache and bilious
headache is liable to be very troublesome, more
especially if the true nature of the underlying con-
dition is not recognised and treated. This matter
is fully discussed in the next chapter, but I may
say here that the name bilious, as applied to these
attacks, is particularly unfortunate, for the reason
that it suggests treatment by mercurial and other

134 MINOR MALADIES.

cholagogiie cathartics, than which, as a rule, nothing
can be more harmful. These attacks are in a very
large number of cases due to ocular refractive errors
and other peripheral irritants ; and unless the patient
is properly fitted with correcting glasses, or the irrita-
tion otherwise subdued, drugs such as phenacetin,
though they may give relief at the time, contribute
nothing whatever to the prevention and ultimate
cessation of the attacks.

The influence of refractive errors in the causation
of vomiting, apart altogether from headache, does not
seem to be sufficiently appreciated. It is by no
means uncommon for a person whose error — say a low
degree of astigmatism — has been corrected, and, before
he has accustomed himself to the use of the glasses,
to complain that the glasses cause nausea, and even
attacks of vomiting. These attacks will often lead
to the discontinuance of the glasses. This is a very
foolish procedure, into the result of which it is impos-
sible here to enter. What it seems necessary to insist
upon is that nausea, vomiting, and a host of other
symptoms, often rightly attributed to neurasthenia, but
more often wrongly relegated to hysteria, are very
frequently due to uncorrected errors of refraction, and
that, unless these errors are corrected, the symptoms
will persist. E3'^estraini is responsible for an enormous
amount of ill-defined nervous troubles of modem life,
and the practice of some ophthalmologists of dismiss-
ing low degrees of error as unimportant is responsible
* See next chapter.

CONSTIPATION, DIARRHCEA, ETC. 185

for much of the futility in the treatment of these
troubles.

Sea-sickness is in many cases, at any rate, traceable
to the ocular apparatus. The landsman is unable,
because he is unaccustomed, to accommodate his
visual machinery to the rapid and sudden changes of
movement caused by a rough or choppy sea, and his
efforts to bring about this accommodation give rise
to nausea and vomiting. That, in many cases, this is
the sole factor at work is evident from the fact that
the simple expedient of wearing a patch over one eye
when on board has been sufficient in so many cases to
prevent sea-sickness. No efforts are made to reconcile
the workings of the two eyes ; strain is prevented, and
sickness remains absent. It is not, of course, suggested
that sea-sickness is always due to this cause, but it
very often is, and the above-mentioned expedient is
consequently always worth a trial. In the majority
of cases, no doubt, other factors are also at work, and
in most of them we must suppose that there is an
undue irritability of the nervous system, which causes
a too ready response to slight stimuli.

In patients of this type it is generally quite easy to
prevent sea-sickness if we can commence treatment a
week or so before the voyage begins. The excitability
of the general nervous system is reduced to normal by
giving bromide of ammonium in 10-grain doses three
times a day for at least three days. The primse vise are
suitably cleared, and, with a view of exercising a
special effect upon the stomach, some liq. bismuth.

lS(i MINOR MALADIES.

ammon. cit. (2 drachms) with tr. nucis vom. (3
minims) is added to each dose of the bromide
mixture.

The medicine should not be taken on board — not
only because it is then too late, but also because there
is another drug which has proved in my experience
unfailing, even when given without any preliminary
preparation by bromides — namely, chloretone. A good
way of giving chloretone is to prescribe it in 5 to 10
grain cachets — one cachet to be taken during the train
journey down to the boat, another as soon as the
patient is settled on board, and a third, if necessary,
at any time during the voyage. If the patient is
directed to preserve the dorsal posture when on board,
the third cachet is very seldom necessary. I have
now prescribed chloretone in a great number of cases,
and where the way has been prepared for it by the
bromide mixture, I have not known it fail, and even
in the absence of any such preparation, I have learned
to have the utmost confidence in it. It may be given
in 10-grain doses if sickness threatens. It will often
stop an attack which is actually in progress.

It is not infrequently necessary to treat sympto-
matic vomiting, either pending the removal of the
cause or when the cause is unfortunately not re-
movable. A great many expedients have been
suggested for this purpose, some of which are often
useful, but which seem as often to be without effect.
The application of a blister or a mustard-plaster to the
epigastrium is often very successful, but no less often

CONSTIPATION, DIARRHCEA, ETC. 137

useless. Occasionally successful, also, is the application
of an ice-bag to the same region, or a poultice, or
gentle massage. These are all well worth trying, for
they are simple enough, and if they do not succeed,
they cannot do any harm.

Of drugs, the simplest is undoubtedly lime-water,
and Burney Yeo urges strongly that it should be given
a trial more frequently than is now the case. A table-
spoonful, he says, should be administered hourly for
several hours before recourse is had to other means.
He recommends, further, the addition of one drop of
creosote well shaken up with each dose, in case the
lime-water alone is unsuccessful. Champagne is per-
haps one of thfe most popular of all remedies for this
condition, and it has the merit of being one of the most
efficacious. It should be given, preferably iced, in
quite small doses, say 1 to 2 drachms, repeated at
intervals of ten minutes or a quarter of an hour, until
vomiting ceases. I have known many cases in which
this succeeded when all other measures had failed.

Yin. ipecac, liq. arsenicalis and hydrocyanic acid
have all enjoyed some reputation in the treatment of
vomiting, and for this purpose they are all employed
in minute doses — i.e., not more than 2 minims. Ringer
speaks highly of vin. ipecac, but not everyone is
able to share his enthusiasm. Fowler's solution is
admittedly useful in the morning vomiting of
drunkards, but I have found it beneficial in sympto-
matic vomiting arising from other causes. Hydro-
cyanic acid is usually very reliable, but it is not wise

138 MINOR MALADIES.

to restrict its use to the small doses above suggested.
It may be necessary to prescribe it in 3 or even
5 minim doses to produce the required effect, but
these must obviously not be frequently repeated. A
combination of all three drugs in 1 - drop doses,
repeated at intervals of ten minutes or a quarter of
an hour, is an expedient to which I have occasionally
resorted with success.

Bismuth is a useful drug in vomiting, and, in
combination with oxalate of cerium, it is, when the
stomach will retain anything, probably the most
reliable of all. It is best given in cachets :

a.

But the cachet must be well moistened before any

attempt is made to swallow it. Finally, morphia by

hypodermic injection, though it often causes vomiting,

will not infrequently stop it When given for this

purpose the dose should be relatively large — that is,

about J grain. Small single doses are much more

liable to cause gastric disturbance than large ones.

In association with vomiting it seems appropriate

to consider briefly the allied condition of GIDDINESS.*

Although this condition is common in cerebellar

disease, especially cerebellar tumours, in disseminate

sclerosis, and is not altogether uncommon in tabes, it

* See ' The BorJor-Land of Epilepsy,' by Sir William Gowera
(J. and A. Churchill, 1907).

Bismuth subnii

•••

•••

•••

gr-

XX.

Cerii oxalat.

...

•••

...

...

gr-

V.

M.

Ft.

pulv

.in

cachet L

CONSTIPATION, DIARRHCEA, ETC. 139

should not be regarded as necessarily indicating the
presence of some grave cerebro-spinal mischief. It
is frequently due to ocular troubles ; paralysis of an
ocular muscle will give rise to it, and errors of refrac-
tion are among the commonest causes. Abnormali-
ties in or about the ears very readily occasion the
symptom, hardened cerumen being among the most
frequent.

Mdni^re's disease, or aural vertigo, which is due to
an affection of the semicircular canals, may cause
paroxysmal attacks of giddiness, accompanied by
vomiting, and is thus liable to be mistaken for
migraine {q.v,, p. 172). Meniere's disease is, however,
almost always associated with some degree of deaf-
ness, which is seldom the case in migraine ; moreover,
in aural vertigo the giddiness is very pronounced ; so
much so that the patient not infrequently falls. For
the treatment of aural vertigo, bromide of potassium
and belladonna, persevered with over long periods,
often do a great deal of good. During the attacks
both quinine and the salicylates are highly spoken of.
The former should be given in large doses (10 to 15
grains or more) ; the latter, in the form of aspirin
(10 to 15 grains), is probably equally efficacious and
less liable to produce unpleasant by-effects. Some-
tinaes hydrobromic acid acts better than any of the
bromide salts. This drug is much the most reliable
remedy we have in those persistent noises in the
head which occasion annoyance and alarm to those
who suffer from them.

140 MINOR MALADIES.

Giddiness is said to be sometimes duo to causes
arising in the digestive apparatus. There is very con-
siderable doubt as to the stomach ever being directly
responsible for the symptom. The real cause of
giddiness in most cases, apart from those which have
just been noticed, is some disturbance in the vaso-
motor mechanism. We know that toxins originating
in the digestive tract are very powerful disturbers of
this mechanism, and it is exceedingly likely that
digestive disturbances may cause giddiness in this
way. The disturbance as a rule takes the form of
vaso-constriction, but there seems no reason why the
opposite condition of vaso-dilatation should not also
bring about the same result. The circulatory
apparatus in the brain is of so delicate a nature that
any alteration of the calibre of the conducting vessels
is liable to cause symptoms. The giddiness of elderly
people usually means atheroma; that of the gouty,
either high arterial tension or its next stage, arterio-
sclerosis ; even the giddiness of epileptics is probably
circulatory in origin, and that which is so common at
the climacteric is certainly so.

Attacks of giddiness, therefore, should never be
lightly regarded. They may be due to transitory
causes, but they may, on the other hand, indicate
some very serious condition. They should always
lead to a careful examination of the nervous system,
including the special senses, and, failing the discovery
of a cause therein, the question of the state of the
heart and bloodvessels should engage the most

CONSTIPATION, DIARRHOEA, ETC. 141

anxious attention. It is not too much to say that
the vast majority of cases of * simple ' giddiness
are due to vascular changes, and that among these
high blood-pressure occupies the first place. For a
consideration of this question and its treatment, the
reader is referred to the chapter on Goutiness,

R.

ADDITIONAL FORMULJS

For Colic (Ludlow).

Chlorof

... sa.

Morph. acetat

... gr.iii.

Olci anisi

... irixvi.

01. meaith. pip

... taxvi.

Syr. acacia

... 5ss.

Aq[. camph

... ad 5iv

M. 5ii.-5ss. for a dose.

For Colic with Constipation (Paris).

B.. 01. cajuput niiv.

Saccb. alb. gr. x.

Hub together, and add :

Tr. jalap 5L

Decoc. aloes co ad gisa.

M. Ft. haust.

For Colic of Infants (AViderhofer).

]^. Tr. cascarillae ffix.

Tr. kramerisB ... ... ... „ , "ix.

01. anthemidis tna-ii.

Syr. simplicis Siiss.

Aquam ad 5ii.

M. Sig. : One teaspoonful every two hours.

142 MINOR MALADIES.

Constipation in very Young Infants (Monti).

Mannite ... ... ... gr. ol.

Hot water 5i8s.

M. A dessertspoonful every hour until it acts.

Sir James Paget's Cure for Constipation.

1 lb. French plums, in enough water to cover them.
Stew for three hours, simmering gently, and then
remove stones.
1 oz. of ground ginger (good weight).
1^ oz. powdered senna.
1 lb. Demerara sugar.

Mix the whole together well in a pudding basia.
Dose : A teaspoonful at bedtime.

Pills for Gouty Constipation.

^. Iridin gr. xxiv.

Aloes pulv gr. xviil

Ext. hyoscyam. gr. vi.

M. et divide in pil. xii. Sig. : One at bedtime, followed
by a saline in the morning.

For Diarrhoea in Infants, after an Aperient

(Eustace Smith).

I}, Saponis duri Hispanioli gr. xvi.

Cretae prep. ... ... gr. xx.

Syr. flor. aurant 5ii.

Aq. menth. sativ 3iii.

Aquam foeniculi ad 51.

M. Sig. : A teaspoonful every eight hours for a child
between six and twelve months of age. Older children
may take the same quantity every six hours.

(6) li. Spts. ammon. aromat. nixx.

Tr. rhei nixxiv.

Tr. opii miv.

Spts. chlorof mxxiv.

Aquam carui ... ... ... ... ad 5i.

M. Sig. : One teaspoonful every eight hours for a
child of six mouths old

CONSTIPATION, DIARRHCEA, ETC. 143
Diarrhoea of Adults, after an Aperient (Hare).

(a) 1^, Tr. kino S.

Tr. catechu ... 5i,

Mist. cretfiB 5iii.

Aquam cianamomi ad 5vL

M. Big. : 5ss. every three hours.

(6) ^. Acid, sulph. aromat 5s8.

OL cajuput „ taxL

Ext. heematoxyli 3ii

Spts. chlorof. 3i.

Syr. zingiber ad 5iiL

M. Big. : 3L in water every two or three houri.

CHAPTER IV.

RHEUMATISM, NEURALGIA, HEADACHE.

RHEUMATISM is a term which, if it ever had a precise
meaning, has now, unfortunately, lost it. As applied
to acute rheumatism or rheumatic fever, it bears, no
doubt, a definite significance, but it is now generally
admitted that the disease which is so described has no
real relationship with the numerous other morbid
conditions to which the terms * rheumatism' or ' rheu-
matic ' are commonly applied. These terms are made
to comprise most of the arthropathies, both acute and
chronic. The arthropathies have been very con-
veniently divided into the essential and the accidental ;
the former being those in which the joint affection is
the predominant feature in the disease, such as gout,
acute and subacute, rheumatic fever, morbus coxse
senilis and rheumatoid arthritis ; the latter being those
in which the joints are involved secondarily to some
other affection, such as pulmonary osteo-arthritis, and
the arthritis of gonorrhceal, scarlatinal, septic,
syphilitic or neuropathic origin. These conditions
are, of course, quite distinct from each other, and, as
they all belong to the sphere which is properly

x44

RIIEUMATlSiAf, xNEUIlALGIA, HEADACHE. 145

covered by the text-books, they need not concern us

here. There remain for our consideration, then,

chronic gout and chronic rheumatism. The former

is dealt with in the next chapter ; into the problems

presented by the latter I now propose to enter.

In the existence of chronic rheumatism, properly so

called, I may say at once that I do not believe. I do

not be?ieve, that is, that there is any chronic form of

the condition which we call acute rheumatism, or

rheumatic fever. Fagge says : * Chronic rheumatism

ought to mean a chronic arthritis of the same

pathology as the acute outbreaks of rheumatic fever.

Such a disease, we may affirm, does not exist.' With

this opmion, though it is not shared by all,

even by so great an authority as Osier, I am in

entire accord. Certain chronic joint troubles, it is

true, are liable to appear as sequelae of rheumatic

fever; but these same joint troubles appear equally

often after true influenza, after sore- throats, and, in

the predisposed, after local injury to joints, such as

sprains. Moreover, these joint troubles, inasmuch as

they affect, not the cartilage, synovia or bone, but

merely the fibrous tissues surrounding the joint, have

no real relationship to those which occur in acute

rheumatism. The conditions which are admittedly

closely related to true rheumatism, such as chorea,

tonsillitis, and subcutaneous nodules, have, of course,

no arthritic element, and are not in any sense of the

term chronic; so that although their power of

causing rheumatic endocarditis should never be lost

10

146 MINOR MALADIES.

sight of, it is impossible to include them in such a
term as ' chronic rheumatism.'

The fact is, chronic rheumatism has nothing what-
ever to do with true rheumatism, and it would be
well if some authoritative name could be applied to
the condition which is variously described as rheu-
matics, chronic rheumatism, muscular rheumatism,
tendinous rheumatism, rheumatic myositis, myalgia,
and neuralgic rheumatism; for the morbid state
which is thus buried beneath misleading and con-
fusing names has a very distinct and very definite
existence, with its own pathology, symptomology,
and therapeutics, so that the retention of the term
* rheumatism ' in connection with it is not to be de-
fended even on the ground of convenience. In the
meantime, being to some extent bound by custom,
I propose to use the expressive, illiterate, but highly
convenient term * rheumatics,' invented by and be-
loved of the laity, to designate the condition.

Rheumatics, then, may be described in the terms
of Stockman,^ who has done so much to introduce
order into the chaos which previously existed on
this subject, as a condition in which the essential
pathological changes are confined to white fibrous
tissue ; in which, therefore, the manifestations appear
chiefly in aponeurosis, fibrous septa, the sheaths of
muscles and nerves, periosteum, and the fibrous
structures surrounding the joints. 'The lesion,' he

* British Medical Journal, February 27, 1904.

RHEUMATISM, NEURALGIA, HEADACHE. 1 17

says, ' consists in inflammation and hyperplasia of
the connective tissue in patches, and the condition
may be widely spread over the body or be confined
to a certain area of it.'

When once the conception presented by this
description is realized, the isolated and disconnected
facts which have hitherto been associated with the
condition at once fall, as it were, into their appro-
priate places. White fibrous tissue is found prac-
tically in all parts of the body, so that the rheumatics
may appear anywhere; but inasmuch as there is a
special distribution of this tissue in connection with
joints, voluntary muscles, and nerves, it is not sur-
prising to find 'that it is in these structures that the
disease most often shows itself. It is thus evident
that so-called chronic articular rheumatism, muscular
rheumatism, or myalgia, especially in the form of
lumbago, neuralgia, especially in the form of sciatica
and brachialgia, are all one and the same disease, the
only real difference between them being the anato-
mical situation of the fibrous tissue which is attacked
by the inflammation and hyperplasia described by
Stockman.

Where the fibrous tissues all over the body are
more or less impartially attacked, the result is what
is known as febricula, or feverish cold — a condition
to which reference has already been made (Chapter I.)
as a fruitful source of error in diagnosis ; those who
do not remember its existence almost invariably
labelling it * influenza,*

148 MINOR MALADIES.

* Rheumatics,' then, includes arthritis, lumbago,
torticollis, and other aponeurotic and muscular inflam-
mations, wherever situated; sciatica, intercostal and
other neuralgias ; and, inasmuch as the pericardium,
pleura, and dura mater are all richly supplied with
white fibrous tissue, it will be proper to comprise in
this category certain forms, at any rate, of cardialgia,
pleurodynia, and rheumatic headache.

This inflammation of white fibrous tissue or
' fibrositis,' as Sir William Gowers has named it,^
is said to be due to a variety of causes. It certainly
seems to be determined by many conditions and
influenced by many others, but the cause is probably
always the same. This cause is connected with the
gastro-intestinal tract, and is almost certainly pro-
duced by the absorption of toxins therefrom. The
toxins are the result of defective metabolism, from
the too free ingestion of meat foods and alcoholic
drinks, or their inadequate elimination.

Such a state of matters does not constitute gout,
but it constitutes a condition very nearly allied
thereto, and we are generally quite safe in treating
a person who is subject to fibrositis as if he were
goutily inclined. And this we may do in spite of
the fact that the manifestations are by no means
confined to the old or middle-aged. The old are,
perhaps, more prone to be attacked by chronic
arthritic fibrositis, but myalgia is more common in

* 'Lumbago,' by Sir William Gowers {British Medical
Journal, January 16, 1904).

RHEUMATISM, NEURALGIA, HEADACHE. Ud

young adults, and even children are occasionally
affected.

Of determining causes, damp, cold, and atmospheric
changes appear to be the most potent. It is difficult
to trace the connection between the states of the
weather and the incidence of fibrositis, but that
there is a very intimate connection everyone who
has ever suffered from the disorder will readily agree.
Many a patient complains that he is a regular baro-
meter, that he can be sure that a change is imminent,
but none can foretell with any approach to accu-
racy what the nature of the change will be. Some
will have an attack when the wind is going to the
east, others when it is going to the west, and most
will predict an increase in atmospheric humidity.

The question is an interesting one, about which,
however, very little is at present known. These
atmospheric influences, whatever they may be, are
particularly liable to affect joints or muscles which
have been the seat of injury or overwork. Thus,
the rheumatics will always select by preference the
fibrous tissue surrounding a joint which has been
sprained, and the ' golf shoulder ' or ' tennis elbow '
will be found afflicting the particular joint which has
borne the brunt of the season's work. The prevalence
of lumbago is almost certainly susceptible of a similar
explanation, in that the muscles and aponeuroses
therein concerned are those which maintain the erect
posture.

The application of sudden cold is a very powerful

150 MINOR MALADIES.

determining cause. Sitting in a draught will un-
questionably bring on an attack in a predisposed
person. A common history is that of a sudden onset
during the cold morning tub, and some bathing
fatalities are probably due to this cause. But what-
ever may be the exciting or determining cause of
a particular attack, the point to remember is that
the essential condition precedent is the existence
of a toxin in the blood, and that that toxin in
the large majority of cases, if not in all, is of
gastro-intestinal origin. This fact at once points to
the two most important indications in the treatment
of a fibrositis wherever it may appear, and these are
the cleansing of the gastro-intestinal tract by a
mercurial purge, and the careful regulation of
the diet by the diminution of meat foods and
alcoholic drinks. An additional measure of the
utmost utility at the outset is an ordinary hot bath of
100° F. or over, or, better still, the hot wet pack. A
radiant heat bath is probably better than either
where this can bo procured without exposing the
patient to the risk of subsequent cold. Warmth and
equability of temperature are very important during
the first forty- eight hours of an attack.

So much, then, for the etiology, pathology, and
general indications for treatment of fibrositis. Let us
now proceed to consider the condition as it appears in
the various parts of the body ; and first, as to its
manifestations in the neighbourhood of the joints.
One of- the characteristics of the condition is that one

RHEUMATISM, NEURALGIA, HEADACHE. 151

joint only is usually affected. This is the rule, to
which there are, of course, exceptions, but it is seldom
indeed that more than three are affected. In
recurring attacks it is nearly always the same joint
which is involved, and, if any joint in the body has
ever been the seat of injury, it is tolerably certain
that the fibrositis will select that one. When once
the process has established itself in a joint there is
not, as in true rheumatism, any tendency to leave
that joint and go to another. The complaint in
connection with the affected joint is one of pain and
impaired mobility, the latter usually depending very
much upon the former. The pain is not often to be
described as merely chronic ; it is much more often
subacute, and occasionally it is even acute. It is
aggravated by sudden and violent movement, and
varies greatly with changes of temperature and
atmospheric humidity. The arthritis is never
accompanied by fever, and it has no tendency to
produce endocarditis or other complications.

The medicinal treatment of this manifestation of
* rheumatics ' is not very successful The salicylates,
especially in the form of aspirin (10 to 15 grains
three times daily), are occasionally beneficial, though
I have had better and more uniform results from
iodide of potassium and guaiacum (10 grains of each
three times daily). Antipyrin, together with salicy-
late of sodium, is a useful combination, especially where
pain is a prominent symptom ; but this combination is
less useful here than in the neuralgic type of tho

152 MINOR MALADIES.

afFection. Locally, the application of warmth is
invaluable. A hot douche, which, in the case of
such joints as the wrist, knee, or ankle, can be
improvised at homo by holding the part under a hot
tap, is an excellent expedient, to which recourse may
be had two or three times a day with great advantage.
Hot fomentations, especially when frequently re-
peated, are also very useful, and compresses of
potassium iodide and citrate of lithia often seem to
hasten resolution. Local exposure to radiant heat is
in my experience one of the very best means oi
bringing about resorption and disappearance of the
fibrous thickening which is the essence of this
condition.

Although it is, on account of the pain, necessary to
keep the joint for the most part at rest, this mast not
lead to forgetfulness of the fact that movement is
absolutely essential to anything approaching a
satisfactory issue. This movement must at first be
slight and passive, but as the pain subsides it should
become free and active. An enormous amount of
avoidable crippling is brought about by allowing
patients to * coddle ' joints thus affected. Movement
is the essence of the cure, and if it is neglected the
joint very readily becomes stiff and disabled. Of
course, the movement must be applied with sympathy
and discrimination. It is better that the doctor
himself should do it during the acutely painful period,
if there be ono, and as soon as circumstances permit
he may delegate the duty to a competent masseur, or,

RHEUMATISM, NEURALGIA, HEADACHE. 153

where such is not available, it is usually not difficult
to instruct a member of the household in this means
of restoring function.

These and similar measures are in very chronic or
recurrent cases much better carried out at a spa than
in the patient's own home. It is, indeed, in the treat-
ment of such cases that the baths, douches, and
massage for which such places are famous, justify
most completely the confidence which is now so
generally accorded them. Of Continental summer
resorts Aix-les-Bains justly enjo3^s the highest
reputation, but Vichy, Luchon, Baden-Baden, and
many others, are fully equipped for the treatment.
In winter Salsomaggiore, in Italy, is a place to which
such patients may very suitably be recommended.
In this country at Buxton, Woodhall Spa, Llandrindod
and Harrogate in summer-time, and at Bath and
Sidmouth in winter, the necessary treatment is
admirably carried out; and by no means the least
advantage of the home stations is that the practising
physicians have, owing to the English climate,
opportunities for gaining an amount of experience in
the various phases of the condition which is denied to
their continental brethren.

MYALGIA. — If, of the pains of arthritic fibrositis, it
may be said that they are subacute more often than
chronic, of those of myalgia, or muscular fibrositis, it
may be affirmed that they are acute more frequently
than subacute. They vary, of course, as do the others.
They are generally confined to one set of muscles, as

154 MLNOR MALADIES.

those of one shoulder-joint or one side of the neck
(torticollis) ; they are usually relieved by firm pres-
sure, and are invariably worse at night This
aggravation at night, or rather in the early morning,
is very characteristic. The patient wakes in great
pain, so great that he doubts the possibility of being
able to dress himself; nevertheless, when he begins to
move, even in his bed, he finds that matters are not
so bad as they at first seemed, and by the time he
gets downstairs his troubles may have resolved them-
selves into stiffness and fear of sudden movement.
The onset of myalgia is generally sudden, occasionally
so sudden as to give the impression of a blow, and
when it starts in this way it is apt to be very acute.

Lumbago is often quoted as the typical form of
myalgia. This in my opinion it certainly is not, for
the reason that in most cases, if not in all, the fibrous
tissue in connection with structures other than muscle
are always involved. Luff ^ is certainly right when he
says : ' In the majority of cases of lumbago the affection
is not in the quadratus lumborum, nor even in the
deeper muscles of the back, but is in the fibrous
tissues directly over the sacro-iliac joint and in the
joint itself.' It is from the spreading of the inflamma-
tion along the sheath of the sciatic nerve that we
find lumbago and sciatica so frequently associated.

A much better instance of myalgia, though even
here tissues other than the muscular are often
included, is supplied by deltoid and brachial myalgia.
» Clinical Journal, October 11, 1905.

RHEUMATISM, NEURALGIA, HEADACHE. 155

This is liable to be very acute, and is generally of long
duration ; it is of all others perhaps that which is
most conspicuously influenced by meteorological
variations, and subject to nocturnal exacerbations.
StiflP neck, or torticollis, is another good instance.
This is especially common among young adults, and
is fortunately very amenable to treatment.

Myalgia will often pass off in a few days without
anything more heroic in the way of treatment than a
hot application and some rubbing. More often, how-
ever, it becomes obstinate to household remedies and
demands careful management. Internally nothing
can compare with iodide of potassium, and externally
nothing is so eflScacious as massage. The latter, to
be effectual, should be applied twice a day by some-
one who is conscious of the needs of the situation.
Mere superficial effleurage is useless. The muscles
must be handled gently but firmly, so as to promote
the lymph-flow within their substance. This will
cause a certain amount of pain at first, especially if
the operator be unskilful ; but, in spite of this fact, the
treatment must not only be continued, but it must be
reinforced by the application of warmth in the form
of poultices and fomentations and by the addition of
stimulating liniments. A good plan is to rub the
part with liniment of iodine and then apply a poultice.
Camphor liniment and chloroform liniment are also
useful for this purpose. Luff ^ prefers anodyne appli-
cations, and recommends a mixture of equal parts of
^ Loc, cU.

15G MINOR MALADIP:S.

chloral hydrate, camphor, and menthol, which he
says, when well rubbed together, form a liquid.
Methyl salicylate and mesotan are in his experience
also very valuable. But, whatever the medicament
employed, a large part of its power for good resides
in the method of its application, and unless this in-
cludes vigorous massage — as vigorous, that is, as
pain will permit — the virtues of the drug will remain
largely inoperative. For chronic cases, the massage
should be accompanied by douching, as at Aix-les-
Bains, by light baths, or by electricity.

Lumbago, as wo have just seen, is a mixed fibro-
sitis, partly muscular, partly aponeurotic, and largely
arthritic, and inasmuch as it is so frequently accom-
panied by sciatica, it may be considered as in a sense
neuralgic. Acute lumbago is startling and disabling.
It is startling from the extreme suddenness of its
onset, and disabling from the fact that the trunk
cannot be moved except with great pain, so that the
patient is obliged to remain in bod. It is most
common in men, at or about middle age, who usually
present themselves with a diagnosis ready made ; for
* lumbago ' with the laity means any pain in the small
of the back. Such a diagnosis should, of course,
never be accepted, and we ought to be careful
always to examine the back, the knee and plantar
reflexes, and the urine, before confirming it. I have
known very grave mistakes to be made through initial
negligence of these very simple precautions.

A line of treatment which was much in vcgae

RHEUMATISM, NEURALGIA, HEADACHE. 157

twenty years ago for a sudden attack of lumbago
consisted in a hot bath (100° to 103° F.), a dose of
Dover's powder (12 grains), and a drachm of sweet
spirits of nitre, supplemented by a linseed-and-mustard
poultice to the loins. This I still believe to be an
admirable course of procedure in a large number of
cases ; but I hare learnt to distrust the action of the
opium, especially in the very patients — namely, those
about middle life — who are most prone to suffer from
the complaint, so that I came to use James's powder,
(pulv. antimonialis) 6 grains, in its stead, and to give
therewith a mercurial cathartic. This method I have
found to be not only more efficacious, but entirely
free from the disadvantages attaching to the exhibi-
tion of opium in such cases.

For the rest, it is only necessary to reiterate what
I have said above as to the value — I would almost
say the paramount importance — of massage and
stimulating applications in the further treatment of
the condition, and the necessity for regulating the
diet of the patient so as to eliminate as far as possible
meat foods and alcoholic drinks. As long as pain is
present the patient must keep his bed, not only on
account of the pain itself, but because of the fact
that equability of temperature is an important feature
of the cure. Cold influences are not only in the
highest degree unpleasant, but they tend above
everything else to prolong convalescence and retard
recovery.

The NETIEALGIC FIBROSITIS which so often accom-

158 MINOR MALADIES.

panies lumbago may occur independently thereof, and,
when so occurring, it may be regarded as the type of
an affection which is liable to attack almost any nerve
in the body, some common examples of which are
supplied by cervico-brachial neuralgia (often called
neuritis), intercostal neuralgia, coccydynia, and plantar
neuralgia. In sciatica, as in lumbago, we should be
especially cautious in accepting a ready-made diag-
nosis, for pain along the sciatic nerve may be due to
causes other than fibrositis ; and if the pain is markedly
worse at night, or, if both sciatic nerves are involved,
it is tolerably certain that some much more serious
factor is in operation.^ A * sciatica ' may be caused
by a loaded rectum, by uterine and ovarian displace-
ments, by tumours and disease of the spinal cord
itself, and such possible factors should always be
carefully and exhaustively investigated before the
pain is pronounced to be due to a neuralgia, and
treated as such.

For this purpose it is important to determine
whether the pain is due to pressure, or to some
factor in the nerve itself or in its sheath. In
the former case the pain will not be sensibly
aggravated when the nerve is put on the stretch ;
it may, indeed, be to some extent relieved by
the process, whereas, when the mischief is in the
nerve or its sheath, the stretching will obviously
increase the pain. In order to set this point at rest,

1 F. J. Smith, ' Mistakes ' (Clinical Journal, December 27,
1905).

RHEUMATISM, NEURALGIA, HEADACHE. 159

the patient is placed upon his back and the pelvis
firmly fixed against the bed by an attendant. The
limb on the affected side, which must be kept fully
extended at the knee, is then gently and gradually
raised by the examiner until it is at right angles to
th6 couch. This will put the nerve on the stretch,
and if no aggravation of pain results, then the cause
is to be sought outside the sheath of the nerve ; it is
not due to a fibrositis, and the condition is not,
properly speaking, a sciatica.

So far as the treatment of sciatica is concerned,
there is not much to add to what has already been
said in connection with other forms of fibrositis.
Massage, which is of the utmost importance in all these
forms, is in sciatica the one l«cal remedy upon which
any great reliance can be placed. Dr. Lee^ says :
* It is in sciatica, of all the neuralgias, that massage
has won its greatest reputation. Truly astonishing
results have been obtained, even when the affection
has been of many years' standing, and after every
other conceivable means of relief has proved un-
successful.'

This coincides completely with my own experience,
and since I have used massage perseveringly, assisted
in suitable cases by douching and the application of
stimulating liniments, I have had no occasion to
resort to acupuncture, surgical stretching of the nerve
and other heroic remedies which are often recom-
mended, and which the tedious nature of these cases
^ Hare's ' Practical Therapeutics.'

160 MINOR MALADIES.

so often suggests to the despairing physician. If
massage were employed early in all cases, few would
become chronic ; and if it is persevered with in cases
which have become chronic, even to the causing of
marked wasting of the muscles, it will in time al^rays
bring about a cure. Some of the antineuralgic drugs,
which will be noticed presently, may also be used
concurrently. Some of them, especially phenozone
and butyl-chloral, have often seemed to me to do good
in the way of rendering the massage more tolerable.
Without massage these drugs may be palliative, but
they are never curative, as they are in neuralgia due
to causes other than fibrositis.

It would be easy to multiply instances of the
manifestations of the ' rheumatics ' as they occur in
various parts and structures, but no good purpose
would be served by so doing. The essential points
to remember are that these manifestations are due to
inflammation of white fibrous tissue ; that they may
be acute, subacute or chronic ; that they are seldom or
never accompanied by constitutional disturbance ; and
that they are very amenable to treatment, more
especially by iodide of potassium internally; and
externally, by massage, passive movements and stimu-
lating applications.

NEURALGIA. — Pain which follows the distribution
of certain nerves is a very common disorder. It may,
as wo have just seen, be due to fibrositis ; but, so far
at any rate as the smaller nerves are concerned, it is
much more often due to other causes. Chief among

RHEUMATISM, NEURALGIA, HEADACHE. Ib'l

these are unsatisfactory blood states. That neuralgia
is the cry of a nerve for healthy blood is an oft-quoted
saying, and certain it is that undue toxicity of the
blood, from whatever cause arising, is an important, as
it is certainly the most common, agent in the causa-
tion of pain. For toxins in the blood act not only
by direct irritation of a nerve, but they also act, as in
gout, by causing vaso-constriction, thus depriving
the nerve of its due quantity of nutritive material.
Burney Yeo suggests that a factor of an opposite kind
is not infrequently in operation — namely, that the
blood state may give rise to vaso-dilatation, and
that it is a kind of blushing in the neighbourhood
of the nerve which determines the pain.^ How-
ever that may be, all that it is necessary to
realize is that impure blood is the most important
cause of neuralgia, and that it may produce this
effect not only directly, but also by interference with
the normal vasomotor mechanism. Another cause,
scarcely less in importance, is the existence of an
irritant causing fatigue of the involved nerve.

The presence of a neuralgia, then, should suggest —
(1) a fibrositis, (2) an unsatisfactory blood state, and
(3) the existence of an irritant. With the first I
have already dealt ; there remain, therefore, the other
two to consider. Of unsatisfactory blood states the
commonest is surely anaemia. Whether this be due

* See also * The Vasomotor Factor in the Pain of Migraine/
by Dr. Francis Hare, Clinical Jowmal^ January 24, 1906.

11

1G2 MINOR MALADIES.

to convalescence from acute disease, to mere chlo-
rosis, to deficient coagulability of the blood,^ or other
cause, it is very frequently attended by neuralgia,
more especially about the head and lower part of the
trunk on one side.

The treatment of such cases resolves itself into
the treatment of the anaemia by suitable hygienic,
dietetic, and medicinal means. So far as hygiene
is concerned, an out-of-door life in a bracing climate
is strongly to be advised. The diet should be gene-
rous, including meat foods and wines — preferably a
good Bordeaux or Burgundy — and plenty of fats.
Fats seem to be concerned in some very special
manner with the nourishment of the nervous system,
and in the form of butter and cream they may be
freely given to such patients as we are now considering.
The best medicine is undoubtedly iron, but the
stronger salts, the sulphate and perchloride, are
much less efficacious than the citrates and tartrates.
The two latter are readily assimilated, whereas the
former are very apt to upset the stomach. A useful
formula is as follows :

Ferri ammon. citrat

•••

gr. X.

Liq. arsenicalis .

.• ••. •*.

...

mii.

Inf. quassias

...

ad^ss.

M, Sig.:

: Ter die post cib.

As the patient's strength improves it may be desirable
to substitute the following :

^ Boss, Lano0i, Jannary 20, 1906.

RHEUMATISM, NEURALGIA, HEADACHE. 163

R. Ferri quin. citrat. gr. xx.

Liq. arsenicalis niv.

Tr. nucis vom taiv.

Aquam aurant. flor ad 3ss.

M. Sig. : Ter die post oib.

The presence of quinine, even in such doses, may
help to subdue the neuralgia. When giving iron
in any form and for any purpose, it is of the utmost
importance to keep the bowels open. This is best
done by means of aloes at first, because this drug
enhances the effect of the iron, and later by cas-
cara. A daily morning dose of a natural mineral
water is also very useful.

But where the neuralgia is an obtrusive feature
of the condition, it is generally necessary to prescribe
something which has a direct influence upon the pain
when this occurs. In anaemic cases and in all those in
which defective nutrition is pronounced I have had
better results from quinine and gelsemium than from
any other combination.

Bt. Quin. mxir. gr. v.

Acid, hydrobrom. dil itlxx.

Tr. gelsemini itix.

Aquam chloroformi .., Sss.

M. Sig. : Every twenty minutes till pain ceases. Not
more than four doses to be taken.

This mixture, like most others where the relief of
pain is concerned, acts better in small doses repeated
at short intervals than in single large doses.

The state of the blood in goutiness is such as to

164 MINOR MALADIES.

bo highly provocative of neuralgic pains. Inasmuch
as this condition and its treatment are fully considered
in another chapter, it is here only necessary to em-
phasize the advisability of examining for high arterial
tension in all cases of neuralgia, and where this is
present, to point out the value of iodide of potassium
in the treatment of the accompanying neuralgia. As
this is the most potent of all drugs in counter-
acting the gouty state generally, a gouty neuralgia
ought very readily to yield to the measures proper
to the treatment of the blood state itself. Occasion-
ally, however, it does not, and then it is well to have
recourse to the following combination :

9. Sodii salicjlat. ")

Phenazon J aa gr. v.

Syr. zingiber 3i.

Aq. ohloroformi ad 5i.

M. Sig. : Every quarter of an hour until pain ceases.
Not more than four doses to be taken.

This is a most admirable combination in the
migrainoid neuralgic attacks to which the gouty
are peculiarly prone. I have appealed to it in a
very large number of cases, and so far never in vain.
For a reason which it does not seem possible to
explain, the combination of these two drugs is in-
finitely more efi'ectual than either given alone. When
directed to be taken as above, the mixture acts
better than in single large doses.

A fruitful and easily overlooked cause of neuralgia,
especially in women, is the toxic blood state induced

i

RHEUMATISM, NEURALGIA, HEADACHE. 165

by chronic constipation. This must be treated by
the curing of the vicious habit on the lines laid
down in Chapter III. ; but here again we may have
to treat the neuralgia concurrently with the treat-
ment of the constipation, in which case the pheno-
zone and salicylate mixture just described will usually
be found the most useful, though quinine and gelse-
mium are to be preferred where, in consequence of
the long duration of the constipation, the patient is
anaemic and emaciated.

Neuralgia is considered by some as a hysterical
manifestation. This, of course, it may be, though
hypersesthesia is less characteristic of hysteria than
anaesthesia. Neuralgia certainly occurs frequently in
neurotic women, but I have generally found that
there is some discoverable and removable cause for
the neurosis of which the neuralgia is an occasional
manifestation, and this cause is more often than not
a peripheral irritation, of which the origin is to be
found in the teeth, the ears, or the eyes. Such
irritation, when acute, is a recognised cause of
neuralgia in those who are not neurotic, and there
is no difficulty in supposing that, when chronic, it
may give rise to that nervous instability to which
the term neurotic is applied. A common site for
such irritation is the ovarian region. Examination of
this region in neurotic women will often reveal pain
on pressure over one or both ovaries, in which case
infinitely the best drug to use is belladonna. It is
usefully combined with phenozone, and its adminis-

166 MINOR MALADIES.

tration should always be accompanied by tbe applica-
tion of blisters, small in size, but frequently repeated,
in the region where the pain has been elicited.

A practical point of considerable importance in con-
nection with the management of these cases is charac-
teristically expressed by Goodhart, in that altogether
admirable little work 'Common Neuroses' (which
should be carefully read by every young practitioner)
in the following passage :

' I have said it is a bad day for a man when he first
knows he has a heart ; it is a ten times worse day for
a woman when the pelvic pains to which so many are
subject are focussed for her by medical opinion upon
uterus or ovary. If there is anything which curdles
my blood, it is to hear a woman talk of her ovaries as
she might of some intimate acquaintance.'

In the manufacture of incorrigible neurotics the
word ' ovarian,' blurted inadvertently from incautious
lips, is a common and potent ingredient.

Irritation within the buccal cavity is a frequent
cause of facial neuralgia ; and it should be remem-
bered that it is not only teeth which are obviously
carious which may produce this result, but, as
SavilP points out, careful examination, by tapping
the teeth, or by the application of hot and cold
liquids alternately, will often reveal the existence of
an irritated pulp in an apparently sound tooth, the
proper treatment of which is necessary to a cure.
For the relief of neuralgia of facial or cranial distribu-
^ ' A System of Clinical Medicine,' vol. iL

RHEUMATISM, NEURALGIA, HEADACHE. 16'

tion arising from such a cause butyl-chloral is
probably the best of all internal remedies. It should
be given in pill form, 5 grains every half-hour
until pain ceases ; not more than six pills to be thus
taken. It is usefully combined with gelsemine,
which is another drug with a selective influence over
cranial neuralgias. For this purpose the pil. butyl-
chloral c. gelsemina (Martindale) is very useful.
Local applications are not usually accounted of much
value in facial neuralgia, but I have found that the
lin. aconiti carefully painted with a camel-hair brush
over the area occupied by the pain is not only helpful
in assisting the » action of drugs taken internally, but
that it is in some cases suflScient of itself to cut short
an attack. For the vague, ill-defined neuralgic and
* rheumaticky ' pains of which people not infrequently
complain, I have found chloride of ammonium, 20
grains, combined with tr. cimcifug., 20 minims, more
effectual than any of the above-mentioned remedies.

One of the most valuable drugs for the relief of
neuralgic and neuritic pains, wherever situated, is
acetanilid (antifebrin). In spite of its undoubted
powers in this direction, even where such pains as
those of tabes are concerned, it has of late fallen into
disuse. This has been due in a large measure to the
fact that it is credited with the production of un-
toward effects. This is in reality only partly true.
When properly employed, it is no more dangerous
than any of the numerous drugs which daily floAv,
freely and callously, so to speak, from the point of

16a MINOR MALADIES.

the prescriber's pen. First, then, as to dose. The old
official dose of 10 grains is too high, at any rate, to
start with. It is better to begin with 2 grains, which
will in many cases be found sufficient. If not, the
dose may be gradually increased to 10 or even 15
grains. It should not be increased above the latter
if, the physiological effect having been produced, the
pain fails to yield. This physiological effect is slight
cyanosis. The lips and nails become a dusky red.
This effect has in a great measure been responsible
for the disuse into which the drug has fallen. There
is nothing alarming about it, and it is necessary to
remember that, as in the case of so many other drugs,
the curative virtues of acetanilid very often decline to
show themselves until this physiological effect has
been evoked. These facts seem worth insisting upon,
because, apart from morphia, acetanilid is in my
judgment by far the most powerful anti-neuralgic at
our disposal. It will relieve the pains of locomotor
ataxy and of other organic diseases of the nervous
system when nothing else will, and he who allows
himself to be frightened by the occasional cyanosis
which it causes, deprives himself of a most valuable
therapeutic agent. That its use requires a certain
amount of caution is not a sufficient reason for
abandoning it. Acetanilid being practically insoluble
in water, is best given in cachet, combined either with
salicylate of sodium (10 grains) or camphor mono-
bromat (6 grains).
It is scarcely necessary to mention morphia as an

RHEUMATISM, NEURALGIA, HEADACHE. 169

anti-neuralgic, except to say that it is not employed
as often for this purpose as it might be. It is, of
course, most undesirable that its use should be pro-
longed, but there is no objection to exhibiting it for
the relief of pain, pending the action of other
remedies. For the intense neuralgia which some-
times accompanies true influenza and other acute
toxoemias it has no equal. Its use in recurrent
neuralgias is undesirable, not only on account of the
patient, but also for the sake of the practitioner, who,
unless he is careful, will find himself urgently
summoned at all hours of the day and night to
administer the necessary dose. This, which is
unsatisfactory enough, is on the whole preferable to
entrusting, as is too often done, a needle and a bottle
of tabloids to the all too willing patient.

Another unduly neglected means of relieving
neuralgic pains, in suitable cases, is leeching. One
would not, of course, recommend it in weakly, anaemic
subjects, but in full-blooded individuals the relief it
gives often approaches the miraculous. This is
especially true where the pain seems to be in, or to
radiate from, the ear. A leech placed behind the ear
and allowed to take its full quantity of blood will
often give complete relief where other means have
failed.

HEADACHE. — There remains to be considered a
highly important peripheral irritant, perhaps the most
important of all in the causation of neuralgia, which
I have left to this stage that I might discuss it inassocia-

170 MINOR MALADIES-

tion with headache, to which it also gives rise with great
frequency — namely, eye-strain. Where eye-strain is
concerned neuralgia and headache may be regarded as
synonymous terms, for it is impossible to be certain
where the one ends and the other begins. And I may
say at once that these two conditions by no means
exhaust the troubles to which eye-strain may give
rise. It is, as we shall see presently, a frequent,
though too often unsuspected, cause of neurasthenia,
melancholia, intemperance, and drug habits, to say
nothing of such minor matters as irritability of
temper, dyspepsia, constipation, and * sluggish liver.'
The first point to remember in connection with eye-
strain— and it is one upon which it seems very
necessary to insist — is that the condition is produced,
not by gross defects, but by slight ones ; not by high
degrees of errors of refraction, but by minor ones.^
So much is this the case that patients are often
indignant that any aspersions should be cast upon
their eyesight, which, they will protest, has always
been exceptionally good. And the truth is that such
patients are able to see as well as anyone, for the
reason that, the defect being slight, it has always
been well within their power, by contracting the
ciliary muscle, to overcome the defect. In the case
of those with gross defects no amount of ciliary
contraction enables them to see clearly, and so the
efibrt, even if it is ever made, is very early abandoned.

^ See ' Kefraotion of the Eye,' by Ernest Clarke (Bailli6re,
Tindall and Cox).

RHEUMATISM, NEURALGIA, HEADACHE. 171

In the case of those with minor defects the difficulty
arises from the fact that it is no more possible to
keep the ciliary muscle contracted for hours on end
than it is to keep any other muscle in the body so
contracted without giving rise to fatigue. Especially
does this apply when astigmatism is present, as the
ciliary muscle is then contracted not only continuously,
but also irregularly. The difference between the
ciliary and other muscles is that in the latter the
symptoms of fatigue are easily recognised as due to
fatigue, but in the case of the eye, so long as
the vision remains unimpaired, the seat of origin
is almost certain to go undetected. The patient
sees well, but in the majority of cases, he does
so at a cost which, physiologically speaking, he
cannot afford to pay. He lives well up to the limit of
his nervous income, and any slight unexpected attack
will very readily project him into bankruptcy. It is
when he has reached this state that he appeals to his
doctor to be relieved of a headache or an attack of
neuralgia. For, be it remembered, the pains which
are caused by eye-strain are by no means always
present ; frequently — indeed, generally — they require
some extraneous cause to provoke them. As long
as the patient is permitted to pursue the even tenor
of his way, he is able to live within his income
and keep his enemy at bay ; but no sooner is that even
tenor disturbed, as by worry or an over-generous
dinner, than he finds himself at the end of his
resources, with his enemy at his throat. The factor

172 MINOR MALADIES.

which in a very large number of cases supplies the
disturbinof element is the advance of time. As lonsr as
a man is young and vigorous his nervous income is
equal to almost any strain, but as years wear on this
income gradually diminishes, and as he approaches
the presbyopic age, when another disturbing element
awaits him, he is always more or less on the margin of
symptoms. When the presbyopic age is actually
reached, and the lens has lost a great deal of
its original elasticity, the ciliary muscle has still
more work thrown upon it, and consequently
such symptoms are liable to be of very frequent
occurrence.

The nature of these symptoms varies within very
wide limits. Neuralgia and headache, with which we
are for the moment especially concerned, take the
first place. Neither the distribution of the neuralgia
(except that it is generally cranial) nor the type of
the headache, aiSbrds any indication that it is the eyes
which are at fault, so that it is all the more important
to keep constantly reminding ourselves of the now
well-established fact that where either of these
symptoms cannot be traced to any obvious cause, eye-
strain is, in all probability, the main factor in their
production. Another common effect of refractive
errors is giddiness. This is liable to occasion very
considerable alarm to patients, who are generally
afraid that it indicates intracranial mischief. To
medical men it generally suggests gastric disorders,
auraj troubles, or circulatory disturbances. These are

IIHEUMATISM, NEURALGIA, HEADACHE. 173

all common causes, but probably the most common,
especially in people about middle life, is that which is
least frequently remembered — namely, ocular defects,
which are slight, and therefore unsuspected by the
patient.

Nausea and vomiting, as we have already seen
(vide Chapter III.), are often due to eye-strain. In
these cases, as in most others, it is to be remembered
that something more than eye-strain itself is generally
required to precipitate an attack. That something is
often so slight a matter that it altogether escapes
notice unless the presence of eye-strain, acting as a
chronic underlying irritant, is realized. In all these
cases it is the summation of slight stimuli which
produces the effect, and of these slight stimuli that
which is constant and ever present is the one whose
removal is important. With that gone the others
cease to be operative.

But the manifestations of eye-strain are not all so
definite as the foregoing.^ The condition, indeed,
expresses itself even more frequently in forms, which,
until we are familiar with its almost unlimited
capacity for producing indefinite symptoms, are very
difficult of recognition. *The Autocrat of the
Breakfast Table ' says that it is better to lose a pint of
blood from your veins than to have a nerve tapped.
Now, that is precisely what eye-strain does : it taps

1 See • The Medical Aspect of Eye- Strain,' by Ernest Clarke,
Clinical Joumalj October, 1905. * Eye -Strain as a Cause of
Headache,' by L. H. Jessopp, PractiUonerf July, 1906.

174 MINOR MALADIES.

a nerve. The energy runs to waste, and the whole
cerebro-spinal system becomes exhausted. When
once the outline of this picture is clearly discerned, it
is by no means difficult to fill in the detail. For
cerebro-spinal exhaustion, though it has no symptoms
by which it may with certainty be recognised by the
doctor, has a very real existence for the patient. In
its slighter degrees it may mean no more than the
deprivation from a particular viscus, say the stomach,
of its fair share of nervous energy, leading to
dyspepsia ; or it may spell an evident want of control
in the higher cerebral centres, causing irritability of
temper, undue emotionalism, or a craving for
stimulants. In more pronounced degrees it will
cause the grouping of symptoms to which the term
neurasthenia is applied. It may cause hysterical
ebullitions, and may even be responsible for epileptic
attacks. In degrees still more pronounced it may
lead to melancholia, and even to suicide. There is, in
short, no functional disturbance of any portion of the
central nervous system which may not own eye-
strain as its essential cause, so that it is impossible to
insist too strongly upon the importance to every
practitioner of being able to detect slight errors of
refraction. Into the details connected with the
necessary examination it is impossible to enter here,
but the following hints may serve as a useful guide.

1. Objective Examination. — (a) Defects of vision
may be suspected if the patient screws up his
eyes or places his head on one side in order to

RHEUiMATISM, NEURALGIA, HEADACHE. 175

road or to see some object at a distance. If
there is a hypersemia of the margin of the lids,
generally the upper lid, an error of some kind is
usually the cause ; and if a patient under forty years
of age presents an arcus senilis, especially if one eye
only be thus affected, it is almost certain that the
premature degeneration has been brought about by
eye-strain of some kind.

(6) When the eye is examined by the indirect
method with a concave mirror and focussing-glass.
Hyperopia is present if the disc is larger than usual,
and appears to diminish on withdrawing the glass
from the eye ; Myopia is present if the disc is smaller
than usual, and seems to enlarge on withdrawing the
glass ; and Astigmatism is present if the disc is oblong
and appears to alter in shape on withdrawing the
focussing-glass.

(c) By direct ophthalmoscopy. Hyperopia is present
if convex glasses improve the view of the fundus;
myopia, if concave glasses do so; and astigmatism
shows itself by parts of the fundus being out of focus,
while other portions at right angles are in focus.

2. Subjective Examination.-— Ryj^eio^ia. is probably
present if the patient's vision is not made worse
by convex glasses ; myopia is suspected if the patient's
reading distance is nearer than normal; and astig-
matism, if the patient can read some of the letters in
the lowest line of the distant type, but makes
mistakes even when reading a line half-way down;
or if, when looking at radiating lines, put at a distance

176 MINOR MALADIES.

of 4 to 6 metres, some of the lines look blacker than
others.

It must, however, be distinctly borne in mind that
if the patient is not under the influence of a cycloplegic,
these tests, if negative, prove nothing, as he may be,
and probably is, involuntarily correcting his error.

Eye-strain is, however, by no means the only kind
of chronic peripheral irritation which may give rise
to headache. Dental troubles which fall short of
gross caries, frequently produce it, overcrowding of
the mouth, owing to eruption of the wisdom teeth,
being a common and often unsuspected cause. Im-
pairment of respiratory power, brought about by
obstructions in the nose and throat, are other easily
overlooked causes, chief among them being deviations
of the septum and other factors acting upon one
nostril only. Aural troubles of every sort should
always be carefully examined for.

A form of headache which presents special features,
and concerning whose aetiology there has been a
great deal of speculation, is migraine, or hemicrania.
The latter name is applied to it because the pain
generally begins on one side of the head, and is
sometimes confined to that side throughout the
attack. The characteristic of migraine is its
periodicity. The attacks recur at intervals, though
not necessarily at regular intervals, and their origin
is exceedingly difficult to trace. Migrainous people,
hke epileptics, are always more or less liable to an
attack, and, like epileptics, they have premonitions ;

RHEUMATISM, NEURALGIA, HEADACHE. 177

they know the sort of influence which may affect
them, and immediately after an attack they know
that they will enjoy immunity for a variable time.
The attacks usually begin, significantly enough, with
some ocular phenomenon, such as flickering lights of
various forms and zigzag lines of colours in different
parts of the field of vision; then follows an intense
headache, accompanied generally by nausea, vomiting,
and extreme prostration, which may last for varying
periods. At the end of forty-eight hours the patient
is generally well again.

To understand the phenomena presented by
migraine we have, as in epilepsy, to assume some
underlying instability of the nerve-centres, which
are provoked into a stormy condition by stimuli
which leave ordinary individuals unaffected. The
attacks are common in the studious, in the sedentary,
in the highly cultured, and are rare in the bucolic.
In the light of what has been said above on the
question of eye-strain, and the capacity of this
condition to produce a disturbance of nervous
equilibrium, coupled with the fact that migrainous
attacks are almost invariably accompanied by ocular
phenomena, very special care should be taken to
eliminate this element in every case. A very large
number of people have slight defects of vision, and
such slight defects, while harmless to the peasant of
robust organization, may very readily provide a con-
stant irritant to the studious of delicate organization,

and thus contribute a powerful underlying cause for

12

178 MINOR MALADIES.

the attacks. A migrainous person should be examined
very minutely by physician, oculist, aurist, and
gynascologist, and any defect in any department,
however slight, which could possibly act as a cause
of irritation, should be removed. The physician
should pay particular attention to the cardio-vascular
system, the oculist to the state of the refraction, and
the aurist to any remediable errors in the ear, throat,
or nose. If nothing abnormal can be discovered, then
we are reduced to attempting to lessen the general
nervous reactive sensibility by hygiene, diet, and the
exhibition of bromides. A country, open-air life, a
diet free from stimulating foods and alcoholic drinks,
and the bromide of ammonium in 10-grain doses,
three times daily, for a week every now and again,
will very often keep the enemy at bay. During the
attacks rest and a darkened room are essential.
When taken in time — that is, before the attack has
had time to develop — the phenozone and salicylate
mixture above prescribed (see p. 160) will often —
indeed, generally — act admirably. I have found it
superior to phenacetin (10 grains), in which some
people, however, express great confidence.

Upon headache as a symptom of intracranial
mischief it is unnecessary to dwell. When the pain,
as in migraine, is accompanied by vomiting, the
fundus oculi should always be examined for anything
suggestive of optic neuritis, and careful search should
be made for other physical signs of organic disease
in the nervous system. Intracranial tumours and

RHEUMATISM, NEURALGIA, HEADACHE. 179

meningitis are causes which should always be borne
in mind.

There is a certain class of headache which is
occasionally described as congestive. The term is
misleading, because headaches due to a diversity of
causes might legitimately be so called. If, however,
we qualify the term by the adjective * mechanical,'
it is possible to recognise a separate and distinct
group. Headaches due to mechanical congestion are
produced by factors which are easily overlooked.
Anything which interferes with the proper circulation
of the blood may occasion them, and in ordinary life
tight corsets in .women and tight collars in men will
be found to be common causes. This type of head-
ache, which is described as a general fulness,
aggravated on stooping, may be the first indication
of the existence of a lesion at the mitral valve, so that
a complaint of such a nature, more especially when it
is accompanied by a history of epistaxis, should always
lead to a careful examination of the cardiac area.

Nasal obstruction, whether from enlarged tonsils,
adenoids, or deviations of the septum, is exceed-
ingly likely to cause headaches of the congestive
type. The two former are nowadays very readily
recognised, and very promptly — perhaps too promptly
— removed, but the latter is often allowed to con-
tinue unremedied. Nasal deformities constitute an
exceedingly common cause of headache in adults,
and as they are nowadays easily remedied, there need
be no hesitation in advising their radical cure, even

180 MINOR MALADIES.

in people who have passed middle life. The correction
of these deformities must be left to the expert, but I
would suggest that the most speedy, complete, and
lasting benefit is to be obtained from the recently
introduced method of submucous resection, by which
the cartilaginous and bony obstruction is entirely
removed, leaving a fleshy septum, an intact mucosa,
and a clear air-way.^

Headache is very often caused by change of climate.
The removal of a person from sedative to bracing
conditions, and, even more frequently, vice versd,
commonly brings about changes in the vascular
pressure, which, in the absence of adequate reactive
power in the individual (in the convalescent, for
example), very frequently cause headache and de-
pression of spirits. If these symptoms do not pass
off in a few days, it may be necessary to resort to
treatment. Where the headache has been induced
by relaxing climatic conditions, a mixture contain-
ing 2 grains of quinine and 5 minims of liq. strychnin,
will generally do all that is necessary. Where, on
the other hand, the climate is * too strong,' as
the expression is, 10 grains each of the iodide and
bromide of potassium three times a day will be found
useful. In each case the mixture, should be preceded
by a dose of calomel.

^ St. Clair Thomson : Proceedings of the Laryngological
Society, London, May and June, 1904 ; Transactions of the
Clinical Society, London, October 25, 1905 ; Lcmcetf June 80,
1906.

RHEUMATISM, NEURALGIA, HEADACHE. 181

Pain in the head of a superficial character, such as
seems confined to the scalp, is a frequent accompani-
ment of * colds ' in the head. In such cases the pain
is usually due to a fibrositis of the tissues overlying
the skull, and is to be treated on lines already
suggested.^ Headache is a common symptom of
neurasthenia.

Most headaches are due to what are comprehen-
sively described as hlood-states. A good instance
is supplied by chlorosis, in which the headache is
due to the abnormal condition of the corpuscular
elements ; and the same is presumably true where
the symptom ap]f)ears in leukaemia and other associated
conditions.

The offending blood-state in the majority of cases
is, however, a toxaemia. There are numerous familiar
instances of this. All the specific fevers are liable to
be ushered in with a headache more or less severe,
and the poisons of alcohol and lead almost invariably
cause the symptom. Among the toxaemias due to
defective excretion, kidney disease and diabetes are
classical instances of causative factors while chronic
constipation is probably both the commonest and the
most generally overlooked. In all these cases the
discovery of the cause immediately points the way
to the proper treatment, and some people have en-
deavoured to aid in the discovery of the cause by
mapping out certain cranial areas in which pain
occurs, and attaching to each area a particular group
^ See Chapter I.

182 MINOR MALADIES.

of causes. Thus, pain which is mainly vertical is
said to be due to the following : ansemia, hysteria,
neurasthenia, epilepsy, and disease of the uterus or
appendages. A headache which is chiefly frontal is
deemed gastro-intestinal, renal, ocular, syphilitic, or
myalgic. An occipital headache is considered sug-
gestive of intracranial mischief and spinal irritation.
While believing a great many of these to be fanciful, I
think there is no doubt that headaches due to de-
fective elimination, such as those caused by ursemia,
diabetes, constipation, and impure atmospheres, are
generally frontal, and that those which appear in
functional nervous troubles seem to have a preference
for the vertex ; but even in such cases it is not wise
to attach much importance to so variable an element
as the site.

In everyday life it is certainly the toxins of gastro-
intestinal origin which are most frequently respon-
sible for the occurrence of headache. These toxins
generally act by interfering with the intracranial
vaso-motor mechanism, causing now undue contrac-
tion, and anon, undue dilatation, of the cerebral
vessels. The indications in either case are the same —
namely, to cut off the supply of the toxins, and to
promote the excretion of those already absorbed.
The means of doing this are fully discussed in the
chapter on Goutiness, so that here it is only necessary
to emphasize the importance of dietetic simplicity,
such as absence of meat foods and alcoholic drinks,
and of excretory vigour by means of purgatives

RHEUMATISM, NEURALGIA, HEADACHE. 183

and diuretics. Stress may, perhaps, be laid on the
importance of the latter, which seem very generally
to be neglected. The salts of potassium, especially
the iodide and citrate, are most useful, but the best
of all renal stimulants is undoubtedly theobromine.
Some physicians, who are possessed by the uric acid
bogey, object to this drug on account of its close
relationship with xanthine and the other purin
bodies. An over-curious regard for these would,
however, lead also to the condemnation of caffeine,
whose efficacy as a heart tonic in suitable cases is
second only to that of digitalis.

Whatever its connection with other bodies with the
radical C5N4, and however dangerous such a connection
may seem theoretically to be, there can be no doubt
that theobromine is the most active renal evacuant
we possess, and it may be prescribed with every
confidence in all cases where we are desirous of
ridding the system of a toxin, such as a nitrogenous
toxin, which is normally disposed of through the
kidneys. It is best given in cachets of 15 to 20
grains three times daily. It occasionally operates
as a drastic purgative, in which case the dose must
be lessened. Some people prefer to give it in the
form of 'diuretin,' in which it is combined with a
salicylate.

In addition to general evacuants, it is generally
desirable to prescribe measures directed to the relief
of symptoms. Where there is reason to suppose that
the headache is due to vaso-constriction, liq. trinitrini

184 MINOft MALADIES.

is very useful. Its efiect, however, is transitory, and
it should not, for obvious reasons, be frequently re-
peated. It is best given in conjunction with hydro-
bromic acid — thus :

^. Liq. trinitrini tiiiv.

Acid, hydrobrom. dil nixx.

Aquam ad 5ss.

M. Sig. : Tor die.

Another useful drug for the symptomatic treatment
of headache is cannabis indica. If given as the
tincture, in combination with other drugs, it must be
suspended in mucilage ; it is, therefore, better to give
it separately in the form of extract, of which from J
to 1 grain may be made into a pill with lycopodium
and given three times daily.

G. W. Ross, in a valuable paper contributed to the
Lancet,^ describes a chronic headache which shows
itself as a dull, heavy ache, worse in the morning
and tending to wear off as the day advances, and
accompanied by mental and physical lassitude. This,
he says, is associated with deficient coagulability of
the blood, and yields readily to the exhibition of
chloride of calcium (see Chapter YIII.).

In very persistent headaches which resist all
treatment, it is well to try the effect of a blister on
the nape of the neck, to be kept open with savin
ointment for a week or ten days on end. I have
known this expedient succeed where other measures
had failed.

> January 20, 1906.

RHEUMATISM, NEURALGIA, HEADACHE. 185

ADDITIONAL FORMULiE.

For Neuralgia, especially when Intercostal, or due to
Eye- strain.

9. Phenacetin gr. x.

Ca£feiiie citrate gf- v.

M. Ft. pulv. in cachet i. Sig. : Every two or
three hours till pain ceases.

For Neuralgia, Migraine, and the Fains of Organic
Nervous Disease and Menstrual Troubles.

]^. Pyramidon, gr. v. to viii , dissolved in water, three times
daily.

Hypnotics (Whitla).

(a) 9. Paraldehyde 3i.

Mucil. acac 5ii*

Syr. simpl 3ii.

Aquam cianamom. ... ... ... ad 5 ii«

M. Sig. : To be taken at bedtime.

{h)'^. Lupulini gr. iiL

Camphor gr. iii.

Ext. hyoscyam. gr. iii.

M. Ft. pil. ii. To be taken at bedtime.

(0) Sulphonal (gr. xx.), Trional (gr. x. to xxx.), and Veronal
(gr. V. to X.) are all valuable hypnotics. They should, however,
be accompanied by appropriate remedies when the sleeplessness
is due to pain.

(d) Bromidia (Battle) is a useful hypnotic. It containa
chloral, potassium bromide, and cannabis indica.

Local Applications.

(a) 9. Lin. aconite |

Lin. chloroform. ) ^*

Sig. : To be gently rubbed into the painful part
in myalgia or other fibrositis.

186 MINOR MALADIES.

(6) Dr. G. H. Kenyon Btrongly advocates the local application
of tartarated antimony in lumbago. The img. antimon. tartarat.
is thoroughly rubbed into the part twice daily, if necessary, until
the characteristic pustules make their appearance {British
Medical Journal, January 13, 1906).

(c) Antiphlogistine (Denver Chemical Manufacturing Company)
is a convenient and, in some cases at least, a very efficacious
form of stimulating local application. Over poultices it has the
great merit of cleanliness and aseptioity ; to fomentations it is to
be preferred in that it need only be applied once in twenty-four
hours. It contains inter alia glycerine, boraoic and salicylic
acids, eucalyptus and iodine.

CHAPTER Y.

GOUTINESS.

Goutiness is a sufficiently common and sufficiently
well-understood term, but inasmuch as it is also a
very elastic one, I must begin by explaining the
limitations which are here applied to it. First
of all, then, we must exclude acute articular gout
and those forms of subacute gout, such as tophaceous,
as are usually described. Neither need we consider
such conditions as renal and hepatic calculus. These
are, in many -cases at any rate, truly gouty in
origin, but they are also in the nature of classical
complaints, whose symptoms, diagnosis, and treat-
ment are fully set forth in standard works. With
these exceptions the whole field of troubles caused
by the gouty diathesis is open to us, but I may as
well say at once that I do not propose to try
and exhaust it; I shall, however, endeavour to
include the most important points, and shall seek to
lay stress upon those which seem to me to require
emphasizing.

In considering any question connected with gout,

one is immediately brought face to face with

187

188 MINOR MALADIES.

the numerous and very divergent theories which
have been expressed on the subject of its causation by
very competent observers, and one finds one's self
forced to confess that very little is really known
concerning it. Fortunately, however, that does not
prevent us from obtaining a very fair workable
estimate of it from a clinical standpoint, nor from
being able to treat it with a measure of success.
Gout, it is generally agreed, is due to insufficient or
perverted metabolism, leading either to the formation
of material which is foreign to the healthy economy,
or to the inadequate discharge of normal excreta.
Whichever of these views is correct matters nothing
for our purpose. What we have to realize is that
there is a something circulating in the blood which, in
its endeavours to escape, may project itself, so to
speak, upon any organ or tissue, and that the form
which the gouty manifestation will assume will
depend upon the organ or tissue selected. What
determines that selection in any particular case it is
quite impossible to say. Thus the ' something ' may
project itself into the neighbourhood of joints, causing
a chronic gouty arthritis ; it may project itself into
the sheaths of nerves, causing a gouty neuritis ; it may
project itself on to the integument, to cause a gouty
eczema, a gouty psoriasis, and, what is contrary to
general belief, a furunculosis. It may attack the air-
passages to cause pharyngitis, laryngitis, bronchitis,
or asthma ; it may find its way to the stomach and
cause dyspepsia; it may select the brain and give

GOUTINESS. 189

rise to irritability, somnolence, and disinclination for
work ; it may provoke a cystitis, and, according to
some, even a urethritis. There is, in fact, no part of
the body which can be said to be free from the
liability to invasion by the gouty poison, and
fortunate indeed is he who, being obliged to suffer
manifestations of the diathesis in any situation,
suffers them in some painful and easily recognisable
shape rather than in the painless, insidious, but far
more inexorable, forms of arterio-sclerosis and kidney
disease.

The main thing, then, to remember about gout is
not to forget it. In the presence of a disturbance of
any sort, in any part of the body, it is wise to ask our-
selves the question * Is this due to gout V Many of
us who do not forget the question are, perhaps, too
liable on insufficient grounds to answer it in the
affirmative, but such an attitude is less liable to lead
to disaster than omission to remember it. The points
upon which a correct answer to such a question
depends are too numerous to enter into here. They
involve such matters as heredity, habits, aspect,
slight manifestations in other organs, and the like,
which can in reality be acquired only by clinical
observation and experience. There are, nevertheless,
some points in connection with the condition of
which the most experienced may profitably remind
himself, some of which we will now briefly consider.

Gouty symptoms are rare before middle life, and
when that period is reached they are commoner in

190 MINOR MALADIES.

those whose youth has been athletic. Our national
pride in outdoor sports might well be tempered by
the consideration that the habit of body which these
sports engender is very apt to lead to gout in those
who, having once indulged in them, are ultimately
condemned to a sedentary existence. The boy is father
of the man, and the man is apt to suffer if he is unable
to continue the catabolic activity to which the boy has
accustomed the organism. It is said that women do
not suffer from gout. This is true only in so far as
acute ' big-toe ' gout is concerned ; for women certainly
suffer very frequently from irregular gout, especially
in the form of headache, neuralgia, and bronchitis,
and after the menopause they exhibit a very decided
tendency to conform to the types, such as chronic
arthritis, skin affections, and dyspeptic troubles,
which are so common in men.

The chief cause of gout, in whatever form it may
appear, is want of balance between intake and output.
Either the intake is too great or the output is too
small. Not infrequently both factors are in operation.
So far as the intake is concerned, the excess is not
necessarily one of quantity. Meat foods and alcohol,
even when taken in what is usually considered modera-
tion, by a predisposed person leading an inactive life,
are very powerful producers of gout ; and, in the same
way, a man who takes a great deal of exercise may be
very gouty if he indulges too freely in the pleasures
of the table. The discovery of a gouty manifestation,
then, immediately provides two cardinal indications :

GOUTINESS. 191

the one is to check the source of the poison, the other
is to aid and hasten its elimination. The first of
these is met by prescribing and insisting upon a
suitable dietary ; the second, by increasing metabolism
and invoking the active aid of all the emunctories.

In the matter of diet the most important point is
the reduction of the alcoholic drinks. Beers and
wines in contradistinction to spirits are often spoken
of as peculiarly productive of gout. It is no doubt
true that the beer- drinker is more liable to gross and
obvious forms of the malady than the spirit-drinker,
but to argue from this that spirits are harmless to a
goutily-disposed person is to play the part of the
ostrich. Spirit-drinking, though it may not provoke
arthritis or eczema, is in the highest degree calculated
to cause arterial degeneration and granular kidneys,
and these, though less strikingly, are no less truly
gouty in origin than the others. That spirits, not
being productive of gout, are therefore harmless and
even ' wholesome ' to gouty people is a heresy which
would be ridiculous were it not so pernicious, and no
words of condemnation are too strong for him who
aids in its dissemination.

Alcoholic drinks of all sorts are in the highest
degree harmful to the goutily inclined, and the
larger the percentage of the contained alcohol, the
greater is the harmfulness of the beverage. The
first thing to do, then, with a gouty person is to
make him, if possible, into a teetotaller. The
* ostrich ' view of the question should be impressed

192 MINOR MALADIES.

upon him, and it should be brought home to him
that it is practically impossible to check the manufac-
ture of an article except by stopping the supply of
the raw material.

If we have happily succeeded in this endeavour,
our next care should be to convert him into some-
thing approaching a vegetarian; for after alcoholic
drinks, the ingestion of meat foods takes the highest
place in the production of the malady. In the time
of our forefathers there was a saying that the gouty
patient should have three meals a day — * one of fish,
one of flesh, and one of neither.' This may be a use-
ful formula for a recalcitrant patient, whom we are
trying to persuade into the paths of physiological
righteousness, but it is far indeed from being a
counsel of perfection. The three meals of a person
with definite manifestations of goutiness in any form
(I am not now referring to such as are merely goutily
disposed) should consist of one of fish or flesh and
two of neither. Even the one of fish or flesh
represents in the judgment of many a concession
which it is sometimes necessary to make to the
weaker brethren, for the less nitrogenous food of
animal origin which a patient can be induced to take,
the more rapidly and the more completely will he
get rid of his troubles. There are, of course, nitro-
genous foods and nitrogenous foods, and there seems
no doubt whatever that those which, roughly speaking,
are obtained without the sacrifice of animal life are less
deleterious to gouty people than those which entail

GOUTINESS. 193

such sacrifice. For instance, milk, cheese, eggs, and
the pulses (peas, beans, and lentils), though rich in
nitrogen, are, compared to flesh, poultry, fish, and
game, very poor in the constituents which help in the
elaboration of the gouty poison. It is from the
former, then, that the gouty patient should be
encouraged to draw his nitrogenous supplies, and it
should be made clear to him that, in the presence of
a manifestation however slight, the latter will pro-
long the attack and militate against the action of
remedial measures.

It used formerly to be believed that sugar was
productive of- gout. Although this is now very
generally recognised as fallacious, there seems to be
some measure of truth in it, inasmuch as sweets are
very Hable to upset the stomachs of gouty people.
This they do more especially when introduced into
that organ without having been thoroughly insalivated.
Gouty people who are afilicted with a sweet tooth, as
the saying is, should therefore be warned against
indulging it unduly; and it should be explained to
them how they may indulge it with the best prospect
of doing so with impunity — namely, by efficient
mastication.

Another question closely connected with diet, which
has been engaging a considerable degree of attention
during the last few years or so, is the part played by
common salt in what we may call the indirect causa-
tion of many morbid conditions which are associated

with faulty metabolism and insufficient excretion. It

13

104 MINOR MALADIES.

has been recognised since 1850 that the chlorides are
retained in the body during acute illnesses, to be
discharged en masse as soon as convalescence sets in.
It has also been known for a long time that (edematous
fluid contains a very large percentage of common salt,
which is excreted by the kidneys as soon as the
oedema disappears. Another fact which has been
recognised for some time is that the amount of NaCl
contained in the blood itself, is always the same under
all normal circumstances, quite irrespective of the
amount ingested — that is to say, if more is ingested
the surplus is immediately excreted.

Now, WidaP has shown that in many conditions
which are associated with renal inadequacy,- of which
goutiness may be taken as a type, the inadequacy
first shows itself by an undue retention of chlorides.
The common salt passes out of the bloodvessels into
the tissues. Here it attracts to itself fluids, and
oedema is the result. This oedema is at first visceral
and deep-soatcd, so that clinically it is not easy to
detect, except by careful comparative observations of
the patient's weight And, as one would suppose,
among the first of the viscera to be attacked are the
kidneys. They become oedematous, and, consequently,
to their inadequacy in the matter of chlorides there
is superadded a general inadequacy.

Thus it is that chlorides, though not poisonous in

^ La Presse M/dicale, June 29, 1908, and Gompt, Bend. Soc.
Biol., 1904. See also Treatment, August, 1903, and an article
in Tlie Fractitioner, Auguit, 1906, by J. H. Bryant.

GOUTINESS. 195

themselves, very easily lead to the retention of otheu
matters, and of these other matters, many are highly
toxic. Widal has, in fact, shown that, in kidney
affections, uraemic symptoms may be provoked or
suppressed at will, by largely increasing or greatly
diminishing the amount of common salt ingested.

In view of these facts, it is obvious that chloride
of sodium constitutes a very grave potential danger
to the goutily disposed, and we should be particularly
careful to warn such against the habit of adding
large quantities of salt to their food. For the same
reason, highly salted foods, such as bacon and salt-
fish, are better -avoided, and those natural mineral
waters which contain large quantities of NaCl — and
a great many of them do — should not be recom-
mended as habitual laxatives. Widal's work teaches
us a further lesson of some importance — namely,
that the amount of chlorides in the urine offers a
very fair gauge of the functional renal capacity of
the patient, thus helping us to a very early diagnosis
of renal inadequacy.

Having by these dietetic regulations so arranged
matters that the supply of the poison shall so far as
possible be checked, our next care is to help in the
disposal of that which has been already formed. To
this end a vigorous appeal must be made to all the
excretory organs for aid in ejecting the invader. Now,
it is to be remembered that no appeal to the excretory
organs is ever successful which is not accompanied
by a liberal supply of fluids. An abundance of wat«r

196 MINOR MALADIES.

is necessary to the action of each and all of them,
and to ask them to excrete poisons without fluid is to
ask them to make bricks without straw. It is said
by those who wish to belittle the spa treatment of
gouty conditions that this treatment is successful
only because of the large quantities of fluid which
\he patients are made to consume. It is not necessary
to give adherence to this suggestion in order to learn
a lesson from it. If the ingestion of large quantities
of water, as water, is beneficial at health resorts, it
must be equally beneficial at home ; and certain it is
that if a gouty patient can be induced to take, say,
from 2 J to 3 pints of water in the twenty-four hours,
he is materially aiding his recovery in a most essential
particular.

So much being established, let us see when and
how the water is to be taken. First and foremost, it
should be taken before meals, and not with or after
meals. Half a pint may be taken half an hour before
breakfast ; about half a pint at 11 a.m. ; the same
quantity half an hour before luncheon, and again at
4!.30 p.m. ; before dinner a similar amount, and
before bedtime a full pint. This is a large quantity,
but if all the excretory organs are to be kept
working vigorously, it is not too much. The
question of how the water is to be taken, whether
hot or cold, whether plain or with additions, must be
left to individual tastes and peculiarities to decide.
Some people will take water hot when they will not
take it cold ; some will take water ii^ v/hich tea h^

GOUTINESS. 197

been infused, or to which some fresh lemon-juice has
been added, when they will not take it plain ; others,
again, will attach virtues to a water poured from a
bottle which they will deny to that which is drawn
from a tap. These are largely matters of fancy on the
part of the patient and of diplomacy on the part of
the doctor; the only suggestions on the subject
which I have to make are that still waters are
preferable to sparkling waters, and that lightly miner-
alized waters are preferable to those which are strongly
charged. Inasmuch as fresh lemon-juice is believed,
by many observers whose opinion is entitled to
respect, to have a beneficial influence upon some, at
any rate, of the gouty manifestations, it is well to
encourage its use ; for even if it has no other merit —
and, as will appear presently, I am one of those who
believe that it has — it can certainly claim to render
the dose more palatable.

Among drugs which possess a general influence in
aiding the elimination of the gouty poison, iodide of
potassium stands pre-eminent. There is no gouty
manifestation which does not yield in a large
measure to its intelligent employment — and by
intelligent employment I mean its association with
other drugs or measures specially directed against the
particular manifestation present The mistake which
is usually made in connection with it is fear of large
doses. The ordinary dose of 2 grains is much
too small If the drug is given at all, it should be
given in doses which commence at 10 grains, and,

198 MINOR MAT.ADIES.

curious though it may seem, the larger quantity is
infinitely less liable to produce coryza and the other
symptoms of iodism than the smaller.^ If there is any
suggestion of a rash appearing in consequence of its
administration, a few drops of Fowler's solution added
to the mixture readily prevents further trouble.

Another drug which is very valuable in counteract-
ing the gouty poison, and one which resembles iodide
of potassium in the fact that the exact nature of its
working is still hidden from us, is guaiacum. The two
may very suitably be given together in cachet form :

^. Pulv. guaiaci )

Potass, iodid. ) ° '

M. Ft. cachet. Sig. : One three times daily.

If the guaiacum causes purging, the dose must be
reduced, or 5 or 10 grains of creta prsep. added
to each cachet. In any case the cachet should be
followed by a draught of water. It is not desirable to
give guaiacum in a mixture. Patients readily rebel
against it on account of its unpleasant taste and ob-
jectionable consistence.

The salicylates, while regarded by some writers as
excellent remedies in gouty conditions, are loudly
condemned by others, notably in France. The
objection urged against the salicylates, especially
that of sodium, is that they are depressing and have
an irritating effect upon the kidneys. There may bo
some truth in this, but my personal experience with
aspirin (10 to 20 grains) has so far been quite
1 See Chapter VIII., p. 310.

GOUTINESS. 199

favourable. It is, however, well to remember the
renal charge which is, on the Continent, very actively
brought against it. Many people complain that the
salicylates are inert. When this is true, it will
usually be found that they have been combined with
alkalies, and I find, in point of fact, that the combina-
tion of salicylate of sodium and bicarbonate of sodium
is a very favourite one. When salicylates are given
they should be prescribed either alone or in conjunc-
tion with such a drug as nux vomica, which does not
influence their chemical medium; for in the body
they play the part of acids, and it is in virtue of this
action that they do good.

Another acid whose virtues in the gouty state have
recently been attracting considerable attention on the
Continent is phosphoric acid. According to the
experiments of Joulie^ it would seem that gouty
manifestations are due to the retention in the blood
of matters whose escape is favoured not by alkalies
but by acids, and the acid which he has fixed upon as
most potent in this connection is phosphoric acid. I
believe there is a large measure of truth in his
contentions; at any rate, I have been successful in
giving relief with dilute phosphoric acid where
iodide of potassium and guaiacum had failed me.

Citric acid, in the form of lemon-juice, has often
been lauded in the management of the gouty

^ ' L' Acidity Urinaire,' par M. H. Joulie {Revue 0/n/rale de
€linic, Paris, 1901). See also * La Medication Phosphorique,'
Dr. Jean Nicolaidi (Paris, Octave Doin, 1904),

200 MINOR MALADIES.

diathesis. This drug, when taken in large doses — say
^ ounce in the course of the day — undoubtedly
renders the blood more fluid by precipitating the
calcium salts. What it does with these salts is a
matter which still seems to await investigation;
at any rate, they disappear from the blood, thus
rendering the fluid more mobile and better fitted for
its purpose of bathing and flushing the various
tissues, and so promoting eflScient excretion. I
believe citric acid to be a most useful general cor-
rective to the gouty tendency.

Having now paved the way for the efficient action
of the excretory organs by ensuring for them an
adequate supply of water, and having, by the action
of the above-mentioned drugs, rendered the process
of elimination more easy, let us inquire into the best
means of setting these organs to work. So far as the
bowels are concerned, if guaiacum is given, then the
quantity in the above cachet may do all that is
necessary. Where it does not, some purgative salts,
preferably sulphate of magnesium, in doses of 30 grains,
with nux vomica {vide p. 112), should be added to
the morning dose of water, and also perhaps to the
evening dose ; or some of the natural aperient waters
which are not overburdened with NaCl may be
substituted.^ Either course is much to be preferred

* Arabella water, which contains chiefly the sulphate and
bicarbonate of sodium, may be said, for practical purposes, to be
free from the chloride. It has therefore a special value in
gouty oases.

tiOUTINESS. 201

to the exhibition of cholagogue cathartics, which are
so often recommended. There is no objection to an
initial dose of calomel (say 2 to 3 grains) : it is an
excellent measure, especially in sthenic cases ; but the
practice of a sustained exhibition of hepatic stimu-
lants is much to be deprecated. It was introduced
in conformity with the theory that gout in all its
forms was due to some dereliction of duty on the
part of the liver, which could be counteracted by
stimulation of that organ. As this theory is very
far from being established, and as the continuous
administration of cholagogues has well recognised
drawbacks, the practice is not to be recommended.
In gouty conditions the liver, together with all the
portal radicles, require unloading, but this may be
done quite efficiently with the mixture above pre-
scribed, especially when this is occasionally reinforced
by small doses of calomel (1 grain), podophyllin
(J grain), iridin (2 grains), or euonymin (1 grain).

The excretory organs to whose action the greatest
importance is, in this connection, universally attached
are the kidneys. It is my purpose to avoid as far as
possible expressing an opinion about any of the
theories concerning the causation of gout, but it is
safe to admit that uric acid and the biurate of sodium
are both in a measure actively engaged in producing
the symptoms of the complaint ; and as these
substances are normally excreted by way of the
kidneys, it is obvious that anything which tends to
increase renal activity will materially aid the dis-

i^02 MINOR MALADIES.

charge of these matters, and thus lessen the incidence
of the manifestations. The importance of fluid, which,
as already stated, is considerable in the case of all the
excretory organs, is here paramount, and water must
therefore be exhibited in full quantities. As aids to
its discharge by the kidneys rather than by any
other route, it is well to have recourse to diuretics.

There are diuretics, such as digitalis and sco-
parium, which act by increasing the general blood-
pressure, including that in the kidneys. As will
appear later on, the blood - pressure in the gouty
already rules over- high, so that such drugs are care-
fully to be avoided. The routine prescription of
digitalis, bad as it is in cardiac disorders, becomes, in
conditions accompanied by high arterial tension,
something in the nature of a therapeutic crime. It
increases the arterial tension and acts as a diuretic
only when oedema is present. For diuretics in the
gouty state, then, we must look to those which
increase the renal activity without raising the blood-
pressure — such, for example, as the salts of potassium,
the infusion of buchu, and theobromine.

Fothergill says that buchu has upon the urinary
passages the same inexplicable soothing influence
which bismuth has upon the digestive apparatus.
This I believe to be true, and it has often seemed
strange to me that so valuable a drug should recently
have fallen into disuse. It is by no means un-
palatable, and it increases very conspicuously the
functional activity of the kidneys. Of the salts of

GOUTINESS. 203

potassium, those which are most used are the citrate
and bicarbonate. No one, I imagine, now gives these
salts in the vain hope of increasing the alkalinity of
the blood, so as to obtain the solution of uratic
deposits ; but whatever the motive with which they
are given, there can be no doubt either that they
exercise a beneficent action over the symptoms, or
that they increase very materially the renal activity.
It is probable that such merits as these and all other
alkaline salts may possess are due mainly, if not
entirely, to their action as diuretics; and that the
salts of sodium, even though they be, as some are
still found to' maintain, wrong in theory, are useful
in practice, owing to their possessing a similar
eliminative action.

To insure the adequate discharge of the excreta
from the kidneys, we have, then, to see, first, that
enough fluids are being taken. The importance
of this is so obvious that it seems absurd to
dwell upon it, and in reality my only reason for so
doing is to point out that the rule is liable to an
exception. If there is too much fluid in the vessels,
the urine is scanty because there is undue pressure
in the kidneys. In such circumstances, to increase
the amount of fluid ingested is to decrease the
amount of urine excreted. If, therefore, after a few
days the urine fails to increase in quantity, the fluids
should be decreased until the urine flows freely.
The next thing to do is to construct a prescription
which will include such diuretic drugs as will assist

204 MINOR MALADIES.

in the discharge of this fluid by the renal routa
If the cachet^ be discontinued, we can include its
most important ingredient, the iodide of potassium,
in this prescription, which would then be as follows :

'^. Potass, iodid gr. x.

Potass, citrat 5s8.

Inf. buchu ad 5i-

M. Sig. : Ter die.

If, as is not altogether infrequent, the patient be
anaemic, 5 to 10 grains of the potassio-tartarate of
iron may suitably be added to this mixture, which
should be taken immediately after the three principal
meals of the day.

There is another time-honoured drug which is not
used as frequently in these conditions as it might be
— this is spts. seth. nitrosi. When combined with
citrate of potassium and acetate of ammonium, as in
the following formula, it makes a very useful and
agreeable mixture, increasing notably the flow of
urine and acting, to some extent, as a diaphoretic.

9. Potass, citrai 5ss.

Spts. 8Bth. nitros. 3L

Liq. ammon. acetat 5ss.

Aquam ad 5ii.

M. Sig. : In a tumblerful of water three times a day.

In connection with spts. aeth. nitros. it is important
to remember that it must not be combined with iodide
of potassium, as the result is an explosive mixture.

A diuretic of which Professor Huchard speaks in
1 Page 194.

GOUTINESS. 205

the highest terms is theobromine. He prefers it to
diuretin, in which it is combined with salicylate of
soda, because he believes that the latter is very liable
to irritate the kidneys. Of theobromine (which he
prescribes in 10 to 15 grain cachets, three times daily)
he says : * It is one of the most powerful and
reliable diuretics with which I am acquainted. It is
by far the best medicament in all cases where we
desire to increase the secretory activity of the kidneys,
and I prescribe it all the more confidently because
it does not increase arterial tension, nor has it any
effect upon the strength or frequency of the cardiac
contractions. _ It acts solely upon the renal secretory
elements.*

The natural mineral waters of Contrex^ville, Vittel,
and Evian have very powerful diuretic properties, and
may be prescribed with great confidence for all gouty
patients. These waters can be obtained in bottles in
this country, but it is infinitely preferable to send the
patient to the spring itself, as there is reason to
believe that a measure of their efficacy is lost either
in the bottling process or in transit. Of these three
places, Evian, situated on the Lake of Geneva, is
much the most agreeable. It has a very fine
bathing establishment, and its waters act very
markedly in increasing the renal output.^

The next most important excretory organ is the

1 See A. E. Wright, Lancet, AprU 2, 1904, 'On a New
Method of Testing the Blood ajod the Urine, with Special
Ueference to the Excretory Efficiency of the Kidney.'

206 MINOR MALADIES.

skin. There are several drugs which increase
cutaneous activity, chief among which is pilocarpine.
This is a useful drug in many contingencies, and may
occasionally be helpful in the gouty state, but the
condition in which it is most generally recommended
is precisely that in which it ought never to be
employed — I mean uraemic poisoning. Pilocarpine
induces not only a free flow of perspiration, but it
induces also a great increase of bronchial, laryngeal,
and tracheal secretion, and if the patient is partly
insensible, these secretions may very easily choke
him. Those who have a fancy for pilocarpine should
reserve its use for patients who are conscious, and
avoid it carefully in uraemia and other semi-conscious
states. On the question of pilocarpine, I may
mention parenthetically that it is one of the most
useful of all drugs in the treatment of pruritus,
whether local to the anus or vulva, or associated with
a skin disease such as eczema, or even when general,
such as sometimes causes so much distress in old age.
It should be given in doses varying from J to J grain,
and when combined with atropine, say ^hs grai"» it
does not cause inconvenient perspiration.

In ordinary goutiness, however, the skin is best
stimulated by means other than drugs. Pre-eminent
among these stands muscular exercise in the open
air. This should be sufficient, but not excessive;
sufficient, that is, to induce free perspiration without,
at the same time, giving rise to more waste products
than the organs can conveniently deal with. When

GOUTINESS. 207

wo are trying to dispose of an excess of a material we
must be careful not to pursue a policy which may
have for one of its results the production of that
material, or a similar one, in increased measure.
The nitrogenous waste which is produced by muscular
exercise has to be excreted for the most part by the
kidneys, and it is well that these organs, which
already stand in need of stimulation, should have
no more work cast upon them than is absolutely
necessary.

A good substitute for muscular exercise is to be
found in baths of various kinds combined with
massage. These are undoubtedly best administered
at a health resort, under the guidance of an ex-
perienced physician who is accustomed so to graduate
them as to obtain the maximum benefit with the
minimum of fatigue. Hot baths followed by massage
may be administered at the patient's own house, but
when this is done, careful instructions should be given
as to temperature and duration. The temperature of
the first few baths should not exceed 100° F., and
their duration should be limited to ten minutes.
Both may be cautiously increased until the one
reaches 105° F. and the other twenty minutes. Each
bath should be followed by massage or shampooing,
and thereafter the patient should be swathed in
flannels and encouraged to perspire by the adminis-
tration of hot water. Such baths are, however, in-
ferior to the hot wet pack which I shall presently
describe.

208 MINOR MALADIES.

Turkish baths, though excellent in many respects,
have this against them : that very few, if any, of the
establishments in which they are administered are
adequately ventilated, so that the bather, especially
when he is in the hot rooms, is breathing an atmo-
sphere which is loaded with the cutaneous and
pulmonary excreta of others. The home Turkish
bath, of which there are now many patterns on the
market, is not open to this objection; but, then, it is
lacking in those agreeable elements of shampooing,
douching, coffee, cigarettes, and gossip, which recon-
cile people to the discipline when administered in
well-conducted establishments.

Of all the forms of bath obtainable under ordmary
circumstances in large towns, that which I have
learned to value most highly is the radiant-heat bath.
The addition of light to the hot air certainly seems
to confer upon the latter properties which in the
absence of light it does not possess. At the Dowsing
Institutes, of which there are now a great number all
over the country, these baths are well and carefully
administered. They may be followed by massage if so
desired, but even without this addition, I know of
nothing so well calculated to stimulate cutaneous
activity and to bring about resorption of gouty
deposits in properly selected cases.

Of routine household procedures nothing can com-
pare with the hot wet pack. This is an old method,
which has become unduly neglected. It is useful in
a great variety of conditions, and as it is practically

GOUTINESS. 209

always available, I shall describe it in detail. All
that is required is a mackintosh sheet, two ordinary
blankets, a cotton sheet, a hot- water bottle, a pail of
boiling water, and a wringer ; all of which, except the
last-named, can be obtaii^ed in an ordinary house-
hold. The wringer can be manufactured at short
notice by hemming in enough of the two ends of a
towel to allow a walking-stick to be passed through
each end easily. The mackintosh is placed on the
bed, and on top of it, the two blankets fully spread
out. The sheet, having been wrung out of the boiling
water, is then laid on the upper blanket. The
patient is then placed on the sheet, so that his
occipital prominence is on its upper margin. With
the patient's arms raised, the upper corner of
the sheet on his right side is carried across and
tucked under his left scapula. With his arms by
his sides, the opposite corner is brought across and
tucked under his right scapula. Each blanket is
then carried across in a similar manner, the hot-
water bottle is placed near the feet, and the free ends
of all the coverings are tucked under the heels. In
a period varying from twenty to forty minutes per-
spiration will be found on the forehead, and that is
the signal of sufficiency. The temperature taken in
the mouth generally shows a rise of 1 or 2 degrees.
After a tepid or cold sponging the patient is removed
to bed, on which the coverings should not be too
heavy. Two or even three of these packs may be

given in a week. Patients, especially children, for

14

210 MINOR MALADIES.

whom they are very useful in many conditions, always
enjoy them, and an intelligent nursery nurse can be
taught to administer them quite satisfactorily.

The use of such' means as are above indicated for
stimulating the skin, derives its importance, not only
from the point of view of excretion, but also from the
point of view of vascular dilatation. One of the
effects of the gouty poison (whatever it may be) is to
irritate the bloodvessels, especially the arterioles and
capillaries, causing their contraction, and thus giving
rise to heightened arterial tension. Now, high
arterial tension, if long continued, leaves its mark
upon the vessel walls in the form of arterio-sclerosis,
and ultimately, in the form of dilatation and relative
insufficiency, upon the heart itself. The involvement
of the coronary arteries in the sclerotic process may
give rise to anginal attacks, and the inclusion of the
renal arteries to cirrhosis.

But we need not multiply examples in order to
realize the necessity for taking early steps to over-
come the chronic contraction of the bloodvessels,
which is the direct cause of the increased blood-
pressure. The general measures, dietetic and medi-
cinal, already indicated, especially the avoidance of
meat foods and alcoholic drinks, together with the
exhibition of mercury and potassium iodide, will in
the long-run do much in this direction ; but cutaneous
stimulation by means of baths and massage causes
prompt dilatation of the vessels over an enormous
area, which lasts a considerable time, and may be

GOUTINESS. 211

repeated frequently. The assistance in combating
the condition to be obtained by such dilatation is the
secret of a large portion of the success which attends
the balneological treatment of these cases.

So much, then, for the management of the gouty
state in general Let us now consider how we are to
treat the various symptoms of this state as they arise
in different parts of the body. The most important
are those which affect the joints, causing a subacute
or chronic arthritis. When this arthritis is a legacy
from an acute attack, its treatment, in so far as
it differs from what has above been indicated,
resolves itself into that which is laid down in all the
text-books as proper to the attack itself.^

Into the details of this it is not necessary to enter
here, but I should like to say that where pain is at
all obtrusive colchicum is the best palliative, and
that it is desirable to withdraw the remedy as soon as
the pain has subsided. There are, however, a great
many varieties of gouty arthritis which are truly
chronic from the beginning, attacking various joints,
notably the small joints of the hands and the meta-
tarso-phalangeal joints in the feet, giving rise to
enlargement and deformity rather than to pain.
This is the so-called chronic deforming gout, so
frequently labelled chronic rheumatism, which is by
no means easily distinguished from rheumatoid
arthritis, especially if we make the mistake of concen-
trating our attention upon the local manifestations of

I See T). lf>4

212 MINOR MALADIES.

the disease to the exclusion of the general state of
the patient. For in the gouty condition there is, as
a rule, no difficulty in discovering the existence of
sthenic manifestations in other organs or tissues,
whereas in rheumatoid arthritis not only are such
manifestations absent, but the clinical picture is
essentially one of asthenia, demanding not an elimina-
tive but a generous regime.

The arthritis of chronic gout is probably more
amenable to electric light baths than to any other
therapeutic measure. The baths, especially when
combined with massage, bring about the absorption of
the deposits with a rapidity and completeness which
is astonishing to those who have never tried them.
Hot-air baths, douches, and the various measures of a
similar kind which are employed at health resorts,
stand next in order of efficacy, and where the patient's
means permit, it is always well to advise a visit to a
suitable spa.^

For the rest it is important to insist that chronic
gouty joints should not be allowed to become
fixed and deformed for want of exercise and move-
ment. Massage is an excellent measure, so is elec-
tricity ; so, in fact, is anything which will insure

^ Vichy and Royat are two places which may be recommended
with confidence. Aix-les-Bains has deservedly a world-wide
reputation. Buxton, Bath, Harrogate, Woodhall Spa, and
Llandrindod offer exceptional advantages to people who prefer
to stay at home. It should be remembered that the ingestion
of sulphur waters seldom suits the gouty ; their external
application does.

GOUTINESS. 213

reo'ular stimulation. In this direction much can be
done by the patient himself, and there is generally no
difficulty in inducing him to do it, if it is brought
home to him that ultimate recovery of a crippled
joint depends more upon his willing and intelligent
co-operation than upon the assistance of others.
Stimulating liniments are very useful adjuncts,
especially when applied after the part has been
steeped in hot water. Poultices and compresses con-
taining bicarbonate of sodium or citrate of lithium
are also very helpful in reducing swelling and
restoring movement.

A method of treating stiff and painful joints which
is very highly spoken of by some, is cataphoresis, by
which medicinal substances are transferred to the
joint through the unbroken skin by means of the
constant electric current. Theoretically the positive
pole should be that to be placed in contact with the
drug, but clinically it is found that some drugs
penetrate better with the negative pole, and amongst
these are iodide of potassium and salicylate of sodium.
A procedure which has seemed to me to give good
results is to paint the part with iodine, and then
place upon it a pad of lint which has been steeped in
a solution of lithium citrate. The positive pole is
then placed on the pad, and a current of about 10
cells is allowed to flow. When the pad is removed
the colour of the iodine will be found to have
disappeared. Whether this fact has any * suggestive '
effect in bringing about the result I am unable to say.

fil4 MINOR MALADIES.

I feel I ought not to leave this question of gouty or
iiieumatic arthritis without saying a word in connec-
tion with the reprehensible practice of lightly
dismissing joint troubles in children as due to this
cause. Such troubles, it is true, are seldom labelled
gout, but they are labelled rheumatism with a
frequency which is far from creditable. The truly
rheumatic state in children so rarely takes the form
of an arthritis that, apart from the disease closely
resembling rheumatoid arthritis and associated with
the name of Dr. Still, such a condition may almost be
said not to exist. Rheumatism in children shows
itself as chorea, tonsillitis, subcutaneous nodules,
erythema, purpura, and the like, but seldom or never
as an arthritis. An enlarged or stiff and painful
joint in a child, therefore, especially if only one joint
be involved, is exceedingly unlikely to be rheumatic
or gouty in origin, and great care should be taken in
BO describing it. Such conditions are more often
due to tubercle than to anything else. Their progress
is fraught with considerable anxiety, and their treat-
ment demands the utmost care and watchfulness.
Numberless limbs have been sacrificed and lives lost
owing to the loss of precious time, due to the otiose
diagnosis of ' a little rheumatism ' where arthritis in
a child has been present.

Of abarticular gout there are a great many forms.
Chronic pharyngitis is by no means uncommon,
chronic laryngitis is common, and chronic bronchitis
is not rare. The gouty poisons as they affect the

GOUTINESS. 215

lower air-passages seem, however, to void themselves
in acute explosions rather than in chronic irritation.
Thus, an acute bronchitis of gouty origin is an
exceedingly common event. It is important to
remember this, because bronchitis is invariably
attributed to chill, and if we allow ourselves to be
beguiled by such etiological suggestions we shall
fail to treat the case as it should be treated — namely,
by mercurial purges and the addition of iodide of
potassium, and perhaps some colchicum, to the drugs
intended to combat the bronchial irritation. Asthma
is another very common form of gouty ebullition.
Inasmuch as iodide of potassium is one of the most
useful remedies in ordinary spasmodic asthma, failure
to recognise its gouty origin is, so far as the attack
itself is concerned, not of much consequence ; the
recognition becomes of importance only when we are
considering the best means of providing against
further attacks, and if we do not reahze their true
origin, our precautionary measures are likely to prove
singularly ineffectual. One of the commonest associ-
ations of asthma, which is a symptom and not a
disease, is with high arterial tension. As this impor-
tant question is considered in some detail later, it is
here only necessary to call attention to the fact, and
to insist that the high tension should be treated by
appropriate means, rather than the asthma relieved
by habit-provoking sedatives.

The gouty affections of the nervous system consist
in myalgia, neuralgia, neuritis, insomnia, mental

216 MINOR MALADIES.

irritability, mental depression, migraine, and epilepti-
form attacks.

In the skin the diathesis may show itself as an
eczema, a psoriasis, an erythema, and, contrary to
what is generally believed, as furunculosis. Boils are
commonly regarded as a symptom of asthenia ; they
are, especially when occurring in successive crops, in
my experience much more often due to the gouty
poison. Why this poison should favour the activity of
staphylococci in the hair follicles it is difficult to say,
but that it does so is, to my mind, abundantly clear.

An excellent treatment for boils consists in the
administration by the mouth of pills of calcium
sulphide (1 grain) three or four times daily (smaller
doses are useless), and the local application of ichthyol
ointment (about 15 per cent.). This does a great
deal of good where the boil is a ' singleton,' relieving
very considerably the local pain and hastening
resolution. Where, however, the boils, as is often the
case, tend to appear in successive crops, the patient
should be injected with antistaphylococcic serum.
This treatment, introduced by A. E. Wright, is
practically painless; there is no constitutional dis-
turbance, and the result is uniformly satisfactory. It
does not, of course, in any degree influence the under-
lying gouty condition, which should be treated on
the lines already suggested.

In treating of boib and carbuncles, when once
established, a mistake which is often made is that of
allowing them to heal prematurely by scabbing, with

GOUTINESS. 217

the result that the retained poison shortly seeks exit
by a neighbouring hair follicle, and another boil is
the result. An old woman's remedy, consisting of
a mixture of sugar and soap, is very effectual in
preventing this. A. E. Wright explains this efficacy
by showing that this curious combination prevents
the lymph from clotting, and as a scab consists of
clotted lymph, the effect of the soap and sugar is to
keep the door open for the exit of the poison. It is
often said that boils should not be poulticed or
fomented, because such applications are apt to pro-
duce a crop of smaller ones in the neighbourhood.
Poultices ara not easily rendered aseptic, but they
can be applied with safety if the skin be first smeared
with thymol vaseline. Fomentations wrung out of
boracic solution are usually quite safe, but even here
the use of the thymol ointment is an advantage,
because the vaseline lessens the chance of irritation
from slight scalding.

Gouty men tend to become bald early, probably
owing to vaso-constriction of the arteries in the scalp,
and their nails assume a reedy appearance from
longitudinal striation.

So far as the other skin manifestations are con-
cerned, such as gouty eczema, in the existence of
which some dermatologists affect to disbelieve, they
are to be treated locally according to dermatological
rule ; but if their recurrence is to be prevented, their
underlying gouty cause must receive adequate atten-
tion on the lines already laid down.

218 MINOR MALADIES.

In the eye, gouty iritis and gouty conjunctivitis are
common. These conditions, when of gouty origin,
are less liable to be acute than when they own some
other cause, and consequently the local treatment
need not be so vigorous. A blister and a few
hot fomentations, and perhaps a little atropine,
are all that is required. If the blood state
is properly treated the condition will quickly
yield.

In the alimentary tract dyspepsia is very common.
The indigestion of gouty people is usually, but not
invariably, of the sthenic variety, demanding alkalies
and bismuth ; but it may, on the other hand, be
asthenic, and require hydrochloric acid and pepsin for
its relief.^ Another form of indigestion — namely
intestinal indigestion — is much more common in gouty
people than is generally supposed, more especially in
such as take large quantities of alcohol. It takes
the form of diarrhoea* often accompanied by flatulence.
It is generally painless, and is usually confined to the
morning. If possible, it is well to refrain from
interfering with this discharge ; the flux should,
indeed, be encouraged by mercurial cathartics, for
the process is entirely beneficial, in that it rids the
system of efiete matters without irritating the
kidneys. Tannigen (10 grains in cachet) is an
excellent simple astringent. Tincture of catechu
(1 drachm) is another. Whatever is used, it is

* Vide chapter on Indigestion.

* Vide Constipation and Diarrhoea, p. Il7.

GOUTINESS. nd

important to remember that neither lead nor opium
should ever be prescribed.

The connection between gout and kidney disease
is one which has long been recognised. There exist,
however, very decided differences of opinion as to the
exact nature of this connection ; and yet the matter
does not seem to present any very great difficulties.
Luff expresses the balance of modern opinion on the
subject of gout generally when he says that the
disease is due to faulty metabolism giving rise to an
auto-intoxication. He goes on to say : ' This auto-
intoxication coincides with, or is followed by, in the
majority of oases, a deposition of sodium biurate in
certain of the joints or tissues, which constitutes the
climax of the gouty attack. I cannot but think that
with our increasing knowledge and experience of the
disease, uric acid and its salts will, in all probability,
have to be relegated to a position of subsidiary
importance in the pathogenesis of gout. The joint
manifestations are probably dependent upon much
more general and much larger conditions than a mere
excess of uric acid in the blood. The deposition of
sodium biurate is possibly merely the sign of the
disease, not the essence of it.'

Now, if we admit the auto-intoxication — and there
is no escaping it — the connection between gout and
kidney disease seems simple enough. And not only
the connection between gout and kidney disease, but
the connection between gout, kidney disease, and
arterio-sclerosis. And this is how the matter would

no MINOR MALADIES.

seem to stand : the toxin circulating in the blood has,
as one of its results, the irritation possibly of the vaso-
motor centres, but almost certainly of the bloodvessels
along which it passes. The effect upon these blood-
vessels is to cause their contraction, and when the
contraction is continued for a long period of time,
the vessels become sclerosed.

Now, this poison is normally excreted by the
kidneys, so that it is projected on to these organs
not only in a concentrated form, but with 'nozzle
velocity.' If the initial power of resistance in these
organs is weak, the renal vessels quickly sclerose, and
the sclerotic process spreads, as it were, all over the
viscus. Then arise the phenomena with which all are
familiar — the increased blood-pressure, the enlarged
left ventricle, and the consequent progressive arterio-
sclerosis over the whole body.

This is easy to understand, and is very generally
realized. What seems to me to require insisting upon
is that this process is frequently reversed, in the sense
that the arterio-sclerosis, instead of beginning in the
kidneys, may originate elsewhere and spread to these
organs, so that the granular nephritis, instead of being
the first stage, figures either as an accident or as the
final event in the morbid process. For the process,
like all other morbid processes, will begin at the site
of least resistance, and this site will vary with the
individual, so that if the renal vessels are not primarily
below par there is no special reason why they should
be first affected. And, as a matter of fact, they very

GOUTINESS. 221

seldom are, and I am convinced that a great number
of the cases of granular kidney and general arterio-
sclerosis might be checked if sufficient regard were
paid to the detection of the earlier manifestations of
arterio-sclerosis in other parts.

Now, although we are for the moment dealing with
the gouty poison, I must not be understood to suggest
that this is the only form of toxin which may give
rise to the phenomena we are about to consider. It
is, on the contrary, well recognised that the poisons of
lead, tobacco, syphilis, typhoid, acute rheumatism,
scarlatina, and other acute specifics, frequently carry
arterio-sclerosis in their train ; and that worry,
anxiety, and concentrated brain- work are very liable
to produce it. But this I am prepared to affirm
— that by far the commonest cause is to be
found in those dietetic and other errors, such as
excess of flesh foods, alcoholic drinks, and insufficient
exercise, which all agree in associating with the pro-
duction of the gouty state.

The French have an aphorism to the effect that
*gout is to the arteries what rheumatism is to the
heart,' which means, of course, that arterio-sclerosis
is as common an accompaniment of gout as endocar-
ditis is of true rheumatism. The idea would, however,
be better expressed in English by saying that * gouti-
ness' is to the arteries what rheumatism is to the
heart ; for in acute gout the poison usually exhausts
its virulence during the attacks, which consequently
protect the sufferer from the symptoms of goutiness.

^22 MINOR MALADIES.

Now, if we bear this aphorism in mind it helps us in
a great measure to understand that otherwise baffling
element of ubiquity which characterizes the symptoms
of goutiness, by teaching us to regard these symptoms
as due primarily to some dereliction of duty on the
part of the arteries in the immediate neighbourhood.
Such an explanation does not, perhaps, cover all
the facts ; it serves, at any rate, to remind us of what
in our search after the exact nature of the gouty
poison we are sometimes in danger of forgetting —
namely, that this poison has a particular affection for
the arterial vascular system.

Let us now consider its modus operandi. We
have already seen that the gouty poison causes
contraction of the arteries. It is important to re-
member that this contraction is at first functional,
and therefore curable, but that if it goes undetected
and unremedied, it becomes organic, and therefore
incurable. It becomes incurable in the ordinary
acceptation of the term, but its effects may neverthe-
less be mitigated, and in the earlier stages even
nullified, by suitable treatment. The functional, the
curable, stage is called by the French the stage of pre-
sclerosis, and it is, of course, in this stage that it is
desirable to recognise the condition, and to set about
its treatment. For when once the stage of pre-
sclerosis is past and the stage of organic sclerosis is
entered upon, the disease, though much easier
to detect, is much more difficult to treat. Now,
how are we to recognise this first stage — the stage

GOUTINESS. 223

of pre-sclerosis ? Well, it is by no means easy,
and, as I have already said, in connection with
goutiness generally, the first thing to remember is
not to forget it. Because it must always be sought
for; it never calls attention to itself by any very
obtrusive symptoms, and the indications of its
presence are very variable. The first effect of a
general contraction of the branches of the arterial
tree will be increased vigour of the heart's action.
The cardiac muscle is stimulated by the resist-
ance, which it seeks to overcome by^ slower and
more forcible contractions. Now, if we keep these
two facts in mind, the contraction of the vessels and
the increased vigour of the heart's action, the
phenomena to which they give rise, individually and
collectively, are not difficult to follow.

First of all, then, with the contracted arterioles we
find pallor of the surface, more especially of the face,
cramps and numbness, together with coldness of the
legs and feet, and fingers that * go dead,' slight
giddiness, and momentary mental confusion, which
are very liable to be mistaken for attacks of petit-mal,
which may, indeed, degenerate into such attacks
unless their true origin is recognised and treated.
Further, there may be mental lethargy, and, although
the patient sleeps badly, he is always drowsy. Epis-
taxis, conjunctival and other haemorrhages are
common. There is also disinclination for work,
especially pronounced in the morning. Another
effect, referable to the nervous system, is the pro-

224 MINOR MALADIES.

duction of neuralgias of various sorts ; persistent or
recurrent neuralgia, or headache, is very suggestive
of high arterial tension. Someone has said that
neuralgia is the cry of a nerve for healthy blood, so
that if the arterioles which supply a particular nerve
contain impure blood, and by reason of their contrac-
tion are able to deliver such blood in reduced
quantities only, it is not surprising that the nerve
should become painful. The facial and sciatic are
those most frequently involved.

The effect of the vascular contraction in the
bowels is, as one would suppose, the production of
constipation, and in the kidneys, polyuria. These
symptoms are fairly constant, more especially the
polyuria. The contraction in the systemic periphery
naturally causes plethora in the pulmonary periphery,
and thus we find dyspnoea to be prominent, an
important and a highly characteristic symptom.
This dyspnoea, the dyspnoea of slight effort, must
not be confused with the asthma which is so liable
to supervene in the later stages of the affection.
This dyspnoea, even when extreme, never has the
characteristic laborious expiration of asthma, but
resembles far more closely the panting of renal air-
hunger, which one so often sees in the last stages
of a chronic nephritis. It is provoked by very slight
exertion, it is often accompanied by a vague feeling
of uneasiness in the chest, or by palpitation, and is
liable to occur at night, without obvious cause. This
symptom derives its importance partly from the fact

GOUTINESS. 225

that it is the one which usually brings the patient
under observation, and largely from its liability to
be confused with the dyspnoea and palpitation of
ordinary dyspepsia.

The complaint of dyspnoea would naturally lead
every conscientious practitioner to an examination of
the cardio-vascular system, and no examination of
the cardio-vascular system is even partially satisfac-
tory which fails to include a careful instrumental
estimate of the blood-pressure. In previous editions
of this book it seemed necessary to insist that digital
estimation of the * arterial tension,' as it used to be
called, was altogether fallacious. The opinion of the
profession has fortunately moved rapidly in this
direction, and they are few indeed who do not now
realize the importance of the use of a reliable instru-
ment. It is long since Clifford Allbutt pronounced
the final word on the subject by saying that to
appreciate variations from the normal blood-pressure
it is just as necessary to use a mechanical appliance
as it is necessary to use a thermometer for the
accurate appreciation of temperatures. There are a
great number of very reliable instruments on the
market. The best for the consulting - room is
probably one of the many modifications of Riva
Rocci's mercurial instrument. Dr. George Oliver's
alcoholic instrument is also convenient and reliable.
For family practice the best, because it is the most
portable, is undoubtedly Dr. Rogers* Tycos mano-
meter. It has, however, the disadvantage of being
more than double the price of the others.

226 MINOR MALADIES.

The normal systolic blood-pressure in a young and
healthy male adult may be taken as 120 mm. Hg.
In women it is rather lower, say 110 mm. Hg; in
children lower still, say 90 to 100 mm. Hg. This
pressure tends to rise with advancing years. At
fifty years of age it may be 150 mm. Hg without
exciting alarm ; at sixty a pressure of 160 mm.'Hg
is not abnormal ; and from seventy years onward it
may be 200 mm. Hg with apparent impunity.
Nevertheless, a pressure of 200 mm. Hg, even in
the aged, must always be regarded with a measure
of anxiety, and in those under seventy years it
presents a danger-signal which ought not to be dis-
regarded.

And here let me once more emphasize the fact that
high blood-pressure does not necessarily indicate
renal disease. In many cases, if not in most, the first
event is the high pressure, which, if undetected and
unchecked, leads to arterial disease. The particular
region in which the arterial disease may reveal itself
it is impossible to predict, but the end is just as
liable to come with a cerebral haemorrhage as with a
contracting granular kidney.

Now, how is this high blood - pressure to be
lessened ? Obviously, by removing the poison which
provokes it, and by taking such steps as will insure
the permanent reduction of its manufacture in the
system. Into the general principles which should
guide us in these matters I have already entered in
some detail, but I may briefly recapitulate those which

GOUTINESS. 227

have a special bearing upon the question under con-
sideration.

First, then, as to diet, without careful attention to
which it is quite hopeless to attempt the treatment of
high arterial tension of gouty origin. The embargo
upon meat foods must be absolute ; and under meat
foods, let it be clearly understood, are included fish,
poultry, and game. Alcoholic drinks, tea, and coffee
must also be absolutely forbidden. The patient must
be encouraged to drink plenty of milk, and to take
fruits and vegetables freely. What I have said about
the great importance of taking plenty of fluid in the
gouty state generally must be accepted with consider-
able reservation in the case of high arterial tension.
If the excretion of the extra fluid can be insured, then
the extra fluid can do nothing but good. If, on the
other hand, an appreciable portion of it remains, then,
by increasing the actual quantity of blood in the
vessels, and by thus adding to the state of tension, it is
liable to do harm. For this reason, a flushing policy,
though excellent when it succeeds, should in the first
instance, at any rate, be undertaken with caution.
The emunctories must, nevertheless, all be urged to
do their part in ridding the system of the gouty
poison, and the purgatives, diuretics, and sudorifics
already referred to must be pressed into the
service.

So far as purgatives are concerned, nothing can
compare with mercury, and for a diuretic it is as well
to use that which has been so highly spoken of by

^28 MIxNOll MALADIES.

Professor Huchard, to whose teaching we owe almost
all our knowledge of the pre-sclerotic state — namely,
theobromine (see p. 205). The waters of Evian, Con-
trexeville, and Vittel are admirable aids to all diuretic
drugs, and would seem, especially the first named, to
possess a special value in the condition we are
discussing. The best means of stimulating the skin —
that is, by warm baths and electric light baths — have
already been referred to. Another excellent general
measure — namely, massage — is capable of rendering
yeoman service in states of high arterial tension,
especially when applied to the abdomen ; for it helps
to dispel * abdominal venosity,' and to pass the blood
rapidly through the organs which are credited with
being actively concerned in the manufacture of the
gouty poison. This, which is mere recapitulation,
refers to general measures, the importance of which
should never be lost sight of.

We now come to the question of our ability to
act directly upon the high blood-pressure and to reduce
it by moans medicinal or otherwise. Do such means
exist ? Well, they do, but none of them are satisfac-
tory ; for the reason that their action is very transient,
and their continued employment is by no means
unattended with danger. First among them stands
blood-letting. Where we find ourselves in an
emergency, face to face with a threatening of cerebral
haemorrhage or an anginal attack, no one would, I
presume, hesitate to abstract blood from the arm to
the extent of half a pint or more. But it is obvious

GOUTINESS. 229

that this is a process which cannot be often repeated,
and, as the high arterial tension depends less upon
the quantity of the blood than upon the state of the
vessel wall, it is useless to reduce the one (especially
as the reduction cannot be maintained) without
influencing the other.

And a similar objection applies to th6 drugs hitherto
introduced for this purpose. Nitrite of amyl, though
entirely trustworthy in emergencies, is incapable of
prolonged action. Trinitrin is in reality only a degree
better. It takes longer to act than nitrite of amyl, and
its effect is maintained for a longer period ; but the relief
it gives is ill-sustained, and it cannot be frequently
repeated. The same objection applies to erythrol
tetranitrate (1 grain in tablets three times daily),
though to a much less extent. Thyroid extract
seems to act beneficially in a good many cases, and
where tachycardia is not yet present it may be tried
with considerable confidence. In the high arterial
tension which is so common with women at the
menopause some observers claim to have had good
results with ovarian extract. The physiological
basis for its employment is certainly sound, and if it
does no good, it can do no harm. Aconite has been
recommended by some people, and chloral extolled by
others. The employment of both these drugs is, how-
ever, fraught with such obvious drawbacks that it
is scarcely necessary to consider them.

In the way of drugs, then, there is nothing upon
which we can, in the present state of our knowledge,

^30 MINOR MALADIES.

depend for a definite and sustained action of a
specific nature, without incurring risks which it
does not seem to me that we are justified in taking.
And this is perhaps all to the good ; for if we had
such a drug we might be tempted to use it to the
exclusion of those general principles of diet and
hygiene on which the successful management of the
gouty diathesis is known to depend, and on which,
especially when combined with the judicious employ-
ment of mercury and iodide of potassium, full reliance
may always be placed.

It must not be concluded from the foregoing that
an Abnormally high blood-pressure is of necessity so
evil a thing that, when discovered, all our efforts
must be directed to its immediate reduction. So far
is this from being the case that a rapid reduction of
arterial pressure, as by means of nitrite of amyl, may
very easily be attended by fatal results. We have to
remember that the arterial pressure must always be
higher than the venous pressure. If it is not, the
medulla is starved, and the patient dies. If, therefore,
the venous pressure is unduly high (as, for example,
in mitral stenosis), there must be a coincident and
corresponding rise in the arterial pressure, and the
manometer will register a very high figure. The
indication here is to reduce, not the pressure in the
arteries, but that in the veins. To attempt the former
is to interfere with Nature's dispositions for the con-
tinuance of life.

The same considerations apply when the arterial

GOUTINESS. 281

pressure rises in response to an augmented intra-
cranial pressure. In order to secure that the blood
shall reach the medulla in spite of the obstacle thus
provided, the blood-pressure in the arteries is in-
creased commensurately with the increase of pres-
sure inside the cranium. Here again the manometer
will show a very high reading ; but if we allow our-
selves to be beguiled into reducing the arterial pres-
sure by venesection or other means, we shall surely
place the patient in imminent danger of his life. It.
is essential to remember that high blood-pressure is
not a disease 'per se, and although in many cases — the
majority, perhaps — it is very desirable that it should
be reduced, there are nevertheless others in which its
thoughtless reduction would certainly be attended by
very serious consequences.^

But if it be true that high blood-pressure is in the
minds of many ineradicably associated with renal
disease, it is even more strikingly the fact that
albuminuria is still regarded by many more as a
condition so desperate as to require an undertaker
rather than a physician. Inasmuch as this attitude
creates a great deal of unnecessary alarm and inflicts
great injustices, it seems profitable to consider the
question here.

The most convenient method of dealing with the

* See 'The Vagaries of Blood-Pressure' (The Hospital^
June 22, 1907) ; and ' Blood-Pressure and the Nervous System '
{Clmdcal Journal^ October 2, 1907). Also article ' Blood
Pressure ' in Murphy's ' Practitioner's Encyclopaedia of Medicine.'

^32 MINOR MALADIES.

subject would seem to be briefly to review the
physiological aspect of the matter, and see what light
is to be obtained therefrom.

We have it on the authority of Virchow, Martin,
Hofmeister, and others that albuminuria is the rule
with new-born babies. The amount of albumin is at
first abundant, but diminishes gradually, until by the
fourteenth day it has completely disappeared.

Adolescents, who are apparently in good health,
are subject to what is described as cyclical or postural
albuminuria, a phenomenon which is now admitted
on all hands to be devoid of pathological significance.
Amongst adults of mature age, military men and
doctors, Leube and Furbringer have described a con-
siderable number of cases of this postural or cyclical
albuminuria, unaccompanied and unfoUowed by any
morbid tendency.

Adolescents, who are undoubtedly in good health,
very easily develop albuminuria as the result of
fatigue. This has been conclusively shown by
W. Collier, of Oxford,^ who examined young men in
training for races, men who may therefore be assumed
to have been in a high state of physical and physio-
logical eflSciency. In a very large percentage (from
57 to 100) of these young men albumin appeared in
the urine a short time after hard exercise, to dis-
appear again after a period of repose.

According to Playfair,^ albuminuria occurs in 20 per

* British Medical Journal, January 5, 1907, p. 4.
■ ' Handbook of Midwifery,' 2nd edition, vol. i., p. 222.

GOUTINESS. 233

cent, of pregnant women after the third month, and
in a much larger percentage of primiparse. Some of
these cases, it is true, progress to definite renal
disease, but the vast majority suffer no inconvenience
from the occurrence of the symptom.

Finally, there is Senator's statement to the effect
that every urine will be found to contain albumin if
sufficiently concentrated.

The foregoing are, all of them, admittedly physio-
logical conditions, the significance of which it is
necessary to explain if we would realize the meaning
of albuminuria as it occurs in conditions which are
not physiological. Now, it is universally conceded
that albuminuria may be caused by a congested state
of the renal vessels, a fact with which we are all
familiar in heart disease and similar conditions.
Perhaps the most striking instance is afforded by the
albuminuria due to injuries of the spinal cord, in
which the vaso-motor nerves are paralyzed. But
lesser degrees of congestion will produce the same
results. Chills to the surface, for instance, as after
cold bathing, especially in the sea, are known to
provoke the appearance of albumin in the urine,
presumably by increasing the amount of blood in the
splanchnic area, and thus inducing a transient renal
stasis. Let us see what bearing this has upon the
physiological albuminurias just mentioned.

The newly-born infant is but partially adapted to
the new conditions to which he is suddenly subjected.
Most of the powers which he subsequently develops

234 MINOR MALADIES.

are in a very embryonic state. More especially 13
this true of the co-ordinating or controlling power.
He can, for instance, use muscles, but he has not
learned to co-ordinate them. His sphincters act, but
he is unable to control them. These powers are
developed only by degrees and by training. We
must, I think, assume the same to be the case in a
much higher degree with the complicated mechanism
of vaso-motor co-ordination and control. The blush-
ing and pallor which occur involuntarily on any slight
emotion, even at a very much later period, are
sufficient to show that this mechanism is an exceed-
ingly delicftte one, which demands a considerable
amount of training and adjustment before it can be
considered to be in good working order. When a
baby comes into the world he leaves a warm and
equable climate for one which is cold and liable to
considerable variations. However carefully he may
be protected from such influences, they are bound to
reach him, to the extent, at any rate, of causing very
decided differences in the balance of blood distribution
to which he has hitherto been accustomed. His skin
is now, for the first time, called upon to contract, and
this contraction causes the blood to seek refuge in the
organs of the splanchnic area. The vessels in this
area have not yet learned how to behave in the
presence of such an influx, and the organs suffer a
certain degree of congestion. The renal vessels are
among those affected, and an albuminuria results.
After a few days the splanchnic vessels lea^n their

GOUTINESS. 235

lesson, the congestion is gradually reduced, and the
albuminuria disappears.

The case of the adolescent is not very different
from that of the new-born baby. As the boy is being
transformed into the man, and the girl into the
woman, new activities are developed, which place an
enormous strain upon the delicate vaso-motor
mechanism, which tends, in consequence, to fail.
Failure of this mechanism is almost invariably in one
direction — in that, namely, of undue vaso- dilation.
The calls upon the nervous system are so consider-
able and so pressing that the tone of the peripheral
arteries is not adequately maintained, with the result
which always ensues in such circumstances, namely,
that during the erect posture the blood collects in the
capacious vessels of the splanchnic area. Then ensues
a congestion in the renal vessels, with consequent
albuminuria. So long as the patient is recumbent
the blood does not tarry unduly in the splanchnic
area; there is no renal congestion and no albumin-
uria. No sooner, however, is the erect posture
assumed than the albumin reappears. The fact that
in some of these cases the albumin diminishes or
disappears towards the end of the day only signifies
that by that time the vaso-motor mechanism has
been provoked into a sense of its responsibilities, and
has realized the necessity for contracting the splanchnic
vessels in response to the change of posture. This
postural or cyclical albuminuria is quite common in
people who have been obliged to keep their beds for

236 MINOR MALADIES.

a considerable time for some such cause as a fractured
leg. In them the vaso-motor response atrophies from
disuse, so to speak, and has to be re-educated as the
erect posture is resumed.

As an instance of what is liable to happen to an
adolescent who exhibits the phenomenon of postural
albuminuria, let me briefly relate the case of a young
man, aged twenty-three years, whom I first saw some
years ago. Eighteen months previously, after he
had been working hard at the University for his
degree, he tried to insure his life, but was refused.
This naturally alarmed him, and ho consulted his
doctor. The latter found that his urine contained no
less than 40 per cent, albumin, told him that he had
Bright's disease, and ordered him to Cannes for the
winter. I may say parenthetically that if the patient
had really had nephritis, the Riviera, with its abrupt
variations of temperature, was about as bad a place
as could possibly have been selected for him. How-
ever, to the Riviera he went, and returned home no
better. His doctor then sent him to bed, and put
him on a diet consisting only of milk. In about a
week the albumin had completely disappeared, where-
upon he was allowed up again. In two days the
albumin had reappeared, but in reduced quantities,
and he was sent back to bed. Again the albumin
disappeared, to reappear as soon as he was allowed to
get up. My notes do not say exactly how long this
game of battledore and shuttlecock continued, but
eventually the patient wearied of it. Having, in con-

GOUTINESS. 23T

sultation with his friends, decided that appendicitis
could be the only explanation of the mystery, he came
up to town to consult a surgeon, through whose instru-
mentality he eventually came to me, still, curious to
relate, wearing his appendix intact. He was also
wearing three or four layers of thick woollen under-
garments, his skin was relaxed and sodden, his blood-
pressure was 85 mm. Hg, his urine scanty and loaded
with albumin. The most careful examination failed,
however, to reveal any evidence of organic disease, so,
when I had satisfied myself as to the absence of
albumin after a few days in bed, and the absence of
granular casts at all times, I instructed him how to
clothe himself. I sent him to Margate with some
strychnine and calcium chloride, and told him to pull
himself together and live hard. Being anxious to get
well, he did as he was told, and is now working hard,
taking plenty of exercise and feeling perfectly well.
He has learned how to test for albumin, and he tells
me that, except after a dance or a hard set at tennis,
his urine is now quite free from it.

The albuminuria of young athletes described by
Collier, and previously by Dunhill ^ of Melbourne, is
not quite so easy of explanation as the foregoing. It
is nevertheless safe to assert that it is purely vaso-
motor in origin. The train of events is probably
somewhat as follows : We know that during muscular
exercise the general blood- pressure is raised. The
heart increases the number of its systoles, the vessels

^ Intercolonial Medical Journal of Australaaia^ July 2Q. 1902.

238 MINOR MALADIES.

in the splanchnic area are contracted, while those
which supply the muscles actually in use are dilated.
After the exercise is over there is a reaction, which
varies in degree directly with the magnitude and
duration of the effort. After severe and prolonged
exertion, therefore, the splanchnics dilate, and the
n uscular vessels tend to contract. If this contraction
is hastened, as it generally is in young men at Uni-
versities and public schools, and as it was in all,
Dunhill's ^ cases, by a cold shower or plunge, the
blood is driven inwards with such rapidity that a
renal congestion is produced, and albuminuria results.
It is probable, however^ that, apart altogether from
the cold shower, the reaction from the conditions
which necessarily obtain during active exercise are
sufficient to induce a renal stasis, more especially in
young men in whom we have seen the vaso-motor
response to be but partially educated. It seems,
however, that this may not be the whole explanation,
for not only is the composition of the blood materially
altered by vigorous exertion, in that the waste
products are largely augmented, but the sudden and
considerable elevation of blood-pressure entailed by
such exertion is of itself sufficient to provoke a
transient albuminuria.

The presence of albumin in the urine of pregnant
women after the third month is obviously mechanical.
The enlarging uterus, even if it does not exercise
direct pressure upon the renal veins, materially alters

^ British Medical Journal^ April 27, 1907, p. 1031.

GOUTINESS. 239

the distribution of pressure in the splanchnic area,
and if the normal compensatory mechanism is not in
good working order, a stasis with consequent albu-
minuria is not difficult to imagine. It is a significant
fact that such an albuminuria is more common in
primiparae.

We have^ then, in albuminuria a symptom which
may occur, and constantly does occur, in conditions
which are purely physiological. We know, further,
that it occurs in states which, though pathological in
various degrees, are nevertheless not such as even to
suggest that the kidneys are at fault, I have already
mentioned cardiac disease and spinal injuries, but
these by no means exhaust the conditions in which
albumin is frequently, if not constantly, found in the
urine. In pronounced myxcedema it is a classical
and well-known finding, and it is also well known
that the albumin rapidly disappears under thyioid
treatment. It is by no means uncommon in minor
degrees of thyroid insufficiency. In certain conditions,
which are wrongly labelled obesity, which are nearly
related to myxcedema, though quite distinct there-
from, as shown by the fact that thyroid extract has
no beneficial influence upon them, albumin is often
present in the urine in very large quantities, and
disappears rapidly under suitable treatment. Albu-
minuria is very commonly present in chlorosis, in
Graves' disease, in tonsillitis, even other than diph-
theritic ; in some forms of dyspepsia, and in almost all
cases of hepatic congestion; in migraine, in epilepsy,

240 MINOR MALADIES.

during the gouty paroxysm and in most toxic
pyrexias. Among pulmonary conditions it is found
as an early sign of tubercle. It is common in asthma,
and by no means uncommon in the bronchitis of
emphysematous patients. Moreover, a very large
number of drugs will give rise to it ; cubebs, copaiba,
turpentine, mercury, morphia, quinine, arsenic, and
phosphorus, are among the most important, but they
by no means complete the list. Passing abnormalities
anywhere in the urinary passages may provoke the
symptom. An excess of oxalates in the urine will
produce it ; so will the irritation of small calculi or
sand. A slight cystitis is by no means an uncommon
cause, and an exceedingly common one is the presence
of spermatozoa in the urethra. Altered blood states,
as in the essential anaemias, almost always provoke
albuminuria. Women, at or about the menopause,
very frequently have an appreciable quantity of
albumin in the urine, especially if this be examined
at the time when an expected period has failed to
appear. The combination of this with a certain rise
of blood-pressure, which is very common at the
climacteric, has frequently given rise to serious and
alarming mistakes in diagnosis.

It seems scarcely credible that a symptom which is
common to so many diverse conditions, both physio-
logical and pathological, should have succeeded for so
long in masquerading as necessarily connoting renal
disease. And yet it is within the experience of all of
us that people have been, and, alas ! still are, refused

GOUTINESS. J241

for life assurance and otherwise condemned as
damaged individuals merely because, from some of
the above-mentioned causes, a little albumin has
been found in their urine. It would be just as
logical — it would, indeed, be more reasonable — if
dyspnoea were regarded as necessarily indicating
pulmonary or cardiac disease. Dyspncea is in many
cases very significant of such disease, but inasmuch
as we have all of us become very breathless hundreds
of times in the course of our lives without any
untoward effects, we have acquired some sense of
perspective in the matter. It would be a good thing
if the presence of albumin in the urine could bo
manifested by some sign equally gross and obtrusive.
We should then come to realize how frequent an
occurrence it is, and how seldom it indicates anything
more serious than a passing change of pressure in the
bloodvessels of the splanchnic area. Albuminuria,
like dyspncea, may be the expression of very grave
and fatal diseases, but, like dyspncea, it may also
indicate nothing more serious than a considerable,
though perfectly harmless, alteration in the distribu-
tion of blood- pressure. We all make it a rule to
gauge the significance of dyspnoea by the causes
which provoke it. No one would dream of shaking
his head and crying * heart disease' because a man
was breathless after a mile race; but it cannot be
said that no one could be found to shake his head
and cry ' renal disease ' because the same man pro-
duced albuminous urine after the same ordeal.

16

242 MINOR MALADIES.

Very often, of course, the meaning of an albumin-
uria is suflSciently obvious. It is seldom, indeed,
that we find ourselves in doubt about acute nephritis,
or chronic tubal nephritis, or amyloid disease. In
these cases and in gross tuberculous renal lesions,
the coexisting symptoms are almost invariably such
as to point unmistakably to the true source of the
albumin. The cases which give rise to perplexity
are those in which the albumin constitutes the only,
or almost the only, symptom. In such cases one has
no right to express anxiety, much less to pronounce
a sentence of incurable disease, unless in addition to
albumin the urine also contains definite evidence of
structural disturbance in the kidneys. This ought to
be an absolute rule which permits of no exceptions.
Such evidence is afforded by the presence of epi-
thelium, of blood, of tube casts, more especially of the
granular or fatty variety. Hyaline casts, although
they are suspicious, have not the same significance,
for not only may they be found in small numbers in
almost any urine if sought for with suflficient
diligence, but they are often present in large numbers
in nervous and febrile conditions which have no renal
connection. It must be admitted, no doubt, that a
specific gravity of less than 1015 is a suspicious
factor, but inasmuch as nervous people very often
have urine of low specific gravity, it affords no excuse
for any relaxation of the above rule.

CHAPTER VI.

MINOR GLANDULAE INSUFFICIENCIES.

Although it is my intention to devote this chapter
mainly to the consideration of thyroid insufficiency,
it is well for the reader to understand that the
interdependence of the endocrine glands renders it
very difficult in the present state of our knowledge
to be sure which particular gland is at fault. It is
exceedingly likely that some of what we now take to
be manifestations of thyroid insufficiency of slight
degree, are in reality due to insufficiency of some
other gland, partly opponent and partly comple-
mental, such as the pituitary or the adrenal, which
may be stimulated into increased activity by the
exhibition of thyroid extract.

If we consider the symptoms which in the various
monographs are confidently attributed to the failure
of the particular gland in question, say the thyroid,
the pituitary, or the adrenal, we cannot fail to be
struck not only by the resemblance between many
of these symptoms, but with their practical identity.
With substates of the thyroid, for example, we are
accustomed to associate adiposity, infantilism, sub-

243

S44 MINOR MALADIES.

normal temperatures and subjective frilosity, a slow
pulse, somnolence and mental hebetude, together
with hairlessness and dermic pigmentation. In
substates of the pituitary we find that all these
conditions are not only present, but are regarded as
characteristic — if not pathognomonic. In the caso
of adrenal insufficiency, some of them, notably the
infantiUsm, the low temperature, the hairlessness
and pigmentation are prominent symptoms. It is
therefore evident that when one member of the
endocrine hierarchy is at fault, the mere disturbance
of the glandular balance is sufficient to produce
certain symptoms of which one can only affirm that
they point to a disturbance somewhere in the
endocrine system — the pluriglandular syndrome, as
it is called. There are some indications, though, so
far, they are not many, which enable us to say which
gland is probably the primary offender. It is these
which I now propose briefly to consider.

Confusion is most Hkely to arise between insuffi-
ciency of the thjo-oid and pituitary insufficiency.
Adrenal inadequacy, though it may in its very early
stages present some features which might lead to a
mistaken diagnosis, is nevertheless as a rule suffi-
ciently distinctive in its evolution. Here there is
never adiposity ; the change in bulk, if any, is always
in the direction of emaciation. Moreover, however
much the general symptoms, such as asthenia,
frilosity, and depression, may suggest thyroid or
pituitary insufficiency, the urgency of the gastro-

MINOR GLANDULAR INSUFFICIENCIES. 245

intestinal symptoms should prevent any mistake.
These are anorexia, diarrhoea, and vomiting of a
natm-e progressive and intractable, which are
usually accompanied by pain and tachycardia. The
diagnosis of adrenal insufficiency has been much
assisted by Dr. Emile Sergent of Paris, who described
the phenomenon of the ' white adrenal line.' This is
his description:

' To bring about this phenomenon the skin of the
abdomen is selected by preference and on it is traced
a geometrical figure — a rectangle, triangle, or cross —
thus obviating any possible confusion with lines
possibly caused by scars, folds of the skin, etc.
Ordinarily I outline a square around the umbilicus
with a blunt object, as the rounded end of a fountain
pen, or, simply, the finger tip, taking special care
to avoid rubbing, particularly with the nail. The
figure should be made by a simple superficial stroking
— one must neither bear down nor scratch. The
motion should be deliberate and never rapid. The
early or premature appearance of an outline is
always a sign of clumsiness, as such treatment
strikes and surprises the vasomotors, thus inter-
fering with the reaction instead of causing it. I am
in the habit of telling my students that such a
procedure is Kkely to be a source of error. When
the tracing has been made properly, all movement
on the part of the patient is prohibited and one
waits a short time. Immediately following the out-
lining nothing is seen, provided the proper technique

246 MINOR MALADIES.

has been followed; but after a few seconds, about
half a minute, a pale line or band begins to be noticed
following the course of the finger (or pen). Gradu-
ally this becomes more and more distinct and white,
at the same time becoming larger, so that eventually
the line exceeds in size the actual area touched by
the finger tip.'

It is necessary to draw a distinction between
adrenal insufficiency and Addison's disease. The
tribute of the suprarenal glands to the blood-stream
may become deficient from various causes. Addison's
disease, which is due to tuberculosis of the glands — a
tuberculosis which is always primary to those glands
— is only one of the causes. Its original descrip-
tion was so vivid and the complete clinical picture
which it presents is so striking, that it has tended to
obscure the minor manifestations of the glandular
difficulties; much as myxoedema in its complete
form so long obscured the lesser degrees of thjrroid
insufficiency. Perhaps the most striking objective
signs of adrenal insufficiency are to be found in the
vascular system. The tone of the bloodvessels is
below par, as evidenced not only by the manometer,
but also by the instability of the pulse and the
absence of reserve power in the heart itself. This,
when accompanied by a subnormal temperature, as
is usually the case, and somnolence with an over-
readiness to fatigue, physical and mental, may
easily give rise to a suspicion that the thyroid or
pituitary is at fault, but, as I have already said, the

MINOR GLANDULAR INSUFFICIENCIES. 247

emaciation which is characteristic of suprarenal
insufficiencies is not often seen in these others, and
the gastro-intestinal troubles seldom or never. Diffi-
culties may nevertheless arise when, as frequently
happens, especially after acute specifics, two or more
of the endocrine glands are simultaneously exhausted.

The resemblance between the phenomena of
thyroid insufficiency and those of pituitary insuffi-
ciency is so close as often to require great care in
arriving at a decision as to which of these two glands
is really at fault. And here again it is necessary to
remember that there is nothing to prevent a depres-
sion of activity in both of them simultaneously.
Both are charged with the neutralization of toxins,
endogenous and exogenous; both are essential to
bodily growth and mental development; both are
intimately concerned with the function of reproduc-
tion. The two are said by some to antagonize each
other, and there is very definite evidence that in
certain conditions the one will, so to speak, replace
the other — or endeavour to do so. It is therefore
not surprising that confusion should often arise as to
which is the chief offender when symptoms point in
the direction of either. It is of course true that no
one with any experience is likely to mistake myx-
cedema for Hutchinson's syndrome,^ but it is all too

^ I.e.y dystrophia adiposo-genitalis, commonly called Froelich's
syndrome. The condition was, however, first described by
Jonathan Hutchinson in the Archives of Surgery, under the name
of * lipomatosis uoivarsalia asexualls,' and it ought in common
justice to bear his name, if anyone's.

248 MINOR MALADIES.

easy to be led into error in cases which fall short of
their complete evolution towards these distinctive
clinical pictures.

I have already said that in both there is adiposity
subnormal temperature and subjective frilosity, a
slow pulse, mental hebetude, together with hairless-
ness and dermic pigmentation. Such is the rule.
I': is by no means the rule, but it may occur in either,
that adenoids and nocturnal enuresis appear in
children and that transient swellings, psychic dis-
turbances, and menstrual vagaries appear in adults.
But if you will look beyond these resemblances you
will find differences which are illuminating. To
begin with, the adiposity in the two cases is different
in type and distribution. In pituitary insufficiency
it is, to use Hutchinson's expression, universal;
whereas in the case of the thyroid it favours certain
well defined regions. Moreover, in certain cases
even of complete thyroidlessness, the patient shows
no appreciable adiposity, a state of matters which I
have never seen associated with any pronounced
degree of pituitary depression.

The condition of the skin affords a striking contrast
in the two cases. Where the thyroid is at fault,
in degrees varying with the severity of the case, the
skin is harsh, dry, and coarse, proceeding occasion-
ally to the length of definite ichthyosis. Its minor
manifestations favour certain regions, notably the
the hands and the skin over the triceps. When the
ptuitary is the primary offender the skin is never

MINOR GLANDULAR INSUFFICIENCIES. 249

coarse. It may be dry; it often is, but it is always
fine, and in many cases it seems almost atrophic.
The difference in the two cases extends to the
nails, which in the case of the thyroid are coarse and
brittle; in the case of the pituitary they are small
and thin, and are often unprovided with crescents
at the roots. It is much the same with the hair.
On the head, subthyroidic hair is ill-nourished and
tends to faU ; it may be dry or greasy, but the indivi-
dual hairs are of good calibre. Subhypophyseal
hair is always fine, almost baby-like in texture, and
shows no great tendency to fall out.

Investigation of the eyes may afford valuable
information. In the lids themselves there is often a
sufficient deposit of ' mucoid ' tissue to give a heavy-
eyed appearance to the subthyroidic; and in extreme
cases both upper and lower lids may be so suggestive
of the oedema of renal disease, as to deceive all but the
most experienced. I have never met with anything
of this kind in hypopituitarism. In this condition
the ocular troubles, if any, are visual, and are due
presumably to some circulatory disturbance in the
neighbourhood of the pituitary itself. Hypopitui-
tarism is often accompanied by an enlargement of the
gland, just as hypothyroidism is frequently accom-
panied by a goitre. Hertoghe has described one case,
and I have seen another, in which amblyopia was
present in fully developed myxoedema; in both
instances it cleared up under treatment by thyroid
extract. Such a complication is, however, so rare

250 MINOR MALADIES.

that it is safe to regard visual disturbance as a sign
rather of pituitary deficiency than of thyroidal.

The enlargement of the gland which occurs in
simple hypopituitarism is almost certainly the cause
of the persistent headache, presenting exacerbations
of extreme violence, which is a characteristic feature
of the complaint. A very slight degree of enlargement
is sufficient to cause pain within the closely packed
cranium. The headache of hypothyroidism is a
dull ache which is seldom insisted upon; but the
headache of hypopituitarism is not infrequently the
symptom whose urgency drives the patient to seek
advice. In any case, it is one which is always put
in the forefront of the indictment. Pituitary extract
relieves it with astonishing rapidity. The effect of
aspirin, pyramidon, and their congeners is often good,
but always transient.

In thyroid deficiency the teeth usually show
evidences of the disturbance of calcium metabolism.
They decay rapidly in children, and in adults they
tend to fall out. The calcium function of the pitui-
tary is believed to be opposed to that of the thyroid.
The latter is said to fix these salts in the body, the
former to discharge them. We should therefore
expect a deficiency of pituitary essence in the blood
to lead to a retention of calcium salts. There are a
great many facts which go to support this view, by
no means the least striking among which is the
excellent state of the teeth in most cases of hypo-
pituitarism. This is a feature which has before now

MINOR GLANDULAR INSUFFICIENCIES. 251

guided me to a correct diagnosis when the other
signs were ambiguous.

Although mental hebetude is a frequent accom-
paniment of pituitary insufficiency, it is very far
from being characteristic. I would indeed go so far
as to say that a bright intelligence is a conspicuous
feature of uncomplicated pituitary insufficiency. It
is usually a concomitant thyroidal defect which
causes the hebetude.

Before leaving the subject of the pituitary, which
I now propose to do, in order to concentrate attention
upon the better understood thyroid, there is one
matter upon which I desire to lay special stress. It
is well recognised that the hypodermic administra-
tion of pituitary extract raises the blood-pressure.
Great care is therefore necessary in applying this
form of medication to those in whom the arterial
tension is already too high. That is a precaution
upon which it is quite right to insist. It should,
however, be distinctly understood that this pre-
caution is quite unnecessary when the extract is
given by the mouth. When introduced by the oral
route the powerful pressor substance is not absorbed ;
it is presumably destroyed in the stomach. I have
now on several occasions made very careful observa-
tions on this point, as the result of which I can quite
confidently affirm that pituitary extract administered
by the mouth even in very large doses, has no appre-
ciable effect upon the blood-pressure. This is an
extremely important fact, which if it were genera ly

252 MINOR MALADIES.

recognised would remove the timidity which now
prevails about the exhibition of the drug to patients
who are clearly in need of it.

Pituitary feeding is said to produce no toxic
effects. Although, in a general way, I am disposed
to agree with this, it has more than once occurred to
me, owing to the absence of any other explanation,
to saddle the treatment with the responsibility for
occasional acute though transient rises of tempera-
ture which have occurred during its course. The
only harm which these febrile movements appeared
to do, was to occasion very considerable alarm to
those in charge of the case.

Gushing points out that one of the characteristics
of hypopituitarism being an abnormally high sugar
tolerance, a fair gauge for the dose of pituitary
extract required by a particular case is the degree
to which this tolerance is reduced by the treatment.
My experience has been that the necessary sugar
tests are so much disliked by patients that I never
now suggest them.

Minor degrees of th3nroid insufficiency are at first
very difficult of recognition. The observer's eye must
be educated and his senses kept on the alert. In order
to enable him to do this his attention must be called
to the importance which may underlie the apparently
trivial. It is this which I now propose to attempt.
That the thyroid secretion is essential to the
development of the foetus is shown by several facts.
Myxoedematous women seldom become pregnant,

MINOR GLANDULAR INSUFFICIENCIES. 253

and when they do, in the absence of thyroid medica-
tion they invariably abort. It is normal for women
during pregnancy to develop an enlargement of the
thyroid gland, which subsides to some extent after the
child is born, but is continued during lactation. By
no means the least important function of the thyroid
gland is that of fixing the calcium salts in the body.
In order to permit of bone formation in the foetus
the mother is obliged to provide more secretion than
under normal circumstances she requires, and the
gland consequently hypertrophies. After the birth
of the child, the same degree of this increment being
no longer necessary, the gland tends to resume its
normal proportions. In some women this prolonged
call of pregnancy has the effect of unduly exhausting
the gland, and they are unable in consequence to
suckle the child, for lactation is dependent upon a
due supply of thyroid secretion.^ Such women
generally become obese and lethargic, and remain so
for varying periods until the thyroid has had time to
recover itself. Judicious thyroid medication will
frequently not only enable a mother to suckle her
infant, but will materially shorten the period of her
post-partum difficulties.

But to return to the child. Unsatisfactory babies
are almost invariably the subjects of thyroid
deficiency. Other dyscrasiae may of course act as

1 Hertoghe, ' Nouvelles Recherohes sur les insuffisances
thyroidiennes,' Bulletin de rAcademie Royale de M^decine de
Belgique, vi. serie, tome xxi.. No. 4.

264 MINOR MALADIES.

contributory causes, more especially the syphilitic
and the tuberculous; but even of these it may be
said that some, at any rate, of their effects are due
to their depressing action on the thyroid. It has
more than once occurred to me to succeed in trans-
forming an unsatisfactory child into a satisfactory
one by a combination of grey powder and thyroid
extract, after having tried both separately with very
partial success.

When we pass from the region of general unsatis-
factoriness to demonstrable cUnical entities, we are,
at this period of life, immediately brought face to
face with rickets. Now, with regard to rickets, I feel
in a position positively to alB&rm that if all the
symptoms of the disease are not due to thyroid
insufficiency, then certainly its most salient features
are.. Especially does this apply to the bony
phenomena which are the most obvious signs of the
disease. These phenomena are obviously due to
inadequate osseous development, and, as in the
foetus, so in the growing infant, thyroid secretion ia
essential to the full utilization of the calcium salts.
It is known that the bony phenomena are due to a
relative absence of calcium salts, and it is also known
that these salts, given in large excess though they be,
have no influence in arresting the disease. This is
because the all-essential link is missing, the thyroid
secretion, by whose means alone the ingested calcium
can be so assimilated as to be incorporated in the
osseous tissues. No originality is claimed for this

MINOR GLANDULAR INSUFFICIENCIES. 9,55

yiew as to the essential factor in rickets. It was
first advanced by Professor Marfan in 1907/ and
upheld in an interesting paper which does not appear
to have attracted the attention which it deserves.
My own experiences have convinced me that the
view is correct. If it be true anywhere, as the adage
has it, that naturam morhorum curationes ostendunt,
it is pre-eminently true in the sphere of opotherapy ;
and every case of rickets in which I have employed
thjToid extract has shown such decided improve-
ment as to leave no doubt in my mind that thyroid
insufficiency is the main causative factor in the
disease.

As a child progresses in years, deficiency in thyroid
secretion may reveal itself in various ways. One of
the most dramatic and alarming is the production of
night terrors. I do not pretend to be able to explain
the association between these unpleasant ebullitions
and a deficiency of thyroid essence in the circulation,
but I can most positively affirm that they rapidly
disappear under the influence of thyroid extract.
I have already shown that nocturnal enuresis,^
though it may own other causes, such as phimosis or
intestinal worms, is in the vast majority of cases
caused by thj^roid inadequacy and is readily curable
by the administration of thyroid extract. In the

^ ' Lo Rachitisme dans ses rapports avec la deformation ogivale
de la voute palatine,' etc., La Semalnz 3Icdicaley September 18,
1907.

2 'Adenoids, Nocturnal Enuresis, and the Thyroid Gland*
(Bale, Sons and Danielsson, Ltd., 1909).

256 MINOR MALADIES.

same connection I discussed the question of adenoids,
and made so bold as to suggest, concerning them,
that they constituted one of the stigmata of thyroid
insufficiency. The views expressed may be briefly
summarized as follows: Adenoids and enlarged
tonsils occur in children who have an inadequate
supply of thyroid secretion. The hypertrophic
condition in each case is apparently the result of an
endeavoiu: on the part of the organism to supply an
internal secretion as nearly allied as possible to the
one which is lacking. If the hypertrophy is not very
pronounced, and if it has been not very long in
existence, great enough and protracted enough, that
is, to produce complications, such as disease in the
tonsils themselves or in the ears, then the exhibition
of thjToid extract will cause their regression. It is
only when medicinal means have failed that operative
interference becomes justifiable.

Enlarged lymphatic glands, so often observed in
the necks of weakly children, are not infrequently
due to thyroid inadequacy. Whatever their position
and accompaniments, they are usually quite confi-
dently attributed to tubercle, and are treated as such
with more or less indifferent success. Arthur Latham
has recently pointed out that even where their origin
is undoubtedly tuberculous, there is no justification
for removing them until other means have failed.
But these glandular enlargements are less often due
to tubercle than is commonly supposed. I have
seen a good many children thus afflicted to whom I

MINOR GLANDULAR INSUFFICIENCIES. 257

was emboldened to administer thyroid extract by
th© presence of some unmistakable coexisting sign
of thyroid insuflEiciency. The enlarged glands in
these cases have always been situated at the angle
of the jaw; they have been hard and not tender, and
have shown no tendency to suppurate. In this
matter it is necessary to be quite sure of our ground
before administering thyroid extract, because if the
case be really tubercular the extract, instead of
doing good, may very easily do harm. For some
reason, which is so far unexplained, the majority of
tuberculous people bear thyroid badly. In connec-
tion with this matter of enlarged lymphatic glands,
it is interesting to not® that Dr. John On, of Edin-
burgh, has had good results with thyroid extract in
Hodgkin's disease.^

In tracing up to this point in its development the
difficulties which may beset a child with an inade-
quate thyroid gland, it has not been necessary to draw
any distinction between the sexes. They appear to be
equally affected. When we reach the age of puberty,
however, we find that the boys have practically
disappeared. There are, it is true, some few cases
of delayed puberty — infantilism — most of which
yield readily to thyroid extract, and there are also
the cases of adolescent albuminuria which also yield
readily to the same treatment; they are clearly a
matter of calcium metabolism; but in the vast
majority of boys and young men the changes which

» Folia TherapeiUica, July, 1909.

17

258 MINOR MALADIES.

occur at this period appear to eroke such an activity
of the thyroid gland as to protect them during the
immediately ensuing decade from any eridences of
thyroid inadequacy, always excepting those bony
deformities which a previous insufficiency has
stamped upon them. In the case of girls it is far
otherwise. With them, it is precisely at the age of
puberty that the worst of their troubles begin. But
before separating the sexes I must make a generaliza-
tion which refers equally to both. I stated at the
outset that the prolonged call which pregnancy makes
upon the thyroid gland frequently resulted in its
exhaustion. The same thing must be said of the
infectious diseases generally, more especially of those
which are called the infantile diseases — mumps,
measles, Grerman measles, and scarlatina. It is
evident that the internal secretion of the thyroid
constitutes one of the defences of the organism
against microbic invasion, for not only are sub-
thyroidic children more liable to such invasion, but
the occurrence of one of these diseases in a previously
healthy child very often proves the starting-point of
troubles due to thyroid inadequacy. The resistance
to the effects of the poison makes a heavy demand
upon the activity of the gland, and when the demand
is over the gland becomes exhausted and its function
depressed. A very large percentage of cases of
rickets, adenoids, and nocturnal enuresis will be
found on inquiry to date from one of the infantile
febrile diseases. In connection with this aspect of

MINOR GLANDULAR INSUFFICIENCIES. 259

the matter it is convenient to call attention to the
very depressing effect which real influenza at all ages
is liable to exercise upon the functions of the thyroid.
I say real influenza in contradistinction to the
transitory febrile attacks which are diplomatically
so labelled to satisfy importunate relatives who
thirst after a label. Real influenza, as is well
known, produces a degree of subsequent mental and
physical asthenia which defies the ordinary tonics
and remains obdurate to everything except time.
Such, at any rate, was my experience until, on the
theory of thyroid exhaustion, I began treating these
cases with thyroid extract. The results of this
treatment have always been gratifying, and I have
no hesitation in affirming that if we were to realize
more fully the exhausting effects upon the thyroid,
and indeed of the endocrine system generally, of all
acute specifics, we should be much more successful
in dealing with the period of convalescence, which,
to some natures, is even more trying than the disease
itself.

This defensive power of the thyroid secretion ia
one which deserves to be emphasized. When it has
attracted the general attention which it certainly
merits, we may look for good results from the
exhibition of thyroid extract during the course of all
acute specific diseases. It should be remembered
that, if it be sought for, an enlargement with tender-
ness of the thyroid will be found to be present in a
large number of febrile diseases, notably in acute

260 MINOR MALADIES.

rheumatism. The headache which is so often
present in such cases may reasonably be attributed
to the pituitary, and the asthenia to the supra-
renals.

Let us now return to our chronological order, and
proceed to consider the troubles imposed by thyroid
inadequacy as the years advance. We had arrived
at the age of puberty, at and after which boys may
be dismissed as affording an interest which is but
occasional and fortuitous. Of girls it is a truism to
say that the establishment of the menstrual function
constitutes a crisis no less critical than that which
occurs at the menopause; but it is insulB&ciently
realized that at both periods the pivot round which
the critical phenomena revolve is the behaviour of
the thyroid gland. That there is a certain physio-
logical antagonism between the internal secretion of
the ovary and that of the thyroid is well established,^
and the observed facts go far to prove that the
activity of the ovary normally provokes a corre-
sponding activity on the part of the thyroid. The
clinical evidence of this is provided by the enlarge-
ment of the thyroid, which is to be observed in the
majority of women at each menstrual period. It is
obvious then that, given a girl with a congenitally
inadequate thyroid, the advent of menstruation will
serve to emphasize that inadequacy, and thus bring
into view various symptoms which up to that time

1 • Cardiopathies of the Menopause,' Clinical Journalt March 3,
1909.

MINOR GLANDULAR INSUFFICIENCIES. 261

had lain dormant. One of my cases of nocturnal
enuresis^ was certainly due to this cause. Without
going much more fully into the matter than my
present purpose permits, it would be impossible to
offer an explanation of a clinical fact, of which any-
one may easily convince himself — namely, that both
dysmenorrhoea and menorrhagia are more frequently
than not due to an insufficiency of thyroid secretion.
Persistent amenorrhoea, whether it be congenital or
acquired, is almost always due to hypopituitarism,
and can generally be cured by pituitary f ceding. ^

That simple enlargements of the thyroid are due
to an insufficiency of the internal secretion of the
gland is now generally admitted.^ That migrainous
attacks, more especially such as affect by preference
the menstrual period, are due to the same underlying
cause, is a proposition which originated with Leopold
Levi and H. de Rothschild,* and has been supported
by numerous subsequent observations by these
authors, and by others. Of dysmenorrhoea and
menorrhagia enough has already been said. To this
list of the disabilities which an inadequate thyroid
may impose upon the female sex I would add one
more — namely, sterility. From the fact that the
thyroid enlarges dm-ing pregnancy, it may be taken

^ * Adenoids, Nocturnal Enuresis, and the Thyroid Gland,*
p. 27.

2 • The Byways of Thyroid Inadequacy,* American Medicine,
April, 1914.

3 ' Organotherapy,* by H. Batty Shaw (Cassell and Co.).
* Hertoghe, op. cit.

262 MINOR MALADIES.

as certain that the maternal economy requires an
additional amount of the internal secretion during
that period, and it is evident that if this additional
quantity be not forthcoming, the pregnancy will be
brought to an abrupt termination. In the case of
women whose thyroid activities are markedly in-
adequate, this unhappy result will occur as soon as
the first strain is put upon the gland — that is, when
the next menstrual period is due. Many women
who are labelled as hopelessly sterile are so only
because of the general failure to recognise the para-
mount importance of the thyroid gland in the func-
tion of reproduction. I have known at least one
case in which the repeated abortions were confidently
attributed to syphilis, in which, nevertheless, the
administration of thyroid extract brought a preg-
nancy to a most satisfactory conclusion. Where
thyi'oid feeding alone is ineffectual, it is well to
associate it with pituitary feeding. The addition of
suprarenal feeding may even be necessary.

So fascinating and, in a sense, so facile is the
diagnosis of thjToid insufficiency that it threatens
soon to supplant gout in the position so long held by
the latter as the last resort of the perplexed prac-
titioner. When you have been fortunate enough
to produce strikingly good results by prescribing
thyroid extract, you are tempted to attribute a great
many ills to thyroid insufficiency which have no
necessary connection therewith. To this mental
attitude must be attributed the tendency of the

MINOR GLAiNDULAR INSUFFICIENCIES. 263

moment, which is most apparent in France, towards
blaming the inadequate thyroid for many mutually
exclusive diseases. From the already formidable
list of maladies for which the responsibility has been
cast upon the thyroid, two seem to deserve more
than a passing notice; one of these is rheumatoid
arthritis, the other is chorea. Now, neither rheuma-
toid arthritis nor chorea la, to coin an expression, a
self-contained disease; each of them represents a
group of symptoms which may be produced by
several different causes. In both, thyroid inade-
quacy may occasionally play a leading part, but
either may occur in patients who do not show, nor
ever have shown, the slightest sign of insufficient
action of the gland. It has fallen to my lot to
produce very brilliant results with thyroid medica-
tion in both these conditions, but in the majority of
the cases so treated the results have been negative.
In these diseases and many others it is to be pre^
sumed that an insufficiency of thyroid secretion
provides a soil which is favourable to the unhindered
action of the toxins, and that consequently the
rectifying of the inadequacy will do much to protect
the individual against invasion, though it can seldom
ameliorate matters quickly enough and profoundly
enough to influence the results of an invasion which
has abeady succeeded. Chorea is often very favour-
ably influenced by thyroid extract, but only in those
who are definitely subthyroidic. In those who
present none of the ordinary stigmata of thyroid

264 MINOR MALADXES.

inadequacy, the extract does not succeed. Rheu-
matoid arthritis may be due to many causes, of
which pyorrhoea, tubercle, and thyroid or other
internal glandular inadequacy are only some. The
commonest and the most potent is a toxsemia of
intestinal origin. If the stigmata of thyroid insuffi-
ency are apparent in any individual case, thyroid
extract will probably give good results, but even
then only when combined with other accredited
measures, directed to the removal of the causative
toxaemia .

Women who have been perfectly healthy aU their
lives very often display a marked tendency to thyroid
insufficiency about the time of the menopause. It
is not only the reproductive organs proper which
resign their functions at this period. A great many
glands which are, in a manner which is still obscure,
related to these organs, tend to become concomi-
tantly deranged, and chief among them is the thyroid
gland. The changes incidental to the menopause
often begin much earUer than is commonly supposed
to be the case. In this country we are taught to
expect them about fifty years of age. In France the
recognised age is forty. But the age varies not only
with race and chmate, but also with the individual,
and it is far from unusual to find both spinsters and
those married women who have begun childbearing
at a comparatively early age, exhibiting very distinct
evidences of the approaching climacteric as early as
thirty-five years. Of such evidences a great many

MINOR GLANDULAR INSUFFICIENCIES. 265

will be found to be very closely related to thyroid
inadequacy, and a very considerable improvement,
both subjective and objective, may usually be
brought about by judicious thyroid medication. True
myxoedema in my experience more often owns the
climacteric as its cause than any other factor or
combination of factors.

For reasons less obvious and in a manner less
dramatic than the menopause, the conditions sur-
rounding the mere advance of years tend to produce
inadequacy of the thyroid function. It is not that
the thyroid gland declines more rapidly than the
other internal secretory glands, for all of them, even
including the spleen, tend to diminish both in size
and activity as the years advance. It is that the
thyroid gland is so important to the economy that
any diminution in its activities reflects itself un-
mistakably in a great many directions. So much is
this the case that one foreign writer contends that if
the activities of the thyroid could be maintained
unimpaired the condition of old age could never
arise. It is not necessary to subscribe to such an
extreme view in order to appreciate the value of
suitable doses of thyroid extract in most of the
troubles which are liable to beset the senile period.
There are very few of these troubles whose treatment
by the recognised means is not rendered more rapidly
successful by the addition of thyroid extract.

I now pass to the consideration of some of the
signs and symptoms from which we obtain confirma-

9.66 MINOR MALADIES.

tory evidence when the existence of thyroid in-
adequacy is in question. Some of these I have
already noticed in considerable detail,^ and I need
not therefore do more than enumerate them. Among
the most important is the subnormal temperature,
which is usually a marked feature, and is not only
revealed by the thermometer but is also complained
of by the patient, who protests that she never feels
warm. The eyebrow sign (signe de sourcil), first
described by Hertoghe, consists in a rarefaction,
amounting sometimes to complete absence, of the hair
on the outer two-thirds of the eyebrow. This sign,
when present, is certainly very suggestive, but in my
own experience very perfect eyebrows are compatible
with a marked degree of thyroid inadequacy, more
especially when this has been provoked, as by an
acute specific, after the patient has attained to
maturity. Carious and irregular teeth should always
excite suspicion. So, likewise, should delay in the
eruption of the permanent teeth.

The most important among the signs which reveal
a persistent deficiency of thjnroid secretion are those
which refer to the skin and its appendages. Amongst
these, that which is most easily observed is the eye-
brow sign just described. Premature greyness is
generally, though not always, a sign of thyroid in-
adequacy. The same may be said of premature
baldness of a pronounced kind. Both these degenera-
tions are so common in comparatively young people

* * Adenoids, Nocturnal Enuresis, and the Thyroid Gland.*

MINOR GLANDULAR INSUFFICIENCIES. 267

In this country that little diagnostic value is attached
to them. They are nevertheless, both of them, very
suggestive, and should always excite a suspicion
either that the thyroid is not acting properly or that
its functions have been gravely depressed in the past.
Abnormalities of cutaneous pigmentation are
exceedingly common in all disturbances of the thy-
roid, whether such disturbances take the form of
excess or perversion, as in Graves' disease, or of
inadequacy, as manifested by myxcedema, rheuma-
toid arthritis, rickets, or climacteric disorders. The
abnormalities in pigmentation which accompany
such disturbances are not, as a rule, very obtrusive,
nor, when present, must they be regarded as pathog-
nomonic; but they afford valuable evidence in
favour of suspicions otherwise aroused. Of these
abnormalities, leucodermia is by far the most
common. Amongst the grosser forms of skin lesion,
that which is most frequently encountered in thyroid
inadequacy affecting adults is certainly psoriasis,
but eczema is almost equally common. RadcHffe
Crocker^ found thyroid extract exceedingly useful
both in lupus vulgaris and ichthyosis. Urticaria,
and transitory oedemas affecting the deeper struc-
tures, are concomitants of thjroid insufficiency to
which Levi and de Rothschild attach very consider-
able importance. In cases of what we may call
Bubmyxoedema in adults, there is usually a slight
deposit of myxcedematous tissue under the skin,

» • Diseases of the Skin,' by Radcliffe Crocker, 1903.

268 MINOR MALADIES.

and this is more noticeable in certain parts of the
body. In such cases it will be found that although
the skin of the hand and forearm can be pinched up
with ease, that which overlies the deltoid and the
upper part of the trapezius cannot be so pinched up.
In women, the area immediately below the breasts
often presents the same phenomenon. This condi-
tion has been called ' panniculitis,* an unfortunate
name, though less unfortunate perhaps than the
French ' cellulite.*

The so-called obesity of the subthyroidic is not a
true obesity. True obesity is a caricature of the
normal outline; hypothyroidic obesity is a carica-
ture of true obesity. The deposit of tissue favours
certain regions. Not infrequently there is a decided
hump over the seventh cervical vertebra, so pro-
nounced as to give to a patient who is really upright
the appearance of stooping. This hump occasionally
attains to the size of a closed fist. Its consistence
is hard, giving a sensation to the fingers which is
quite unlike that of ordinary fatty tissue. The
region over the deltoids is often covered with the
same material, and that over the triceps almost
invariably. In some cases the breasts themselves
remain relatively small, though even then they are
apt to be hard; but the region immediately below
them is generally covered by roUs of tissue which
may easily be taken for true fat. In both men and
women the walls of the abdomen are furnished with
the same material, but in women the most noticeable
deposit takes place in the gluteal region.

MINOR GLANDULAR INSUFFICIENCIES. 269

Subthyroidic people, like the fully myxcedema^
tous, though voluble about irrelevant matters,
often seem curiously reticent about themselves,
Their brains move slowly and they are very forgetful.
It is therefore necessary to interrogate them very
closely on questions which are purely subjective.
That they are unduly sensitive to cold, that they
have considerable difficulty in concentrating the
attention, that their memories are unreliable,
especially in small matters, that they are very
somnolent, especially at certain times of the day,
are all facts which must be elicited by cross-examina-
tion. Fatigue, muscular and mental, is very
characteristic of the condition. Although this
element is very rarely absent from a case, the fact
of its presence is never volunteered. This is due
as a rule to its having been quite confidently and
often brutally attributed to ' nerves,' ' fancies,'
' vapours,' or whatever the epithet of the moment
may happen to have been, and the patient has been
urged to rouse herself and take plenty of exercise.
Needless to say, this is very bad advice, which not
only causes a great deal of unnecessary suffering,
but militates very decidedly against any tendency
to improvement. Such patients demand physical
and mental repose, and it should on no account be
denied them.

THYROID MEDICATION.— Success in the treat-
ment of disease by thyroid extract depends in
the first place upon the employment of a reliable

270 MINOR MALADIES.

preparation, and in the second upon a very careful
supervision of the dose. In the matter of the former,
my own experience is not very extensive. I have
tried but four preparations, with all of which I have
been satisfied. One is Messrs. Burroughs Wellcome's
tabloids, another is Messrs. Oppenheimer's Pala-
tinoids, the third is the Elixir Colloid of Messrs
Squire and Sons, of Oxford Street, and the fourth is
a French preparation, the Thyratoxin of Byla and
Co., of Gentilly. The disadvantage of the tabloids
used to be that the minimum dose is J grain,
which, as will appear later, I now regard as a
large dose. This, however, is now remedied. The
Palatinoids are made in doses of J grain. The
advantage of these two preparations is that they are
portable and reliable. The French preparation is a
solid one, in the form of * tablettes.' The makers
claim that they have eliminated the lipoids and
leucomaines which are present in all ordinary prepa-
rations in such quantities as to give rise to symptoms
which are regarded as those of physiological intoler-
ance. It is certainly a fact that this preparation is
very weU borne by patients who seem unduly
sensitive to those in more common use. One of the
advantages of Messrs. Squire's Elixir is that the
word ' thyroid * does not appear on the prescription.
A very large number of patients or their friends
have made unpleasant and even tragic acquaintance
with the drug, and are consequently apt to take
fright at the mere name of it. It is therefore con-

MINOR GLANDULAR INSUFFICIENCIES. 271

venient to be able to prescribe it under a different
name. Another advantage is that one may vary
the dose to any desired extent. The strength of the
Elixir is IJ grains to the fluid drachm, so that
5 minims represent J grain, a dose with which I
prefer to begin the treatment, even of severe cases.
As it is very frequently desirable to associate other
drugs with the thyroid, it is a convenience to include
them in one mixture. The Elixir has no incompa-
tibles. It is right to add that I have occasionally
believed my results to be better with the solid
preparations than with the liquid.

The dose of thyroid extract is quoted in most text-
books at 3 to 10 grains, three times daily: a dose so
large that it would be ludicrous were it not so
dangerous. The proper dose is from one-tenth
grain to 1 grain, three times daily. With the
exception of certain types of lunatics, it is only the
most robust among healthy people who can take
larger doses with impunity, unless these larger doses
have been arrived at progressively from very small
beginnings. There is one important fact which the
prescriber of thyroid extract should keep ever
before him, which is, that the more a patient requires
the drug, the smaller is the initial dose which he will
tolerate. This is probably to be explained as
follows : The want of thyroid essence has given rise
to the deposit of mucin in various parts. Under the
influence of thyroid medication this mucin is liberated
into the circulation with a view of its excretion. If

272 MINOR MALADIES.

it is liberated too rapidly, as by large doses it certainly
is, there ensues such a surfeit in the blood that the
excretory organs are unable to deal with it, and
urgent symptoms of intolerance quickly arise.
Professor Murray warns his readers against the
exhibition of large doses in advanced cases of myxoD-
dema, lest the degenerated myocardium fail under
the strain and cause sudden death. The warning
is much needed. And not only in advanced cases,
for there are in reality very few cases of whatever
degree of inadequacy which can tolerate without
very grave disturbance an initial dose of more than
J grain twice daily.

It is commonly stated that the symptoms of
excessive dosage are tachycardia, palpitation,
diarrhoea, vomiting, excitement, and even maniacal
symptoms. These certainly do occm*, but only in
the case of a dose so grossly excessive that its
administration by accident would afford its only
excuse. If the drug be given with circumspection,
the fact that the limit has been reached will reveal
itself quite unmistakably long before any of the
above symptoms have time to develop. A httle
looseness of the bowels there may be, but there
ought to be nothing resembling real diarrhoea.
A certain degree of quickening of the pulse-rate
Is to be expected, but if it amount to anything
approaching heart-hurry, the management of the
case has been very unskilful. To quicken men-
tality and promote alertness is one of the physio-

MINOR GLANDULAR INSUFFICIENCIES. 273

logical effects of the drug, but it argues ignorance or
carelessness when these results are allowed to reach
the stages of excitement and restlessness. If it is
intended to give thyroid extract over a period of
several weeks, it is necessary to make observations
upon the temperature and pulse-rate. If the drug
is really required, the temperature is almost without
exception subnormal, especially in the evening, and
the pulse-rate is as a rule slow. When the tempera-
ture rises to normal, the drug should be suspended,
at any rate for a time, and the pulse-rate, whatever
its initial figure, should never be allowed to go above
95 without calling a halt. In the case of children,
other than cretins, the body -weight is a useful
indication of the success of the treatment. So long
as the weight increases the drug may be continued;
as soon as the weight becomes stationary the drug
should be suspended, and if the weight decreases
the drug must be discontinued. Having ascertained
by cautious increase from small beginnings the dose
which best suits the patient, my usual practice is to
continue the dose for three weeks. I then suspend
it for a week and then resume it for three weeks, and
so on. If the pulse-rate is not slow at first, or if
there is any other factor in the case which makes me
fear intolerance, I give the drug for a fortnight, and
suspend it for a fortnight. In the case of adult
women, it is well to arrange so that the menstrual
period should occur during an interval from the
drug. Given in the doses above recommended, and

18

274 MINOR MALADIES.

managed in this way, there is only one sign of
commencing intolerance for which one need be on
the lookout: this is coryza. A sudden and profuse
nasal catarrh sometimes surprises people who are
taking thjrroid extract, and unless the physician
realizes that such a thing is possible, he may attri-
bute the catarrh to some ordinary cause and fail to
discontinue the drug. Another signal which has
occurred in some of my cases is a painless enlarge-
ment of the glands at the angle of the jaw. It has
always disappeared on suspension of the drug. A
/Blight tenderness of the parotids, one or both, some-
times occurs.

In a few instances, at the commencement of
thyroid medication, patients have exhibited all the
symptoms of acute pancreatitis — i.e., a sudden
attack of violent pain in the epigastrium, with
vomiting, constipation, and local tenderness, which
have in each case all passed off in a few hours. The
close antagonistic relationship between the activities
of the thyroid gland and the pancreas is my reason for
regarding the latter as the seat of pain. The sudden
active stimulue of the thyroid extract upon a
pancreas which for a considerable period had been
free from that stimulus would probably result in
such a degree of pancreatic hyperactivity as to
cause the symptoms. The few patients in which
these symptoms occurred were badly in need of the
drug. Short of producing violent symptoms of this
kind, it is by no means uncommon for patients taking

MINOR GLANDULAR INSUFFICIENCIES. 275

thyroid extract in doses which appear otherwise to
suit them, to complain of feelings of discomfort after
meals. The symptoms are usually those of the acid
type, and they generally yield to alkalies and bis
muth. Not infrequently, however, the combination
of HCl and pepsin seems to be more eJBficacious.
Thyroid extract is said to be useful in the treatment
of urticaria, its action presumably being that of
utilizing fully the calcium salts in the diet. This
may be so, but it is to my mind quite certain that
thyroid medication tends to provoke urticaria even
in those who are not subject to this irritating
complaint. I have frequently been obliged to
suspend the drug on this account, with the invariable
result that the urticaria has subsided.

Thyroid medication will occasionally, but by no
means always, regulate the bowels. The stools of
those taking the drug regularly generally become
very light in colour. This may be due to an absence
of bile pigment or to the presence of fats in excess.
The latter cause is the usual one.

When it is acting satisfactorily in an ordinary case
of moderate degree, thyroid medication increases
very largely the urinary output. The occasional
presence of albumin in the urine need not excite
alarm, but the appearance of sugar should lead at
once to suspension of the drug.

If the best results are to be obtained from thyroid
medication, the ordinary mixed diet of the present
day requires some slight modification. Carbohydrate

276 MINOR MALADIES.

foods and alcoholic drinks are recognised as depres-
sors of thyroid activity. I therefore direct those who
suffer from thjToid insufficiency to be sparing in
their use of them. Common salt I also endeavour
to banish from the dietary.

CHxVPTER VII.
GENERAL HEALTH.

• O, wist a man how many maladies
Folwen of excess and of glotonies
He wolde be the more mesurable
Of his diete, sitting at his table.' — Chaucer.

To obtaiQ clear ideas on the subject of general health,
it is necessary to realize two very obvious, but
frequently overlooked, facts. The first is that, what-
ever his intellectual and moral development may be,
man is essentially an animal, primarily adapted to
certain conditions and surroundings ; and the other
is that the needs of civilization have imposed upon
him the necessity for, or the temptation to, certain
modifications of these conditions and surroundings.
The problem which presents itself is this : How far
and in what manner can the modifications be efiected
without impairing his animal powers — that is, his
physiological or animal efficiency ?

That man was originally a semi-nude animal, living
in the open air, who obtained his food by tilling the
ground and hunting his game, may be taken aa
beyond controversy. These were the conditions and
surroundings to which he was originally adapted.
Ho has, in course of evolution, become a very much
beclothed animal, who lives in houses, and obtains
his food less by the sweat of his brow than by the

277

273 MINOR MAIJ^DIES.

work of his brain. This change of environment
ought, logically, to entail corresponding changes in
his habits.

Certain changes have, doubtless, occurred, but they
have for the most part been dictated, not by con-
siderations of physiological suitability, but by those
of pleasure or convenience. Departures from health
are almost always due to offences against man's
animal or physiological requirements; and if we
would fully realize what those requirements are,
we must endeavour as far as possible to understand
his primeval conditions and surroundings, untram-
melled by the mists in which his pleasures or his
convenience have enveloped him. This is the only
scientific attitude from which to approach the subject
of his general health ; for unless a scheme of living
is in consonance with these general principles, it must
necessarily rest upon a basis which is theoretical, and
therefore insecure. The whole subject is too large to
permit of its consideration in any real detail, but
some aspects of the matter, approached from this
point of view, may be useful in illustrating the ad-
vantage of appealing to Nature for guidance rather
than to fashion.

There can be no doubt that man was intended to
be a working animal ; and by work is meant some-
thing which must be done day in, day out, whether
the doing accords with the inclination or not. Physio-
logical efficiency in every part of the body is de-
pendent upon the regular exercise of function, and

GENERAL HEALTH. 279

what is true of each part is necessarily true of the
whole. The man who does not work is never a
reliable person, and he is seldom a healthy one — at
any rate, for long. The normal individual demands
legitimate outlets for his energy, and if he does not
obtain them the energy becomes diverted into ille-
gitimate channels. The majority of alcoholics, of
hypochondriacs, and of neurotics, are people with
nothing to do ; and one, at any rate, of the reasons
why women are more prone than men to functional
nervous ebullitions is that they are, compared to
the men of the same class, the leisured portion of
the community.

To be healthy, then, a man should work. It is,
of course, not an easy matter to compel a person
to work who has no financial incentive thereto ; but
there is plenty of voluntary work for those who have
the leisure to devote to it, and it would be a good
thing if all members of the profession were to im-
press upon idlers the incontrovertible fact that
idleness is by far the most potent enemy to healthy
existence.

Whether or not man was intended by Nature to bo
a naked animal is a subject which need scarcely
detain us. The climate of the temperate zone and
the exigencies of modern life have imposed a certain
measure of covering upon all civilized races. The
question for us to consider is whether the nature and
the amount of the CLOTHING which fashion now
prescribes are such as to bo conducive to man's

280 MINOR MALADIES.

physiological efficiency. To elucidate this question
we must glance for a moment at two of the functions
of that important organ the skin.

The first of these to be considered is the power in
virtue of which it contracts to a cold influence and
relaxes to a warm influence. This power, in common
with all the other vital powers, is dependent for its
integrity upon its proper exercise. Here, as else-
where, use gives rise to increase of function, disuse
to abeyance, or loss of function. It is, therefore,
obvious that the amount of clothing should be so
regulated as not only not to interfere with this power,
but, on the contrary, to afibrd every reasonable
opportunity for its exercise. And we must not lose
sight of the fact that the degree of efficiency of
this function is a measure of the efficiency of the
skin as a whole, because when one function of an
organ suffers, the efficiency of the others becomes
impaired. The right amount of clothing for a healthy
person, therefore, is that which, while sufficient to
protect the body from the harmful exposure to
temperatures in which contraction cannot prevent
undue loss of heat, is nevertheless not such as to
protect the body from such a degree of cold as is
necessary to the proper activity of the contractile
power. In other words, the proper, the ideal, amount
of clothing for a healthy person is the minimum
\7hich wiU protect that person from undue depression
of temperature while following his usual employment.

If these conclusions, which are indeed sufficiently

GENERAL HEALTH. 2S1

obvious, be correct, it is clear that the great majority
of people are grossly overdo thed. To judge by the
general practice in this matter, one would be driven
to suppose that the object to be attained was the
avoidance, not of harmful degrees of cold, but of all
degrees of cold. This practice, objectionable as it is
in the case of adults, amounts to something in the
nature of a hygienic crime where children are
concerned; for in addition to the interference with
adequate metabolism which it causes in young and
old alike, in children it militates against healthy
development. The overclothed child has little
incentive to run about and exercise his limbs and his
lungs in the manner essential to normal animal
evolution, and so it happens that rickets, adenoids,
and ill-formed chests are, among the children of the
well-to-do classes, the rule rather than the exception.

Parents should be reminded at every possible
opportunity that their children are primarily young
animals, and that the practice of coddling inevitably
means defective development, with its consequent
physical and mental degeneracy. A full measure of
cold should always be allowed to reach the skins of
young people. It keeps the cutaneous contractile
power in good working order, and incites the children
themselves to the muscular exercise upon which their
proper development depends.

One of the best means of exercising this function of
the skin is the cold morning tub. The exact
temperature of the water to be used is a matter of

»»5 MINOR MALADIES.

some importance, but it is one which can be decided
only after a review of all the circumstances connected
with each case. Speaking generally, it should be cold,
but never so cold as to leave the bather chilled and
miserable. The fashion of the moment prescribes
the use of full-length baths. There is no objection
to these in the case of healthy people, but for those
who are weakly, the sitz bath is infinitely preferable.
In the full-length bath all the blood is driven
inwards to the internal organs, whereas in the sitz
bath, the cold affusion being applied to various parts
of the surface in turns, the determination of blood
inwards is less sudden.

One of the advantages of the cold bath is that the
whole cutaneous surface is thereby exposed to the air
at leaat once daily. To reap this advantage to the
full, care should be taken that the atmosphere in the
bath-room is as pure as possible, and this is best
secured by the open window. The cold bath has
other incidental advantages. One is that to obtain
the desired reaction people usually apply friction to
the skin with a rough towel. This entails a certain
amount of exercise which is altogether to the good,
and it results in a general stimulation of the whole
cutaneous surface, which is highly conducive to its
physiological eflSciency.

One of the cutaneous appendages — namely, the
hair — often suffers from want of adequate stimu-
lation. There has been a good deal of ingenious
speculation as to the causes of baldness, especially

GENERAL HEALTH. 2S8

as to why it should bo comparatively common in
men and relatively rare in women. The absence
of physiological stimulation in the one case and
its presence in the other supplies in reality the
solution of the riddle. Men cut their hair short, and
so deprive the follicles of the stimulus which the
mere weight of long hair affords. In addition, hair
which is long entails a great deal more brushing and
general attention than hair which is short, so that the
hair follicles in man are deprived of a double measure
of stimulus. If these facts were more generally
recognised and acted upon, there would be less
premature baldness than there now is. The drying
process after the cold morning tub affords an excellent
opportunity for thoroughly massaging the scalp by
moving it freely on the underlying bone. If after
this the brush is used forcibly enough to redden the
skin, premature loss of hair is very unlikely to occur.

The drying process should also be utilized for the
purpose of applying friction to the ears. By this
means the sclerotic process which so often gives rise
to premature deafness may be indefinitely postponed.

The other function of the skin which it is necessary
to consider in this connection is the excretory func-
tion. The cutaneous excretions are discharged either
as fluid or watery vapour, and it is, therefore, very
properly held that the clothing to be worn in contact
with the cutaneous surface should be of an absorbent
nature. The material should have the power, that is,
of rapidly taking up the moisture. Curiously enough,

284 MINOR MALADIES.

the material which is all but universally prescribed
for underwear — namely, flannel or wool — is precisely
the one which has the least capacity for absorption.
Flannel is a warm material, as it is called. No
material is, of course, warm per se. All warmth is
derived from the body itself, and one material is
warmer than another in virtue of the fact that one is
a worse conductor of heat than another. Flannel is a
non-conductor of heat, by reason of the air-spaces it
contains, because air is a bad conductor ; but flannel
is not absorbent. Silk, linen, and cotton are in a
diff'erent category. These are all highly absorbent
materials, but as their fibres contain no air-spaces
they are not * warm.' It is, however, possible to manu-
facture them in such a way that they shall contain
air-spaces, and thus become efficient non-conductors ;
whereas it is quite impossible so to treat flannel as to
render it absorbent.

The obvious inference is that flannel is not a
suitable material for underwear, and that silk, linen,
and cotton can all be rendered very suitable by
causing their fibres to contain the air-spaces on which
the reputation of flannel rests. These materials are
all now manufactured on these principles, so that
there is no longer any excuse for advising people
to utilize wool or flannel for underwear. These
two substances, which are in reality the same thing,
as being practically unabsorbent, are inimical to
healthy animal existence. When worn next the skin
they imprison the moisture, and thus give rise to

GENERAL HEALTH. «85

deficient evaporation, diminished metabolism, and
great disinclination to mental and bodily exertion.^

And not only should clothing be of a suitable
material, but it should be constructed so as to give
the limbs free play and allow the circulation to
proceed without let or hindrance. Tight vests and
clinging drawers are much too common, especially
with the young. It is not very long since the pro-
fession had good reason to deplore the tight corsets
affected by women. Fashion has fortunately decreed
that these shall no longer be worn, but en revanche
she has imposed upon the smart women of this
generation a burden almost as deleterious. The
tight, high collars stiffened with whalebone, which are
de rigueur to-day, are scarcely less objectionable than
the * stocks' worn by our ancestors, or the highly-
starched, double dog-collar beloved of the con-
temporary city clerk.

It should be remembered that the neck is an
isthmus containing very important organs. To say
nothing of the larynx, the thyroid, and lymphatic
glands, it contains large bloodvessels for the supply
of the brain, and is traversed by many important
nerve-trunks. Very little consideration will show that
constriction of such a tract must seriously impede the
free movement upon which so much depends. The

^ For a detailed discussion of this question, see * Three
Lectures on Personal Hygiene,' CUnical Journal, July 6, 13,
and August 10, 1904 ; ' Some Aspects of Obesity,' Practitioner^
May, 1904; and * Rheumatics in Relation to CHmate,' Bir-
mvngham Medical Beview, May, 1906.

S86 MINOR MALADIES.

muscles waste, and the underlying organs become
exposed to a pressure which Nature never intended
them to encounter, with the result that headaches,
giddiness, and the various symptoms of thyroid
embarrassment quickly ensue. The neck should be as
free as possible, and under no circumstances should
tight or high collars be tolerated.^

General physiological efficiency is dependent more
upon an ADEaUATE SUPPLY OF OXYGEN to the
tissues than upon anything else. No one is capable of
his best work unless he is able to obtain air of normal
purity, and any habitual falling short of the normal
lessens the general powers of resistance, and leads to
disease. The normal standard of purity is given by
authorities as 21 per cent, of oxygen and "04 percent,
of COg, and they go on to say that a rise of CO2 to '08
per cent, is distinctly harmful. The normal standard
is obtained from the examination of air in the country,
on mountains, at sea, and in open spaces of towns,
and it is found to be remarkably uniform in all
portions of the globe, inhabited and uninhabited.
The air in houses falls short of this standard, the
proportion of COg very commonly reaching '05 per
cent., and where a large number of people are gathered
together, as in churches, theatres, concert-rooms, and
the like, it not infrequently reaches '08 per cent., or,
indeed, *1 per cent., either of which percentages
represents gross impurity. The degree of impurity of

^ See a paper by Dr. Walter G. Walford, British Medical
Journal, AprU 20, 1912, p. 886.

GENERAL HEALTH. 287

an atmosphere is stated in terms of COg, because the
amount of this gas is comparatively easy of estima-
tion. The practice has one great disadvantage, how-
ever, which is that it is apt to give rise to the
supposition that the impurity consists solely in tke
presence of an excess of COj, and we are liable, in
consequence, to forget the far more deleterious
substances which an impure air contains. These
substances comprise organic matters, watery vapour,
bacteria, and decomposing organic matter given off by
the skin and lungs. It seems necessary occasionally
to remind ourselves that the skin and lungs are
excretory organs, the degree and importance of
whose activities it is, on account of their unobtrusive
nature, very easy to underestimate.

It is unnecessary to attempt any enumeration of
the diseases and morbid states which are directly
due to vitiation of the atmosphere.^ When it has
been said that such an atmosphere lessens the vital
resistance to the attacks of the bacteria, which at
the same time it supplies in great abundance, all has
been said that is requisite for the appreciation of the
paramount necessity for the mainteuance, in the
highest possible state of purity, of the atmosphere
in which each one finds himself.

And this is a matter in which a very reasonable
complaint may be lodged against the profession as a
whole. In spite of the emphasis which has recently

* Seo 'Maladies oansed by the Air we Breathe,' by Dr.
Thomas Oliver (Bailli^re, 1906).

%88 MINOR MALADIES.

been laid upon the importance of fresh air, in the
brilliant results obtained thereby in the treatment of
phthisis, medical men, as a rule, are far too tolerant in
their patients, and in the public generally, of impure
and even grossly vitiated atmospheres. This tolerance
is due in a large measure to the persistence of what
may be called the chill theory — the theory, that is,
by which any morbid condition whose etiology is
obscure is attributed to the action of cold or chill.

It is not very long since phthisis, pneumonia, and
influenza were confidently stated to be due to chill,
and there are still some people who believe in pleurisy
a frigore. In times still more remote, almost all
diseases were deemed the result of chill. It is not
surprising, therefore, that in the lay mind the word
should suggest some obscure yet serious menace,
nor that every precaution should be taken to guard
against so deadly and ubiquitous an enemy. Among
the causes of chill, draughts are always given the
first place. To sit in a draught is regarded by many
people who are otherwise sane and reasonable as
the most unwise and dangerous proceeding, not be-
cause it is unpleasant, but because it is directly
calculated to lead to serious disease.

There is not only no justification for this view, but
it is diametrically opposed to what we now know to be
the truth. The majority of diseases are due to
microbic invasion: microbes of all sorts abound in
polluted atmosphere, and there is no means of pre-
venting an atmosphere from becoming polluted

GENERAL HEALTH. 289

except by the admission of fresh air. The admission
of fresh air necessarily produces a draught, so that
it is quite obvious that we have to choose between
a draught, which is salutary, and stagnation of the
atmosphere, which is deadly.

If the open-air treatment of phthisis has estab-
lished anything, it has proved beyond all cavil that
currents of air are not injurious. The patients at
sanatoria live, as I have heard it expressed, in a
gale of wind, and it is a fact that when they return
from these institutions people are particularly in-
tolerant of anything in the nature of stuffiness.
These patients, we must remember, are what the
French call poitrinaires — lung sufferers — and are
therefore drawn from amongst those to whom, accord-
ing to the chill theory, draughts are most deadly.

The success of the open-air system is in reality the
reductio ad absurdum of the chill theory. Extreme
cases are taken, not of the disease, of course, but of
those who have delicate and debilitated air-passages,
and who are therefore susceptible above all others
to the supposed baneful effects of draughts. They
are taken generally from the heart of a draught-
eschewing household, and are suddenly, even in the
depths of winter, deliberately and of malice afore-
thought subjected to a system in which exposure
to draughts is the leading and essential feature.
And what is the result ? If there were the slightest
basis of truth in the chill theory, they would die

like flies ; but, instead of doinjg so, they not only

19

290 MINOB MALADIES.

continue to live, but they increase in vigour and in
weight, and their disease becomes arrested. No
more convincing proof could possibly be afforded
of the baselessness of this ignorant and pernicious
fallacy which is gnawing at the vitals of the com-
munity.

The moral of this is simple enough. We cannot
all live in open-air sanatoria, even if we would, but
we can all put in practice the principles of which
these places have established the correctness and the
value. It is the duty of the profession to instruct
the public in the prophylactic aspect of the matter,
and to educate people into realizing that tuberculosis
is only one, even though it be the most important
one, of many evils which inevitably follow in the
wake of polluted air, and that a pure, clean atmo-
sphere is as essential to the maintenance of healthy
lungs as pure, clean water is to the preservation of
healthy intestines. It is unnecessary to enter into
detail on this subject People can only be weaned
from the chill theory by having it pointed out to
them that those who practise it are unhealthy, and
by being made to experience the superiority of the
effects of fresh air, however productive of draughts
its ingress may be.

Without adequate ventilation there can be no
such thing as physiological efficiency, and in the
present method of house construction the only means
to adequate ventilation is the open window. And
the window should be kept open day and night, not

GENERAL HEALTH. 291

occasionally only, nor * a little bit at the top ' (the
virtues of which little bit being sadly marred by
drawn blinds, well-secured shutters, and heavily-
draped curtains), but sufficiently open to provide for
that really effective circulation of the air upon which
healthy animal existence necessarily depends.

The importance of DIET in the maintenance of
health is now very generally admitted, the difficulty
being to decide between the merits of the various
rival systems which are advocated with considerable
ability and much insistency by their respective
authors. Dr. Alexander Haig^ asks us to believe
that any uric-acid-forming food is a slow poison, and
invites us in consequence to delete from our dietary
not only all fish, fowl, game, and meat, but also such
vegetables as peas, beans, lentils, asparagus, onions,
together with oatmeal, tea, and coffee. Dr. Hare,' on
the other hand, brings a serious indictment against
carbohydrates, and warns us to eschew them if we
would avoid gout, asthma, migraine, and other evils.
Dr. Chittenden 3 has made experiments to show that
the main fault in our present system of dietetics is
that we have hitherto overestimated by one-half the
amount of proteid which is necessary to full mental
and bodily activity, and that we can attain to real
physiological economy only by reducing our intake
under this head. Mr. Yan Someren* insists that

1 ' Uric Acid in the Causation of Disease.'
8 * The Food Factor in Disease.'

* • Physiological Economy,' etc.

* Britiih Meddcal Journal, October 12, 1901.

292 MINOR MALADIES.

inadequate mastication is the root of all dietetic evil,
and that every mouthful should be masticated not
thirty-two times only, but until the mass is both fluid
and tasteless.

All these writers — and each of them has many
followers and co-workers — advance their various
theories with great skill, and illustrate them by
convincing cases. It is obvious, however, that they
cannot all be right, and that to escape from bewilder-
ment on the subjoq^it is necessary to find a common
denominator, a platform on which each can take his
stand side by side with the other. Such a platform
would seem to be provided by the proposition that
the gravamen of the charge against the existing
admittedly faulty system is that it leads in one form
or another to surfeit. Dr. Haig, Dr. Chittenden, and
Mr. Van Someren, either explicitly or by implication,
condemn the use of food which has been obtained by
the taking of life — food, that is, through which blood
has circulated. They are, in fact, to a large extent,
lacto-vegetarians. Dr. Haig's index expurgatoritus is
exceedingly comprehensive, but, then, it is the
outcome of a theory — that, namely, which attributes
to the action of uric acid the responsibility for the
majority of complaints with which the human body
is afflicted. This theory has had a great vogue not
only with the profession, but with the public, but it is,
nevertheless, one which it is very difficult to sustain.

It is admitted that unexcreted nitrogenous waste
products are highly deleterious, and it is undeniable

GENERAL HEALTH. 29S

that uric acid is one of these. Bat, although it is the
most easily identified and measured, it is by no
means the only one, and to use its ease of identifica-
tion as an argument in favour of its sole responsibility
is as fallacious as it would be to suppose that carbonic
acid gas constituted the sole cause of the pollution of
an atmosphere in which it was present in excess.
Dr. Haig's diet, then, if it succeeds, as in many cases
it undoubtedly does, succeeds for reasons other than
those which are advanced in its favour.

It is a matter of importance to determine how far
these systems can be reconciled with the incontro-
vertible fact that primeval man was to a very large
extent a carnivorous animal. The matter would seem
to stand thus : Primeval man was nomadic, and
depended for his sustenance largely upon hunting,
and other forms of vigorous muscular exercise, which
enabled him to digest and dispose of large quantities
of animal food.^ In course of time he has become
stationary and even sedentary, so that the muscular
exercise which justified, and even perhaps necessi-
tated, his carnivorous habits is no longer an essential
portion of his existence. Thus it comes about that he is
now physiologically unable to deal with foods of any
sort, but especially with flesh foods, in anything like
the same quantity as formerly. The muscles are the
great furnaces in which foods are burned, and if the
furnace bums low the foods are suboxidized. The

» Dr. Harry Campbell : * A Lecture on Diet,' Clinical
Journal, March 14, 1906.

294 MINOR MALADIES.

fuel, inatead of being burned to ash and discharged,
is converted into cinder and retained. There are two
ways of meeting such a difficulty — the one by
increasing the oxidation, the other by diminishing
the fuel. In the case of the ordinary twentieth-
century man the former is practically impossible, so
that the physician and the hygienist must have re-
course to the latter.

Of course, there are enormous personal differences
in the individual capacity for dealing with excessive
food, differences as striking and as inexplicable as
those which exist in the matter of stature ; but there
seems to be no doubt that each succeeding generation
becomes less able than its predecessor to cope with,
and adequately to dispose of, a diet which in quantity
as well as quality is an imitation of that to which
primeval man accustomed the race.

The exigencies of our present mode of life being
what they are, it seems necessary that we should seek
to adapt our dietetic habits thereto, and our guide in
this matter, as in all others, should be the attainment
of physiological efficiency. A truly scientific working
standard could be arrived at only by gauging the
irreducible minimum upon which full physiological
efficiency could be maintained. For various reasons,
which include personal, racial and climatic differences,
such a standard is beyond our reach, but inasmuch
as food is agreeable, it is safe to assume that such
dietetic errors as are habitually committed arise from
excess rather than deficiency of its consumption.

GENERAL HEALTH. 295

The systems of diet above referred to have this in
common, that they aim at a general reduction of
intake. Most of them, it has been shown, provide for
the abolition of flesh foods.

Now, this last arises partly on account of the fact
that some individuals, an increasing number perhaps,
are unable to consume such foods without suffering
from troublesome symptoms ; but it is also due to the
stimulating properties of such foods, to the effect
which they produce in augmenting the whole quan-
tity of intake — the provocation, that is, of the insidious
* appetite which comes with eating.' The foods of a
lacto -vegetarian regime, if they possess this tendency
at all, possess it in a very minor degree ; so that one,
at any rate, of the advantages of such a regime is
that there is, in those that follow it, much less likeli-
hood of the evils of over- alimentation than there is in
the case of the ordinary mixed feeder.

The explanation of Dr. Hare's position, that it is the
excess of carbohydrates rather than of proteids which
is responsible for those faults of metabolism as to the
existence of which all are agreed, would seem to
indicate that some individuals tend to revert to the
physiological type which prevailed in man's carnivor-
ous period, and that these persons, therefore, display
an inability to cope with carbohydrates which is as
definite as the inability of others to cope with
proteids. But even these cases can be reduced to
the common denominator, which is represented by the
necessity for a general reduction of intake. Though

296 MINOR MALADIES.

meats are undoubtedly stimulating and appetizing
when consumed along with other kinds of food, a
regime consisting solely of proteids very soon induces
that form of disinclination and ready satiety which is
expressively known as toujours perdrix.

There would seem, then, to be no escape from the
position that such evils as are associated with our
present system of dietetics are evils which arise, not
from any faults in the quality of the foods ingested,
but rather from the quantity of these foods which, in
spite of his sedentary occupations, man still insists on
consuming. It is a commonplace that we all eat too
much, but a recitation of the belief seems very
seldom to lead to an improvement in the practice,
and such improvement is not likely to occur until we
can succeed in bringing home to our patients the
physiological inefficiency and its consequences which
habitual excess necessarily entails. The causes of
this excess are numerous. The most prominent is
perhaps mere selfish indulgence in the pleasures of
the table, accompanied, as it often is, by a grim
determination to suffer the consequences of surfeit
rather than forego the pleasures. Another cause is
mere careless habit. When people are young and
vigorous they can consume large quantities of food,
not only with impunity, but even with seeming
benefit, and the habit thus begotten is apt to be con-
tinued long after the age of impunity is passed. A
third cause is the deficient mastication of foods.
This is the keystone of the system which Mr. Van

GENERAL HEALTH. ^97

Someren has brought into prominence, and there
remains no doubt in the minds of those who have
tried this system, that adequate mastication, according
to the standard laid down, leads to a decrease in the
whole quantity of intake, which is very surprising.

The rationale of the system may be briefly stated
as follows : We live by what we digest, and not by
what we eat. That we eat more than we can digest
is evidenced by the large amount of faeces which we
daily evacuate, and whose regular discharge we have
come to regard as so urgent a necessity. For faeces,
we are reminded, are not the products of digestion;
they are the materials which have escaped the
digestive process, and represent, therefore, the excess
of intake over the legitimate physiological needs.
And we take this excess because we do not prepare
our foods by adequate mastication and insalivation.
If we did this, we should not feel the desire for the
excess which many now feel. The desire is probably
begotten by the demand from the economy for
suitably prepared food. In response to this demand,
a food is supplied which is not suitably prepared,
and the needs of the economy are, therefore, im-
perfectly satisfied, so that the demand is continued
until the stomach is physically incapable of holding
more, and a mechanical satiety is induced. The
ultimate disposal of this excess places a great strain
upon the digestive and excretory organs, more
especially the kidneys, so that suboxidation and
deficient excretion, leading to dyspepsia, gout, and

298 MINOR MALADIES.

constipation, are the conditions which dominate our
everyday lives.

Among the remaining causes of excessive eating,
the practice of drinking fluids with the meals must
be given an important place. This prevalent practice
is quite unphysiological. If we seek a lesson from
the lower animals in the matter, we find that none of
the mammals are in the habit of drinking with their
meals. The taking even of pure water with a meal
enables the person to eat more than he otherwise
would. There are some differences of opinion as to
why this should be, but the fact itself is not in
dispute. The probability is that the extraneous fluid
supplies the moisture which ought in reality to be
supplied by the saliva. The saliva not only digests
certain foods, but it also lubricates the whole mass,
and if this lubrication is artificially provided, the
person tends to take an excess of solids. Fluid is,
of course, very necessary to the economy, but it
should not be taken at meals. The best time to take
it is about half an hour before a meal, but if this is'
inconvenient, as it often is, the drink should be
delayed until all the solids have been eaten. There
is one great advantage in taking fluid before a meal,
which is that it exercises a flushing effect on the
stomach, and tends to free that organ from any
remains of a previous repast which it may happen
to contain.

And if the taking of fluids of all sorts can thus bo
held responsible for a larger consumption of food than

GENERAL HEALTH. 299

is necessary, it is obvious that the ingestion of a local
and general stimulant, such as alcohol, must be produc-
tive of the same effect in a very much higher degree.

It is impossible to enter here into the ethical side of
the question of alcohol. The physiological side may
be expressed by saying that whereas its occasional and
infrequent consumption may justly be regarded as a
legitimate indulgence, its habitual use, especially for
those who have to work with brain or muscle, is
undoubtedly fraught with evil ; and further, that, if
taken at all, it should be taken, not with the meal,
but after all the solids have been consumed.

There is, however, one aspect of the matter whicli
seems deserving of brief notice — namely, the form
in which, when it is recommended, it is now the
fashion to take alcohol. It has now been the
custom for some years to recommend those who
insist upon taking alcohol of some kind to take
it in the form of spirits rather than in the form
of wine or beer. This custom has very little to
recommend it. In the first place, spirits are by far
the cheapest, the easiest, and therefore the most
insidious, form in which alcohol may be taken, and
thus lead much more readily to habitual excess than
either wines or beers. Moreover, of the diseases
which are commonly attributed to alcohol, such as
cirrhosis, hepatic and renal, and various diseases of
the nervous system, the great majority appear in
spirit-drinkers, and not in those who take merely
wine or beer. Most spirits contain 50 to 60 per

800 MINOR MALADIES.

cent, of alcohol, and they all owe their stimulating
properties almost exclusively to this element in their
composition. Wines, on the other hand, contain on
an average about 10 to 15 per cent, of alcohol, and
owe their stimulating properties largely to the
volatile ethers which give them their bouquet. The
alcohol, as we know, leaves its mark upon the liver,
kidneys, and nervous system — that is to say, it
circulates a long time in the blood before it is
excreted. The ethers, on the contrary, pass rapidly
out of the system through the lungs, and a few hours
after their ingestion they have quite disappeared.
And yet we hear it said that whisky is ' wholesome.'
What exactly is meant by the adjective in this
connection it is difficult to say, but this, at any rate,
is certain — that of all the methods of taking alcohol,
spirits, whether in the form of whisky, brandy, gin,
or liqueurs, are the most insidious and dangerous
beverages to recommend to patients.

A practice which is commonly associated with that
of whisky-drinking is the taking of aerated waters.
This is another custom which, on physiological
grounds, it is impossible to defend. Gaseous dis-
tension of the stomach leading to dilatation is a very
common complaint. It may be too much to say
that it is often induced by the consumption of
aerated waters, but there can be no doubt that it
is frequently gravely aggravated thereby. These
waters are in public favour apparently because they,
too, are considered * wholesome.' No good purpose

GENERAL HEALTH. 301

can possibly be served by introducing carbonic acid
gas, normally a waste product of metabolism, into
the system at all, and to introduce it into an organ
which is all too frequently the subject of gaseous
distension is a dietetic error too obvious to dwell
upon. The drinking of fluids with meals, then, as
tending to over-alimentation, should be discouraged.
If alcohol is taken at all it should be in the form
of well- matured wine, and its consumption should be
reserved for the end of the meal. Aerated waters are
powerless for good, and very potent for evil. Their
habitual ingestion should, therefore, be forbidden.

Such are among the most important causes of
overeating. The broad eflfects of this practice may
now be briefly considered. Unnecessary food which
is introduced into the system is not, as is commonly
supposed, passed on and discharged as useless. All
assimilable material is assimilated; it is only the
unassimilable which is rejected. If too much
assimilable material is taken, the organs concerned in
the metabolic processes have too much work thrown
upon them. If they are able to perform this work,
the blood becomes surcharged with oxidizable matter,
so that instead of being a nutrient, the plasma is in
the nature of a depressant, producing the same
results as an excess of fuel produces on a fire.
Hence it is that overeaters are generally dyspeptics,
and are usually either drowsy or irritable after a meal
The organism, however, makes an effort to cope with
this excess, and calls for a plentiful supply of oxygen

80« MINOR MALADIES.

to carry on its work. This explains the dyspnoea, the
breathlessness of slight effort, of which such people
generally complain. The overloaded condition of the
plasma constitutes an irritant either to the walls of
the bloodvessels or to the vasomotor centres in the
brain, thus producing constriction of the smaller
arteries, and a consequent general rise of blood-
pressure. The task of excreting the excess is under-
taken mainly by the kidneys, which important
organs have therefore cast upon them an amount of
work which is out of all proportion to the physio-
logical necessities of the case. If the metabolic
processes do not succeed in adequately coping with
the surplus food, the surplus is suboxidized, and
causes the symptoms in various parts which are
spoken of as gouty or rheumatic. The evils of
excessive eating, therefore, may show themselves in
any system or organ, but, except perhaps in the case
of the stomach itself, the disturbance is due to the
overloaded state of the liquor sanguinis, and it is
consequently in the circulatory system, by the
occurrence of dyspncea and increased blood- pressure,
that the earliest symptoms are most likely to show
themselves {vide Goutiness, p. 221).

There are two ways of combating the evil effects
of overeating in its early stages : the one is by the
obvious course of reducing the amount of the intake ;
the other, by increasing the oxidizing processes. It is
unnecessary to dwell upon the former further than to
emphasize the fact that the older a person grows the less

GENERAL HEALTH. 808

food does he require. The French say that man does
not die — he kills himself; and the same idea is ex-
pressed in our own saying that man digs his grave with
his teeth. Certain it is that when middle age is reached,
it is only those who live a vigorous life in the open air
who can indulge in the pleasures of the table with any
degree of impunity. For the sedentary liver who
would retain a full measure of physiological eifficiency
a considerable, if gradual, reduction of intake becomes
essential at this age, and the reduction should
proceed pari passu with advancing years, until at
three score and ten it has reached a minimum. A
distinguished physician, who is still alive, has
explained his vigorous old age by saying that he
never rises from a meal without feeling that he could
sit down and eat it all over again.

The alternative of increasing the output by stimu-
lating the oxygenating processes brings us to the
question of EXERCISE. Here, again, having regard
to the enormous personal differences which exist, it is
quite impossible to lay down any hard-and-fast rule.
This, however, may be said with confidence — that he
who eats much, must exercise much, and the man for
whom much exercise is impossible must meet the
situation by consuming little. It is a common
experience that brain work in the study is, with
some people at any rate, an even greater provoker of
appetite than muscular exertion in the fields. The
explanation of this fact is too involved to enter upon
here, but it may be asserted that the hunger begotten
of study should not be appeased in the same manner

«04 MINOR MALADIES.

as that which is begotten of muscular exertion. For
the latter, a plentiful supply of nitrogenous foods,
especially of meat foods, is sometimes considered
appropriate. Although very decided doubts are now
expressed upon this point, it seems generally to
be agreed that such foods when taken in abundance
by a sedentary worker lead inevitably to impaired
health. The man, then, who has ample oppor-
tunity for efficient oxidation may be left to
work out his own dietetic salvation; but he who is
deprived of such opportunity should have it explained
to him that, be his study-begotten appetite never so
vocal, he must satisfy it otherwise than by meat
foods and alcoholic drinks.

Of exercise in general, it may be said that the
necessary amount depends upon individual require-
ments, a powerful factor in determining which is the
amount of food consumed. It also depends to a great
extent upon individual opportunity, and the amount
to be recommended in each case can be arrived at
only after due consideration of these points. The
best kind of exercise is also a matter which must
vary considerably in each case, though riding and
golf are, as a rule, appropriate to both sexes and all
ages. The objection, however, which is to be urged
against these and most other exercises, with the
exception of rowing, is that they contribute nothing
to the development of the abdominal muscles. The
importance of keeping these muscles in good condition
must bo evident to those who remember that,
practically, they constitute the anterior abdominal

I

GENERAL HEALTH. C05

wall, and that if the}' are allowed to become lax they
fail to give adequate support to tha internal organs.
There was at one time a good deal of talk about the
responsibility of the * abdominal pool/ or ' splanchnic
lake,' for deficient metabolism, and practitioners at
health resorts, especially in Germany, are still in the
habit of attributing a good many of the morbid
conditions which they are called upon to treat to
'abdominal venosity.' These are, in reality, all
synonyms for the same thing — namely, the state of
matters which is brought about by lax and un-
developed abdominal muscles.

To keep these muscles firm and in good order
their regular use is essential, and, as the ordinary
forms of exercise help but little in this direction,
it is evident that we must resort to an exercise ad
hoc, Yarious forms of such an exercise have been
recommended, but the one which seems to be the
best, in that it is not difficult, violent, or time-
consuming, is the following : Wearing as little
clothing as the circumstances permit, and with
the windows wide open, the patient lies on his
back on the floor, with his feet under the opened
lowest drawer of a chest of drawers, or anything else
which will keep his feet from rising from the ground.
With his arms fully extended above his head and
touching the floor in their whole length, he proceeds
to pull himself into the sitting posture by means of
his abdominal muscles, keeping the knees unbent.
Care must be taken not to advance the arms beyond
the line of the trunk, and to perform the movement

306 MINOR MALADIES.

deliberately. This will be found a very trying
discipline to those who are unaccustomed to use their
abdominal muscles ; indeed, it is to many quite
impossible, so that it is wise to begin with a
modification, which consists in allowing the arms
to be crossed on the chest while the rectus muscles
pull the trunk forward.

This exercise should be done two or three times
each morning to begin with ; and when it can be
done seven times without undue effort, the arms
should be placed above the head as first described.
With the arms thus placed, the number of
times must again be reduced and then gradually
increased as before. Another exercise which may
immediately follow on the foregoing is performed as
follows: The feet are released from the chest of
drawers, and, still lying flat on his back, the patient
raises the fully extended legs until they are at a right
angle to his trunk. While this is going on, the hands
are engaged in pinching up the skin and otherwise
massaging the abdomen. These procedures may
sound very formidable, but they are in reality not so.
If they are done regularly, without hurry or strain, they
take very little time and can do no harm, while their
effect in keeping the figure from becoming aldermanic
is very marked. This consideration appeals to most
people — more especially to women — and if a greater
number of the fair sex undertook these exercises
there would be fewer cases of floating kidney and
other abdominal and pelvic troubles than now
unfortunately exist.

GENERAL HEALTH. 307

Of other exercises which are adapted to ordinarily
healthy people who have insufficient opportunities
for spending much time in the open air, skipping
holds a high place. Although usually regarded as
suitable only to children, it is in reality a very
excellent discipline for middle-aged and even elderly
people, when undertaken with due regard to the
necessities of each case. It exercises every part of
the body, including the abdominal muscles, and
subjects the internal organs to a species of massage
which is very beneficial.^ There are several systems
of exercises, Swedish, Danish, and others, now in
vogue, the majority of which, as entailing no violent
exertion, and as tending to keep most of the muscles
in good working order, may be confidently recom-
mended to healthy persons. All these exercises
should, if possible, be performed daily, as a matter
of routine, in the morning before the bath, and
preferably in a room the window of which is wide
open.

The question of the temperature of the daily bath
is one which is often referred to the medical man.
I have already said that as a general rule it should
be cold — that is, of a temperature between 40°
and 60° F. This, however, refers only to healthy
people under middle age, in whom a reactionary glow
is easily obtained by the aid of a rough towel. To
such people a cold bath is very invigorating ; it

» The Girbola.

308 MINOR MALADIES.

promotes metabolism and effectually exercises the
contractile power of the skin. If, however, it should
not be followed by a reactionary glow, or if it should
cause headache or loss of appetite, it should be
discontinued. People who from any cause have a
blood-pressure which is definitely above the normal,
always complain of discomfort after a cold bath.
The contraction of the peripheral arterioles increases
the arterial tension, and if the baths are persisted in,
accidents are very liable to happen. I have more
than once been led to the discovery of an otherwise
unsuspected vascular disorder by complaints of head-
ache, giddiness, and the like, which have been
positively referred to the cold morning tub.

Where for any sufficient reason it is decided that
the daily bath should not be taken quite cold, it is
necessary to decide at what temperature it should be
taken. A tepid bath is one which, though definitely
below the normal temperature, is, nevertheless, not so
cold as to cause much contraction of the cutaneous
vessels — that is, from 85** to 95° F. A warm bath is
one which is about the same temperature as the
surface of the body, and causes neither contraction
nor dilatation of the cutaneous vessels — that is, from
90° to 98° F. A hot bath is one which is substantially
higher than the normal body temperature, and tends
to cause dilatation of the cutaneous vessels — that is,
from 98° to 105** F. In connection with the hot
bath, it is to be remembered that its effect varies not
only with its temperature, but with its duration, and,

GENERAL HEALTH. 309

further, that there are a great number of personal
idiosyncrasies in the degrees of heat which can be
tolerated. Women, as a rule, can take baths at much
higher temperatures than men.

Very hot water causes an initial contraction of the
cutaneous vessels, but if the bath be prolonged, this
effect gives way to one of dilatation, and the ultimate
result is one of general relaxation. If, therefore, the
hot bath is substituted for the cold morning tub, it
should be made clear that the exposure to the hot
water, though it should not be so prolonged as to
produce a general relaxation, should nevertheless be
prolonged enough to enable the cutaneous vessels to
recover from their initial contraction. If a daily hot
bath of long duration is desired, it should be taken,
not in the morning, but at night, when the day's
work is over and relaxation is normal and physio-
logical.

It is said by some physicians, chiefly on the
Continent, that a daily bath is not only unnecessary,
but actually injurious, on account of the fact that the
natural oil of the skin is thereby removed. Such a
view has nothing whatever to support it. The
' natural oil ' of the skin is an excretion, and it should
be removed at least once daily with the aid of soap
and a due amount of friction. For those who are
unable to take a cold morning tub, the warm bath of
not more than 100® F. is the most generally suitable
for these necessary daily ablutions. The duration of
such a bath should not exceed five minutes.

CHAPTER VIII.
OLD AGE.

But yesterday we were being told that a man is too
old at forty. To-morrow we shall have to regard
him as still youthful at fifty. For so large a pro-
portion of those between twenty-five and forty-
five will have passed dutifully and gloriously into
the eternal shadows that our estimates will undergo
a compulsory reviaion. The desire for longevity,
instinctive but wholly irrational, will thus become
something like a duty; provided always that the
longevity is accompanied by a fair measure of
physical and mental rigour. Length of days with-
out competency is the reverse of desirable. There
is no family so deserving of commiseration as that
which includes a member who is a senile and peevish
autocrat, or, worse still, one who is a senile and
physically healthy imbecile. Old age with mind and
body unimpaired is admirable; it carries with it
lovable qualities of heart and brain which are
seldom otherwise encountered; but old age as it is
too often seen is unlovely and unlovable. In the
vast majority of cases it is true as Cicero puts it,
that atntctus ipsa morbus est. When efficiency

310

OLD AGE. Sll

becomes seriously impaired, continued existence is
an incurable disease, by no one, in no wise, to be
coveted.

Some of those who recall Solomon's admonition,
' Remember now thy Creator in the days of thy
youth, while the evil days come not, nor the years
draw nigh, when thou shalt say, I have no pleasure
in them,' seem to imagine that, by taking thought,
they may indefinitely postpone the evil days; and
their method of taking thought not infrequently
leads them into very fantastic precautions. Forget-
ful or, more probably, ignorant of Plato's profound
saying that * attention to health is the greatest
hindrance to life,' they become converts to every new
hygienic gospel, and sit willingly at the feet of any
prophet, dietetic or psychic, who will peddle them
an earthly Paradise from an ass's pannier.

With the wit and truth which scintillate in so
many of their sayings, the French have it that:
' Pour vivre longtemps il faut une bonne digestion
et un mauvais coeur.' Matthew Arnold, in a
characteristically grim couplet, remarks that the
only thing which old age has in common with youth
is discontent. In another poem, the same staid
cynic of the seventies says that when old we ' feel
but half, and feebly, what we feel; deep in our hidden
heart festers the dull remembrance of a change, but
no emotion, none.' The arch-cynic Swift goes
gloatingly into greater detail. He portrays for us
the Struldbrugs whom Gulliver found on the island
ofLuggnagg. These creatures never died. Gulliver

S12 MINOR MALADIES.

at first envied them, but he ended by hating them.
* They were not only opinionative,' he says, ' peevish,
covetous, morose, vain, and talkative, but incapable
of friendship and dead to all natural affections.
Envy and impotent desires were their prevailing
passions.'

In spite of Cicero's saying, old age is not, of course,]
physiologically, a disease, any more than infancy ij
a disease. It is a stage in the evolution of the indi-
vidual. It may come early or late; but it comesj
Some people — e.g., the victims of pogeria — becom(
senile at puberty; others have already run thei
course at forty-five ; some retain their manhood until'
the sixties; but it is very rare to find anyone overj
seventy who does not bear quite unmistakable marks
of physical decline.

As infancy is the time of tumultuous, erratic,
disorderly reaction, and adult life the period of
deUberate, generalized, orderly reaction; so is old
age the period of slow, blunted, and apparently
dissociated reaction. There is a story of Rudyard
Kipling's in which the various parts of a ship on its
trial trip keep crying out to one another, but by the
end of the journey there was no further conversation
as there were no longer any parts. The ship had
found herself and become homogeneous. It is thus
with the human body. In infancy one organ which is
hurt cries loudly to the others, all of which join lustily
in the discordant chorus. As the years advance the
response becomes less and less, until in old age each
organ keeps its grievances to itself. This is very

OLD AGE. 813

puzzling to those whose practice has been mainly
among children and adults, for the general reaction
and concomitant symptoms upon which they are
accustomed to rely for confirmatory evidence are
generally wanting. The pulse- temperature ratio,
for example, is very different to that which is
customary in febrile states in adult Hf e ; for the pulse-
rate remains low though the temperature be high.
It is the same with the pulse-respiration ratio, for
in old age dyspnoea is easily provoked by slight
causes, whereas heart-hurry seldom occurs. As
each organ is thus to a large extent autonomous,
there is no massing of the general powers of resistance
of the whole organism, with the result that acute
affections in old age show a great tendency to become
chronic.

In dealing with elderly people this cardinal fact of
their blunted reaction and lengthened period of
recoil from stimuli must never be lost sight of. It
is the key to much which would otherwise seem
paradoxical; it explains the otherwise inexpHcable.
Pain, for example, is never so acute in the aged as it
is in the adult or the young. Even the pains of
hepatic or nephritic coUc, which in the adult are
amongst the most agonizing which he can endure,
are so much reduced in old age as to become almost
imjperceptible ; and the older the patient, the less
is the pain. The question of temperature affords
another example. When the thermometer is used
in the ordinary way by being placed in the mouth
or the axilla, it may fail to register any febrile move-

SU MINOR MALADIES.

ment although the real temperature, as taken
patiently in the rectum, may be as high as 101° F.
The reaction to mental and moral stimuli is notori-
ously enfeebled in old people. Even when they do
not exhibit the vices of Struldbrugs they tend to
become self-centred and heedless of matters which
do not concern their physical condition; or, they
tend to lose the control of the higher centres, and
display unreasoning and impulsive irritability. The:
expression ' second childhood ' is by no means a^
pointless gibe.

The general hygiene of old age differs in many
material respects from that which is applicable even
to late adult life. The aged are, for example,
peculiarly liable to external parasites, both animal
and vegetable. Pediculi of all kinds seem to have
an instinctive knowledge of the easy prey which old
people present, and this, coupled with the relative
insensitiveness to pain in the victim, tb liable to give
rise to results against which special precautions rre
necessary. Among vegetable parasites Microsporon
furfur is extremely common. It is not infrequently
mistaken for the pigmentation which is so common
in the senile skin, possibly as the result of supra-
renal insufficiency.

The maladies which afflict the decadent period of
life are none of them peculiar jto that period. The
same diseases and affections are met with in the
adult, the adolescent, and even in the child. It is
nevertheless true that certain diseases are more
common in advancing: years than they are in the

OLD AGE. S15

earlier periods, and that the diagnosis of these
diseases presents difficulties and their treatment
demands modifications, due solely to the age of the
patient. Among the best illustrations of these
peculiarities are those connected with the gastro-
intestinal tract. The dyspepsias of old people very
seldom conform to the types with which all are
familiar in the adult and the child. Not only has
the physician to bear in mind the spectre of car-
cinoma, but he has to remind himseK that gastric
and duodenal ulcers are by no means uncommon,
and that they give rise to little or no pain and very
few general symptoms. Chronic constipation is so
frequent in old age as to amount almost to a normal
accompaniment of senescence, and even when very
obstinate it sometimes seems to do no harm what-
ever. Elderly patients have often been known to
protest that they feel much better when they are
constipated. In the presence of gastro-intestinal
troubles in the aged the possible responsibility of a
hernia should never be lost sight of. Herniae are
almost as common in old people as constipation
itself. Cardio-vascular affections bear a character
of their own and attain to a special significance with
advancing years. These in themselves would con-
stitute a long chapter. Deviations from the normal
in the domain of the central nervous system are in
many respects very dissimilar from those which
occur in the adult. To the rule of relative analgesia
which has already been referred to as characteristic
of senectitude there are two notable exceptions.

316 MINOR MALADIES.

One is that true neuritis in old age is liable to be very
protracted and severe, as for example the pain which
follows herpes zoster. The other is that pruritus,
both general and local, is certainly more intense,
more obstinate, and more wearing in the old than it
is in the young.

There has been much discussion concerning the
causes which determine that one man should be
senile at fifty and another similarly circumstanced
should stiU be young at seventy. It is said to be a
question of their respective constitutions. That is
doubtless true, but it is necessary that we should
understand what we mean by a constitution. The
constitution of any given person depends upon the
accuracy of his metabolic changes. By accuracy I
mean the proper co-ordination of his intake, his
assimilation, and his output. If at the outset he is
well endowed with co-ordinative power, if, as the
French say, he is originally well equilibriumed, then
his constitution is good. If, however, there be a
piece which does not quite fit the dovetail, whether
it be too large or too small, a thought too narrow, or
a trace too wide, the other members are strained,
and though in favouring conditions the machine may
appear to work smoothly enough, the weakness
becomes painfully apparent in times of stress and
the duration is less seriously affected.

Of these three, intake, assimilation, and output,
in the early years when the constitution is being
stereotyped, as it were, the assimilation is by far the
most important. In later life the importance of

OLD AGE. 317

this element wanes, and it is the output which be-
comes paramount. Adequate anabolism in infancy
and childhood, energetic katabolism in adult life
and advancing years — these are the bulwarks of
the constitution.

Time was, and that not so very long ago, when
our knowledge of matters metabolic was very rudi-
mentary. Tissue change was regarded partly as a
nervous phenomenon, but mainly as a dietetic
drama, in which a harmless enough creature called
uric acid very successfully posed as the villain.
To-day we know more, but there is much knowledge
still to seek. We know that metaboHsm is under the
direct control of the internal secretory glands. We
know that these glands preside over growth and
development in infancy and childhood, that they
are essential to mental, physical, and reproductive
efficiency in adult life, and that they are responsible
for the maintenance of katabolic balance in the period
of decline. It is therefore no exaggeration to define
the constitution of an individual as the resultant of
his internal secretions.

Lorand has sustained at some length and with
considerable ability the thesis originally put forward
by Leopold Levi to the effect that the causes which
give rise to the phenomena of senescence are due to
the decline in the activities of the th3a'oid gland. It
is not of course suggested that old age itself is due
to a failure of the thyroid, but it is contended that
many of the disagreeable and disabling concomitants
of senescence can be directly traced to this cause.

318 MINOR MALADIES.

Leopold Levi has compared some of these ooncomi-
tants with the symptoms of myxcedema, and points
out that they have much in common. The asthenic
state of the skin and its appendages, the subnormal
temperatm'e, both subjective and objective, the
muscular weakness, the failure of memory and the
difficulty of mental concentration, the affections of
the gums and the disorganization of the teeth, the
rheumatic pains, the constipation, and the tendency
to vascular degeneration, are all of them salient
features both of myxcedema and senility, and present
a series of similarities which can scarcely be dismissed
as fortuitous. This is certainly an unduly restricted
view of the matter, for it is quite certain that in
common with the thyroid, aU the endocrine glands,
notably the gonads, the suprarenals, the pituitary,
and the pancreas, undergo anatomical changes which
seriously impair their functional activities. The
phenomena of old ag© are therefore due to a general
lowering of endocrinic activity and not to the failure
of one gland only, important though that one gland
admittedly is. There can, for example, be no doubt
that the testicular decline is an important factor in
the production of some of these phenomena, nor that
the suprarenal and chromaffine failure accounts for
others ; and it is more than probable that some will
ultimately be traceable to the pituitary and others
to the pancreas. The practical value of this view
of the question is to be found in the light which it
throws not so much on old age itself, as on its prema-
ture onset and on many of its least bearable accom-

OLD AGE. 819

paniments. It holds a promise that the study of
the ductless glands in health and disease will enable
us to afford a measure of relief in the treatment of
senile conditions which has hitherto been impossible.

The personal hygiene proper to the senescent does
not differ very materially from that which should be
observed in the middle years. It might be expressed
as ' Fresh air, meagre fare, freedom from care.'
Upon the first, it is unnecessary theoretically to
insist; but practically a great deal of insistence is
often necessary. The low body temperature and
subjective chilliness which characterize the aged is
all too often made the excuse for stuffy parlours and
se9,led bedroom windows. The inevitable conse-
quence is deficient oxygenation with its resultant
decHne in metaboHc activity. It is said that Queen
Victoria owed her length of days and her maintained
mental vigour to her careful regard for Sir William
Jenner's repeated injunctions about fresh air and
the open window.

In the matter of * meagre fare,' medical insistence
is even more necessary. Unfortunately, however,
it is seldom forthcoming. The ordinary layman,
and even more the ordinary laywoman, is convinced,
with a conviction which nothing can shake, that the
feebleness of the elderly requires correction by a
liberal dietary, and the ordinary practitioner either
from weariness or tactfulneOB declines to engage in
an unequal combat on this prickly question. When
he is courageous enough, he will not fail to point out
that a feeble body means feeble digestive organs.

320 MINOR MALADIES.

and that enfeebled digestive organs cannot in the
nature of things be expected to deal with a liberal
intake. Let him repeat, even ad nauseam^ that
man lives by what he digests, and not by what
he eats. ' Meagre ' in this connection applies aa
much to quality as to quantity. In place of the
strong meats which his womenkind unceasingly
thrust upon him, the elderly man should be en-
couraged to eat vegetables and fruits, especially
such as are uncooked. It is a popular, and as yet an
unexploded, fallacy which teaches that uncooked
foods are difficult of digestion. The exact opposite
is the truth. There are some principles, called
vitamines, which, though present in abundance in
most uncooked foods, are nevertheless absent from
foods which have been subjected to any cooking
process. The exact nature of these principles ia
unknown, but observation and experiment have
shown that they are of vital importance both to the
very young and the very old. Those with feeble
digestions should be encouraged to take such foods
as are known to contain them in relatively large
quantities. Such are dairy produce — milk, cream,
butter, eggs, cheese; uncooked vegetables — lettuce,
tomatoes, celery, endive, watercress, cucumber, and
the like; and fresh fruit of all kinds. For the rest,
sooked vegetables are better than meat, poultry, and
fish; green vegetables are better than root vegetables.
The best among the green vegetables is spinach —
le halai des intestins, as the French call it. A dietary
regulated on these principles will be found to supply

OLD AGE. 821

a large sufficiency of nourishment without putting
any undue strain upon the endocrine system.
Talleyrand described man as * une intelligence
contrariee par des organes.* The organs to which he
referred, though he did not know it, were the organs
of internal secretion: their contrariety arises from
their exhaustion by excess of unsuitable food.

Freedom from care is a blessed state to which we
all aspire, but it is by no means certain that it is
good for us when we get it. Freedom from petty
worries is desirable at all periods of life, because
energy expended upon unessentials, such as trivial
domestic troubles, leaves so much less for appHcation
to essentials; but it is not desirable that anyone at
any period should be wholly free from such cares as
are necessarily incidental to the serious business of
his life. No good craftsman finds his work a pas-
time, and it is good for a man, mentally, morally, and
physically, to have work to do which he feels under
an obligation to do well. This is true at every stage
of life, but it is more especially true as the years
advance. There is an old saying that it is better to
wear out than to rust out, and certainly the best way
to avoid rusting out is to work. That a busy and
even a harassing life is quite compatible with un-
impaired efficiency and length of days is evident from
the examples which could be furnished from pubHc
men in all countries, and there is little doubt that
the maintenance of efficiency into the octogenarian
period in these cases has been due to the continued
vigorous exercise of the mental faculties.

CHAPTER IX.

SOME DRUGS, AND THEIR USES.

It is told of Sir Astley Cooper, who was not only a
great surgeon but a wise man, that he was in the
habit of warning his students against new remedies.

* If,' he said, ' you are too fond of new remedies, two
consequences will follow. The first will be that you
will not cure your patients ; the second, that you will
soon have no patients to cure.' Much the same idea
is expressed in the phrase attributed to a distin-
guished physician of a later period, to the effect that

* the dangerous man is he who treats symptoms with
new drugs.' There is, of course, nothing inherently
wicked in the use of new drugs ; it may, indeed, be
affirmed that if no one ever tried them a correct
estimate of their respective values would never be
formed.

On the other hand, it seems to be a fact that an

affection for new drugs hsis a tendency to lead to a

neglect of those whose virtues are well established;

and as a large proportion, a very large proportion, of

new drugs are useless, the man who employs them

helps his patients but little. Moreover, there are

322

SOME DRUGS, AND THEIR USES. 323

certain drugs which are so well established that they
constitute the standards by which we measure their
new competitors, and it is obvious that if we are not
thoroughly at home with our standards, no useful
comparison is possible.

It is said that the late Sir Henry Thompson, at one
of his professional dinners, which were called octaves
(eight o'clock, eight people, eight dishes, and eight
wines), placed a card in front of each guest asking
him, without consulting with anyone, to write thereon
the names of the eight drugs he would select if he
were in future to be rigidly confined to eight. History
does not record the result of this election, but we
are given to understand that there was a wonderful
similarity in the voting-papers.

If the result had ever been published it would
almost certainly have shown that old drugs, such as
opium and mercury, headed the poll, and that new
drugs were conspicuous by their absence. I should
myself be very sorry to be confined to eight drugs —
or to eighteen, for that matter — for the remainder
of my career; but if such a calamity were to befall
me, of those eight not more than one would be less
than twenty-five years old. I propose now to refer
to some points of practical interest in connection
with such of the well-known drugs as I am best
acquainted with. I do not, of course, pretend to
exhaust the applicability of any of them — that is a
text-book matter — much less to say anything which
has not been said before.

324 MINOR MALADIES.

IODIDE OF POTASSIUM.— This is one of tho most
generally useful of all drugs, and the aphorism * When
in doubt try iodide of potassium ' is a striking tribute
to its many-sided therapeutic effects. To explain
this many-sidedness is, however, no easy matter. We
must, I suppose, grant it a specific effect upon
gummata and some other syphilitic lesions ; but no
such explanation can be made to account for its
activities in such widely differing conditions as
emphysema, aneurysm, asthma, goutiness, rheumatism,
and several others of minor importance. In seeking
for a factor in connection with the drug which would
throw some light upon the property of ubiquity, which,
above all others, it seems to possess, one is immediately
struck by the fact that a large proportion of the
morbid conditions in which it is successfully employed
are associated with high blood-pressure. This is
true of those already mentioned ; it is also true of
chronic renal disease, of pains, especially where these
are nocturnal, and of arterio-sclerosis. For whatever
else it is, iodide of potassium is undoubtedly a
powerful reducer of blood-pressure, and it is to this
fact that we may probably attribute, not only its
merits, but also its drawbacks, as a therapeutic
agent. I have certainly never given it in asthenic
conditions unprotected by nux vomica, or some other
drug which tends to raise blood-pressure, without
causing unpleasant symptoms.

Iodide of potassium is, under certain circumstances,
a great reliever of pain. Fains of all sorts, whether

SOME DRUGS, AND THEIR USES. 325

they be due to syphilis, goutiness, or what not,
which are worse at night are almost invariably
relieved and generally cured by the exhibition of this
drug. It is, however, in aneurysm that its great
value in giving relief from suffering is most manifest.
The intolerable agony from which many of those
suffer who are the subjects of this condition is more
quickly and more lastingly relieved by this, than by
any other form of medication. It is necessary to
remember that in order to bring about this result the
dose must be very large. It should begin at 20 grains
three times daily, and may be increased cautiously
to 30 grains. Sufferers from this disease generally
show a remarkable tolerance for the drug.

In emphysema iodide of potassium is by far the
most generally reliable agent. It cannot, of course,
cure the condition ; but it has a power in relieving
the symptoms which is equalled by no other agent
which I have employed. Emphysema is to the lungs
what chronic interstitial nephritis is to the kidneys.
The morbid process at work in the two cases is almost
identical, and the effect upon the functions of the
respective organs is practically the same. The iodide
is much used, and rightly, in the treatment of renal
cirrhosis, and it has always seemed strange to me
that it should be so much neglected in emphysema.
In out-patient practice I have had more expressions
of gratitude from prescribing this drug in this con-
dition than from anything else.

The number and severity of the attacks of

326 MINOR MALADIES.

spasmodic asthma are more readily reduced by iodide
of potassium than by any other drug. Asthma is, of
course, a symptom and not a disease, and it is a
symptom of many conditions which may be related
to gastric, cardiac, nervous, and other disturbances ;
but whatever the origin, the effect is usually the pro-
duction of high arterial tension. This being lessened
by the drug, the symptoms generally yield. Asthma
is often spoken of as if it were a condition or tendency
which was much influenced by climate. This it may
be, but it is certainly much more powerfully influenced
by diet, and if this factor be carefully regulated in the
direction of reducing, not only the meat foods, but also
the whole quantity of food, the necessity for drugs of
all sorts may easily disappear. It has fallen to my
lot on more than one occasion to cut short an
asthmatic attack by the simple expedient of clearing
the gastro-intestinal canal by means of an emetic and
an enema. This treatment is not popular with
patients, who prefer, as a rule, to be given soothing
and habit-inducing sedatives and narcotics, a prefer-
ence which ought never to be indulged, except,
perhaps, in extreme cases, by a hypodermic injection
of morphine.

Asthma of gastric origin is very often due to
asthenic dyspepsia, in which case HCl and strychnine
should be given between the attacks, the iodides
being reserved for the treatment of the attacks them-
selves. A drug which is most valuable in conjunction
with HCl and strychnine under these circumstances is

SOME DRUGS, AND THEIR USES. Srt

arsenic. It seems to have a special effect in com-
bating that form of gastric irritability which expresses
itself in asthmatic ebullitions.

^. Acid, hydrochlor. diL v\xz.

Liq. strychnin. ... niv.

Liq. arsenic, hydrochlor niiv.

Aquam menth. pip ad gss.

M. Sig. : Ter die ex 51. aquee post cib.

In this connection, it is perhaps permissible again
to express a warning against giving liq. strychnin,
with iodide of potassium. The tr. nucis vom. is
nearly as useful, and there is then no danger of the
alkaloid being precipitated. The combination of
arsenic and iodide of potassium in asthma is an
excellent one.

Iodide of potassium is said to be as useful in affec-
tions of the aortic valve as digitalis is in affections of
the mitral. It is difficult to see whence this saying
arose, because the action of the iodide is on the heart
as a whole, and not on any particular portion of it.
The salt affects the heart beneficially by dilating the
peripheral vessels, and so lessening its labours. Of
these peripheral vessels, the coronary arteries are
among the most important. If these were originally
constricted, and if, in response to the iodide, they
dilate, an increased amount of blood is permitted to
reach the cardiac substance, so that the nutrition of
the latter is improved. The dilatation has the
further effect of inducing a flushing of the waste

328 MINOR MALADIES.

products, which are liable to accumulate in the
muscle of fatigued hearts, and the action of the
iodide itself in helping the solution and elimination
of these products is most marked. It is also believed
to lessen swelling and induration of the orifices and
valves, an action which, having regard to its very
marked absorbent powers, one can quite readily
believe it to possess.

In the treatment of certain forms of cardiac com-
plaint, where the heart is beginning to flag as the result
of its efforts to overcome an increased peripheral resist-
ance, the conjunction of the iodides with digitalis works
admirably. The dose of digitalis should be small —
certainly not more than 5 minims of the tincture to
begin with, and preferably less. And it should be
remembered, more especially in this connection, that
in order to reduce blood-pressure, the dose of the
salt should be what is usually considered large —
namely, 10 grains or more. Small doses, such as 2
grains, tend rather to increase the intravascular
tension than to lower it, and may therefore do an
infinity of harm in most of the conditions which we
have been considering.

Iodide of potassium is credited (Ringer) with the
power of cutting short a common cold. It is both
generally and locally a powerful absorbent, especially
where glandular swellings are concerned, and it seems
to have a particular power in promoting the absorp-
tion of simple swellings of the thyroid gland — simple
in the sense of being neither cystic nor accompanied
by otner evidences of Graves' disease.

SOME DRUGS, AND THEIR USES. 329

Iodide of potassium is the best remedy in petit-mal.
On this form of epilepsy the bromides have practically
no influence. Owing to the * automatic acts ' which
are so liable to follow a fit of minor epilepsy — acts of
pure animalism, uncontrolled by any higher centre —
this type of the malady, though less arresting and
alarming, is apt to be of much greater social import-
ance than the ordinary type ; for those who are not
trained to observe generally overlook the small fit,
and attribute the subsequent automatic act to pure
wilfulness. As many of these acts constitute breaches
of the criminal law, including even attempted murder,
it is highly desirable that their cause, the petit-mal,
should be recognised and treated. Very large doses
of iodide of potassium will often lessen the number
and improve the quality of these fits. There is,
unfortunately, nothing which can be relied upon to
bring about their cessation.

LufF^ has a high opinion of iodide of potassium in
the treatment of rheumatoid arthritis. He combines
it in a cachet with carbonate of guaiacol, giving of
each 10 grains three times daily, and insists that
the treatment should be continued for at least twelve
months. In addition, he lays great stress upon
hygienic, dietetic and climatic details.

Such being some of its principal spheres of useful-
ness, what are the dangers and inconveniences of its
employment? The only danger in connection with
it — and it is a serious one — is presented by the fact

* Practitioner, July, 1905.

S80 MINOR MALADIES.

that its administration has been known to cause
cedema of the glottis. Eisner and Huchard have
both recorded cases of this kind, so that it is well to
warn a patient to whom we are giving it for the first
time to stop the medicine and report himself if any
throat discomforts arise. Of inconveniences 'there
are many. Perhaps the most pronounced is the
occurrence of diarrhoea, either alone or accompanied
by vomiting. This is not altogether infrequent,
because the drug certainly has an irritating effect
upon the gastro-intestinal tract, and should there-
fore be given with caution where this system is
deranged.

A form of iodism which has often given rise to
unfortunate mistakes is that which causes pain and
swelling in the parotid gland, accompanied by other
symptoms strongly suggesting mumps. Ignorance of
this fact may easily cause a deal of useless trouble
and alarm in a household, and if the iodide is not
stopped the condition will persist. The commonest
forms in which intolerance shows itself are in the
production of sore gums, sore throat, running at the
eyes and nose, and metallic taste in the mouth.
These vary much in degree, and may generally be
checked by the addition of a few drops of Fowler's
Solution to each dose. Next in order of frequency
come the skin manifestations of iodism. These are
numerous — they may, indeed, take almost any form —
but it is well to remember the purpuric form,
especially when we are giving the drug to a rheumatic

SOME DRUGS, AND THEIR USES. S31

subject ; for if we forget it, it would be our duty to
confine the patient to bed until some time after all
signs of the rash had disappeared. True rheumatic
purpura is just as liable to give rise to cardiac com-
plications as acute rheumatism or chorea.

The best way of giving iodide of potassium is in
cachet form, followed by a draught of water. If given
in solution over long periods of time, it is well to add
small doses of arsenic and nux vomica. The latter
seems to prevent the occurrence of the mental and
physical depression which some people experience
when taking it for long. Sarsaparilla, liquorice and
syr. pruni virg. are said to disguise its taste.
According to some writers whose opinions are
eminently deserving of attention, the iodide of
sodium is more easily tolerated than the potassium
salt. Professor Huchard, who has great faith in the
iodides, insists very much upon this superiority of
the sodium salt, which he seems to think is to be
preferred on more grounds than one. That iodism
in all forms is much less liable to occur with large
doses — e.g.^ 10 grains — than with the ordinary dose
of 2 grains, is a matter of common observation.
The late Sir George Macleod was in the habit of
teaching that if symptoms of intolerance occurred
the right course was to double the dose, whatever
its original amount.

BROMIDE OF POTASSIUM.— My first object in refer-
ring to this valuable salt is to strike a note of warning
concerning its use. It does not seem to be sufficiently

332 MINOR MALADIES.

known that it has a very deleterious effect upon old
people. Even in the ordinary doses of 10 grains
three times daily, in a person over sixty, KBr is very
liable to give rise to mental confusion, and if perse-
vered with it may cause permanent impairment of
the intellectual powers. The drug produces its effects
presumably by lessening the blood-supply to the
brain — hence its value in epilepsy — ^but in elderly
people the lessening of this supply may mean
thrombosis of some of the vessels, and consequent
softening. With a drug which presents such pos-
sibilities we cannot be too careful, and it is a good
thing to make a rule not to prescribe bromides after
the age of sixty unless their effects can be very
carefully watched.

Another fact in connection with bromides which
is worth remembering is that their effect in epilepsy
is said to be very much enhanced, so that smaller
doses produce the desired effect, when the diet is kept
free from common salt. This plan, first advocated
by Richet and Toulouse in 1899, has proved very
successful in the hands of many who have tried it.

In nocturnal epilepsy the action of the bromides is
said to be augmented by adding 6 to 10 drops of
the tincture of digitalis to the evening dose.
Bromides being very rapidly eliminated, it is un-
scientific to give one large dose in the twenty-four
hours where the attacks are not confined to the
night, and even when they are, it is better to keep
the patient under the influence of the drug during
the day.

SOME DRUGS, AND THEIR USES. 333

The addition of 3 or 4 drops of Fowler's Solution
and 2 of tincture of nux vomica will prevent any
unpleasant consequences from taking the salt, even
over long periods of time.

An enema containing 30 to 40 grains of bromide
of potassium is very useful in the vomiting which
occasionally follows the prolonged administration of
an anaesthetic.

DIGITALIS. — This is a drug which is probably used
wrongly more often than it is employed rightly. It
is used wrongly — that is, harmfully — whenever it is
given as a matter of routine on the discovery of a
valvular lesion. A well-compensated lesion, even at
the mitral orifice, not only requires no digitalis : it
resents it. It resents not only digitalis, but every
other form of meddling. It cannot be too often
repeated that a murmur in itself is no indication for
therapeutic intervention, and of itself affords no
legitimate excuse for serious prognosis. What we
want to know about a heart is its capacity for carry-
ing on the work of the circulation. So long as this
is adequate, the noises which it may emit in the per-
formance of its task become a matter of purely
academic interest. Digitalis is used wrongly when-
ever it is exhibited without very special attention
being paid to the state of the blood-pressure ; for
digitalis is a powerful raiser of blood-pressure ; and to
increase the pressure when it is already unduly high
is to court terrible disaster. Thus, it should not be
given in any stage of arterio-sclerosis, in atheroma, in

834 MINOR MALADIES.

granular kidney, or in any condition, indeed, which is
characterized by a slow pulse and full arteries. It
is used wrongly when it is employed as a diuretic
where oedema is absent, for its powers as a diuretic
are confined to the cases in which this condition is
present. It is used wrongly when, in the later
stages of heart disease, oedema being present, it is
persevered with after it has become evident that no
good is to result from its use. Digitalis acts upon
the myocardium and on the arteries, and when, as
in such cases, the muscular tissue of the heart has
become largely replaced by fibrous tissue, it is
impossible for the drug to exercise any cardio- tonic
effect, so that its sole action is that of constricting
the peripheral arteries, and thereby adding to the
burden of the already overtaxed central organ. It
is used wrongly when it is given in aneurysm, for
in this condition our object is to weaken the
ventricular systole, not to strengthen it; to lower
the blood -pressure, not to raise it. It is used wrongly
when it is given in endocarditis or pericarditis, for
in neither condition can it do any good, and, by
raising the blood-pressure, it may easily do a great
deal of harm. It is used wrongly when it is employed
for the relief of palpitation, unless it is quite certain
that this symptom arises from feebleness of the heart
itself, and is not caused by obstruction in the
systemic periphery. The palpitations of dyspepsia,
of chlorosis, of nervous afiections, and of the abuse of
tobacco, are all aggravated by the exhibition of the

SOME DRUGS, AND THEIR USES. 335

drug. It is used wrongly when by its means an attempt
is made to overcome the tachycardia of Graves' disease.

The commonest . error in connection with the
employment of digitalis is its exhibition as a routine
procedure whenever the existence of a morbus cordis
can be established. A valvular lesion, it must be
remembered, is a mechanical break-down which no
line of treatment can hope to cure. Nature herself
goes as near as is possible to overcoming the difficulty,
and if by giving digitalis we interfere with her
methods, we upset the balance which she has
established, and by our ignorance and officiousness
we provoke the very state of broken compensation
which we are above all things most desirous of
avoiding. The French teachers are never tired of
repeating that *une lesion d'orifice n'est pas une
maladie du cceur,' and of insisting that it is not
until the heart shows unmistakable signs of breaking
down — until, that is, the myocardium fails to contract
properly — that cardiac therapeutics come into play.
Until that occurs the giving of digitalis is mere
meddling, and meddling of a peculiarly pernicious kind.

It is said that digitalis should never be given
in aortic regurgitation, because, by prolonging the
diastole, it encourages a larger reflux into the
ventricle. This view, though perfectly sound theo-
retically, requires some modification, not only in
view of different effects of the drug according to
the dose employed — a question which is considered
later — but also because its employment is justifiable

33fi MIxNOR MALADIESj

and necessary in aortic regurgitation of rheumatic
ori^gin, when disaster threatens from progressing
weakness of the myocardium. In aortic regurgitation
caused by aortitis and other conditions associated
with high arterial tension, it is, on account of its
constricting effects on the peripheral vessels, never
justifiable to administer the drug.^

Digitalis, like mercury, is well tolerated by children.
It is exceptionally well borne by alcoholics, and in
febrile conditions it may be given more boldly than
under ordinary circumstances. In disordered states
of the stomach it should be given with caution,
because it has itself a tendency to irritate the gastric
mucosa. A great deal has been written about the
toxic effects of the drug, and while there is no doubt
as to its tendency to cumulative action, the dangers
thereof are usually much exaggerated. These dangers
may be avoided without any risk of lessening the
beneficial action of the remedy by suspending it
every sixth day for a day or two, for the action
will continue during the interval. The appear-
ance of toxic effects is usually, but not always,
heralded by a condition of the pulse which,
though by no means peculiar to intoxication by
digitalis, is nevertheless very suggestive of it. This
pulse has been described as one of * rhythmic
arhythmia,' or 'regular irregularity.' Other names
have been applied to it, such as the ' coupled pulse,'

1 Vide 'Aortic Insufficiency,' British Medical Journal,
August 4, 1906, p. 277.

SOME DRUGS, AND THEIR USES. 337

and the ' pulsus bigeminus,' intended to indicate that
it is regular for two (or perhaps three) beats together,
a disturbance of the regularity then occurring, which
immediately ceases, to return again at regular inter-
vals. It might be expressed thus — — — —
The supervention of a pulse of this nature while
a patient is taking digitalis should lead at once to
the cessation of the medicine, and its existence from
any cause should suggest the utmost caution in
prescribing the drug.

The exhibition of digitalis should always be pre-
ceded by a brisk purge ; some writers even go so far
as to say that the ground should be prepared for it
by venesection. This is not necessary in the vast
majority of cases, but the purgative, preferably in
the form of a blue pill (5 grains), followed by a saline,
should never be omitted, and it may be repeated from
time to time with great advantage.

This refers to cases of ordinary severity. In the
presence of symptoms of more than ordinary gravity,
with much oedema, great arhythmia, and urgent
nocturnal dyspnoea, where the liver is greatly enlarged
and the urine very scanty, it is necessary to be much
more drastic. In such cases it is quite useless to
give digitalis until the portal radicles have been freely
unloaded for several days in succession, and this
must be brought about by what, under ordinary con-
ditions, would be regarded as purgation of quite
brutal severity. Some writers speak of 10 grains of
calomel every night, others of 2 drachms of pulv.

338 MINOR MALADIES.

jalap. CO. three times daily, whilst a third set praise
a saturated solution of magnes. sulphat. in J-ounce
doses hourly. I mention these merely for the purpose
of insisting upon the fact that purgation must be very
severe, and the more urgent the symptoms, the more
drastic should it be. A point of great practical im-
portance is that such cases, even when apparently at
their last gasp, bear evacuants surprisingly well, so
that one need never hesitate to push the remedy to
the point of heroism. Where digitalis fails to act, or
where it produces vomiting in the first few doses, it
is generally a clear indication that the way has not
been sufficiently prepared for it, and the purgation
must be continued. During such continuance it is
well to prescribe a hypodermic injection of morphine,
■J grain (not more) every night, and to exhibit liq.
strychnin. (5 minims) and theobromine (15 grains),
three times during the day.

Another fact which should not be forgotten in con-
nection with digitalis is that the full benefit of the
drug is to be obtained only when the patient is in
bed. In slight cases it may, and often does, act when
he is moving about, but smaller doses will bring
about better results, and in a shorter time, if the
recumbent posture is insisted upon. Another im-
portant point to be remembered is that its action,
whether it be used as a cardiac tonic or as a diuretic,
is very much enhanced by a pure milk diet. Stimulat-
ing foods interfere with its action. If it is desired
to use stimulants, which it often is, carbonate of

SOME DRUGS, AND THEIR USES. 339

ammonia is the best. Alcohol may be necessary, but
it is usually better avoided.

M. Huchard, who amongst French writers is the
chief exponent of the virtues of digitalis, says, at
the close of an eloquent passage^ : ' Le seul medica-
ment cardiaque est la digitale.' Few English phy-
sicians would be disposed to agree with this, for in
this country we place great reliance both upon
caffeine and strychnia, but everyone will admit that
in its own particular sphere digitalis stands alone and
unrivalled. Now, what is this sphere ? Well, it is
sufficiently circumscribed, as may, indeed, be judged
by the length of the index expurgatorius which has
already been recited. The matter may be summed
up by saying that digitalis is called for when, from
whatever cause arising and whether or not a valvular
lesion of any sort be present, there is weakness of the
contractile power of the heart, provided that this weak-
ness is accompanied — (1) by arhythmia, (2) by a lower-
ing of arterial and a heightening of venous pressure.
And, because of its diuretic efi'ect, the drug is all the
more urgently demanded when these conditions are
attended by oedema, ascites, visceral congestion, and
diminution of the urinary flow. This state constitutes
the kingdom over which digitalis holds sovereign sway,
but even here its power is limited ; for, as 1 have
already pointed out, when the cardiac muscular sub-
stance becomes replaced by fibrous tissue, as it
ultimately does in all cases of long standing, the drug
* ' Nouvelles Consultations M^dicales,' p. 434.

840 MINOR MALADIES.

ceases to do good and may easily be mischievous. It
is, nevertheless, safe to say that he who confines its
employment, in the ordinary doses, to cases of the
kind above indicated, will seldom do harm, and the
good he will do will add greatly to his credit and
satisfaction.

One of the chief difficulties in connection with the
exhibition of digitalis is the unreliability of the
ordinary preparations. The amount of active prin-
ciple present in any given sample of leaves seems
to vary more in the case of this drug than in
any other, with season, soil, and other factors nob
easy to ascertain. Hence it is that of two samples of,
say, the tincture, obtained from different druggists,
one may be active and satisfactory and the other
inert except for the production of vomiting and other
unpleasant effects. This is no uncommon experience,
so that before deciding that the drug cannot be
tolerated it is wise either to change the form in which
it is being used, or try the effect of sending the
prescription to another chemist. It is often said that
the infusion is more trustworthy than the tincture.
This I believe to be true, but only when the infusion
is freshly made. In France it is very generally held
that a freshly-made cold infusion is one of the best
means of giving the drug. About 3 grains of the
powdered leaves are macerated in about 10 ounces of
distilled water for twelve hours. The liquid is then
filtered to prevent any solid particles obtaining access
to the stomach : the amount is divided into 4 or 6

SOME DRUGS, AND THEIR USES. 341

doses, which are taken at intervals during the
following twenty-four hours. The very unpleasant
taste of this infusion may be mitigated by allowing
a few slices of lemon to macerate along with the
digitalis, or by adding the juice of half a lemon to
each dose. If for any reason the tincture should
prove unsatisfactory, an infusion thus made may be
appealed to with confidence.

The solid preparations of digitalis are seldom well
tolerated under precisely those conditions when the
drug is most urgently required, and I have long
since ceased to employ them. The form in which the
drug has, in my hands, proved most trustworthy
is the preparation of the French Codex called * solute
ofiBcinel de digitaline cristallis^e,' of which the dose
is 5 to 15 minims. It is quite easily obtained in
this country, and is infinitely more reliable than
any of the ordinary preparations. It was originally
suggested by Potain, and its value has been acclaimed
by nearly all the French writers since his time.
Professor Huchard, who never uses any other prepara-
tion, declares that so certain is it in its action, that
want of success with it necessarily means want of
skill on the part of the prescriber.

The granules or pills of crystallized digitaline
(Nativelle) are useful when the solution cannot be
obtained, but in common with all the solid prepara-
tions, they have a greater tendency to upset the
stomach than the above-mentioned solution.

Digitaline should not be administered hypodermi-

Sn MINOR MALADIES.

cally if it can be given with any prospect of success
by other means, because even the best preparations
are very liable to cause pain at the site of injection,
which lasts for several days.

In ordinary doses (10 to 30 minims of the B.P.
tincture) digitalis produces the general effects which
we have just been considering. It quiets the heart's
action, strengthens the systole, and prolongs the
diastole. If it regularizes the pulse and slows the
beats, it is doing good ; if it does not produce these
effects, it is either useless or harmful.

My own custom, however, except where symptoms
of urgency are present, is to begin with much smaller
doses than are usually prescribed. If I see a case
where compensation is only just beginning to fail, in
which the arhythmia is slight and there are no urgent
Bigns, I prefer to give a dose of 2 minims, combined
as follows :

9. Tr. digitalis vel Sol. digitaline cristal.

(Codex) TJiii.

Caffeinffi citrat gr. ii.

Tr. nucis vom , tail

Aquam ad 5s8.

M. Sig. : Every four hours for a week, then twice daily.

For reasons which appear later, I am in the habit
of ordering with this mixture 1 grain of blue pill to
be taken four nights a week This practice I have
found admirable in preventing failure of compensa-
tion by affording a slight but sustained tonic
re-enforcing action. If persevered with (allowing,

SOME DRUGS, AND THEIR USES, 343

of course, occasional holidays) it postpones for
months, and even years, the dreaded days of asystole
and intercurrent disease. If a patient is not ill
enough to remain in bed at all costs, then he is
not ill enough to be given — at first, at any rate —
larger doses of tincture of digitalis than 2 to 5 minims :
a dose which a considerable experience of out-patients
has shown me not only to be highly efficacious, but,
even when taken over long periods of time, to be
entirely free from danger.

MERCURY. — Mercury has been called the sovereign
remedy for all evils, and if we include its salts, it
surely goes very near to justifying the title. The
metal itself is the remedy par excellence in syphilis,
in the earlier stages of which it has what we must
assume to be a specific effect. It is also well to
remember that in the so-called tertiary manifestations
affecting the nervous system mercury will often prove
successful when iodide of potassium proves fruitless.
Of the methods of exhibiting the drug in syphilis
nothing can compare with the inunction method as
practised at Aix-la-Chapelle. A full account of this
method and its accessories was given in a paper read
by Dr. Lieven of Aix-la-Chapelle before the East
Anglian Branch of the British Medical Association
in April, 1904, and was published in the Journal of
Balneology and Climatology in July of that year.
Space does not permit me to enter into any detail
concerning the method, but I should like to point out
that it is one which any careful practitioner can carry

34)4 MINOR MALADIES.

out, without sending the patient either to Aachen
or to any of the numerous health resorts in this
country where it can be obtained. It is so superior
to any other means of introducing mercury into the
system, so full of advantages, and so free from risks,
that I do not hesitate to say that he who neglects
it is not doing his best for his patient.

The expression ' alterative ' which was applied to
mercury by our forefathers must still be employed to
denote a quality in the drug which we all recognise,
but which in the present state of our knowledge we
are unable to explain. We know that it is a germi-
cide, that it is a cholagogue, that it is an absorbent ;
but we know, too, that it is something else which we
cannot place in any category. It is to that some-
thing else that we appeal when we prescribe small
doses of gray powder for a bottle-fed baby who,
though being fed on lines which are quite satisfactory,
is nevertheless not thriving. We may feel certain that
there is no syphilitic taint, and yet we place absolute
reliance upon the drug to bring about an alteration for
the better in the child's nutritive process. It is to
that same something which we appeal when we
prescribe mercury for a patient who, though not ill, yet
exhibits undoubted signs of a resisting power which is
below the normal level. And the curious thing is that
the appeal is so seldom made in vain. They are fond
in France of using the terms * parasyphilitic ' and
* paratuberculous ' to describe conditions which are
admittedly neither sypliilitic nor tuberculous, but

SOME DRUGS, AND THEIR USES. 345

which are supposed to bear some relationship to these
infections, and in both the favourite remedy would
appear to be mercury. It would seem as if the vital
soil of some individuals occasionally required digging
over, as it were, with fresh material, in order to bring
their powers of resistance up to the normal level, and
there can be no doubt that that fresh material is more
abundantly supplied by mercury than by anything
else.

In connection with digitalis, I referred to tho
importance of preparing the way for this drug by a
dose of mercury, followed by a saline. That is classical ;
it may even be described as canonical, inasmuch as it
is everywhere recognised that digitalis is ineffectual
until the portal radicles have been unloaded. But
there is an action of mercury in connection with heart
disease and digitalis which cannot be explained by the
mere unloading of the portal radicles. Dr. Murray of
Newcastle^ has strongly advocated the practice of
giving small doses of mercury for long periods of time
to those afflicted with cardiac disease, and he relates a
remarkable case in which the metal appeared to act
not on the peripheral system only, but upon the heart
itself. Whatever be the proper explanation of its
action, I can confirm his observation that mercury in
heart disease has a value, not only when given
occasionally as an evacuant, but also when exhibited
in small doses daily over long periods of time ; that
even apart from digitalis it maintains the functional
* • Rough Notes on Eemedies.'

Sm MINOR MALADIES.

power of the heart ; and that, curiously enough, when
thus given it seems to have little tendency to produce
any symptoms of intolerance. So impressed have I
been with its value in this direction that I now
seldom prescribe a direct cardiac tonic without at the
same time ordering one grain of blue pill to be taken
at least three nights a week.

Of the salts of mercury, that which is probably the
most highly esteemed is calomel. In large doses — i.e.,
from 5 grains upwards — it is a very drastic cathartic ;
in moderate doses — i.e., from ^ grain to 2 grains —
it is a cholagogue ; and in small doses — i.e., from J to J
grain — it is an intestinal antiseptic. In small doses it
acts as a cathartic if it is given three times daily,
and continued for four or five days. This method
has many advantages over that of the single
large dose, inasmuch as it allows the drug time to
exercise its sedative influence — an influence which,
though very marked, is seldom spoken of. In some
cases the single large dose is essential — in delirium
tremens, for example. The late Sir George Macleod
used to declare that a full dose of calomel was
infinitely the best treatment in this condition, and he
seldom employed any other. Dr. Murray advocates
the use of what most people would regard as enormous
doses in acute mania, and he tells of some <;ases in
which he has given as much as 30 grains of calomel
to a maniacal patient with the happiest results. One
case, * after much profuse vomiting and purging,
became as quiet as a child, and fell into a sound

SOME DRUGS, AND THEIR USES. 847

sleep, to awake in a perfectly calm frame of mind.'
There is much shrewd practical common-sense in
this method, and it might be remembered with great
advantage in emergencies similar to those which the
author relates.

In minute doses calomel is of the greatest value in
typhoid fever. It promotes intestinal antisepsis,
prevents borborygmi, and renders the stools less
offensive. I know of nothing to compare with it in the
medicinal treatment of this condition (except, perhaps,
Dr. Burney Yeo's chlorine mixture),* over which it
has the great advantage of simplicity and tastelessness.
Care should be taken in giving it, however, lest it
should accumulate (as it sometimes does), and then
exercise the effect of a single large dose. One-eighth
grain three times daily is a sufficient dose, and
this should not be continued for more than three days
without an interval. It is usefully combined with
3 grains of thymol made into a pill with soap
powder and a little spirit. If the bowels are
thoroughly cleared at the outset by a dose of 2 grains
of calomel, and if this pill is given cautiously during
the first fortnight, the fever will generally take a
benign course.

Another deservedly popular preparation of mercury
is hydrargyrum cum creta. It is, as has already been
mentioned, probably the best alterative for children,

^ ' Manual of Medical Treatment,' second edition, vol. ii.,
p. 6S6.

us MINOR MALADIES.

especially when combined with rhubarb and soda, aa
in the following :

^. Hydrarg. c. cret. gr. i.

Pulv. rhei gr. i.

Bodii bicarb gr. iii.

M. Ft. pulv. Sig. : Nocte mancque.

Dr. Murray speaks highly of the following powder
in the treatment of catarrhal jaundice :

^, Hydrarg. c. cret gr. I.

Pulv. cret gr. i. vel grs. ii.

M. Fi piL Sig. : Ter die sumend.

* In no disease,' he says, * are there more fanciful
and absurd cures in vogue, but they are mostly
useless and injurious. The one remedy I have
faith in is the adminisiration of gray powder until the
gums are touched, and kept so for a month.' In
order to avoid the difficulty of purgation arising from
the use of the ordinary powder, Dr. Murray proposes
the addition of the extra grain or two of chalk which
he has found of signal benefit. In biliary colic Dr.
Carter speaks highly of the value of succinate of iron
(5 to 10 grains), which he and some of his friends
have found more efficacious than any other remedy,
both for the relief of the attacks and the prevention
of their recurrence.

Mercury and its salts would appear to be the sheet-
anchor of dermatologieal therapeutics. Calomel is,
according to Ringer, infinitely the best remedy in that
very troublesome condition, pruritus ani. He pro-

SOME DRUGS, AND THEIR USES. 349

scribes an ointment — calomel 1 drachm to 1 ounce of
lard — which he says seldom fails to relieve, and has
never in his experience caused symptoms of absorp-
tion.

Pruritus pudendi is often quite successfully relieved
by the following simple lotion :

^. Sodii biborat 5i.

01. menth. pip inv.

Aquam Oi.

M. Ft. lotio.

Another successful lotion in all forms of pruritus,
especially pruritus ani when complicated with piles,
is the following :

]^. Chloretone grs. x.

Glycerin "I

S.V.K. I **2'"-

Lotio carbol. 1 per cent. ad 5iii.

Ft. lotio.

A useful ointment for the same trouble is thus
composed :

9. Chloretone "I

Ext. conii J ^^^•

CrenQor enthymol ... ad 5ii.

To this it is often advisable to add grs. viii. of
calomel or hydrastin, or both.

Dr. John Reid, of New York, recommends pilocar-
pine in pruritus, whether local or general, whether
there be any obvious lesion of the skin or not, and

350 MINOR MALADIES.

whether or not the condition is caused by diabetes or
other general disease. He recommends that it should
be given by the mouth in doses of ^ grain three times
daily. Combined with lizy grain of atropine, there is
no sweating.

Mercurial salts are used in a great number of skin
affections. In eczema, especially of the head, a
favourite combination is :

]^ Hydrarg. ammon grg. i,

Liq. carboniB deterg. ... " rnxx.

Vaseliu vel lanolin ad 5i,

M.

The yellow oxide is especially valuable in the
treatment of pustular eruptions, and if applied early
will often succeed in aborting a boil.

Inasmuch as the tendency to falling hair, more
especially in women, is stayed by their use, mercurial
salts would seem to exercise an influence on the
nutrition of the hair follicles. A combination which
frequently acts remarkably well in this condition is as
follows :

^.

M. Sig. : To be well rubbed into the roots of the
hair night and morning.

Ilydrarg. perchlor.

grs. xil

Glycerin

5iii.

Spts. rectif

5iii.

Olei rosaD

inii.

Aquam

ad^vl

SOME DRUGS, AND THEIR USES. 851

Or tho following :

]^. Hydrarg. perchlor.
Acid, carbol.
01. ricini
01. lavandul.
Spts. vin. rect. ...

M.

gr. 1.
taviii.
3i.

lUiii.
ad 5i.

When giving such a prescription it is always well
to warn the patient that the treatment may seem at
first to increase the trouble, the reason being that the
moribund hairs are removed by the rubbing.

* Before leaving the subject of mercury,' says Dr.
Murray, * let me give one practical hint. If in doubt
as to the amount of calomel or grey powder we shall
give to a child, lay bare the nates, and if you find
them thin, flat, and flaccid, give but a small dose.
If, on the other hand, its little gluteal regions come
together like the chubby cheeks of a cherub, you
need have no fear of a free dose.'^

AESENIC. — Arsenic was at one time regarded as
almost a specific in most chronic cutaneous disorders,
but experience has since shown that it is liable to be
a double-edged weapon, which should be employed
with great caution, inasmuch as it has an undoubted
tendency to convert a chronic disorder into an acute
inflammatory condition. In suitable doses it is a very
useful general tonic, and in very small doses (1 to
2 minims of Fowler's Solution) it is an excellent tonic
to the digestive organs, more especially the stomach.
It is very efiicacious in vomiting, especially the morn-
^ Journal of Balneology ^ October, 1906.

852 MINOR MALADIES.

ing vomiting of drunkards and those suffering from
other forms of chronic irritation. It is probably the
most rehable remedy for lienteric diarrhoea in children.

As a general tonic it has a special value in functional
affections of the nervous system, especially when com-
bined with nux vomica. I have found small doses of
both to be more efficacious and better tolerated than
large ones, a good combination being a pill containing
^ grain of arsenious acid and yjj grain of extract of
nux vomica, three times daily after food. This pill
should not bo given in organic disease of the nervous
system, because even the small quantity of nux vomica
it contains is calculated to do harm.

As a digestive tonic, arsenic acts admirably when
combined with citrate of iron and ammonia in those
ansemic and chlorotic patients (and they are very
numerous) who cannot take the stronger preparations
of iron, such as the sulphate and the perchloride.
A mistake which is very often made is to give cblorotics
and anaemics these stronger preparations in the first
instance, a very common and a very futile combina-
tion being magnesium sulphate and iron sulphate.
It has several times fallen to my lot to see a patient
who had failed to make any progress whatever with
a prolonged trial of this, improve by leaps and
bounds as soon as the following was substituted :

Bt. Ferri ammon. cit. grs. x.

Liq. bismuth, ammon. cit 3ii.

Liq. Fowleri tflv.

Aqnam ad 5ss.

M. Sig. : Ter in dio post cib.

SOME DRUGS, AND THEIR USES. S53

I do not at all underrate the value of purgatives in
the treatment of this condition, but there is no special
reason for including them in the mixture. They
may be given independently in the form of a morning
draught, or some other laxative, such as aloes or
cascara, may be employed. Aloes is said to enhance
the action of iron, and there certainly seems to be
good ground for this opinion.

As the result of Dr. Murray's^ enthusiastic advocacy,
arsenic has of late been very much employed in two
conditions on which it was formerly not supposed to
have any influence — namely, diabetes and chorea.
My own opportunities for trying it in diabetes have
not been numerous, but where I have, it has certainly
seemed to be a valuable aid in still further reducing
the amount of sugar after this had been brought to an
apparent minimum by diet and opium or codeia.
The drug is certainly very well tolerated by diabetics,
a fact which in a general way may be regarded as an
indication for its use. It should not, according to
Dr. Murray, be given until the sugar has been so much
decreased by diet and codeia as seems possible.
Arsenic will then not only still further reduce the
amount, but it may be trusted in suitable cases to
cause its entire disappearance, and to prevent its
recurrence, even with an ordinary diet.

The treatment of chorea by large doses of arsenic
was invented by an unqualified practitioner, who, on
his death-bed, disclosed the secret of his success to
* * Bough Notes on Bemodies.*

S54 MINOR MALADIES

Dr. Murray. The secret was this : * that Fowler's Solu-
tion, in 15 to 20 drop doses, might generally be given to
children from ten years old upwards for a few days
without disturbing the stomach, and that so given it
was an almost infallible cure for chorea within a week.'
Dr. Murray's own observations confirmed the value of
the drug so given, but he insists that two rules should
be observed. The one is that the minimum dose
should be 15 drops of Fowler's Solution ; and the
other, that the treatment should not be continued for
more than one week.

A trial extending over several years enables me to
speak with some assurance as to the efficacy of this
method. It does good in the large majority of the
cases; in some instances it is brilliantly successful, and
in a few it fails completely. But I do not agree that
it is essential that the treatment should be stopped on
the eighth day. I have, indeed, found that to do this>
is often to lay down the weapon just as it commences
to be operative ; that it is, in fact, during the second
week of large doses that the symptoms yield. It is,
of course, necessary to call the parents' attention to
signs of intolerance during this second week. I have
found, further, that absolute rest in bed, combined with
a diet from which fish, flesh, and fowl are rigidly
excluded, greatly increases the prospect of cure by
this, or, indeed, by any other method. Finally, I have
found that the addition to the mixture of large doses
(say 20 mmims to 1 drachm or more) of liquid extract

SOME DRUGS, AND THEIR USES. S55

of ergot, as suggested by Dr. Eustace Smith/ notably
increases the percentage of cures.^

There are, however, some cases which obtain no
benefit whatever from arsenic thus given, and although
I have endeavoured to classify them, I am unable to
suggest any point which, in examining a case, would
enable us to suspect beforehand that it was one
which would prove intractable to arsenic. One very
practical clinical point, however, is that the cases
which fail to respond to arsenic will nearly always
(invariably, in my experience) react to trional.
Trional will fail in a very large number of cases where,
under circumstances which are identical as regards
rest and diet, arsenic will succeed ; but I have not yet
come across a case where, arsenic having been found
wanting, trional has failed to produce the most
satisfactory results.

In dealing with chorea, my custom, therefore, is first
of all to insist upon the recumbent posture and upon
a purin-free diet. I then give a mild cathartic and
immediately begin the arsenic treatment. At the end
of a week I am guided by circumstances as to whether
the arsenic is to be continued for another week, or
trional (10 to 15 grains), three or four times a day,
substituted. Very few disappointments will, I believe,
await anyone who follows the same line. Arsenic is
the most reliable remedy in habit-spasm.

^ British Medical Journal, July 18, 1903.
^ Vide 'Ergot and Arsenic in Chorea,' by Olive Bivi^re,
British Medical Journal, February 25, 1905.

356 MINOR MALADIES

Jonathan Hutchison^ regards arsenic as a specific
in herpes of the lips and genitals — when recurrent.
Herpes zoster is often provoked by arsenic, but as in
zoster recurrence is very unusual, the drug does not
act. It is the element of recurrence which con-
stitutes the indication for its use.

In conformity, it is to be presumed, with its
supposed beneficial effect in all affections of the skin,
arsenic is sometimes given by the mouth for the cure
of chilblains. There is no objection to this, but I
cannot say that I have ever seen much benefit from
its use. This troublesome affection is generally
best treated by calcium chloride internally (q.v.),
combined with local measures. The limb should
have an extra wrap worn upon it, so as to encourage
the circulation of blood in the part. The patient should
be warned against subjecting those parts which show a
tendency to this form of stasis to sudden alternations of
heat and cold, because, for some unknown reason, these
alternations seem to be much more active in producing
chilblains than cold alone. Tight boots and tight
gloves must be forbidden. As a local application,
nothing can compare with the unguentum iodi (B.P.),
especially when vigorous rubbing is employed. It stops
the intolerable itching and causes the subsidence of the
inflammatory process. For broken chilblains, touching
with sulphate of copper and dressing with unguentum
resinae will rapidly effect a cure. For checking the
tendency to chilblains — to forestall them, that is —
iron, arsenic, and cod-liver oil are all useful, but

1 British Medical Journal, July 30, 1887.

SOxME DRUGS, AND THEIR USES. 357

calcium chloride is invaluable. Exposure of the parts,
to radiant heat, as by Dowsing's lamps, will not only
assist in checking the tendency : it will also bring about
absorption of the unsightly swellings which chilblains
so frequently occasion. Von Buiz {Therap, der Oegen-
wart, January, 1906) gives the following as an
infaUible remedy for chilblains :

^. Calcinat chlorinat (B.P.) §i.

Paraffin gix.

M. Ft. ungt. Sig. : To be well rubbed in
at night.

BISMTTTH. — In connection with the internal ad-
ministration of this most excellent gastro-intestinal
sedative, most of what is necessary has been said in
Chapter II. I revert to the subject here to emphasize
one or two points in relation thereto. It was at one time
believed that the value of the powder form of the drug
in cases of gastric ulcer was due to a mechanical action.
The powder was supposed to spread itself out on the
floor of the ulcer, and thus afiford a protection against
the action of irritants. Although there seems to be
very little to support this theory, I am quite of
opinion that the solid forms are preferable to the
liquid, and that of these the subnitrate is infinitely
the most useful and reliable. I have always found it
superior both to the oxide and carbonate. The
liquor bismuth et ammonii citratis is the best of the
liquid forms, and, as it is practically tasteless, it can
be so combined as to make an agreeable mixture.
Bismuth in any form taken over long periods of time

858 MINOR MALADIES.

is liable to cause (1) a garlic odour in the breath,

(2) increased pungency of the axillary secretion, and

(3) pruritus and irritation in the vicinity of the
anus. These are all very inconvenient to the patient,
and the drug should be stopped as soon as any of
them arise.

Bismuth is also valuable when used externally. Sir
Thomas McCall Anderson speaks in the highest terms
of the following ointment as a sedative in eczematous
and other irritating eruptions, and my own experience
fully bears out his recommendation :

E. Bismuthi oxid 5ii«

Acid, oleic. 5ii.

Cerse alh. 3vi.

Vaselin 5ii. 3ii.

01. rossB lOi.

M. Ft. ungt.

Another soothing combination containing bismuth
IS the following cream :

"fy. Zinci oxid. \ __

Bismuthi carb- J ^* ^*

Glycerin, carbol. 5ii«

Glycerin, amyli 5i.

Lin. calcis Si*

M. Ft. cremor.

A useful lotion of similar composition is :

&. Bismuthi carb. ^

CalaminsB > • aa 5i*

Mucilag. tragacanth. )

AqusB calcis ... 5iv.

Aquam ad gi.

M. Ft. lotio.

SOME DRUGS, AND THEIR USES. 359

FOEMALIN. — This is an aqueous solution (about
35 per cent.) of formic aldehyde, which has very
considerable bactericidal and preservative powers.
In watery solutions, even when these are weak, it
acts as an irritant on the skin and mucous mem-
branes. When combined with glycerine, however,
the irritant effect seems not to occur. Jordan ^ has
shown that in a combination of 1 to 4 per cent
(formalin, 1 J to 5 minims ; glycerine, 2 drachms) it is a
most valuable local remedy in aphthous stomatitis,
ulcerative stomatitis, and septic throats, and that so
used it produces no caustic effect whatever. Em-
ployed similarly, it is a convenient, painless, and
effective application in parasitic diseases of the skin.

The tablets which are sold under the name of
Formamint present a very convenient and portable
method of applying formalin to the oro-pharyngeal
region. These tablets are agreeable to the taste, and
will therefore be readily sucked by children who
cannot be induced to submit to any other kind of
effective medication. The tablets are composed of
formic aldehyde in combination chiefly with sugar
of milk. Their internal administration has been
recommended in the treatment of flatulent dyspepsia,
and it is not dijQficult to believe that they would do
much to prevent fermentation in cases in which the
pylorus was obstructed.

Formalin is given internally in two other forms, uro-
tropin and helmitol, both of which produce a very

'* Lancet, 1901.

860 MINOR MALADIES.

decided bactericidal effect upon the urine. Urotropin is
produced by the action of ammonia on formalin, and is
given in 10 to 15 grain doses. It tends to check am-
moniacal decomposition, probably owing to its bacteri-
cidal action. This action is very decided, and the employ-
ment of urotropine has in consequence become almost
a routine measure in typhoid fever — not so much for
its effect upon the patient as for its power of disinfecting
the urine before it leaves the body, and thus helping
to provide against the spread of the disease. Uro-
tropin is also used with great success in the cystitis
due to the Bacillus coli communis.

Helmitol is a combination of formalin with citric
acid. It is more eflScacious than urotropin in certain
cases. Urotropin may always be trusted to disinfect
an acid urine, but its action on a urine which is alkaline
is liable to be disappointing. If the alkalinity is due
solely to the presence of bacteria in the bladder, then
urotropin may bo relied upon to check the decomposi-
tion, but if the alkalinity is due to other causes the
effect of urotropin is doubtful. Helmitol, on the
other hand, will render acid a urine which is alkaline
from any cause, and will at the same time disinfect
it. As a general rule, therefore, urotropin should
be given when the urine is acid, and helmitol when it
is alkaline.

CHLORIDE OF CALCIUM.— This drug has been
shown by A. E. Wright to increase very notably the
coagulability of the blood, and it has in consequence
been much and successfully employed in all exudative

SOME DRUGS, AND THEIR USES. 861

conditions, more especially of the skin. Chilblains,
urticaria, erythema, and purpura, are all much
ameliorated by its use, and the tendency to the
formation of blisters (as from rowing, cricket, and
the like) is very much lessened during the time the
drug is being taken. SavilP has extended still
further the practical value of the salt by showing
that many cases of itching are caused by a species of
subcutaneous exudation which disappears under the
treatment by calcium chloride, and he has effected
some very noteworthy cures by exhibiting the drug in
cases of pruritus pudendi and pruritus ani which
had for years resisted every other form of treatment.

Apart from calcium chloride, the best symptomatic
remedy for urticaria is magnesium sulphate ; for
erythema, quinine.

Mayo Robson and others have utilized the power of
calcium chloride in coagulating the blood for the
purpose of providing against haemorrhage, or of
checking it when it occurs. Thus it is given to
women for some days before expected childbed, and to
patients on whom it is necessary to perform opera-
tions in which bleeding is difficult to control
The dose of calcium chloride may reach as much as
1 drachm three times daily without fear of ill effects,
but it is usual to begin with smaller doses. It has
an unpleasant taste, which is, however, sufficiently
well disguised by extractum glycyrrhizse liq. and aqua
monthse piperita).

* Lancet, August 1, 1896.

862 MINOR MALADIES.

Savill,^ in giving the following, says : ' Valuable for
pruritus from any cause. Should be given three times
a day after meals in gradually increasing doses. In
hsemorrhage, uterine or pulmonary, should be given
every two to four hours.' It is quite palatable.

^. Calcii chlorid grs. xx.

Tr. aurantii ... 5u«

Aquam chlorof. ad 5i.

M.

CITRIC ACID AND THE CITRATES.— The work
done by A. E. Wright on the subject of the coagula-
bility of the blood revealed the fact that, while calcium
chloride notably increases this coagulability, citric
acid produces the opposite effect. In doses of
J drachm three or four times daily the acid causes
a disappearance of the calcium salts from the plasma,
thus rendering the blood much more fluid than it was
previously. I have already referred to the thera-
peutic application of this fact in goutiness, and in
skin eruptions such as acne and furunculosis, but I
wish here to refer to another use which may be made
of this property of the acid. In mitral stenosis the
severe symptoms arise from the difficulty with which
the blood passes through the narrowed mitral orifice.
If the blood is viscid, the difficulty is increased ; if it
is fluid, the difficulty is diminished. I have now
for some months been using citric acid in all cases of
mitral stenosis, and although I am unable at present
* ' A System of Clinical Modicino,' vol. i.

SOME DRUGS, AND THEIR USES. SG3

to speak positively, it has seemed to aid in relieving
the back pressure upon which the symptoms depend.

The property of decalcification which is possessed
by citric acid in the case of the blood is possessed by
citrate of sodium in the case of cow's milk. Artus
and Pages had shown that milk which had been
treated with oxalates and fluorides did not curdle
with rennet, and this they attributed to the fact that
the lime salts had been precipitated by the action of
the oxalates and fluorides. A. E. Wright^ followed
up this matter and demonstrated that milk-clots were
formed in two different ways : (1) a firm clot, as with
rennet, or with the human gastric juice; and (2) a
loose clot, as by the action of an acid. He further
showed that if the calcium salts be precipitated from
the milk, the subsequent addition of rennet produces
a clot of the second type, and not of the first. These
facts he applied to the artificial feeding of infants,
which is liable to present difficulties, mainly owing to
the formation of indigestible clot as soon as the milk
enters the stomach. Oxalates and fluorides being
poisonous, Wright tried other precipitants for the
calcium salts, and found that citrate of sodium
answered all the requirements. The practical outcome
of this is that if 1 grain of the citrate be added to each
ounce of milk, not only may the danger of the
formation of clot be entirely disregarded, but there is
not, according to Wright, any necessity whatever of

^ Lancet, July 22, 1893 ; Transactions of the Eoyal Medico-
Chirurgical Society, vol. xxxv. ; see also Poynton, Lancet,
August, 1904.

S64 MINOR MALADIES.

diluting cow's milk for infant feeding so as to
approximate it to ordinary mother's milk. This last
point is very important, and though at first sceptical,
many observers have been found to give unqualified
adhesion to Wright's views. The addition of citrate
of soda is most valuable in insuring digestion of the
large quantities of milk which are usually prescribed
in the rest cure.

SARSAPAEILLA. — This very old remedy has
recently been much discussed in connection with
tuberculosis and other chronic wasting and debilitat-
ing diseases. In the hands of Dr. Carter of Liverpool,^
it has produced most excellent results, and many
of those who have been moved by his convincing
advocacy to try it speak with enthusiasm of its
efficacy. The preparation which Dr. Carter recom-
mends is the decoctum sarsae compositum concent.
The doses should be large and frequently repeated —
that is, about J ounce three or four times daily. It
is well to be careful of such large doses — at any rate,
at first — for they not infrequently give rise to gastro-
intestinal disturbance. If, however, small doses are
administered at the outset, they may be increased
gradually without fear of intolerance. There does not
seem to be any explanation as to how this remedy
produces its effects, but that it is — in some cases, at
any rate — capable of bringing about results which
are little short of marvellous there is no longer
reason to doubt. Sir Felix Semon,^ Sir Clifford

* Liverpool Medico- CMrurgical Journal, January, 1906.

* Britiih Medial Journal, January 13, 1906.

SOME DRUGS, AND THEIR USES. SG5

AUbutt/ and others, have recently strongly testified
to its value in syphilitic cachexia where mercury and
iodides are unavailing.

1 British Medical Journal^ March 24, 1906.

CHAPTER X-

INSANITY.

The subject of insanity, though one which cannot
properly be included in any category of minor
maladies, is emphatically one of those to the under-
standing of which the ordinary text-book contributes
but little. Some of its practical aspects seem, there-
fore, to come within the scope of this volume.

The most important thing to realize in connection
with insanity is that it is a symptom and not a
disease. We have to divest our minds of the idea
that there is some special obscurity in connection
with it, an obscurity of a different character from
that which still surrounds such conditions as cancer,
whose aetiology is still unfortunately hidden from
us. Mental aberration is in many cases as much a
physical condition as leukaemia or pernicious anaemia,
inasmuch as it is due to some alteration either of
the cortical cells themselves, or of the blood which
nourishes them. Our ignorance of the subject and
its difficulties, together with the fact that the
symptomatology is almost purely mental, have com-
bined to surround this department of clinical medicine

see

INSANITY. 867

with an atmosphere of mystery from which it is to
the interest of everyone that it should be emancipated.
The first step towards that emancipation is the
recognition of the fact, which is no longer in doubt,
that the great majority of cases of acquired mental
alienation are due primarily to physical causes, thia
discovery of, and differentiation between, which are
necessary to their ultimate removal.

This atmosphere of obscurity has had for its result
the almost complete neglect of the question by him
who is in a sense the most favourably placed for
studying it in its earlier, aiid therefore its most remedi-
able, stages — namely, the family doctor. It is no dis-
paragement to the excellent work done by alienists
to say that inasmuch as they seldom see the cases
until the malady is pronounced, they are less favour-
ably situated than others for observing and counter-
acting the early symptoms. It is no part of my
purpose to enter into the diagnosis and treatment
of mental diseases ; rather do I wish to emphasize the
position that, ignorance of the accepted classifications
is no barrier to the appreciation of the fact that a
departure from the normal is present in an individual
case; nor need it deter the observer from undertaking
an intelligent clinical investigation into the physical
causes by which this departure has conceivably been
provoked.

Insanity is still too often regarded, as in former
times all disease was regarded, as a visitation of
Providence, in the presence of which medical inter-

3G8 MINOK MALADIES.

ference is not only impotent, but impious. The
obscurities of heredity, degeneracy, and other difficult
social problems, rise up to lend support to this
attitude. But while the power of such influences
is neither to be gainsaid nor minimized, it seems
necessary to insist that they are for the most part
merely predisposing causes which might be success-
fully kept inoperative if the laws of normal develop-
ment and healthy animal existence were more
frequently insisted upon, for purposes both prophy-
lactic and therapeutic. That a person who shows
signs of insanity has had an epileptic father and an
alcoholic grandfather is not a sufficient reason for
abandoning him to the fate with which he is
threatened. It is, however, a very good reason for
inquiring into his habits and mode of life, for
subjecting him to a minute clinical examination — for
investigating everything, in fact, which may reveal
any disturbance which, though slight in itself, may,
nevertheless, be sufficiently powerful in the predis-
posed, reflexly to upset the balance of higher centres.
In other words, we should learn to look upon
ins inity not as the result of causes which are neces-
sarily subtle, remote, and irremediable, but as a
state of the nerve cells to the production of which
many causes have contributed. Some of these, the
exciting, may be, and often are, recent and re-
mediable, and the discovery and removal of these
(a matter which is definitely within the sphere of the
physician as distinct from the alienist) may well
make all the difference between a mere transient

INSANITY. 869

melancholia and a state of matters which urgently
demands institutional treatment.

In conducting a clinical examination it is essential
to observe a definite routine, and to make careful
notes of the findings as the examination proceeds.
Necessary as this always is, from the point of view
of overlooking nothing, where there is any question
as to insanity, it acquires, as will appear later, a
very special importance, because of the fulness and
accuracy in the matter of detail which are necessary
to the filling in of a lunacy certificate.

The system which should first engage the attention
of the examiner is, of course, the nervous system ; and
here, to prevent oversights, it is well to adopt a
regional method, beginning with the head. After
careful inquiries as to memory (especially for recent
events), sleep, and pain, search should be made for
physical signs. Having observed and noted the
presence or absence of general facial asymmetry, the
eyes should engage the most earnest attention.
Both squint and ptosis are important, and in slight
degrees, easily overlooked points. The size and
equality of the pupils, and their reaction to light and
accommodation, must be carefully tested, in each
eye separately.

Nystagmus, even when present only on extreme
lateral deviation, is very significant, and the search
for it should on no account be omitted.

The detection of refractive errors, especially those

which are moderate or slight in degree, is of paramount

24

870 MINOR MALADIES.

importance (vide Chapter IV.), and if there should be
any doubt whatever on this point, the question should
be referred to a specialist. There is no more fruitful
source of grave disturbance of the higher centres than
those slight ocular defects which, while not impairing
the visual power, nevertheless impose a constant
strain upon the ciliary muscle, and lead to exhaustion
of the nervous system.

The fundus on both sides should be examined for
commencing atrophy of the disc, for haemorrhages, or
for any other abnormality calculated to throw light
upon the patient's condition.

Defects of articulation may bo evoked by making
the patient say difficult words, especially those
involving the lips and tongue, such as ' parallelo-
gram,'*laryngological,' * ana3sthetical,' 'preliminary,*
and sentences such as, ' The Irish artillery extinguished
the conflagration.'

ihe state of the facial muscles is best ascertained
by such directions as * Screw up your eyes,' * Show me
your teeth,' * Put out your tongue,' ' Blow out this
light'; and while these directions are being carried
out the examiner should be careful to note the
existence of any tremor, and should study the relative
strength of the contractions on the two sides.

Before leaving the face, the state of the mouth
must be examined. Oral sepsis is a frequent and well-
recognised cause of reflex irritation, so that if present
in any degree, however slight, great care should be
taken to detect and remove it.

INSANITY. 371

In the upper limbs, the force of the grasps on the
two sides should be compared. Tremor and involun-
tary movements are best elicited by making the
patient extend both arms together, and spread out
the fingers of the two hands. He should then be
directed to touch the tip of his nose with each fore-
finger separately, the eyes being closed. This will
elicit intention- tremor, and ataxy. The condition
of the supinator and triceps jerks should be tested.

In the lower limbs, any abnormality of gait or pose
should be noted, and the muscles should be examined
for wasting or rigidity. The patient should be made
to stand with his heels and toes together, and close
his eyes. If this, which is called Romberg's test,
causes swaying or reeling, it indicates the presence of
static ataxy. The knee-jerks must be tested, if
necessary, with what is known as reinforcement — that
is, by causing the patient to clasp his two hands
together, and then to make an effort as if to
pull them apart. Ankle clonus, if present, is very
important, because it affords unequivocal evidence
of the involvement of the pyramidal system. The
same may be said of what is known as Babinsky's
sign — namely, a definite extensor response of the great
toe to plantar irritation.

The sensibility as to touch, pain, and temperature,
should also be investigated, though it must be
confessed that this is an ordeal which is apt to be a
trying one where we have a stupid, inattentive, or
morose person to deal with.

372 MINOR MALADIES.

Such an examination of the nervous system derives
its importance from the fact that it will reveal the
existence of any physical sign of organic disease which
may be present in that system, and as these physical
signs afford very valuable confirmatory evidence of
mental instability, their aid in rendering a certificate
convincing cannot be overestimated. Moreover, the
nature of the physical signs, when present, will
enable us to place the mental symptoms in their
proper category. The discovery of nystagmus and
intention-tremor, for example, will prevent us from
attributing to mere hysteria, an emotional instability
which is really due to disseminate sclerosis ; in the
same way that a slight * perversion of the ego ' will
acquire a peculiarly sinister significance if we find it
associated with unequal pupils and a knee-jerk which
is either absent or exaggerated.

But, although I desire to emphasize the importance
of deriving all possible assistance from the examination
of the nervous system, my present purpose is rather to
insist upon the responsibility of derelictions of duty on
the part of other systems in bringing about the state
of matters which we are considering. Dr. Graham
Crookshank^ says : * No case of neurosis, neurasthenia,
or borderland insanity should ever be treated without
the most careful reference to the condition of eyes,
ears, nose, mouth, heart, lungs, stomach, bowels and
pelvic organs.' The questions of ocular and

1 • The Management of Early, Transitory, and Ill-defined
Mental Disorders,' CUnical Journal, January 25, 1906.

INSANITY. . 373

nasal defects have already been considered (vide
Chapter IV.). The importance of attention to the
state of the mouth has been mentioned above, and
may be here reinforced by another quotation from
Dr. Crookshank : * Attention to oral hygiene is of
vast importance. It is not an exaggeration to say
that cases of alcoholic insanity have been cured by
the dentist.' And not alcoholic insanity only, but
other forms which are due to absorption of toxins
from the mouth, and to digestive disturbances conse-
quent upon deficient mastication.

The responsibility of the intestinal tract for the
manufacture and distribution of poisons which cause
functional derangements in the central nervous
system is now so well recognised that it scarcely
needs a reference. Chronic constipation vies even
with syphilis and alcohol in the multiplicity of its
morbid consequences and their magnitude. Among
these consequences mental troubles occupy the fore-
most place, and there can be no doubt that if patients
in the early stages were adequately purged of their
toxins, the number who ultimately come to certifica-
tion would be considerably reduced. Robert Jones ^
very properly deprecates the advice so often otiosely
given by the uninstructed, that patients suffering
from mcipient insanity should travel. Certainly,
aimless travel is not only useless, but dangerous ; but
travel undertaken with a view of reaching a spa with

^ • How to Treat a Case of Insanity,' Lancet, December 26,
1903.

374 MINOR MALADIES.

purgative waters, such as Carlsbad or Brides-les-
Bains, is a very different matter. It is quite certain
that an annual course of treatment at such a place
constitutes the salvation of many people who would
otherwise from time to time be threatened with
mental instability, a fact which is worth remembering
when we have a difficult patient or recalcitrant
relations to deal with.

Derangements of the reproductive organs, especially
in women, are perhaps the most fruitful cause of
those slight departures from the normal to which the
name * borderland ' is applied, and no pains should be
spared to discover and rectify any defect which may
exist. Adolescent insanities in girls often begin with
constipation, anaemia, and amenorrhcea.

In the cardio-vascular system the most important
matter to investigate is the condition of the blood-
pressure {vide Chapter V.). Slight mental troubles
are very often associated with, if, indeed, they are
not directly caused by, an increase of the blood-
pressure. This factor, as being remediable in its earlier
stages, is of more importance to the investigator than
the state of the heart itself, more especially as cardiac
troubles are so often secondary to an increase of
peripheral resistance.

Finally, it should not be forgotten that delirium*
due to typhoid or pneumonia has not infrequently
been mistaken for acute mania, a fact which
emphasizes the importance of a thorough physical
examination, not only in slight and borderland cases,

INSANITVT. 375

but also in the case of those who are demonstrably
and grossly insane.

There is yet another advantage of approaching
every mental case as though it were one of physical
derangement, and that is the effect produced upon
the patient. A medical man is frequently asked to
adopt *a ruse' in order to see the patient — by
announcing himself as the greengrocer calling for
orders, the man who winds the clocks, or something
equally absurd. J'o this he should never consent.
He should, on the contrary, insist upon appearing in
his true capacity, and lose no time in explaining to
the patient that the object of his visit is to examine
into the latter's health. If, now, the method of
examination is physical, the patient's confidence is at
once secured, and he is far less liable to suspect that
the object of the visit is * to send him to an asylum '
than if some method is adopted with which he is
unfamiliar. Nothing, in these cases, is ever gained by
deception.

If physical examination succeeds in eliciting some
recognised cause of insanity, the removal of which
affords a reasonable hope of rapid improvement, then
the propriety of undertaking the treatment at home
should be duly considered. The question of home
versus institutional treatment is a difficult one, which
can only be satisfactorily decided in view of all the
circumstances of a particular case. On the one hand,
there is the very natural dislike of the stigma
attaching to asylum treatment, and the fear of the

376 MINOR MALADIES.

consequences which such a stigma may entail even
upon unborn generations. Moreover, institutional
treatment is expensive, and expense may be a very
serious consideration, especially where the patient
happens to be the bread-winner. On the other
hand, it is a sad and significant fact that the dislike of
an asylum, natural, and in a sense laudable, though it
be, is responsible for many cases reaching the in-
curable stage which might have been cured had they
been subjected to expert treatlfent in the first
instance. The treatment of insanity is a very special
matter, and general practitioners would be well
advised if they refused to undertake it unaided, unless
they felt very sure that the particular case was well
within their competence. If home treatment is
strongly desired by the relatives of the patient, the
best course to pursue is to refer the whole question to
an experienced alienist, under whose advice the
practitioner may carry out the home treatment,
should this be decided upon. Unless he has had
special experience, the family doctor should make it a
rule to refer the question of the treatment of all cases
of insanity to an expert, in the same way and for the
same excellent reason that he habitually refers all
cases requiring abdominal section to a practising
surgeon. The cases suitable for home treatment are
given by Robert Jones * as follows : * Forms of insanity
referred to malnutrition, such as those caused by
excessive lactation, or the conditions accompanying
* Lancet, December 26, 1903.

INSANITY. 377

the puerperal state ; transient toxsemic states, sucli as
those due to drink or drugs, and the temporary
insanities of young persons ; quiet and harmless weak-
minded cases ; and certain cases of general paralysis
in the last stage, whose friends are desirous of avoid-
ing the much-felt stigma when a father or husband is
said to have died in an asylum.'

When no doubt exists that a person is sufficiently
insane to demand or warrant his removal from home,
the proper course to pursue depends upon whether
that person is a ' private patient ' or a ' pauper ' ;
whether, in fact, he is sufficiently well off' to contri-
bute something towards his keep in an institution, or
whether, removed from his means of livelihood, he is
penniless.

In the case of a * pauper,' notice of the fact and
circumstances should at once be given to two func-
tionaries— namely, the parish doctor and the relieving-
officer. No harm is done by notifying yet a third —
namely, the head of the police in the immediate dis-
trict. As soon as these officials have received proper
intimation the responsibility of the ordinary medical
man is at an end, except that he may be called upon
by the magistrate to furnish particulars. These func-
tionaries are bound by Act of Parliament to take the
necessary steps within three days of receiving the notice.

In the case of a private patient, there are two
methods of procedure : (1) An urgency order, and
(2) an ordinary petition, with statement, two medical
certificates, and a justice's order.

378 MINOR MALADIES.

1. Urgency orders should only be employed in cases
which are in reality urgent. They do not obviate the
necessity for the ordinary certification; they merely
postpone it for a few days, and they cause a great
deal of extra trouble to all concerned.^ An urgency
order consists of — (a) an order signed by one person,
who must be an adult friend, preferably a relative of
the patient ; and (b) a medical certificate signed by a
qualified practitioner, preferably the usual medical
attendant of the patient. These two — the relative
and the doctor — must have seen the patient within
two days of the time that each signs his respective
document, and they must not be related to one
another. The order holds good for seven days,
within which period the ordinary petition, with two
medical certificates and a justice's order, must be
provided. The medical man who signs the urgency
certificate may also sign one of the subsequent
medical certificates, and he may frame the latter on
the same interview, and even couch it in the same
language as the urgency certificate, provided that the
ordinary certificate is furnished within seven days of
the examination of the patient. The manager of an
institution, if he has room, will admit a patient on an
urgency order forthwith.

Forms for urgency orders and ordinary certificates
ought always to be in the desk of every medical
practitioner. They may be obtained from Messrs.

* 'Insanity in Everyday Practice,' second edition, E. G.
Younger (Bailli^re, Tindall and Cox).

INSANITY. 379

Shaw and Sons, Fetter Lane, E.G., or from the
authorities of any licensed house, mental hospital,
or asylum.

2. In the case of a private patient, the procedure,
although it may at first sight seem complicated, is in
reality very simple. When it is decided that institu-
tional treatment is necessary, the superintendent of
the selected institution should be communicated with
without delay. If the practitioner has not any certifi-
cate forms in his possession, the said superintendent
will supply all that may be necessary. The nearest
relative (preferably the father, mother, husband, or
wife of the patient) is supplied with certain forms,
which must be duly signed, and it is in most cases desir-
able that the medical man should assist at the signing.

Two medical certificates are necessary, one of which
ought to be signed by the medical practitioner in
ordinary attendance upon the case. The other may
be signed by any medical man, provided he is neither
related to the patient nor in any way connected with
the institution to which the patient is to be sent.

Inasmuch as the law demands that one certifier
shall be the usual medical attendant, and requires
reasons to be given if this be not the case, it is
obvious that anybody may be called upon to fill in
a lunacy certificate at any time. There was at one
period considerable danger in certifying an insane
patient. Some of these people are very litigious, and
are apt to bring actions against all those concerned in
their detention if they should ever be set at liberty.

380 MINOll MALADIES.

There is now no fear of any difficulty arising, if only
the certifier will take ordinary care. The Act of 1890
protects him fully, ev§n abundantly, if he will realize
what his responsibilities are in connection with the
making out and the signing of the certificate. First,
then, the certificate should be drawn up with the
feeling that it is a document upon which the certifier
may conceivably, at some distant date, be cross-
examined in open court Although, as has just been
pointed out, there is no serious danger of this, yet it
is always well to be provided against every possibility,
and if every certificate were drawn up with the
spectre of a cross-examining counsel at the writer's
elbow, it is very certain that not a single case would
ever come into court.

It is not sufficiently appreciated that if any
proceedings are taken against a person for sign-
ing a lunacy certificate, such proceedings may be
stayed upon summary application to the High
Court, or to a judge thereof, if the court or
judge is satisfied that there is no reasonable ground
for alleging want of good faith or reasonable care
(Lunacy Act, 1890, Section 330, subsection).

This subsection represents the medical practitioner's
Magna Charta in matters relating to the certification of
the insane. Section 330 protects him from losing an
action if he has acted in good faith and with reason-
able care, but it does not prevent proceedings being
instituted. The subsection goes further, and pro-
vides means for stopping an action if there is no

INSANITY. 381

ground for alleging want of good faith and reasonable
care.

Now, in order successfully to invoke the aid of this
subsection, the certificate must be so framed as to
impress the judge that extreme care has been taken
in every detail Medical men are in the habit of
inditing a lunacy certificate much in the same spirit
as that in which they indite a certificate for a club,
stating the inability of one of its members to follow his
ordinary employment. It should be remembered,
however, that there is an essential difference between
a lunacy certificate and any other medical certificate.
This difference resides in the fact that whereas in the
latter the doctor's opinion as an expert is accepted ; in
the lunacy certificate it is not. It suffices for a quali-
fied man to write, *In my opinion this person is
suffering from pneumonia,' but it does not suffice for
him to write, * In my opinion this person is suffering
from insanity.' The club authorities unhesitatingly
accept the one, the Lunacy Commissioners peremp-
torily reject the other. Successfully to frame a lunacy
certificate it is necessary to include facts — not deduc-
tions, but facts — which will carry conviction of the
patient's insanity to a person, or a set of persons, who
have never seen the patient.

Extreme care and due elaboration of detail are thus
essential, not only to the validity of the certificate,
but also to that immunity from vexatious legal pro-
ceedings which the Act of 1890 seeks to confer on the
conscientious certifier. For the certificate must not

382 MINOR MALADIES.

only convince the authorities of the fact that the
patient is insane, but it must also be capable of con-
vincing a judge of the High Court that so much
particularity has been exercised in its framing, that
there is no ground whatever for alleging * want of
reasonable care.'

The examination of a supposed lunatic should
therefore be approached with a grave sense of
responsibility ; and the first thing to remember is
that notes should be carefully taken at the time of
the examination, and as carefully preserved there-
after. This is a precaution which should never,
under any circumstances, be omitted. It is always
well to seek an interview with one or more responsible
members of the patient's household or family before
seeing the patient, in order that some idea may be
gleaned as to the form of insanity which may be
present The full names and addresses of such
persons should be carefully noted, together with
their relationship or nature of connection with the
patient. Facts — not beliefs or opinions — which are
communicated by them are not absolutely necessary
to the due execution of a certificate, but they materi-
ally strengthen the document, and should therefore
be studiously elicited, carefully sifted, and accurately
recorded.

The interview with the patient should be approached
in much the same spirit as the student approaches the
clinical case given him for report at his final examina-
tion. Nothing should be omitted which can be

INSANITY. 383

elicited. Age, occupation, family history, past ill-
nesses and attacks, should be accurately taken down
in writing, and every abnormality which a thorough
physical examination has brought to light should be
recorded, whether such an abnormality may seem to
the examiner to have an immediate bearing upon the
case or not. It is infinitely better to make the
report too full than to leave it too meagre.

When the time comes for drafting the certificate
the great point to be borne in mind is that it is facts
which are wanted, and not conclusions ; evidence, and
not a verdict. The conclusion or verdict is implied —
namely, that the person is insane ; but the facts, the
evidence upon which the conclusion or verdict is
reached, must be set forth clearly and in detail. It is
well to avoid the use of technical terms, such as
' delusion,' * illusion,' and ' hallucination,' because
one, at any rate, of the people whom the certificate
is intended to convince may have a very hazy idea as
to the meaning of such terms. Attention to the
ordinary rules of syntax, with clearness and accuracy
of statement, being essential, it is advisable to employ
the present tense of the indicative mood, as ambiguity
is then less liable to creep in. Thus, the certifier
should begin his sentence with * the patient states '
this, or ' he does ' that, instead of, as is too often done,
using the present participle — e.g., 'going into the
street in her nightgown.' The completed certificate
should be a reasoned, orderly, coherent document,
bearing on its face the fact that it is the work of ao

S84 MINOR MALADIES.

educated man, who has brought to its composition the
desire succinctly to convey positive information to
responsible people who have no other means of
forming a conclusion upon a matter of the highest
importance.

It is scarcely necessary to add that, after efficiency,
brevity is one of the most valued attributes of a
lunacy certificate. These documents have not only
to be perused by several people, but they have
usually to be copied many times over. Neverthe-
less, desirable as it is, brevity should not be attained
at the expense of adequacy, nor should it be sought
for outside the rules of ordinary syntax.

Before a lunacy certificate is sent in the certifier
should read it critically, and ask himself two ques-
tions concerning it. The first is : * Will this convince
a person who has never seen the patient that the
latter is insane ?' The second is : * Will this convince
a judge of the High Court that I have used every
possible care, both in examining the patient and in
drawing up the certificate ?' If it is possible for a
negative reply to be given to either of these ques-
tions, then the document must be redrafted, even
though this should entail a second interview with the
patient. It is only by constituting himself his own
severest critic that the certifier can hope to satisfy
others.

The two medical men who certify a patient to be
insane must act separately and apart. They must
not visit the patient together, and each certificate

INSANITY. 385

must be made out independently of the other.
When the certificates are complete, they, together
with the petition and statement, must be ratified by
a justice's order. The justice may be a County
Court judge, a stipendiary magistrate, or a magistrate
specially appointed. The signature of an ordinary
justice of the peace has only temporary value, because
an order so signed must, within fourteen days of its
date, be approved and countersigned by a justice
specially appointed. It therefore saves a great deal
of trouble to obtain the signature of a specially
appointed magistrate or other qualified functionary
in the first instance.

Briefly to recapitulate ; the procedure in the case of
a private patient for whom institutional treatment
has been decided upon is as follows :

1. Communicate with the authorities of the selected
institution as to the reception of the patient, and, if
necessary, obtain from them the forms for petition
and certificates.

2. As soon as these forms are to hand, see that the
petition and statement are duly and accurately filled
in by the nearest available relative.

8. Arrange with another medical man (not a partner
or assistant) separately to examine the patient and
draw up his certificate.

4. Examine the patient and certify.

6. The petition and statement, together with the

two medical certificates, being complete, the reception

25

386 MINOR MALADIES.

order (the printed form for which is always supplied
with the certificates) must be signed by a County
Court judge, or a stipendiary magistrate, or a justice
of the peace specially appointed. [This official may
or may not' wish to see the patient before signing the
order.]

6. The necessary documents being thus complete,
they are to be taken, within seven days of their com-
pletion, by the person who accompanies the patient to
the institution, and handed by him to the manager,
whose authority they constitute for detaining the
patient. Copies of these documents are forwarded by
the manager to the Commissioners in Lunacy.

INDEX.

Abdomen, massage of, 306
Abdominal belts, 119

exercises, 306

« pool,' 305

venosity, 305
Acetanalid, cyanosis from, 1G8

dose of, 168

in neuralgia, 167
Acid, citric, 362

preparations in cough, 16
Aconite, 229

Acupuncture in sciatica, 159
Addison's disease, diarrhoea in,

128
Adenoids. 13, 22, 256
Adolescent insanities, 374
Adolescents, albuminuria in, 232
Adrenal inadequacy, 244
Aerated waters, 300
Air, impurities of, 287

passages, catarrh in, 3

purity of, 286

spaces in fabrics, 284
Albuminuria, adolescents and,
232

asthma and, 240

athletes and, Dunhillon, 237

chlorosis and, 239

Collier of Oxford on, 232

cyclical, 232

dyspepsia and, 239

epilepsy and, 239

from drugs, 240

Graves' disease and, 239

hepatic congestion and, 239

life insurance and, 241

migraine and, 239

myxoedema and, 239

narrow views of, 35

physiological, 232

Albuminuria, Playfair on, 232

postural, 232, 236

pregnancy and, 233, 238

pretuberculosis and, 35

Senator on, 233

spinal cord injuries and,
233

*K)nsillitis and, 239

tubercle and, 240

various causes of, 240
Alcohol and the menopause, 84

forms of, 299

in lumbago, 157
Alcoholic cough, 18

vomiting, 137
Alcoholics, 279
Alcoholism, diarrhoea in, 125
Alkalies, dilution of, 58

in digestion, 57
Alkaline mixtures, 94
Allbutt, Sir Clifford, on mano-
meter, 225

on sarsapariUa, 365
Aloes, 121
Aloin, 122
' Alterative,' 344
Amblyopia, 249
Ambulatory influenza, 19
Amenorrhoea, pituitary feeding
and, 261

in pretuberculosis, 37
Ammonium bromide, 135

chloride in neuralgia, 167
Amyl nitrite, 229
Ansemia in neuralgia, 161

of soft palate, 41

in tuberculosis, 41

Trousseau on, 41
Anaesthetic, vomiting after, 333
Analgesia, old age and, 315

387 25-2

388

MINOR MALADIES.

Anderson, Sir T. M., on bismuth,

358
Aneurysm, 324

digitalis in, 334
Angina pectoris and indigestion,

85
Animal requirements, 278
Ankle clonus, 371
Anorexia, 245
Antibodies, 122

Antimon. tartrat., ung. in lum-
bago, 186
Antimony, 11

powder in lumbago, 157
Antiphlogistine, 186
Antipyrine in rheumatism, 151
Aortic regurgitation, digitalis
in, 335

valve, affections of, 327
Aperient, diarrhoea after, 143
Aphonia, functional, in pretu-

berculosis, 42
Apwa, 123

Arabella water in gout, 200
Arcus senilis, 175
Argyrol, 130
Arsenic, 351

in asthma, 327

in herpes, 356
Arterial tension. See Blood-
pressure
Arterio-sclerosis, 324

digitalis in, 333
Arthritic, chronic, fibrositis, 148,

153
Arthi'itis, 148

gouty, 211, 214

in children. Dr. Still on,
214

rheumatoid, 329
Arthroposis, 144
Articulation, defects of, 370
Aspirin in febricula, 32

in giddiness, 139
Asthma, 324

albuminuria and, 240

arterial tension in, 214

diet in, 326

dyspepsia and, 326
in gout, 215
Astigmatism, 175

j Astringents in diarrhoea, 127
Ataxy, 371

Atheroma, digitalis in, 333
Atmosphere, pure, 290
Atmospheric changes and fibro-
sitis, 149
Atomizers, 7
Aural cerumen, 13

troubles and giddiness, 139

and headache, 170
vertigo, 139

Babinski's sign, 371
BaciUus, Pfeiffer, 19
Bacteriocide, ferri perchlor. as,

30
Baldness, causes of, 282

in gout, 217
Baths at Bath, 208
baldness and, 283
cold, albuminuria and, 233

rheumatism and, 150
daily, 309
deafness and, 283
Dowsing Institutes, 208
electric Tight, dyspepsia and,
63
gout and, 212
myalgia and, 156
exercises with, 307
full-length, 282
gout and, 207, 210
headache and, 308
hot-air, gout and, 212
hot, catarrh and, 8
diarrhoea and, 127
dyspepsia and, 03
gout and, 207
lumbago and, 157
rheumatism and, 150
light and heat, 208
mineral water, 205
Nauheim, 271
radiant-heat, gout and, 208
rheumatism and, 150
rheumatism and, 153
sitz, 282
temperature of, 207, 281,

307, 308
Turkish, dyspepsia and, 63
gout and, 208

INDEX.

Belladonna in constipation, 122
in giddiness, 139
in neuralgia, 166
Benzo-naphthol, 117
Bermingham nasal douche, 4
Beta-naphthol, 117
Bicarbonate of sodium in go\Jt,

213
Biliary colic, 348
Bilious headache, 133
Biniodide of mercury in diph-
theria, 24
Bismuth, 357

Brunton, Sir L,, on, 03
Burnoy Yeo on, 63
doses of, 64
in fluid form, 65
in indigestion, 63
meal, 120
in vomiting, 138
time of administration of,
65
Blisters, formation of, 361
in headache, 184
in neuralgia, 166
in vomiting, 136
Blood-letting in gout, 228
Blood-pressure and boiled meats,
87
and renal disease, 226
high, aconite in, 229
amyl nitrite in, 229
chloral in, 229
erythrol tetranitrite in,

229
thyroid extract in,

229
trinitrinin, 229
in gout, 210, 227
in indigestion, 86
in neuralgia, 164
normal, 226
vagaries of, 231
Boils, calcium sulphide in, 216
gouty poison and, 216
ichthyol ointment in, 216
sugar and soap in, 217
Wright's serum treatment,
216
Borderland cases, 374
Bowel irrigation, oil for, 130

Brachial myalgia, 154
Bromide of ammonium, 135

of potassium, 331
Bromides in migraine, 178
Bronchial glands and tuberci>

losis, 44
Bronchitis, gouty, 214

Powell, Sir R. D., on, 52
Brunton, Sir L., on bismuth,

63
Buchu, Fothergill on, 202

in gout, 202
Buiz, von, on chilblains, 357
Burroughs Wellcome' s tabloids,

270
Butyl-chloral in neuralgia, 167

in sciatica, 160
Byrom Bram well's alkaline mix-
ture, 94

Cajuput, oil of, in flatulence, 92
Calcium chloride, 360

in chilblains, 356
in headache, 184
salts, 258

sulphide in boils, 216
Calmette's ophthalmic reaction,

48
Calomel, 346

dose of, 99, 116
in gout, 201
in indigestion, 69
Campbell, Dr. H., on diet, 293
Camphor monobromate in neur-
algia, 168
Cannabis indica in headache,

184
Carbohydrates, Hare on, 291
Carbolic acid in flatulence, 91
Cardiac disease, mercury in, 345
Carter, Dr., of Liverpool, 364

on biliary colic, 348
Casoara in constipation, 122
in sthenic dyspepsia, 68
Castor oil, 99

in diarrhoea, 126
Ringer's mixture, 99
Cataphoresis in gout, 213
Catarrh of larynx, 6
nasal, 6
upper air passages, 3

390

MINOR MALADIES.

Catechu in gout, 218
Catheter for enema, 101, 130
Cerebral vomiting, 132
Cerebro- spinal exhaustion, 174
Cerium, oxalate of, dose of, C4

in vomiting, 138
Certificates of lunacy, 378
Cerumen, aural, 13

in giddiness, 139
Cervico -brachial neuralgia, 158
Champagne in vomiting, 137
Change of climate and headache,

180
Charcoal in flatulence, 91
Chilblains, 356
Children, constipation in, 122

arthritis in, Dr. Still on,
2U

li enteric diarrhoea in, 352

night terrors in, 255

overclothing of, 281
Chills, 1, 26

' on the liver,' 31

theory, persistence of, 288
Chittenden on diet, 291
Chloral, 229

Chloretone in sea-sickness, 136
Chlorides, Widal on retention of,

194
Chlorosis and albuminuria, 239
Chorea, 263

arsenic in, 353

ergot in, 355

trional in, 355
Cimcifug. tr. in neuralgia,

167
Cinnamon oil in influenza, 52
Citric acid, 362

Clarke, Ernest, on errors of re-
fraction, 170
Climacteric indigestion, 84
Climate, ' too strong,' 180
Clothing, 279
Clotting of milk, 363
Coccydinia, 158

'Coddling,' joints in rheuma-
tism, 152
Colchicum in gout, 211
Cold bath, 282, 307

common, 328

feverish, 31

Colds, 1

constant succession of, 33

opium for, 8

quinine after, 9

to abort, 4
Colic, biliary, 348

formulae for, 141

Ludlow's formula, 141

of infants, formula, 141
Widerhofer's formula,
141

with constipation, formula,
141
Colitis, mucous, 129
Collars, tight, 285
Collier of Oxford on albuminuria,

232
Congestion, mechanical, and

headache, 179
Conjunctivitis, gouty, 218
Constipation, 95

belladonna in, 122

calomel, dose of, 115

cascara in, 122

chronic, in mental cases, 373

cure, Paget' s, 142

gouty, pills for, 142

habitual, 101

in infants, 138

in neuralgia, 105

in sthenic dyspepsia,
formulffi for, 68

Monti's formula, 142

occasional, 98

symptoms. 111

vaseline preparations in, 11
Continued fever, 39
Cooper, Sir Astley, on new drugs,

Corsets, tight, 285
Corvisart on opium, 21
Cotton, 284
Cough, 1

acid preparations in, 16

alcoholic, 18

causes of, 12

gastric, 17

hepatic, 17

intestinal, 17

lozenges in, 17

mixtures, formulae, 51

INDEX.

^91

Oougb, reflex, 18
* Coupled pulse,' 336
Creosote in vomiting, 137
Crocker, RadclifEe, on diseases of

the skin, 267
Crookshank, Dr. Graham, on

insanity, 372
Cubebs as expectorant, 12
Curdling of milk, 363
Cuti-reaction, von Pirquet on, 48
Cyanosis from acetanalid, 168
Cyclical albuminuria, 232

Danish exercises, 307

Def secation, posture in, 104

Delirium tremens, 346

Deltoid myalgia, 154

Dental caries and indigestion, 76

troubles in headache, 176
Depressing expectorants, 10
Diabetes, arsenic in, 353
Diarrhoea, 124

Addison's disease and, 128

after aperient, 143

alcohoUsm in, 125

argyrol in, 130

astringents in, 127

castor oil in, 126

diet in, 128

fissure of anus in, 128

formulae, 127

Eustace Smith's, 142
Hare's, 143

Graves* disease in, 128

hot bath in, 126

household remedies, 127

in infants, 142

in kidney disease, 125

muco -membranous colitis in,
129

mucous colitis in, 129

neurotic, 125

persistent, 129

potass, pormang. in, 131

stricture of rectum in, 128

sigmoidoscope in, 131

tannigen in, 128
Diet, aerated waters, 300

alcohol in, 299

asthma and, 326

Campbell, Dr. H., on, 293

Diet, Chittenden on, 291

fluids, time for taking, 208
in diarrhoea, 127
primeval man, 204
reducing intake, 302
rival systems of, 291
Hare on, 291
Van Someren on, 297

Digestion, alkalies in, 57
pepsin in, 54
process of, 64

Digital estimation of arterial
tension, 225

Digitaline (Potain), (Nativelle),

Digitalis, 333

and iodides, 328

and milk diet, 338

Huchard on, 339

infusion of, 340

indications for, 339

posture and, 338

purgative before, 337

routine prescription of, 202

solid preparations of, 341

toxic effects of, 336
Diphtheria, bromide of mercurv
in, 24 ^

diagnosis of, 23

knee-jerks in, 23

strychnine in, 25

urine in, 23
Diphtheritic paralysis, 26
Diuretic, digitalis as, 334

natural mineral water as.
205, 228
Diuretin, 205
Do bell's solution, 6
Douche, nasal, 4

Bermingham, 4
Douching in myalgia, 156
Dowsing Institutes and gout.

208 ^

Draughts, 288
Drinking with meals, 298
Drugs, albuminuria from, 240

eight chief, 323

new. Sir Astley Cooper on.
322
Dunhill, albuminuria in athletes.
237 - '

392

MINOR MALADIES.

Durham, Arthur, hospital

throats, 50
Dyspepsia. See Indigestion
Dyspnoea in gout, 224

in pretuberculosis, 42
Dystrophia adiposo genitalis, 247

Eczema, 350, 358
Electric light baths, 212
Electricity for myalgia, 156
Eisner on potassium iodide, 330
Emphysema, potassium iodide

in, 324, 325
Elixir, colloid, 270
Enema, catheter for, 101, 130

soap and water, 100
Epilepsy and common salt, 332

bromides and, 332

in albuminuria, 239

nocturnal, 332

Richet on, 332

Toulouse on, 332
Ergot in chorea, 355

in hiccough, 94
Errors of refraction. See Refrac-
tion, errors of
Erythema, 361
Erythrol tetranitrate, 229

spts. ffith. nitrosi, formula;,
204
Eucalyptus, oil of, 7
Euonymin in gout, 201
Eustace Smith, diarrhoea, form-
ula, 142
Exercise, 303
Exercises, abdominal, 305

Danish, 307

respiratory, 14

skipping, 307

Swedish, 307
Expectorants, 9

depressing, 10

soothing, 9

stimulating, 9, 11
Eye diseases and gout, 218
Eye - strain. See Refraction,
errors of

Fagge on rheumatism, 145
Febricula, 31

and influenza, 32

Febricula and rheumatism, 147

aspirin in, 32
Fermentation, theory of flatu-
lence, 90
of indigestion, 71
Ferri perchlor. as bacteriocide, 30
Feverish cold, 31
Fibrositis. See Rheumatism
Fissure of anus in diarrhoea, 128
Flannel clothing, 284

underwear, 63
Flatulence, 90

and mouth breathing, 90

carbolic acid in, 91

charcoal in, 91

fermentation theory of, 90

mixture for, 94

oil of cajuput in, 92

sulpho-carbolate in, 91

terebene in, 91
Fluid supply in gout, 195
Fluids, time to take, 298
Fomentations, hot, in boils,
217

in myalgia, 155
Formalin, 359
Formamint, 359
Formulae, colic, 141

with constipation, 141

constipation in infants, 142
in sthenic dyspepsia, 68

cough mixture, 51

diarrhoea, 127

diuretic, 202

gargles, 50

Hare, diarrhoea, 143

HCl in indigestion, 73

hypnotics, 185

infant's colic, 141

lozenge, 62

Martindale, pil. butyl-
chloral c gels., 167

nasal washes, 49

neuralgia, 162, 185

pills for gouty constipation,
142

snuff, 61

spts. seth. nitrosi, 204
Fothergill on buchu, 202
Fowler 8 solution in vomiting,
iS3

lNDE:5i

393

Fresh air, profession and, 288

tuberculosis and, 45
Functional aphonia in pretuber-

culosis, 42
Furunculosis in gout, 216

Galbraith, J. J., on ulnar reflex,

47
Gargles, 4, 6, 14, 50

astringent, H
Gastric cough, 17
Gastro -intestinal toxaemia, 32

toxins in headache, 182
Gelsemium in neuralgia, 1G3
General health, 277
Giddiness, 138

aspirin in, 139

aural troubles and, 139

belladonna in, 139

cerumen in, 139

hydrobromic acid in, 139

ocular troubles in, 139

potass, bromide in, 139

quinine in, 139

refraction errors and, 172

vasomotor causes, 140
Glands, old age and, 318
Glottis, oedema of, 15, 330
Glyco-thymoline, 5
Goli as exercise, 304
' Golf shoulder,' 149
Goodheart on neuralgia, 166
Gout, abarticular, 214

alcohol in, 191

Arabella water in, 200

arterial tension in, 210

arthritis and, 211

asthma in, 214

auto -intoxication in, 219

baldness in, 217

baths in, 207

blood-letting in, 228

blood-pressure in, 227

bronchitis and, 215

buchu in, 202

calomel in, 201

cataphoresis and, 213

isatechu in, 218

cholagogues in, 201

citric acid in, 199

colchicum in, 211

Gout, diet in, 191

digitahs in, 202

Dowsing Institutes, 208

dyspnoea in, 224

erythrol tetranitrate in, 229

euonymin in, 201

exercise in, 206

eye diseases in, 218

fluid supply in, 195
intake in, 227

furunculosis in, 216

guaiacum in, 198

hot wet pack in, 208

indigestion and, 218

iridium in, 201

kidney disease and, 219

laryngitis and, 214

lemon-juice in, 197

Luff on, 219

nitrite of amyl in, 229

pharyngitis and, 214

phosphoric acid in, 199

podophyllin in, 201

polyuria in, 224

potass, iodid. in, 197

radiant-heat baths in, 208

salicylates in, 198

skin in, 206

troubles in, 216

sodium chloride in, 193

spas for, 212

stimulating liniments in,
213

sugar in, 193

sweets in, 193

tachycardia in, 229

tannigen in, 218

theobromine in, 202

thyroid extract in, 229

trinitrin in, 229

Turkish baths in, 208

vegetarianism and, 192
Goutiness, 187, 324

in neuralgia, 163
Gouty indigestion, 89
Gowers, Sir W., on fibrositis,

148
Graves' disease, albuminuria and,
239

diarrhoea in, 128

thyroid excess and, 267

594

MINOR MALADIES.

Guaiacum in indigestion, C4

in rheumatism, 151

in tonsillitis, 28
Gymnastics, pulmonary, 13

Haipr, Dr. Alexander, on diet,

291
Hair, loss of, 283, 350
Hare, Dr., on carbohydrates, 291

on diarrhre.a, formulae, 143

on neuralgia, 101
Headache, IGU

aural troubles and, 176

biliousness and, 133

blisters in, 184

calcium chloride in, 184

change of climate in, 180

congestive, 179

cranial areas, 181

dental troubles in, 176

eye-strain in, 170

gastro -intestinal toxins and,
182

intracranial, 178

meningitis, 179

na>al obstruction and, 176,
179

neurasthenia and, 181

peripheral irritant in, 169

presoyopia and, 172

refraction errors and, 170

Ross, G„ on, 184

scalp fibrositis, 181

toxaemia and, 181

vaso-constriotion and, 183

vomiting in, 133
Health, general, 277
Health resorts :

Aachen, 344

Aix-les-Bains, 153, 212

Baden-Baden, 153

Bath, 153, 212

Brides-les -Bains, 267, 374

Buxton, 153, 212

Carlsbad, 374

Contrexeville, 205

Evian, 205

Harrogate, 153, 212

Llandrindod, 153, 212

Luchon, 153

Roy at, 212

Health resorts :

Salsomaggiore, 153
Sidmouth, 153
Vichy, 153, 212
Vittel, 206

Woodhall Spa, 153, 212
Heai-tburn, 60

Heart cases, percussion in, 27
digitalis in, 333
murmurs, 333

tonsillitis and, 27
Helmitol, 359
Heraicrania, 176
Hepatic congestion, albuminuria
and, 239
stimulants in, 201
Hernia, vomiting in, 133
Herpes, recurrent, 356
Hiccough, 92
ergot in, 94
musk in, 94
nitro -glycerine in, 93
oil of turpentine in, 93
persistent, 93
High arterial tension. See Blood-
pressure
Hospital throat, Durham on, 50
Hot bath, 308

in indigestion, 59
pack, 11
wet pack, 208
Huchard, Professor, on theobro-
mine, 205, 228
on digitalis, 339
on potassium iodide, 330
Hutchinson, Jonathan, on ar-
senic, 356
syndrome, 247
Hydrarg. o cret., 347
Hydro bromic acid in giddiness,
139
in headache, 184
Hydrochloric acid in indigestion,

54,73
Hydrocyanic acidinvomiting,l37
Hyperopia, 176
Hypnotics, formulas, 185
Hypochondriacs, 279
Hypopituitarism, 249
Hysterical neuralgia, 166
vomiting, 132

INDEX.

^95

tee- bag in vomiting, 137
Ichthyol in indigestion, 83
Idleness, 279
Indigestion, 53

albuminuria and, 239
angina pectoris and, 85
asthenic, 71

and sthenic, 54
natural mineral waters

in, 74
•silent sorrow* type,

75
Stock Exchange type,
75
bicarb, of soda in, 63
bismuth in, 63
calomel in, 59
climacteric, 84
dental caries and, 76
diagnosis of, 59, 69
dilution of alkalies for, 58
fermentation theory, 71
flatulence in, 90
flatulent, formalin in, 359
gout and, 89, 218
guaiacum in, 64
HCl in, 73

high arterial tension in, 86
hot baths and, 59

wet pack in, 59
ichthyol in, 83
Langdon Brown on, 54
lozenges in, 67
nasal obstruction and, 77
nervous, 90
neurotic, 90
ovarian extract in, 83
irritation and, 89
palpitation in, 86
Fawlow's researches on,

54
pebble-sucking in, 67
pretuberculosis and, 36
pseudo -angina pectoris in,

85
pulse in, 60

refraction errors and, 78
Sir W. Roberts on, 70
sthenic, treatment of, 62
tea-drinking and, 69
tongue in, 60

Indigestion, vasomotor disturb-
ances and, 81

venesection in climacteric,
84
Inflammation, 147

aponeurotic, 148

muscular, 148
Influenza, 8, 18

ambulatory, 19

cinnamon oil in, 52

febricula and, 32

J. C. Ross on, 52

opium in, 21

quinine in, 21

symptoms of, 20

treatment of, 18
Insanity, 366

alcoholic, 373

home treatment of, 375

notification of, 377
Insurance and albuminuria, 241
Intention-tremor, 372
Intercostal neuralgia, 158
Intestinal cough, 17
Intracranial disease, 131, 132
Inunction, mercury, 343
Iodide of potassium, 324

of sodium, 331
lodism, 330

Sir George Macleod on, 331

skin forms of, 330
Ipecacuanha, 11
Iridin in gout, 201
Iritis, gouty, 218
Iron, succinate of, 348
Irrigator, Dr. Woakes', 4
Isotonic nose lotions, 5

Jalap, 121

James's powder in lumbago, 157
Jaundice, catarrhal, 348
Jones, Robert, on insanity, 373
Jordan on formalin, 359
JouUe on gout, 199

Kalabolik balance, 317

Keith, Professor A., on defa3ca-

tion, 106, 107
Keith's motors, 113, 120, 121
Kenyon, G, H., on lumbago,

186

m

MINOR MALADIES.

Kidney disease, diarrhoea in, 125
gout and, 219
vomiting in, 132

Kidney, granular, digitalis in,
324

Kingston Fowler on pyrexia, 39

Krameria lozenges, 17

Lacto-vegetarians, 292
L'dje cripusculairCt 83
Langdon Brown on indigestion,

54
Laryngeal tuberculosis, 41
Laryngitis, gout and, 214
Larynx, catarrh of, 6
Latham, Arthur, on lymphatic
glands and thj'^roid insuffici-
ency, 256
Lee, Dr., on sciatica, 159
Leeching in neuralgia, 169
Lienteric diarrhoea in children,

352
Lime water, vomiting and, 137
Lin. aconite in neuralgia, 167
Linen, 284

Liniments, myalgia and, 155
Lithia citrate in rheumatism,

152
Local applications for neuralgia,

185
Ijotion, nose, 6
Lozenges, formula, 52

in cough, 17

in indigestion, 67

krameria, 17

Sir W. Roberts', 67
Ludlow's formula, colic, 141
Luff on gout, 219

on lumbago, 154

on pot. iodid., 329
Luff's formulfi, myalgia, 155
Lumbago, 147

alcohol in, 157

antimony powder in, 157
tartrate ung. in, 186

diagnosis, 156

James's powder in, 157

Kenyon, G. H., on, 186

Luff on, 154

meat in, 157

treatment of, 156

Lunacy, Act of (1890), 380
certificates, 378
private patients, 385

Lunatic, examination of, 382

Lupuline, 185

Macleod, Sir George, on calomel,
346

on iodism, 331
Magnesium sulphate, 121
Man, primitive, 277
Mania, calomel in, 346
Manometer, AUbutt, Sir Gifford,
on, 225

Oliver's, Dr. George, 225

Riva Rocci's, 225

Rogers', 225

Tycos, 225

use of, 225
Martindale, pil. butyl chloral o

gels., 167
Massage, abdominal, 306

gout and, 207

myalgia and, 155

rheumatism and, 153

Bcalp, 283

sciatica and, 159
Mastication, deficient, 296
Meals, drinking with, 298
Meat, boiled, and arterial tension,
87

in lumbago, 157
M6ni^re's disease, 139
Menopause, 264

alcohol in, 84
Mental aberration, 366

habitude in pretuborculosis,
37
Menthol, 7
Mercury, 343

calomel and, 346

hyd. c cret., 347

inunction, 343
Middle age, diet in, 303
Migraine, 176

albuminuria in, 239

bromides in, 178

phenacetin in, 178

phcnozonein, Vt
Milk, clotting of, 363
Mineral waters, diuretics, 205

lNDE:5t.

39t

Mineral v\ator3 in asthenic in-
digestion, 74
natural, 68

and diuretics, 228
Mitral stenosis, citric acid in,

362
Monti, formula, constipation, 142
Morbus coxse senilis, 144
Morphia in neuralgia, 168

in vomiting, 138
Mouth breathing, 4

and flatulence, 90
temperatures, 30
Moxon, Dr., of Guy's, on tubercle,

39
Mucous colitis, Lockhart Mum-
mery on, 129
Muco -membranous colitis, 129
Mummery, Lockhart, on mucous

colitis, 129
Murray, Dr., of Newcastle, on
arsenic, 353
on mercury, 345
Muscular exercise in gout, 206
Musk in hiccough, 94
Myalgia, 148, 153
brachial, 164
deltoid, 154
douching in, 156
electricity for, 156
light baths and, 156
liniments, 155
Luff's formula, 155
massage in, 155
potass, iodid. in, 155
Myopia, 175
Myxoedema, 252

and albuminuria, 239

Nasal catarrh, 6
douche, 4
lotion, 5
obstruction, 13

and headache, 176,

179
and indigestion, 77
operations, St. Clair Thom-
son on, 180
septum, operations on, 179
washes, formulae, 49
Nativelle, digitalin, 341

' Natural oil ' of the skin, 309
Neboline, Oppcnheimer, 7
Nepenthe, 17
Nerve stretching in sciatica,

159
Nervous dyspepsia, 90

system, examination of, 369
Neuralgia, 160

acetanalid in, 167

ammon. chlor. in, 167

anaemia in, 161

arterial tension in, 164

belladonna in, 165

blisters in, 166

butyl chloride in, 167

camphor monobromate in,
168

cervico -brachial, 158

cimcifug. tr. in, 167

coccydinia in, 158

constipation in, 165

formulae in, 162, 185

gelsemium in, 163

Goodheart on, 166

goutiness in, 163

Hare on, 161

hysterical, 165

intercostal, 158

leeching in, 169

lin. aeon, in, 167

local applications in, 185

morphia in, 168

ovarian irritation in, 165

peripheral irritation in, 105

plantar, 158

quinine in, 163

Savillon, 166

Yeo, Burney, on, 161
Neuralgic fibrositis, 157
Neurasthenia and headache, 181
Neurotic dyspepsia, 90
Neurotics, 279
Night terrors, 265
Nigroids, 62
Nitrite of amyl, 229
Nitro-glycerine in hiccough, 93
Nocturnal enuresis, 255

pains, 324
Non-diphtheritic tonsillitis, 26
Nose. See Nasal
Nystagmus, 369

MINOR MALADIES.

Obesity, thyroid extract and, 268
'Octaves,' Sir Henry Thompson

on, 323
Ocular troubles in giddiness, 139
(Edema of glottis, 15
Oil, bowel irrigation, 130

of eucalyptus, 7
Old age, 310

analgesia, 316

ductless glands and, 318

hygieneof, 314, 319

maladies of, 315

meagre fare and, 319

pain in, 313

phenomena of, 318

pulse and temperature in,
313

second childhood in, 314

thyroid failure and, 317

vitamines and, 320

work and, 321

Old people and bromides, 332
Oliver, Dr.
225

George, manometer,

Ophthalmic reaction, Calmette's,

48
Opium for colds, 8

in influenza, 21
Oppenheimer's neboline, 7

palatinoids, 270
Opsonic index in tuberculosis, 48
Optimism in tuberculosis, 39
Oral hygiene, 373

sepsis, 370
Ovarian extract in indigestion,
83
in menopause, 229

irritation, indigestion and,89
neuralgia and, 165
' Ovarian look,' 89
Overclothing of children, 291
Overeating, 301
Oxalate of cerium, dose of, 64
Oxygen, supply of, 286

Pack, hot, 11
wet, 32

gout and, 208
indigestion and, 59
Palatinoids, Oppenheimer, 270
Palpitation ic ixuiigestion, 86

Paraldehyde, 185
Paralysis, diphtheritic, 26
Paresis of vocal cords in tuber-
culosis, 44
Parotid gland and pot. iodid.,

330
Pawlow*s researches, indigestion,

54
Pebble-sucking in indigestion,

67
Pepsin in indigestion, 54
Percussion in heart cases, 27
Peripheral irritation in neuralgia,

165
Petit-mal, 223, 329
Pfeiffer bacillus, 19
Pharyngitis, gout and, 214
Phcnacetin in migraine, 178
Phcnozone and sciatica, 160

in migraine, 178
Phthisis, vomiting in, 133
Physiological albuminuria, 232

requirements, 278
Pilocarpin, 206

in pruritus, 206, 349
uramic poisoning and, 200
Pil. Savonneuse, 122
Pirquet, von, cuti-rcaction, 48
Pituitary insufficiency, 244
Plantar neuralgia, 158
Playf air on albuminuria, 232
Pleurisy a frigore^ 288

and tuberculosis, 45
Pluriglandular syndrome, 244
Podophyllin in gout, 201
Poitrinaires, 289
Polyuria in gout, 224
Post-nasal obstruction, 13
Postural albuminuria, 232, 230
Posture, pathology of the physio-
logical position, 108
dorsal, 136
Potain's digitalin, 341
Potass, brom., 331

in giddiness, 139
iodide, 324
dangers of, 329-330
doses of, 328
Fowler's solution and,

330
Luff on, 329

INDEX.

399

Potass, iodide, myalgia and,
155
rheumatism and, 151
Ringer on, 328
permang. in diarrhoGa,
131
Powell, Sir R. D., on bronchitis,

52
Pregnancy, albuminuria in, 232,
238
vomiting in, 133
Presbyopia and headache, 172
Presclerosis, stages of, 222
Pretuberculosis, 33
albuminuria in, 35
amonorrhcea in, 37
anaemia of soft palate in,

41
dyspepsia in, 36
dyspnoea in, 42
functional aphonia in, 42
inhabitude in, 37
mode of life in, 45
muscular debility in, 37
psychic characteristics of,

39
sexual appetite in, 40
stigmata of, 34
tachycardia in, 35
Primeval man, diet of, 293
Process of digestion, 54
Proteid, Chittenden on, 291
Pruritus ani, 348

pilocarpin and, 206, 349
pudendi, 349, 361
Pseudo-angina pectoris in indi-
gestion, 85
Ptosis, 369

Pulmonary gymnastics, 13
Pulse and temperature in ty-
phoid, 33
in indigestion, 60
Pulsus bigeminus, 337
Pupils, inequality in tubercu-
losis, 44
Purpura, 361
Pyramidon, 185

Pyrexia, pathognomonic, tuber-
culosis and, 39
tuberculosis and, 38
Pyrosis, 60

Quinine after colds, 9

giddiness and, 139

influenza and, 21

neuralgia, 163
Quinsy, 26

Radiant-heat baths in gout, 208
in rheumatism, 150
Reflex cough, 18
Refraction errors, bilious head-
ache and, 134
Clarke, Ernest, on, 170
examination for, 174
giddiness and, 172
headache and, 170
indigestion and, 78
mental cases and, 369
vomiting and, 134
Refraction, minor defects in,

171
Reid, Dr. John, Now York, on

pruritus, 349
Relaxed uvula, 14
Renal cirrhosis, 325

disease, chronic, 324

high blood - pressure
and, 220
Respiratory exercises, 14
Rheumatics. See Rheumatism
Rheumatism,. 144, 324
antipyrine in, 151
atmospheric changes and,

149
in children, 214
chronic arthritic, 148
' coddling ' joints in, 152
Fagge on, 145
febricula and, 147
fibrositic, 148

arthritic, 144, 153
' golf shoulder ' in, 149
Gowers, Sir W., on, 148
guaiacura in, 151
hot bath in, 160
hot wet pack in, 150
lithia citrate in, 152
massage in, 160
muscular, 163
Osier on, 145
potassium iodide in, 151
radiant -heat baths in, 150

400

MINOR MALADIES.

Rheumatism, salicylates in, 151

Bcalp headache and, 181

spas for, 153

Stockman on, 146

' tennis elbow ' in, 149

tonsillitis and, 26
Rheumatoid arthritis, 329

thyioid insufficiency and,
263
Rhjrthmio arhythmia, 336
Richet on epilepsj', 332
Rickets, 254
Riding as exercise, 304
Ringer, castor-oil mixture, 99

on potass, iodid., 328

on vomiting, 137
Riva Rocci's manometer, 225
Roberts, Sir W., on bismuth, 63

on indigestion, 70

lozenges, 67
Robson, Mayo, on calc. chlor., 361
Rogers' manometer, 225
Romberg's test, 371
Ross, G. W., on headache, 184

J. C, on influenza, 52
Rowing as exercise, 304

Salicylates, alkalies and, 199

in rheumatism, 151
Salt, common, and epilepsy, 332

in sthenic dyspepsia, 68
Sarsaparilla, 364
Savill on calo. chlor., 361

on neuralgia, 166
Scalp, massage of, 283
Sciatica, 158

acupuncture in, 159

butyl-chloral in, IGO

Lee, Dr., on, 159

massage in, 159

nerve stretching in, 159

phenozone and, 160
Sea-sickness, 135

chloretone in, 136
Semon, Sir Felix, on oedema, 15

on sarsaparilla, S(;4
Senator on albuminuria, 233
Senna in constipation, 142
Septic throat, 26, 33
Sergent, Dr. Emil, on the white
adrenal line, 245

Sexual appetite in pretuber-

culosis, 40
Sick headache, 133
Sigmoidoscope in diarrhoea, 131
Silk, 284
Sitz bath, 282

Skin diseases, bismuth in, 358
and gout, 216
mercury in, 348
functions of, 280
gout and the, 206
natural oil of, 309
SkijDping as exercise, 307
Smith, Eustace, on chorea, 355
Snuff, 51

Soap-and-water enema, 100
Sodium bicarbonate, 63
citrate, 363
iodide, 331
Soft palate, anaemia of, 41
Solution, Dobell's, 6
Someren, Van, on diet, 291
Soothing expectorants, 9
Sore throats, 2, 22

three types, 29
Spaa. See Health resorts
Spinal cord injuries and albu-
minuria, 233
Spirits, 299
Splanchnic lake, 305
Sputum examinations in tuber

culosis, 48
Squint, 369
Squire and Sons' elixir colloid,

270
Stasis, 106
St. Clair Thomson, 5
Stigmata of pretuberculosis, 34
Still, Dr., on arthritis in children,

214
Stimulating expectorants, 9, 11

liniments in gout, 213
Stimuli, slight, summation of,

173
Stockman on rheumatism, 146
Stricture of rectum in diarrhoea,

128
Strychnine in diphtheria, dose

of, 25
Succinate of iron, 348
Sulpho-carbolatein flatulence, 91

INDEX.

401

Sulphonal, 185
Swedish exercises, 307
Syndrome, Hutchinson's, 247

pluriglandular, 250
Sypmlitic cachexia, 3G5

Tabes, 138

Tachycardia, pretuberculosis

and, 35
Tannigen, diarrhoea and, 128

gout and, 218
Tea-drinker's dyspepsia, 59
Temperature, bath, 307
mouth, 30

thyroid insufficiency and, 39
tuberculosis and, 38
typhoid, 33
' Tennis elbow,' 149
Tepid bath, 308
Terebene in flatulence, 91
Theobromine, Huchard on, 204,
228
in gout, 202
Thompson, Sir H,, on ' octaves,'

323
Thomson, St. Clair, on nasal
douche, 5
on nasal operations, 180
Throat, septic, 26, 33

sore, 22, 29
Thyratoxine, 270
Thyroid extract, 229, 243

Crocker on skin diseases

and, 267
dose of, 270
gland, potassium iodide and,

328
Hodgkin's disease and, 257
insufficiency, p. 243 et seq.
and subnormal tem-
perature, 39
medication, 269-276
secretion, defensive power
of, 259
ovarian and, 260
signs of intolerance of, 274
Thyroidlessness, complete, 248
Tight collars and headache,
179
corsets and headache, 179
Tongue in indigestion, 60

Tonsillitis, 22

aconite in, 28

albuminuria and, 239

guaiacum in, 28

heart in, 27

non-diphtheritic, 26

rheumatic, 26

temperature in, 27
Torticollis, 148, 154
Toulouse on epilepsy, 332
Toxsemia, gastro -intestinal, 32
Trinitrin, 229
Trional, 185

in chorea, 355
Trousseau on anremia, 41
Tubercle, albuminuria and, 240

bronchial glands in, 44

inequality of pupils in, 44

laryngeal, ansemia of soft
palate in, 41

opsonic index in, 48

optimism in, 39

pleurisy and, 45

pyrexia in, 38

pathognomonic, 39

sputum examinations in, 48

ulnar reflex in, 47
Turkish baths in gout, 208
Turpentine, oil of, in hiccough,

93
Tycos manometer, 225
Typhoid, calomel in, 347

pulse and temperature in,
83

Ulnar reflex, J. J. Galbraith on,
47
in tuberculosis, 47
Unguentum iodi for chilblains,
356
resinse for broken chil-
blains, 358
Uraemio poisoning, pilocarpin in,

206
Urgency orders, lunacy, 378
Uric acid theory, 292

forming foods, 291
Urotropin, 359
Urticaria, 361
Uvula, relaxed, 14
scarifying, 15

402

MINOR MALADIES.

Valvular lesions, French view

of, 335
Vaporizer, Oppenheimer, 7
Vasomotor causes of constipa-
tion, 140

disturbances and indiges-
tion, 81
Venesection in climacteric in-
digestion, 84
Ventilation, 2
Veronal, 185

Vision, defects of. See Refrac-
tion errors
Vomiting, 131

after anaesthetic, 333

alcoholic, 137

bismuth in, 138

blister in, 136

cerebral, 132

cerium oxalate in, 138

champagne in, 137

creosote in, 137

Fowler's solution in, 137

hernia and, 133

hydrocyanic acid in, 137

hysterical, 132

ipecac, vin. in, 137

kidney disease and, 132

lime water in, 137

Meniere's disease and, 139

morphia in, 138

phthisis and, 133

pregnancy and, 133

refraction errors and, 134

Ringer on, 137

sick headache and, 133

sudden, 133

symptomatic, 136

Vomiting, whooping-cough and
133
Yeo, Burney, on, 137
Vitamines, old age and, 320

Walford, W. G., on collars, 286
Warm bath, 308
Water-closets, disadvantages of,

104
Watering-places. See Health

resorts
Waters, aerated, 300
Wet pack, 32

hot, in rheumatism, 160
Whooping-cough, 6

vomiting in, 133
Widal on retention of chlorides,

194
Widerhofer's formula, colic in

infants, 141
Wilks, Sir Samuel, on opium, 21
Window, open, 290
Wines, 299

time for taking, 301
well matured, 301
Woakes' irrigator, 4
Wool clothing, 284
underwear, 63
Work, necessity for, 279
Wright, A. E., on calcium
chloride, 360
on citrates, 362
on serum treatment, 216

Yeo, Burney, on bismuth, 63

on chlorine mixture, 347
on neuralgia, 161
on vomiting, 137

Younger, E. G., on insanity, 378

JAILLliiBB, TINDVLL AND COX, 8, UBNRIBTTA STREET. COVJiST OAaCKN. LONDOS.

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