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Full text of "" Google This is a digital copy of a book that was preserved for generations on library shelves before it was carefully scanned by Google as part of a project to make the world's books discoverable online. It has survived long enough for the copyright to expire and the book to enter the public domain. A public domain book is one that was never subject to copyright or whose legal copyright term has expired. Whether a book is in the public domain may vary country to country. Public domain books are our gateways to the past, representing a wealth of history, culture and knowledge that's often difficult to discover. Marks, notations and other maiginalia present in the original volume will appear in this file - a reminder of this book's long journey from the publisher to a library and finally to you. Usage guidelines Google is proud to partner with libraries to digitize public domain materials and make them widely accessible. 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Google Book Search helps readers discover the world's books while helping authors and publishers reach new audiences. google. , VTO. , Ltd. 1898 All rights reserved• COPTBIGHT. 1896, By MACMILLAN AND CO. CiuliInK H Go. - Bwwiek ft Smith Norwood Mam. A42. RUSSELL REYNOLDS, BART. , M. In the Introduction some fuller reference is made to this increase; at present it is sufficient to point out that to aetiology alone the whole chapter of bacteriology has been added. Contributors speak of the difficulty of keeping the matter within anything like the limits assigned to them; for what is true of aetiology is true more or less for every section of every chapter. When nothing more than opinions were needed as support for opinions teaching was easily made dogmatic and compact. In modem Medicine, however, every statement must not only be sub- mitted to verification, but submitted again and again. The methods of verification must also be punctually given, and all statements as accurately reported as if for cross-examining counsel. We cannot be any longer content to state that "the soldier said" such and such a thing, but we must give our testimony at first hand, or from carefully accredited and recent sources. Again, pathology has not only become intolerant of second hand evidence, but is irresistibly leading us to the study of origins — to the study of processes in a disinterested way as an aspect of natural history. It is impressed upon us in the field of Medicine, as in all other fields of knowledge, that to pursue knowledge with a consciously utilitarian end before us is to fail even in our immediate ends. It is as true now as it was two tliousand years ago that Wisdom must be sought with a single heart devoted to her love and service; viii SYSTEM OF MEDICINE and that even the relief of humanity cannot stand always first in our sight. On the other hand, were an Editor to rule out of his treatises all formulated thought on things not measured or comprehended he would err in the opposite direction. In a strange land a tedious, painful and circuitous route is better than no route at all. It has been our endeavour to preserve these traditional practices and these hazy views, where we cannot replace them by more definite measure- ments, lest we pull up wheat with tares, and, waiting for more light deprive sufferers meanwhile of some kind of aid however rude. It has been my duty to consider in what way the large mass of new matter may be accepted without an enormous expansion of the limits of this work. Contributors have done their best to be con- cise, and have not in any instance resented editorial co-operation to this end. Footnotes as a rule have been excluded, and references in the text have been replaced by very select " bibliographies. " — Adv. of L. , lib. 3 No better examples could be given to illustrate this arprument than the revival of counter-irritation and of bleeding on reasonable grounds and discriminating methods. PREFACE ix excised, but I have often held my hand ; and this for several reasons. Continual cross-references tease the reader; the same matter may take on different meanings with changes in its context, and various writers may put the same substance in very different lights. For example, the repetitions involved in Sir Joseph Fayrer's review of "Fevers" from the stand-point of an Indian physician have been accepted; and I am bold to think that my readers will thank me, even at the cost of some additional pages, for presenting to them the imcurtailed opinions of this distinguished member of our profession, particularly those of them who practise in this vast possession of the Empire. To have given cross-references to the respective specific fevers at every division of so important a chapter would neither have been fair to the writer nor tolerable by the reader. Historical matter has been for the most part omitted: this relieved the System of some burden, and at little loss to the reader. During nearly two millenniums of time and over broad domains of the world the story of Medicine has been but a melan- choly study. To the curious scholar the "pseud-ideas" of sophists, the dreams of mystics, the quaint conceits of monkish craft, the devices of magicians, the grotesque or brutal records of folk-lore may be entertaining, or even instructive; far be it from us to find any human things alien. Primus sapientice gradns est falsa inteUigere. Here may be some felicity of observation; there some shrewdness of opinion: yet after all we read the histoiy of medicine rather for the honour of a certain few of our ancestors than for our own instruction. To enter into this subject fully would occupy much of the very pages which I am trying to economise; but I may briefly say that the only period of the past history of our profession which can interest the medical student directly is the Medicine of Ancient Greece, which came to life again on contact with our own. Greek medicine of the fifth century b. seems to be almost of yesterday; English medicine of the twelfth century of our era seems more alien to our thought than the Galenical treatises of the Arabs, and almost as grotesque as the demonology of the Chaldeans. No modem book of Chemistry SYSTEM OF MEDICINE deals with the stories of Alchemy, nor of Astronomy with those of Astrology. The great profession of the Law may feel a just pride in the growth of its reasonable and gradual dominion; Medicine, after the decay of the school of Hippocrates, and in countries which knew not that master, became the tool of priests, slaves, charlatans, or literary men. To trace the living waters of the healing art and the auxiliary sciences in their secret channels under the foundations of the Temple, of the Gymnasium, of the Museum, or of the Marketplace, until they burst forth once more in the time of Vesalius, of Harvey, of Morgagni, of Haller, of Himter, of Bichat, of Bernard, of Laennec, is not a pursuit for these pages. The Prolegomena which open this volimie, and others which will appear occasionally hereafter, are in part to enlarge the concep- tions of the student, to lead him to see the domains of Medicine from points of advantage: in part, by means of these broader surveys of General Pathology, of Statistics, or of Dietetics and Therapeutics, to avoid some repetitions, otherwise necessarily fre- quent, in the several articles of the work. The pleasant duty remains of thanking my contributors for the kindliness, good faith, and intelligent support which they have manifested throughout this undertaking, which, although now pub- lished in small part, is in a fair way of completion. If all be as well as the promise of it the future volumes will be published without long delay. The first volume of such a co-operative work is the most arduous: the time allotted to the several contributors is shorter than to those whose treatises come in later. Moreover, the ieavy sickness of the two past winters played havoc with my staff. Some of these, prostrated with one plague or another, have striven hard on their imperfect convalescence to perform their task. Others, such as the late Dr. Sturges, Dr. Beaven Hake, and Prof. Walley, had finished their work, but not for us. My cordial thanks are due to Dr. Cheadle, to Dr. Phineas Abraham, and to Dr. M'Fadyean, for generously taking up the labours of those who had passed away. Pro- fessor Burdon-Sanderson took up the chapter on Fever at very short notice, and wrote it under severe pressure of time and other engage- PREFACE xi ineuts. Finally, I have to thank those kind and able friends who have not only given me the advantage of their articles on special subjects, but have spent much time and pains, which they could ill spare, in the arrangement of certain sections of the System or in proof reading. Invaluable help of this kind has been ungrudgingly given to me by Dr. Ferrier Cerebral Diseases , Dr. Manson Tropical Diseases , Dr. Payne Skin Diseases , Dr. Savage Mental Diseases , and Dr. Felix Semon Laryngeal Diseases. Venn and Mr. Thomas Marshall, of Leeds, have given me valuable help in the revision of the Introduction, for the contents of which, however, I am wholly responsible. CONTENTS PAOB Introduction......... xix DIVISION L — PROLEGOMENA Medical Statistics. BilliDgs...... 3 Anthropology and Medicine. Beddoe. 21 On Temperament. Rivers....... 30 On the Laws of Inheritance in Disease. Uutclunson. 39 Medical Geography of Great Britain. Haviland. 46 Inflammation. Adami. 64 The Doctrine of Fever. Burdon-Sanderson.... 139 The General Pathology of Nutrition. Mott.... 161 teneral Pathology of New Growths. Shattock and Mr. Ballance. 201 Principles of Drug Therapeutics. Leech.... 217 Climate in the Treatment of Disease. Hermann Weber and Dr. Michael G. Foster..... 247 Artificial Aerotherapeutics. Theodore Williams. 300 Balneology and Hydrotherapeutics. Hermann Weber and Dr. Parkes Weber......... 318 The Medical Applications op Electricity. Lewis Jones 349 Massage: Technique, Physiology, and Therapeutic Indications. Kearsley Mitchell........ 373 The General Principles of Dietetics in Disease ; or, the Feeding op THE Sick. Sir Dyce Duckworth...... 386 The Diet and Therapeutics of Children. Eustace Smith. 412 Nursing. Miss Amy Hughes....... 423 The Hygiene of Youth. Dukes...... 457 Life Assurance. Symes Thompson..... 476 XIV SYSTEM OF MEDICINE DIVISION II. — FEVERS Paet I. Insolation ob Sunstbokb. Sir Joseph Fayrer PAGE. 491 Part II. — The Infections The General Pathology of Infection. Kanthack. 504 Septicemia and Pyemia. Watson Cheyne.... 586 Erysipelas. Watson Cheyne...... 613 Infective Endocarditis. Dreschfeld..... 626 Puerperal Septic Disease. Playfair..... 635 Furuncle ; Carbuncles. Melsome..... 651 Epidemic Pneumonia. Whitelegge...... 655 Epidemic Cebebbo-Spinal Meningitis. Ormerod. 659 Influenza. Goodhart....... 679 DiPHTHEBiA. Gee, Dr. Thome Thome, Dr. Kanthack, and Dr. Herringham. 701 Tetanus. Sir George M. Humphry and Dr. Sims Woodhead. 758 Entebic Feveb. Dreschfeld...... 791 Choleba Asiatica. MacLeod, Mr. Ernest Hart, Dr. Smith, Dr. Kanthack, and Mr. Stephens..... 864 Plague. Pajme....... 917 Relapsing Feveb, ob Famine Feveb. Rabagliati and Dr. Wesbrook. 940 Index 961 ILLUSTRATIONS no. PAOB 1. Spleen Pulp of Monkey....... 82 2. Two Giant Cells from a Rodent. 83 3. Phagocytes from Spleen and Eye of White Rat. 84 4. Anthrax of Pigeon........ 84 5. Cortical Pyramidal Cell. 182 6. 183 7. Microphotograph of Pyramidal Cell undergoing Atrophic Degeneration. 183 S. Atrophic Liver Cells from Cyanotic Atrophy of Liver. 185 0. Microphotograph of Heart, showing early Fatty Degeneration. 190 10. 190 11. Microphotograph of Liver from a Case of Pernicious Anaemia 191 12. 191 13. Cloudy Swelling of Liver Cells treated with Acetic Acid. 192 14. ,t f, ,, 192 15. 305 Id. 307 17. Fraenkers Apparatus for condensing and rarefying Air. 308 18. The Pneumatic Cabinet. 309 19. Compressed Air Bath. 311 20. Tracing showing Depth of Respiration in Compressed Air. 313 2]-:f5. Sphygmographic Tracings showing Pulse-rate. Motor Points of tlio Head and Neck..... 357 27. Motor Points of Extensor Aspect of Upi er Limb.... Motor Points of Flexor Aspect of Upper Limb.... 359 XVI SYSTEM OF MEDICINE no. Motor Points of Posterior Aspect of Lower Limb 31. Motor Points of Leg and Foot 32. Feeding-Cup...... Apparatus for Nasal Feeding PAGE 300 301 302 387 387 CHARTS 1. Death-rates in New York, etc. 2-8. Variations in Temperature of Puerperal Fever. Enteric Fever...... 042-048. To face 7QI 10. Temperature of an Acute Case of Plague, with Temperature in Eectum after Death....... 930 11. Temperature of a less rapid Case of Plague.... 931 12. Temperature and Pulse in Relapsing Fever.... 940 13. 947 PLATE Hsematoidin, Melanin, and Carbon Pigmentation. To face 197 LIST OF AUTHORS Adamiy George John, M. , Professor of Pathology, M'Gill University of Montreal. Ballance, Charles Alfred, M. , F. , Surgeon to the National Hospital for the Paralysed and Epileptic; Assistant Snrgeon to St. Thomas's Hospital, and to the Hospital for Sick Children, Great Ormond Street. Beddoe, John, M. , LL. , F. , F. , Late Physician to the Royal Infirmary, Bristol ; Ex-President of the Anthropological Institute. Billings, John S. , LL. , D. Oxon. , F. Phil. , Snrgeon U. Army; Lihra- rian to the Surgeon-General's Library, and Professor of Hygiene in the University of Pennsylvania. Burdon-Sanderson, John, MD. , D. , D. , LL. , F. , Regius Professor of Medicine in the University of Oxford, Fellow of Magdalen College. Cheyne, William Watson, M. , CM. , F. , F. , Surgeon to King's College Hospital, and Professor of Surgery at King's College. Dreschfeld, Julius, M. , B. , F. , Physician to the Manchester Royal Infirmary, and Professor of Medicine in the Owens College, Victoria University. Duckworth, Sir Dyce, MJ. , LL. , F. , Physician to and Lecturer on Medicine at St. Bartholomew's Hospital. Dukes, Clement, M. , M. , Physician to Rugby School, and Senior Physician to Rugby Hospital. Fayrer, Sir Joseph, Surgeon-General, K. , LL. , M. , F. , F. , Late President Medical Board, India Oflice. Foster, Michael George, M. , M. , L. , M. , San Remo. Gee, Samuel Jones, M. , F. , Physician to St. Bartholomew's Hospital. Goodhart, James Frederick, M. , CM. , F. , Physician to Guy's Hospital, and Consulting Physician to the Evelina Hospital. Hart, Ernest, D. , M. , Editor of the British Medical Journal. Haviland, Alfred, M. , Late Lecturer on the Geography of Disease at St. Thomas's Hospital. Herringham, Wilmot Parker, M. , F. , Assistant Physician St. Bartholomew's Hospital, Physician Paddington Green Children's Hospital. Hughes, Miss Amy, Superintendent of Nurses, Bolton Union Workhouse ; Late Superin- tendent Central Training Home, Queen Victoria Jubilee Institute for Nurses for the Sick Poor. Humphry, Sir Greorge Murray, M. , F. , D. Sc, LL. , F. , Honorary Fellow of Downing College, and Fellow of King's College, Cambridge ; Professor of Surgery in the University ; Consulting Surgeon to Addcnbrooke's Hospital. Hutchinson, Jonathan, M. , LL. , F. , F. xviii SYSTEM OF MEDICINE Jones, Henry Lewis, M. , F. , M. , Medical Officer in charge of the Electrical Department of St. Bartholomew's Hospital. Kanthack, A. , MJ. , M. , F. , Lecturer on Pathology and Pathologist at St. Bartholomew's Hospital. Leech, Daniel John, M. , F. , Senior Physician to the Manchester Infirmary, and Professor of Materia Medica and Therapeutics in the Victoria University. MacLeod, Kenneth, Brigade Surgeon Lieutenant-Colonel, M. , LL. , F. Melsome, William Stanley, M. , Fellow of Queen's College, Cambridge, and Senior Demonstrator of Anatomy in'the University. Biitchell, John Kearsley, M. , F. Phil. , Physician to St. Agnes's Hospital, Assistant Physician to the Orthopaedic Hospital and Infirmary for Nervous Diseases, Lecturer on General Symptomatology, University of Pennsylvania. Mott, Francis Walker, M. , F. , M. , Assistant Physician to Charing Cross Hospital, and Pathologist to the Asylums Board of the London County Council. Ormerod, Joseph Ardeme, M. , F. , Assistant Physician to St. Bartholomew's Hospital, and Physician to the National Hospital for the Paralysed and Epileptic. Payne, Joseph Frank, M. , F. , Late Fellow of Magdalen CoUege, Oxford ; Physician and Lecturer on Medicine at St. Thomas's Hospital. Playfair, William Smoult, M. , LL. , Professor of Obstetric Medicine at King's College, and Physician to Women and Children at King's College Hospital. Rabagliati, Andrea Carlo Francisco, M. , F. , Late Senior Surgeon to the Bradford Infirmary and to the Bradford Fever Hospital. Rivers, William, H. , M. , MH. , Lecturer on Moral Science in the University of Cambridge. Shattock, Samuel G. , F. , Joint Lecturer on Pathology ; Curator of the Pathological Museum, St. Thomas's Medical School. Smith, Eustace, M. , F. , FH. , Physician to the East London Hospital for Children, and to the City of London Hospital for Diseases of the Chest. Smith, Solomon Charles, MJ. , MILC. , M. , Consulting Surgeon Halifax Infirmary, Physician Westminster General Dispensary. Stephens, J. , M. , B. , The Treasurer's Student in Pathology at St. Bar- tholomew's Hospital. Thompson, Edmund Symes, M. , F. , Consulting Physician to the Consumption Hospital, Brompton ; and Gresham Professor of Medicine. Thorne, R. Thome, C. , M. , F. , F. , Medical Officer to the Local Government Board, and Lecturer on Public Health at St. Bartholomew's Hospital. Weber, Hermann, M. , F. , Consulting Physician to the German Hospital, Loudon, and to the Royal Hospital for Diseases of the Chest, Ventnor. Weber, Frederick Parkes, M. , M. , M. , Physician to the German Hospital, London. Wesbrook, Frank Fairchild, M. , Professor of Bacteriology in the University of Minneapolis, U. Whitelegge, Benjamin Arthur, M. , B. , M. , M. , County Medical Officer for the West Riding of York. Williams, Charles Theodore, M. , F. , Consulting Physician to the Consumption Hospital, Brompton. Woodhead, German Sims, M. , CM. , F. , F. , Director of the Research Laboratories of the Conjoint Board of the Royal Colleges of Physicians and Surgeons. INTRODUCTION Medicine as a System. — The title which has been chosen for this work is one which may be necessary for present purposes, but one which on logical grounds cannot be defended : a System of Medicine cannot now be written, either by one man or by many, and this state of things is by no means to be regretted. Of a body of empirical knowledge a system may be made, and in such a system place may be found for new accretions or elaborations ; before the days of Bacon, for example, and even after the publication of the Novum Organon, it was the ambition of learned men to attain to encyclopaedic knowledge, to spread them- selves over the whole realm of it, and laboriously to gather all its prod- ucts into a Corpus or System : this was their end. To construct such an "Orbis Doctrinae" seemed to them to be a mere matter of time, ability and capacity; and to its attainment many noble lives were devoted. It seems probable that even Bacon himself had little idea of the remote consequences of his own method : it seems probable that he believed the new Organon to be a key to the discovery of natural knowledge which at no distant time would reveal that realm to us as a band of scouts, armed with other weapons, might reveal to us, let us say, the parts of Central Africa. A system of natural knowledge would thus have completed the encyclopaedia — the " Institutio in circulo '' — already fairly sufficient for the student of discovered subjects such as theology and philosophy. That his method, as afterwards interpreted and extended by Newton and later thinkers, had an application correla- tive in depth and extent with the perceptible universe, and that, this depth and extent being infinite in all dimensions, its analysis must be inexhaustible. Bacon perhaps never apprehended. Alban, that philosophy is built upon a few vulgar experiments. " The noble St. Alban thought more wisely than this, but not altogether out of this fashion. In saying this I do not forget the well-known 127th Aph. of iV'. , lib. My view is founded upon Bacon's own way of going about to apply his method, which indeed he drew almost entirely from Aristotle. In times when knowledge is almost stationary, as was approximately the case, for instance, in the Arabian schools, a System of Medicine may be thus made; its parts will be classified by means of resemblances only as deep as the foundations of contemporary knowledge : thus, for example, a specious group or class of pulmonary diseases may be made. At no time, however, is knowledge quite stationary ; and, even at its most stable moments, some deeper resemblances, truer explanations that is, are hit upon by this man or the other, and the fixity of the system and of its categories is disturbed. On the revelation of profounder resemblances objects hitherto set near each other are detached, and objects far apart in the system are approximated. Thus, in respect of the pulmonary diseases, kinds of pulmonary phthisis or of pneumonia may be carried away to the class of Infectious Diseases, and so forth ; every new explanation bringing about a change of the order. Moreover, in seeking and verifying explanations, we find that pio- neers in natural researches do not rule themselves as an army in the field, pressing forward on a uniform plan and upon all faces of the enemy at once ; but attacks are made upon certain quarters, and individuals or companies penetrate particular parts regardless of the advance of others. At one time morbid anatomy, at another bacteriology, at another phar- macology, or several quarters of each of these respectively, are the chief subjects of inquiry ; progress in one direction thus passes out of immediate relation to progress in another. Individual tastes, again, occasional facilities, and the advances of ancillary sciences or arts, modify the rates of progress in the several sections of each department of natural knowledge. It is then characteristic of natural knowledge, if not strictly pertinent to it, that its progress should be largely unsys- tematic ; although from time to time generalisations are made, such as the classification by genetic affinities, which break up older systems, and bring some method into large groups of things which before had appeared to be unrelated. Thus no doubt, as generations of men pass, the subjects of knowledge are more and more co-ordinated ; but, if prog- ress continue, we shall observe still that new and irregular adits are driven into the unknown before the older winnings are completely surveyed and classified. In the biological sciences, however, classification, since it has become an expression of affinities, — that is, since the publication of the Origin of Species, — has taken a larger meaning, and is a conceptional summary of permanent and universal convenience. INTRODUCTION xxi he will rather find our knowledge set forth on the whole as immediate convenience and the exigencies of contemporary learning may dictate. The arrangement which may seem good to one editor may be displeas- ing to another : in biological subjects all editors desire to place their matter in groups as natural as possible — to classify its parts by the tie of kind, so that the classification may become explanatory of the matter ; on the other hand, orders of convenience are no less imperative, and a treatise of Medicine must be based upon a compromise. Some endeavour I have made to recompose my matter in accordance with the latest advances of science ; yet when faced on one side by a large block of ignorance, or diverted on another by some dictate of con- venience, I have not hesitated to regard rather the habit and convenience of the ordinary reader than the doctrines of the systematic thinker : I have endeavoured to make provisions for the former and for the latter necessities, yet, systematising where I can, and "distributing our igno- rance" as equally as I can, I have had to present much of the matter in the unconnected way in which it was discovered. Science and Practice. — No thoughtful man versed in the methods of natural inquiry can fail to be reminded at every moment of the ultimate and umversal dependence of every one group of phenomena upon every other. Too often we regard causation as a pedigree drawn up on the plan of primogeniture in the male line — as a series of linear sequences, each result owning a parent, and so on until a primal cause is reached. I need not say that such a conception, and the use of such metaphors as " the chain of causation," are so narrow as to be false. So incalculable are the properties of things, so contingent is each event upon every other, that anything like a final presentment of causation is impossible, nay, inconceivable by our limited faculties ; and our propositions are but pro- visional formulae which, if permitted to harden into aphorisms, become fetters of thought. Our formulae, then, should be in a state of continual flux : fresh exceptions are continually turning up, and fresh qualifications are incessantly made. On the other hand, without provisional formulae we cannot act, and in action lie the purpose and end of medical studies. The " merely scientific " physician is apt to be blind to useful manoeuvres which rest rather upon the accidental than upon the more permanent qualities of things : indeed, the practical man often sees more of the surface of things than does the analytical man, and thus keeps more sense of proportion, more of the sense called " common. " So it comes about that in practice personal tact and character are as important to the operations of a physician as scientific equipment. He has to deal with men of limited vision, full of accidental qualities, and subject to accidental disturbances ; and the tact which deals with these confused and conflicting attributes is born rather of a wide survey of the outsides of things, and of transitory conventions, than of a penetrating insight xxii SYSTEM OF MEDICINE into causation. Excessive concentration, if it fit a man for analytical study, may unfit him for the world. Moreover, the purely scientific physician tends to undervalue opinion, as the man of the world to over- value it. Now, prevalent opinions, though not formal truth, generally contain truth, and this the practical physician does not fail to perceive; nor does he forget that the observations of any one person, however pro- found, being the observations of an individual of brief life and limited faculties, need some tempering by traditional lore — by the embodied opinions of a vast number of observers over a long period of time; opinions which, individually inaccurate as they may be, yet make collec- tively an approximation to truth of no small value to the man, be he statesman or physician, who has usually " to act on a choice of second best courses" [vide paragraphs on Prognosis]. Methods. — We are met at the outset of our study by the questions — Whxit 18 health; and what is disease f The man who lives to the age of a hundred years, and who during that time suffers no pain, and is continually able to make use of the powers proper to his age, would by universal testimony be regarded as an example of health : yet even the life of such an one would not always be at its best ; and health, like every other such name, is to be used in a relative sense. Into the life of the healthiest man disorder must frequently enter. Absolute health is an ideal conception, as the line of the mathematician, the ether of the physicist, and the atom of the chemist ; it is a positive conception of a perfect balance of the moving equilibrium which we call systemic life : disease is a negative conception, and signifies something less than this perfect balance. In other times, nay, even in our own, there has been a disposition to regard disease as something imported into the system, as a possession of it by a malign agent which may be expelled by some sorcery or virtuous herb ; in this sense health and disease are not different attitudes of one thing, but a binary combination. Insensibly this personification of dis- ease falls by a sort of refinement into the " principle " of the vitalists, as in the phrase of a distinguished physician who describes a patient as " saturated with insanity " ; or it becomes the peccant humour of a less unscientific pathology ; or, again, it may be identified with a microbe or a virus. Yet to speak thus is to confound disease with the causes of disease, and to use figurative language to our confusion — the "perilous stuff " from which the bosom must be cleansed is no more a disease than a blackthorn staff is a broken head. The blackthorn may be the cause of a green wound ; by this gate other bacilli, less gross in kind, may enter the body, and cause the oscillations in its system which we call fever; the consequent dislocations and disturbances in the body are properly called diseases. A cancer is no more a disease than the hyssop on the wall : a cause of disease it may be, but the disease is in the damaged tissues, which are irritated, invaded, or choked by the growth. Again, whether the causes be prevented inside the body or outside it, INTRODUCTION xxiii are matters of no essential difference. If we keep clearly before us this distinction between the causes of disease and disease itself, we shall use our remedies more intelligeutly ; we shall see how dominant is the sphere of preventive medicine, and that curative medicine is often but the ancillary mouse which liberates the body for its own work of recovery. To know disease, then, we must first know the latitudes of health ; we must study the balance of forces in their normal play before we can comprehend and neutralise the disturbances to which this balance is sub- ject. The corporeal system of man is one of vast multiplication and differ- entiation of members ; in him, therefore, comprehension of the system is most difficult. As we descend the scale of life, and study simpler sys- tems and simpler functions, description becomes easier ; and physiol- ogists, building up our knowledge of the normal by the comparative method, take pathologists with them, who, in their turn, working upwards from the lowest forms of life, or the embryos of the higher or the embryonic tissues of the higher, are revealing to us day by day the secret ways of the earliest and simplest deviations from the normal — that is to say, the elements of disease [vide arts, on " Inflammation," " Fever," and "Pathology of Infection" in this volume]. Again, as the building up of an organism is not by permanent accretion like the building of a house, but by an incessant repair of decay, the student of the normal, that is the physiologist, is constantly in the presence of pathological features. The comparative method necessarily embraces the work of both, pathology being one aspect of physiology ; to speak metaphorically, it is the reverse view of physiology, the study of accel- erated or irregular rates of decay. Disease is a matter of time relations. What, then, is the nosologist? Cure is an art ; it is the application of these sciences, and is the concern of the physician : a physician is an engineer who cannot construct, but is skilled in conservation and repair. Classification. A fceneral term for minute living things is reqaired, and " micro-organism 'Ms too cumbrous. xxiv SYSTEM OF MEDICINE organisms which have deviated from the normal balance of function, finds that, infinite as are the gradations between health and disease and be- tween one mode of perturbation and another, yet these perturbations tend to resolve themselves in certain ways, to fall into certain morphological groups which present some low degrees of constancy. As the naturalist cannot, however, go far without the auatomist, so the nosologist, soon finding that a study of superficial features leads to classifications which, however convenient for the time, are but provisional, has to classify by likenesses of a deeper and a deeper kind ; and as he does so he becomes a pathologist. As the naturalist without the help of the comparative anatomist might classify, let us say, the swift with the swallow, so the nosologist with- out the comparative pathologist might, as he has done, classify leprosy with psoriasis, tubercular with typhoid enteritis, sarcoma with car- cinoma, and so forth. Here, however, we are led to the reflexion that to regard and name diseases as species, or even as varieties, in a biological sense, is an error of the same kind as to regard them as entities. A disease is a particular state of an individual ; and, although certain families show persistent bents to certain kinds of morbid variation, yet the constancy of this fashion bears- a very small proportion to that of the characters of a variety in a biological sense. Moreover, although careless clinical teachers will continue to speak of the " development " of this or that disease, yet disease is no new advance, but a retreat, a stage of decline failing in relative stability, a state which must end either in a recovery of the normal balance or in dissolution. All attempts to describe diseases in terms equivalent to the genera, species, or natural varieties of plants or animals are then erroneous ; they lead to mistakes both of theory and of practice, and to ignorance of the underlying unity in the various forms of disease. A sick plant or animal is but itself in another state, a state more transient and less useful. On the other hand, amid the instabilities and the frequent and rapid changes of natural perturbation, nosologists in early times — times earlier than our records — observed, nevertheless, that symptoms do not occur haphazard, or congregate pell-mell, but that they tend to arrange them- selves in recurrent groups of some likeness, so that a medical mor- phology is possible. We should anticipate perhaps that, inasmuch as in animals of the same kind the several systems of the body are ap- proximately alike, so their disorders, like autumn leaves, would appear with fairly uniform features within the kind. We do find, accordingly, in man that diseases, or symptom groups, present broad features of resemblance, diversified in subordinate detail as individuals are diverse. No two men are alike at all points, and no two cases of disease are identical ; but comparative nosologists tell us that, so far as observation has gone, each kind of plant and each kind of animal seems on the whole INTRODUCTION xxv to have certain sets of morbid characters more or less peculiar to itself. That symptoms do not occur in disorderly jumbles, but tend to form groups of certain degrees of constancy varying with various organisms, may receive some explanation not only by the set of the lines of least resistance in the several anatomical systems of which the higher organ- isms consist, but also by a study of certain other facts in biology lying as deep as diseases or anatomical systems. Either of two arrangements may be relatively stable, but nothing between them; so that the transition between them can only take place by a swift passage. If this be a true view of biological variations it may have truth likewise in respect of disease. The most stable attitude of the bodily functions is no doubt the position we call " health " ; but there are, we may suppose, several other positions in which component functions have degrees of stability, and these may be the sundry kinds of disease. It may well be, again, that interferences reinforce or neutralise each other along certain lines, so that, wheresoever the disturbance, the set of functional balance, after a brief oscillation, would tend to resolve itself in a particular direction ; thence, after a time of moderate steadiness it may recover the more perfect balance of health or fall into dissolution. These opinions seem likely to illuminate some nosological riddles. We have heard a little too much of the proverb, Natura nihil facit per saUum, and have been led to forget that, however gradual transitions may be, intermediate phases between positions of relative stability may be so rapid as to be elusive ; or again, that retrocession may take place to a certain point, whence a new position is reached. In this light such a saw as "We are, all of us, more or less insane " takes on a new untruth, and we see how it comes that, in respect of mental and other disease, there is not in practice the difficulty which laymen assume of definitely recognising perversions from the normal. Theoretically, of course, "borderland phases" must occur, but they may not be persistent or frequent enough to embarrass us, and a new position of relative equilibrium may be reached so quickly that inter- mediate positions, like the flap of the wing of the albatross, are unper- ceived. Even thought runs, no doubt, in certain grooves. It is not to be supposed that our senses have continual cognisance of every property of things, or exhaust every possible combination of them. We are, as artists, consciously or unconsciously ever selecting. Moreover, in our development our thoughts have probably followed certain lines of balance, cohesion, cleavage, or what not, consisting either in the physical basis of life or in the conditions of the medium. Thus every old fancy may be said to have some quality of science in it. Galton and Mr. xxvi SYSTEM OF MEDICINE inclination to particular attitudes be inherent in the structure of living molecules, or arise in the same way as the differentiation of the seversd anatomical systems, or be impressed upon the organism by the preva- lences of certain combinations of parts in the medium, or be again but an aspect of inertia, is not important to my argument, nor are these, indeed, soluble questions at present. These considerations indicate the factors which make classification and diagnosis possible; perturbations tend to fall into groups which can be arranged in classes by likenesses and separated by unlikenesses. In the earlier stages of pathological knowledge, stages we have scarcely left behind, classification of symptom groups could only be made by reference to superficial and obvious features ; for instance, scarlatina was confounded with measles, typhus fever with typhoid ; all eruptions on the skin were classed together, — small-pox and impetigo, psoriasis and leprosy, and so forth. Even yet we put together certain syphilides and certain tubercular eruptions, and these again with other skin affections, and so on ; and convenience, as I have said, may often con- tinue for a while an arrangement which began in ignorance. As our insight, however, becomes more penetrating, we detect re- semblances more and more profound, and very commonly profound resemblances between diseases so unlike on the surface that we may hesitate at first which signs to follow. In the biological sciences, how- ever, classification consists in the discovery of the profounder resem- blances which have a wider bearing and indicate the remoter genetic origins. Clinical diagnosis, however, is not investigation — a distinction some practitioners forget ; diagnosis depends not upon all facts, but upon crucial facts. Indeed we may go farther and say that accumular tion of facts is not science ; science is our conception of the facts : the act of judgment, perhaps of imagination, by which we connect the unknown with the known. ' As pathology advances we detect still deeper affinities, still more permanent qualities in disease, and we form more natural classifications — classifications, that is, which depend less and less upon those superficial characters which are more likely to be products of accidents ; diagnosis is the art of placing any given morbid group in the class to which at bottom it is most akin. An explanatory classification of disease must rest, then, upon such an analysis of all life, whether animal or vegetable, as may enable us to trace the more intimate processes of disease, beginning with those of widest generality and moving onwards to the more complex. Mill, S. of L. y vol. 189, ed. 1872. Jnd. Set. A local disengagement of heat is a factor of inflammation rather than of fever, which latter term is more properly applied to the irregular propagation of heat waves in a system integrated by blood-vessels and nerves. There is a point where differentiation of fever from inflammation has not begun — where destruc- tive changes for lack of integrating machinery cannot maintain their balance by diffusing their vibrations; when component parts fight as individual members or clans, and not yet as a national regiment. In- flammation, then, is even a more general term than fever. Proceeding farther we find that fever forms part of a large group of maladies within which sub-groups are made according to more and more special differences. Broussais, deplorable as was his teaching on its therapeutical side, destroyed the idea of Fevers as several morbid enti- ties : an immense service to nosology. We now know that cow-pox and small-pox, widely different as they superficially appear, must be classed together, because the processes in the cow and in men follow like initial causes ; although, owing to differences in the media, they reach the sur- face in widely different forms. Within the memory of living physicians Mr. Hutchinson and others have impressed upon us that syphilis, widely eccentric in its superficial aspects, profoundly resembles such febrile diseases as scarlet fever and its kin, and is to be classified with these. "Tuberculosis"], and the malady as a whole carried into the same class of syphilis, small-pox, scarlet fever, leprosy, and so forth, — a class presenting the widest differences in the superficial features of its members. Tuberculosis and syphilis are now indeed recognised as the most exemplary instances of a nosological " series " of which we have cognisance. When we turn to consider the forms in which diseases present them- selves to the eye, we shall find that, even within the limits of the most definite kinds such as small-pox, no two cases are identical ; and in kinds of more aberrant habit, such as syphilis, the imlikeness of cases is so marked that many of the various phases of this protean malady have been fitted into the series within the last few years. We must not suppose, indeed, that our observation of this series is even yet complete. For not only may corresponding members of two or more series of morbid phases differ in degree, but one or more members of the series may be absent — scarlatina may occur without rash, whooping-cough without whoop, angina pectoris without pain, migraine without headache, and so forth. Only by a study of genetic aflinities can we dispose such cases in proper serial order ; and some symptom groups, no doubt, are yet undistinguished, or if distinguished, are not yet placed in a series. The obscure series which we call gout may yet receive many more affections within its limits — attributions perhaps as unexpected as was that of " pathologists' warts," when this deformity appeared in the series we call tuberculosis. Many skin diseases have yet to find their places in series of xxviii SYSTEM OF MEDICINE affinity, places which will be found for them when their causation, im- mediate and remote, is better comprehended. A description cannot, of course, be complete until our knowledge of morbid processes is complete, indeed, classification by genesis, being the expression of the order of our thoughts, is but the form of such knowledge, and it is by the study of aberrant processes that we may often detect the more intimate kinships. When morbid affections are all plotted out in serial order the number of such series may turn out not to be large, and the fashions of disease may indicate the several lines of cleavage or paths of least resistance in each organism or class of organisms. If I may convert Whewell's fine figure to my present purpose, I will compare the field of disease to a large woodland country in which woods are seen of various sizes and kinds occupying hills or valleys in several masses ; in places the confines are definite, in other directions smaller tufts of trees and scattered trees so diversify the intermediate tracts that we cannot precisely say where one wood ends and another begins. So again in respect of the kind of trees: on the limestone uplands we may see beech, fir on sandy knolls, elm and oak in the loam or clay of the lowlands, yet even of these kinds it may be hard to mark the limits, so gradually may clay pass into sand, or sandy clay blend with the lime into marl. So likewise with the various distributioli of the waters we find other changes in the character of the vegetation, whether of the trees, of the shrubs, or of the herbs, which again confoimd the superficial observer by apparent caprice. Yet to one who has penetrated to the underlying facts of causation that which seemed confusion falls into order. Now the forester, if ignorant of causation, yet learns to note the recurrence of these patterns, and the discovery is valuable to him for many practical reasons. By his practised eye the various contents of a group of trees would be thus recognised at once from previous experience, and he would be disposed to set up types in his mind, types of the natural associa- tions of trees and plants with which he is already familiar. He might give names to these recurrent groups, as we name our symptom groups, and would speak approvingly or disapprovingly of individual groups as his convenience was favoured by the sum and qualities of the several kinds of trees which enter into them. But we run into two dangers by so doing : we tend to undervalue diversities and the teachings of diversity, fixing our eyes on the nuggets and forgetting to test the ''tailings"; moreover we keep up the error connoted in the word '' type," which comes down to us from the Platonist schools of philosophy. Diseases are not cast in a mould; nor would any one now affirm that behind phenomenal groups there exists a transcendental type towards which any par- ticular embodiment is an approximation; although biologists of the school of Owen used language very like it not long ago, and the language of some of us, even if we do not talk of the "archi-" or ''schematic mollusc," implies the same thing still. We use the words " type " and " typical " too often, and bring with them something more than the notion of a mean — some sense of approximation to or falling away from a standard or conceptual model. Teachers who would deny that they apply the term " scarlet fever " to a type in the sense of an ideal standard, yet themselves use and allow their disciples to use the word "type" in such a sense. On every page of a student's note-book we see the phrases " a typical case " or a " non-typical " ; by the former some students seem to indicate a complete ease, one, that is, which presents every symptom ever seen in the disease, others a case presenting a mean of them, and better called an ordinary case ; others such a case as their teacher or their book sets forth ; and lurking in the minds of most of them is the notion that there are real standards, or architypes, to which disease ought to conform, a notion which tends to blind them to the continuity of nature and the modes of causation. Description by " type " lends itself, then, rather to the epic of disease as presented in those "systematic" lectures on medicine which are mischievous to beginners, and except in the hands of teachers of fresh and original gifts, do on the whole more harm than good, preferring academic reasoning and pictorial description to the place of immediate observation and measurement at the bedside or in the laboratory. Physicians try to conceive some standard to which a disease approximates, so that a change of type means generally a change of the features of this figment in the mind of the speaker. Thus there are as many types of disease as there are varieties of individual imagination. A change of type in a scientific sense is a " pseud-idea " — one which eludes analysis and defini- tion. Russell Reynolds in Ids Address to tiie British Medical Association in London in 1896. XXX SYSTEM OF MEDICINE of men we realise the correlative of this that there can no more be a standard pattern of disease than a standard pattern of man. I conceive that in the minds of the able and accomplished physicians who somewhat polemically declare that " disease has not changed its type " there survives still — if unconsciously to them- selves — a belief that disease is an entity which so dominates mankind and its circumstances as to impress a large measure of uniformity upon the phenomena of their interaction. Otherwise it seems to me they would hesitate to assert that every perturbation preserves a constant mean rate, and every deflected molecule a constant mean distance from a centre of gravity which never shifts. Yet, if we teach ourselves to regard diseases as oscillations of actual men and women, to assume a constancy of these attitudes is to assume a constancy of the kinds and generations of men, and a constancy of the circumstances under which they live. If the whole argument be not a dispute with windmills, at any rate it will not do in the same breath to denounce the mischief of " modern civilisation. " What ought physicians to mean, then, when they speak of types ; and what shall we lack if this term be denied to us? Now, in any disease, the more closely a particular symptom is con- cerned with the functions of the organ aJffected, the more frequent will be its occurrence. In other words, if a large number of cases in which a certain organ is affected were arranged in order of the intensity with which the direct functions of the organism are affected, it would be found that in the more intense cases certain symptoms were universal or very frequent, and that as the intensity of the infection fell off, so also did the frequency of the occurrence of the symptom noted. The organisms of individuals are variable in themselves, and are subject to disturbances which are not identical in each instance ; but a large number of observed cases of any disease may be grouped about a certain " morbid mean," and any particular case of disease will naturally be compared with the "morbid mean. " Any symptom may vary in excess of or defect from this morbid mean, and thus the morbid mean forms a convenient standard for expressing to our minds the set or bent of the phenomena. " As parallel instances, we 1 Vidit art. on "Typhns," in which Dr. Moore tells us that this sypiptom group varies with inteUectoal cultivation. This is certainly my experience also. INTRODUCTION xxxi may take the variation of the stature of the men of a nation about a mean, or the distribution of bullet marks on a target. Not only this question but many others also might be explained if by plotting out measurable symptoms in curves we could get the mean intensity of each and the amount of its variability ; and could determine whether the measures are symmetrically arranged about this mean. To form such a curve the measurements would be set out along the abscissa, and the numbers of instances as ordinates. This is, however, too difficult an undertaking to discuss here, even were I capable of its discussion. curves might be constructed accurately, but they might be made and used on wrong principles. Again, a like traditional habit of thought may be seen in respect of causation itself. This habit is mischievous in two ways : to divide causes into stronger and weaker kinds keeps up that obstinate habit of men to seek in the word " cause " something more than an indication of invariable ante- cedence, something of a community of nature between cause and effect ; and to associate with the word " cause " some notion of a casting act, of effort, or genesis : moreover, being a confusion of thought it breeds confusion. Need I say that by the causation of a thing we mean those events of the infinite past which preceded it — events which have no degree of rank or affinity, either within themselves or in respect of the thing under observation, and whose invariable precedence is a mere matter of routine experience, and not of generation, enforcement, or even of col- ligation. Some of the antecedent events are nearer, others are more remote ; some vast sections of the system we take for granted, others which immediately concern us we quote ; but there is no difference of quality — indeed, the same event may be called a " predisposing cause " at one moment and an " exciting cause " at another : a certain coccus on one day harmlessly traverses the lung, on the next a chill and the coccus together precede a pneumonia ; which of the two is the exciting cause? Whichsoever comes first, some one may say ; but what if they arrive at the same moment? The distinction is of course absurd. We sometimes even hear of a " plurality of causes," or that one of two or three " causes " might have produced a particular result. This is loose thinking ; a certain general result — such as fever — might have been caused in this way or in that, but a "case," with all its individual characters, could have had but one set of antecedent phenomena and no other. Why this is we know not ; that so it is, experience hitherto has taught us ; and upon this experience we make our forecasts. 1 1 may refer the inqairing reader to a paper by Prof. Karl Pearson in the Proc. Royal Soc, January 24. Xxxii SYSTEM OF MEDICINE Another otiose distinction is made in the formal separation of signs and symptoms — signs being matters rather of direct, symptoms of inferential notation. A cough or a pale cheek is of course as much a " physical sign '' as a mitral murmur ; everything that befalls a patient is a " symptom," and his symptoms are the signs of his malady. Strictly speaking, health is a symptom group as well as disease, and this we must remember although common usage restricts the word to morbid incidents. From what has gone before it becomes evident that all efforts to define diseases fully are in vain. But to define a disease is to build the wall round the cuckoo : natural processes will not be thus impounded; they are infinite and elusive. To define is to pretend to sum up knowledge, or at any rate to enumerate likenesses and unlikenesses which are inexhaustible ; we are no more in a position to define diseases than to define dogs and cats. The aspects of disease are not to be likened to a picture gallery in which every set of impressions is contained within its own frame. The " definitions " of systematic writers on disease are of course no more than brief descriptions, and as such are no doubt useful as mere indications of subject matter. To sum up : disease is a state of a living organism, a balance of function more unstable than that which we call health ; its causes may be imported, or the system may " rock " from some implicit defect, but the disease itself is a perturbation which contains no elements essentially different from those of health, but elements presented in a different and less useful order. Diseases, therefore, have no analogy with the genera and species of the biologist. Diagnosis is the recognition of a disease already classified and the reference of it to its place, and thus differs from research or discovery. Classification is a measure of our knowledge of the pathology of all organisms, and a pathology limited to man, like a geocentric astronomy, is, or ought to be, a notion of the past. — Arist. Met. xii. INTRODUCTION xxxiii The causes of diseases cannot be divided into categories ; causes are merely the antecedent phenomena — the routine found by experience to be invariable. Altliough symptom groups tend to run in sets, yet it is with much inconstancy, infinite variety, and manifold transition ; so that although a disease may be summarily indicated by some prominent features, yet to define it is a bootless quest; a definition cannot be regarded as a schedule. Are then symptom groups so fluid that we can have no nomen- clature? In so far as organisms are differentiated into systems, and their functions into departments, their perturbations will have some corre- sponding orders, and appear in groups which more or less repeat each other ; in other words, the more complex the organism the more differ- entiated its symptom groups. For instance, a blow upon the head of a man is followed by a group of changes different from that which follows a blow upon his spine or abdomen ; indeed, if the violence of the blow be given, the main characters of the resulting group in each case may be foretold with some approach to accuracy. As we descend from man to lower animals, these results will have a more general character and their groups be less definite. Again, symptom groups can be arranged in an order beginning with the most general and endmg with the most special. Fever, for example, is a group of wide generality, and is found at any rate in all warm blooded- animals ; probably heat-regulation or tissue stability is inherent in and conditioned by the very existence of a nervous system. The extraordinary manifestation of electric control in certain fishes also indicates to us that even cold blooded vertebrates have in electric regulation an analogous faculty. So far as I am aware, however, no experiments have been made upon local and general fluctuations of temperature in cold blooded animals subjected to catabolising agents, though tissue changes which occur under such influences are described by Professor Adami in his article on Inflammation in this volume. If fever be a member of the class of most general symptom groups, the elaborate automatic actions of certain human epileptics might be taken as instances of highly special groups of disordered fimctions, and between these extremes we may distinguish multitudes of groups of various stages of complexity, not by any means, as I have said, sharply defined one from the other, insensibly rather melting. at their limits one into another, yet having uniformity enough on the whole to admit of naming in sets. " Well-marked cases " are probably those in which a like perturbation is felt especially by one organ, or by one set of organs ; a uniform irritant falling precisely upon the same spot in the body must produce a group of events only not invariable in so far as the organism may be inconstant. Differences of conditions, however, which to our eyes are apparently very small, or even elusive, may and often do impress so great a change upon the features of definite perturbations in definite spots as to blind us to the imderlying similarity of causation. The so-called protective inoculations may be cases of the same order, though the relations of artificial to natural immunity are not yet made clear ; the former seems hitherto to be of a more temporary kind than the latter. Symptom groups,, then, differ no doubt with the intimate form of grosser or finer parts in the various organisms, and every symptom in- dicates molecular disarray somewhere, could we but detect it ; chemical and microscopical discovery, therefore, as they reveal more of such dif- ferences, will explain more of the variations of disease — for illustration's sake I may refer to the investigations of Metschnikoff, Kanthack, Hardy, and others on the blood corpuscles — yet we have seen already that variations in morbid phenomena bear no direct relation to. the lines of obvious anatomical structure, and may vary enormously with pecu- liarities of organisation, chemical or other, which are so latent as hitherto to have escaped our analysis. If, indeed, we may properly appeal to protective inoculations in this place, the modified qualities of the contrasted animals, however recondite, may not be very profound or permanent When speaking of classification, I indicated these difficulties and the labour of detecting underlying similarities between groups of phe- nomena apparently disparate, and I will not enlarge again upon the same difficulties in respect of naming. We cannot name a series until we have laid down the main lines of it, and as meanwhile we must make provisional classes, so we must make provisional names. Descriptive names cannot be given until we have relatively complete pathological explanations ; but by pathological explanations I mean no more than the formulation of series ; or, in other words, the discovery of the causation — of the " antecedent routine," as Prof. Karl Pearson would say. Until we have set forth the routine of events such names are impossible, or only possible partially and in so far as we have made out some fragments of the "routine. " To compare ethnology with pathology, let us suppose that an ethnologist of the linguistic school had fifty years ago discovered the Basques and called them Mongolian. Later ethnologists, putting language in a much lower place as a test of race, would supplant this name by another — say by the present name, " Basque. " No sooner is the former name uprooted, and the new name affixed, than comes the craniologist to tell us that this people is of mixed race, and that distinctive names for at least two stems are 1 Grammar of Science. London, 1S92. Now, names are not easy to attach, and when attached are still harder to get rid of; moreover, in the sup- posed instance, the name " Mongolian " would, during its existence, not only be defective as an index of quality, but positively mischievous as teaching some positive error — the name " Basque," on the other hand, which conveys no ethnological meaning, being in this respect a better T ne. Thus it is in the nomenclature of disease; to give pathological names prematurely may be to teach error immediately and persistently. By the illustrations I have used above, I have indicated that pathology has yet formulated but few series or even large segments of series of ordinary morbid phenomena. Events and startling features of the greatest import to us and to our patients come before us daily, and many times a day, and cannot be linked on to any other groups with which we are familiar. Before permitting ourselves, then, to fix names significant of current hypotheses upon symptom groups not even half understood, may it not be well, until our knowledge is enlarged, to wait and be content with some name that is but a label? Nay, it is undesirable even in our merely provisional and descriptive names to connote too much ; in so doing we may combine parts of different series the concurrence of which is accidental. Take, for example, the disease often called exophthalmic goitre ; this name, given descriptively, is bad because as a descriptive name it postulates two events, either of which may be absent from the group, while it omits the cardiac events which are at least of equal im- portance. Had a pathological name been given matters would have been worse still, seeing that at least three mutually exclusive hypotheses are on foot Is it not really more scientific after all to be satisfied for a time with such a name as " Graves' disease," which sufficiently indicates the inconstant group of events we have in view, and commits us neither to a fixed order in the group nor to any premature classification? Every physician, again, in his tractable moments will admit the usefulness of such a name as " Bright's disease " which, until the pathology of kidney disease is better understood, saves us from tossing on the conflicting currents of interstitial, of glomerular, or of tubular nephritis. " But, it is argued, these names may confer an immortality on the wrong man! Well, oblivion blindly scattereth her poppies : yet after all, is this often so? These names may occasionally violate the strict order of priority in discovery, as do the names of capes and islands ; but the man who attaches his name to a discovery usually deserves it. If the New World had been called after Columbus, neither Sebastian Cabot nor Amerigo Vespucci would have had reason to complain. Neptune had often been observed before it was " discovered " ; and a recent writer happily said concerning Fraunhofer's lines, " Wollaston xxxvi SYSTEM OF MEDICINE saw them, but did not discover them. And, after all, these names are, as I have said, but provisional tickets, and by no means always dedicatory — as measles, shingles, epilepsy, and the like. Are nosologists so ignorant, then, that as yet we can have no scientific nomenclature? Can none of our names be an intellectual instrument? By no means ; but we must be content to give such instrumental names to the simpler diseases, and thence cautiously to the more complex, remembering that to name scientifically a disease of complex causation is to suppose that pathol- ogy has advanced far beyond its present stage. Meanwhile, beside the ticket names, we have some, such as chorea, which, although given in ignorance of the nature of the malady, are fairly well descriptive ; paralysis agitans is another good name of the kind ; anatomical names also, such as bulbar palsy, disseminated scle- rosis, and the like, are largely displacing those descriptive of symptoms — displacing, I say, and not superseding, because symptoms will prob- ably hereafter be grouped under general and special heads from a clinical point of view, such as modified movements, modified sensations, modified reflexes, modified secretions, and so forth. But with all this we should fall short of any indication of general pathological characters — for instance, mischief in one anatomical seat, say in a joint, may be primarily of traumatic, chemical or microbic causation, and yet at cer- tain stages produce similar modifications of motion and sensation. Identical or closely similar results may be reached from distant, and even widely different starting-points ; and we come back to the conclu- sion that in respect of most diseases we are ignorant of the series to which they belong. We can give a clinically descriptive name to " gen- eral paralysis " ; or we can pathologically call it " chronic encephalitis," but we have not learned to what series — syphilitic or other — it be- longs ; and until we know this we cannot finally name it. A name is not complete, therefore, unless it indicate the tissue ele- ments primarily engaged, and the series of which the affection forms a part. But the subject is far too extensive and various, and our knowl- edge too small to make it profitable to pursue the matter further in this place; indeed it cannot be fully discussed without a survey of that field of comparative nosology — of the symptoms and the causes of them in all organised beings — the exploration of which is scarcely yet begun, unless it be in respect of certain diseases of animals and plants which interfere with our industries. INTRODUCTION xxxvii Of our Terminology I have little to say — technical terms are more fluid than names, and are undergoing continual modification as our knowl- edge increases. As Dr. Kanthack incidentally discusses some weak points in our terminology in his article on the General Pathology of In- fection, I will not speak so fully as I had intended on this subject. The improvement of our terminology is much impeded by the loose clinical slang which too many teachers allow their pupils not only to use at the bedside, but to enter in their case-books also. Colloquial vulgar- isms, effete terms of logic, relics of humoralism and pseudo-scientific phrases, make up a large part of the language of the wards, and so long as our teachers countenance, and even themselves use such slovenly language, so long will students be content with it. It is but fair to add that Medicine is not a subject in which terminology and nomenclature find their best exemplification : the matters of our inquiry, not having relatively fixed specific characters, do not lend themselves as yet to the construction of an appropriate terminology. We cannot yet say when fibrosis is " inflammatory " in origin, or when, on the other hand, it may be relatively atrophic, for we are also imcertain in our use of the terms atrophy or hjrpertropjiy. Still there is no reason why in the near future these terms should not be better defined. I am not without hope that the work of Professor Adami and Dr. Mott in this volume may go far to help us on our way. To illustrate at length the looseness of our terms, and the errors which arise from the equivocal use of any of them, were an undertaking far beyond the space at my disposal. As Mr. Grote has said, no part of the Platonic writings is more useful than those Dialogues in which the disputant is forced to feel how imperfectly he understands the phrases in common use. But it was reserved for Aristotle to recognise " equivocal terms " as a class, and to assign to them a par- ticular name. Until we are at one in our use of terms we cannot formulate propositions as true or false ; we cannot, that is, combine our terms as subject and predicate. As was said of another matter, medi- cal discourse and medical literature are " pervaded by assumptions " : I would therefore earnestly appeal to all bedside teachers to compel their pupils to look every term well over as it comes to them ; to scrutinise it obversely, reversely and edgewise before using it as currency. As things are, candidates for degrees use arguments based upon equivocal terms, shelter themselves under phrases which save them the trouble of 1 Need I qaote from Faust the well-known lines? — " Denn eben wo BegrifFe fehlen Da stellt ein Wort zu rechten Zeit sich ein. " xxxviii SYSTEM OF MEDICINE thought; and are disposed to feel as injured as Thrasymachus if these current phrases are challenged. I have spoken of the causation of disease ; I have shown that diag- nosis is the practical aspect of classification ; I will now conclude with a few words on Prognosis. A living being is found in a given abnormal state diagnosis ; we have then to find how this came about aetiology ; and, thirdly, we have to foretell the state in which the creature will be at a given future time. Such forecasts are already possible when we deal with large numbers. If we wish to know the mean duration of life in a young man of twenty years of age we have tables at hand which will inform us ; if any par- ticular young man be associated with a sufficiently large number of others Uke himself, we can deal with him on a definite "curve of frequency. " But when a particular patient comes to a physician he is not satisfied to know the mean expectation of a thousand sufferers in his case, but he will insist upon knowing the future part of the curve of his own in- dividual phases. If he present himself before a physician of large experience he will get some such estimate — an estimate fallible, it is true, but in many cases having sufficient probability to justify the patient in laying out his plans for the future with some confidence. Now, how is this attained? Suppose that we go a step far- ther still, and construct a class still more subordinate, namely, of young medical students, or of young medical students in a certain imiversity, or of young medical students classed as students, oarsmen, or cricketers, and we may still find something like statistics to guide us. But in thus subdividing our classes, we shall soon arrive at sub-classes for which registered statistics are no longer available — the numbers are too few, the cases too special, or they have not been tabulated. Thus we approach the prognosis of individual cases, and rely more and more upon the quality of the observer. In discussing this matter with Dr. Venn, it appeared to us, nevertheless, that the method is still one of sta- tistics — one of conscious or unconscious abstraction, based upon numeri- cal summary. The accumulated experience, although not formulated, is nevertheless an accumulation of records of cases — cases recorded imperfectly, it may be, but written upon the memory of a skilled observer, and of these the observer more or less automatically strikes a mean when called upon to estimate the expectation of a given life, or of particular events in the life. The observer may rely more upon his note-books, and make a calculation dependent upon their fulness and accuracy; or he may rely rather upon an acquired instinct bred of accumulated impressions upon his senses, and dependent upon the tenacity of his memory and the quickness of his observing faculties : still in either case — whether the judgment be more automatic or less INTRODUCTION xxxix automatic — it is based, in the last analysis, upon statistics, and the result has the more validity as the number of observed cases increases. Again, this acquired judgment does not wholly die with the indi- vidual. As observation becomes more accurate, as the number of observed cases increases, and as classes are better and better distinguished, the nearer will the physician be able to approach an accurate prognosis — though the time when any suffi- cient rule can be applied to individual cases must long be out of our sight ; and the application of any approximate rules must long be sub- ordinate to the instinctive tact of the educated physician himself, who alone can apprehend the sum of the peculiarities which must modify their application to individual instances. Like the so-called cumulative photographic image which results from the blending of many superposed faces of the same kind, there grow up before the mind's eye of the edu- cated physician, images of this morbid facies, and of that, to which he refers individual instances; and he pronounces his opinion of the state and probable future phases of individuals as these severally vary this way or that from the standards within himself. CLIFFORD ALLBUTT. 1 Dr. Venn writes to me on this passage as follows : — "I think this is very important. I have often been struck by the way in which an apparently subjective judgment can be perpetuated, as an almost objective standard, within some specially trained class of persons, who are in frequent communication. In ordinary cases an author's name is a sufficient indication of the corresponding item in the list. DIVISION I PROLEGOMENA VOL. The following table shows these rates for the countries and periods given in the preceding table : — i si• CO B s• 5 s• These people were nearly all Jews, and were 80,235 in number. The death-rate of the offspring of Irish mothers was high, much higher than that of the Germans, and as there were about 400,000 of each of these races, the comparison is a fair one. The Jewish population was poor, crowded in tenement houses. The interesting point to the medical statistician is. What were the forms of disease to which the marked differences in the death-rates of these races were due? To answer this in part, we will take the statistics of deaths for the six years ending 31st May 1890 for the Irish, the Germans, the Russian and Polish Jews, the American white offspring of American mothers, and the coloured in New York City. It seems probable that members of the Jewish race possess a dis- tinctly higher degree of immunity against the bacillus of tuberculosis and the micrococcus of pneumonia as compared with the other races above mentioned; and that on the other hand the Irish and the American negro are specially susceptible to the effects of these micro-organisms. Professor Stokvis has pointed out that in all colonial armies in warm climates the death-rate from diseases of the respiratory organs is more than twice as great among the native troops as it is among the Europeans "On the Comparative Pathology of Human Races," etc.. Practitioner, Lond. xlvi. 1891, p. 233 , while hepatitis is decidedly more fatal in the European than in the native. In the Dutch East Indian colonies the natives are decidedly more liable to beriberi than the Europeans ; but the comparative immunity of the latter against this disease appears to be decreasing in recent years. Even when we have the means of comparing the death-rates of different races in the same locality it is usually impossible to say how far the differences in these death-rates depend upon inherited peculiarities of physical structure, and how far they are due to the poverty, uncleanli- ness, and habits as to different kinds of alcoholic drinks which charac- terise the great mass of the population of certain races. John S. Billings. ANTHROPOLOGY AND MEDICINE 21 ANTHKOPOLOGY AND MEDICINE Our knowledge on this subject is scanty and far from clear ; and the little we believed ourselves to possess has been disturbed by recent changes in pathological theory. Divers diseases formerly supposed to be the outcome of constitutional and hereditary proclivity are now believed to be the results of infection ; and the remoter causes are apt to be neglected in the consideration of aetiology. That many pathological processes are known to be common to man- kind and to other mammalia, or even to animals further removed from us, while others are reasonably suspected to be so, makes it d prion improbable that any great differences should subsist in the distribution of diseases among different races of men. On the other hand, though men and women respectively can hardly be said to have any peculiar and exclusive diseases except in so far as this results from the differences in their sexual organs , yet we see that their respective liability to some at least of these diseases varies. A curious instance of this is afforded by cretinism and goitre : goitre being much more common in women than in men, while cretinism is pretty evenly distributed — if anything there is a preponderance of male cretins. The most conspicuous difference in the external aspect of men and of races of men is in colour ; and here comparative pathology would lead one to look for some corresponding differences in susceptibility to disease, for the experience of horse-breeders aind veterinarians is pretty clearly expressed on this point. Thus Youatt says that the dark chestnut, as a rule, yields to no other colour in any quality ; but that the light chest- nut, which appears to be the analogue of the sanguine-blond man, is spirited, but irritable and delicate in constitution. Black horses, again, number among them some of the very finest of their species ; but many of them are heavy and dull in temperament, and there is an idea afloat that they are particularly liable to malignant disease. Here we may be led to think of the choleric and the melancholic temperaments. Among breeds of sheep, the blackfaced have the reputation of being hardier than the whitefaced. Certain black pigs, according to Darwin, can eat with impunity what would be poisonous to white ones on the same pasture ; and like differences are seen in black and white rats. On the whole, however, the deposition of pigment in the skin and hair of mammals would seem to be the result of processes which connote or accompany health and vigour rather than the opposite. The statistics of morbidity and mortality, which alone could yield a sound foundation for generalisations on this subject, are unfortunately imperfect, or altogether wanting, in the regions where the material would be most valuable — those regions, namely, where nations of different 22 SYSTEM OF MEDICINE colours and constitutions of body live side by side under comparable conditions. In fact, we have hardly any trustworthy statistics, except from the most civilised of the countries, whose populations are com- pounded from more or less distinct divisions of the human race [vide Dr. Billings' art. on "Med. Statistics"]. Much information, more or less trustworthy, as to the distribution of disease among different races, may be gleaned from Hirsch, Lombard, Boudin, Oesterlen, Bordier, etc. ; but even where the facts can be relied on, they are generally capable of interpretations that make them of little value for our purpose. Thus, when we learn that aneurysm is four times more common in San Francisco among foreigners than among native Americans, we must remember that a far larger proportion of the foreigners are males in the prime of life, and that most of the hard bodily labour is performed by foreigners. Negroes are said to be exempt, or nearly so, from piles and from vari- cose veins, and the cause assigned is the greater strength, in them, of the walls of the blood-vessels. Apoplexy, on the other hand using the word in the ordinary sense , appears to have no racial preferences. Thus, in New Orleans negroes and whites are said to die of apoplexy in the pro- portions respectively of 103 and 91. The deaths from brain disease of all kinds, as returned, are singu- larly few in the insular parts of Scotland and in the Highlands, where the inhabitants are in blood very near akin to the Irish, so that here one might have supposed one had lighted on a real case of hereditary exemp- tion, or at least favourable hereditary constitution ; but the fact that. Shetland, where the race is Norse, returns fewer deaths from brain disease than even the Highlands and the other islands, is sufficient to negative the idea that the Gaelic race has any such special immunity. The rate of mortality from this class of diseases is certainly lower in quiet rural districts than amid the hurry and worry or excesses of towns, and this may account for some degree of the apparent immunity ; the remainder must be attributed to the tendency to set down all cases of death in advanced life to simple "old age. " In Shetland and the Hebrides about 25 per cent of the deaths are thus certified. In cancer, again, the enormous differences in mortality reports are doubtless largely due to the non-recognition of internal growths. But the differences reported to exist in divers registration districts in England seem too great to be wholly due to this cause, and the extreme varia- tions in both directions are by no means such as would have been expected on such a hypothesis. For example, rural districts in general seem to suffer quite as much as cities, and ancient cities more than great centres of industry, even allowing for the difference of constitution of the population in respect of age [vide Mr. Haviland's art. on " Med. Geography of Great Britain "]. ANTHROPOLOGY AND MEDICINE 23 There is some little ground for considering cancer to be a disease of civilisation, or of civilised communities and races, though here of course the question of failure in diagnosis comes in with double force. The most formidable death-rates that we have, such as 990 per million living in Drontheim and 930 in Lombardy, come from highly-civilised communities. Cancer is said to be rife in China, but rare in Egypt, the scene of a yet older civilisation. It is thought to be uncommon in the negro race generally, whereas we have seen that it is prevalent in Norway, among one of the blondest populations in the world. The asserted rarity in Iceland may perhaps be remanded for further evi-• dence ; could it be proved, it would be of great importance, the Nor- wegians and Icelanders being of the same race. That the disease is strongly hereditary scarcely any one doubts; and I shall presently submit some evidence to show that in Britain it is especially common among people of dark complexion. Gout is another strongly hereditary disease, common in certain races and communities, but very rare, perhaps non-existent, in others. Boughly speaking, it is a disease of the ruling races and the higher -classes; of the civilised man, not of the savage; of the white man, not of the negro ; of cold and temperate rather than of hot climates. Probably there exist large communities of men among whom it never occurs; but, given some of the requisite exciting causes, habitual but not extreme excess in eating and drinking, disproportionate use of the brain as compared with the muscles, consumption of certain kinds of drinking-water, etc. , it could doubtless be produced in any race and in almost any climate. Negroes, as I have said, are generally free; but Lobengula, the famous king of the Matabele, drank much beer, and suffered severely. The reported distribution of the disease is very instructive. Thus, in India, it is said, the Hindus scarcely ever suf- fer ; the Mussulmans, freer in diet, sometimes. Gout occurs in China, where the mandarin class unite most of the requisite factors. In Mad- agascar, the comparatively clever and light-complexioned ruling race, the Hovas, suffer from it; the subject negroes are not known to be attacked. In the United States of America it occurs in the cities, but is little known elsewhere ; the American farmer is active and temperate. The chief missing factor is probably beer; but at least we are justified in saying that in these cases differences of regimen and climate reduce the mor- tality in the same race to about one-fifth. Still, it must be acknowledged that the distribution of gout has a racial aspect. In France, according to Hirsch, Lorraine, Normandy and Lyons are said to be its chief pasture-grounds : others add Burgundy and blame the wine. The natives of all these districts have more or less of thfe Germanic element in them. In Spain, the least Iberian of Spaniards, the Asturians, are the most gouty. Petersburg and tiie Baltic provinces Grermans again are all said to suffer from it. If there be one thing which all these people have in common, it is that fondness for heavy feeding which has been a characteristic of our own most gouty nation from time immemorial, and belongs particularly to the true Saxon-English type. Phthisis has always been a sort of battle-ground for the believers in infection, and the believers in hereditary transmission and the suscepti- bility of particular types. Until quite recently, though the former opinion ruled in Southern Europe, the latter was almost universally held in England. And though even now clinical and practical experience point in the same direction as formerly, the general and geographi- cal history of the disease seem to support the infective theory. The effects of local conditions of soil and climate, though undoubtedly very powerful, are not always distinct, and may be used in support of either theory. The local statistics of phthisis are of very great interest, and could not, of course, be dealt with satisfactorily within the compass of this essay. Some of them seem to point to the applicability to phthisis of the " virgin soil " doctrine, which at first sight seems incompatible with that of the importance of heredity. Among the more important points which may be taken as estab- lished are — 1. The extreme rarity of phthisis at very high elevations. Its rarity in high latitudes : for example, in Iceland. That some of Mr. " 4. That, among bodily characters, tall stature is the most distinctly unfavourable. The following opinions may be put forward more doubtfully : — 1. That though local situation, varieties of social habit, occupation, and the like, overbear and obscure in Britain anything like racial ten- dency, it would appear that the Gaelic and Kymric or Ibero-Keltic stocks are, caeteris paribus, rather more subject to phthisis than the Saxon and Scandinavian. The principal objection to this statement is furnished by the very unfavourable position of Suffolk, one of the most purely Anglian counties. That the tropical negro is particularly subject to phthisis, at least when removed from his own country. The Melanesians, or Oriental or Pacific negroes may be here included ; these are the people, imcorrectly 1 Bowditch and Buchanan. ANTHROPOLOGY AND MEDICINE 25 called Polynesians, who work in the Australian sugar-fields, and though well fed and fairly lodged, die of consumption in very large proportions — Phthisical Dbath-ratb in Qubbnsland, 1800 and 1891. "Polynesians" per 1000 living. 16-76 Chinese. 117 Europeans and Colonials. In some cases the figures are even more appalling than those I have quoted from Queensland; and in some of the countries into which negroes have been introduced they seem to melt away chiefly from this cause. The most remarkable exception to the rule is that furnished by the southern portion of the United States of America. Here, though within the temperate zone, a negro peasantry has been firmly established, thrives and multiplies. It is even said that the death-rate from phthisis in the Southern States generally is lower among the blacks than the whites. The mortality from this disease waxes and wanes in different countries in a manner that invites speculation on the causes of change. England and Holland used to be thought its special seats. It has also grown in Scotland coincidently with the growth of urban popula- tion, and with what has been regarded as improvement in the dwellings of the rural population. In North Germany the western provinces yield heavier rates than the eastern ; and here too, though some might rely upon the racial difference between the true German and the Slav, I believe the real difference to consist in a rather more elaborate civilisa- tion, which brings with it air tight houses and other fair-seeming but really evil conditions. Yellow fever is one of the most selective and fastidious of diseases ; almost as much so as the sweating sickness of the Middle Ages, which on its first appearance is said to have sought out the well-to-do and lusty Englishman, abroad as well as at home, and let the starveling and the foreigner go scatheless. In New Orleans, for example, there is said to be a regular scale of exemption, complete in the case of the full-blooded 1 Blakeney, Vital Statistics of Queensland. The great in- crease of deaths registered under bronchitis and pneumonia has been at other ages than those at which phthisis has decreased. a6 SYSTEM OF MEDICINE negro, less in the mulattx or other man of colour, less still in the dark- -complexioned Creole of Spanish or French descent; while even the Southern European suffers less than the Englishman, and the Scandi- navian fares worst of all. This sounds a little too artificial ; but all agree that the dark skin connotes a kind of acclimatisation to the scourge similar to that which long residence confers. 1 a. Thus in France — Of 10 brachykepbalic departments, only 1 has more than the average density of population. Of 10 Northern dolichokepbalic departments 10 have more. Of 6 Norman. , 5 Of 4 Breton Of 10 Most blond Of 10 Darkest Of 10 Southern dolichokepbalic 4 9 3 2 We in England, with our almost unchequered experience of higher phthisical death-rates in cities than in rural districts, would be inclined to say at once, " Here, in the greater density of population, is the one and sufficient reason for the greater amount of phthisis in the recruits from Flanders and Picardy and Normandy! '' This would be too hasty a conclusion. In France, as my table shows, the hard-wrought, ill-fed peasantry of the plains suffer much from phthisis and scrofula. The peasantry of Limburg, the most Germanic province of Belgium, and perhaps the most rural except Luxemburg, stand about the worst in this respect. On the other hand Bretagne, the least phthisical part of France, has, as we have seen, a dense population. The fact is the tall, long-headed blond population is where it is by reason of its physical and moral qualities ; its striving, ambitious, masterful character, which enabled it to occupy the best and most fertile parts of France, leaving the hills and heaths to the dark, short-headed Kelts. Mental alienation has not the same distribution as phthisis and pulmonary disease, which seem to affect the dark southern or Mediter- ranean race as much as the fair northern one ; sparing only the sturdy, dark, broad-headed people of the centre, and the anomalous Bretons. It has been affirmed that myopia is structurally connected with dolichokephaly, the deep orbit and the long-axed eyeball going naturally with the long head. A certain amount of evidence has been adduced in support of this idea ; and the tall blond race has been saddled, in the minds of some anthropologists, with yet another hereditary defect. The evidence of my table is not conclusive either for or against this view but it certainly does something to render it unlikely. Of the five de- partments selected as representative of the type, one only, the Aisne, had an excess of myopes ; and of the ten most blond departments only two, 1 1 draw this inference from Boudin's figures, vol. 235-7; but they are perhaps hardly sufficiently detailed, though very striking. VOL. I D 34 SYSTEM OF MEDICINE viz. In fact, myopia distinctly belongs to the dark-eyed inhabitants of the south of France, and to those of the cities, with the strange exceptions of Lyons and the urban district of the Nord : Brachykephals have their full share of it. The subject of defective teeth would, of course, furnish material for a goodly volume. So far as my materials testify, good teeth in France go- with short average stature, dark complexions, and, less distinctly, with, broad heads. Bad teeth concur with tall stature, and almost as clearly with long heads and blond complexion. Or, to put it in another way, teeth are good in the mountains as a rule, bad in the plains, and especially bad, as Boudin himself remarked, around the mouths of all the great rivers. They are good among the Auvergnats or central Kelts , and especially so among the Bretons ; also in the Catalans of Rousillon, etc. ; bad among the northern blond long-heads including the Normans , and among the Gascons ; moderately good among the Ligurians. For example, the Loire Inf drieure was formerly politically a part of Bretagne, but its people were not Bretons in blood and customs. Accordingly the Bretons have a very high mortality and very good teeth ; the Nantese, or Lower Loire folk, have a low mortality and very bad teeth. This connection between good teeth and a high death-rate is strange, but unquestionable. Of the ten departments which furnish the fewest exemptions for defective teeth, every one has an excessive mortality, and in most cases, and on the average, a very excessive one. They are all in two masses, viz. , 1. Auvergne and Lyonnais ; 2. Bretagne- with Mayenne. If we seek for dietetic causes of caries, we shall find that the great wine-producing districts, Gironde, Dordogne, Marne, C6te d'Or, as well as the cider-drinking Normandy, are among the worst on the list. But, after all, there is plenty of sour wine in Auvergne and of cider in Bretagne. On the whole, then, I am disposed to subscribe to the belief of the French anthropologists, that we have here another example of a heredi- tary and constitutional defect. But it is one which cannot be dated back indefinitely ; it must have been developed on French soil. Even now the Scandinavians, the purer-blooded cousins of the northern French, are generally " euodont ; '' and it is certain that when the Saxons invaded England, and the Franks and Normans Gaul, they were still so. If Harold of Denmark, the conqueror of the Cotentin, had not been a singular exception, he would hardly have been nicknamed Blue-tooth. In the British Isles we have no such groundwork of statistics to work upon as those on which I have been building from America and ANTHROPOLOGY AND MEDICINE 35 France, and I have little more than personal observation whereto to trust. This, however, is sufficient to enable me to assert that phthisis is not here, as some have supposed, especially prevalent among blonds. If anything, there is even an excess of black and very dark hair. Some statistics given me by Dr. Edward Liddon of Taunton, from the Brompton Consumption Hospital, are confirmatory of my own. In fact, the typical victim of phthisis is, in my opinion, a tall person with blue eyes, a transparent complex- ion, and dark hair. Such persons are also more liable to haemorrhages ; it would seem that in them other structures partake of the delicate organisation of the skin. I have already said, apropos of the supposed absence of chorea from the Chinese, that, whatever its connection with rheumatism, it is a disease specially belonging to the nervous temperament. Fatal and severe cases almost always present the signs of that temperament. There is usually something remarkable about the development of pig- ment; the hair is often coal black, but sometimes extremely light, flaxen, or pale red. Epileptics, cataleptics, ecstatics, thought-readers, clairvoyants are very frequently of one or other of these strongly- contrasted colour-types. Mania seems to occur rather more often in the xanthous type, with chestnut, red or fair hair ; but with regard to melancholia the observation of the ancients was undoubtedly correct: it belongs especially to the type which they called melancholic, whose outward signs are tall stature, olive complexion, and straight dark hair. More than one theory has been advanced as to the physical con- stitution which furnishes the best seed-bed for cancer. For example, it has been said to be very common in persons with orange-hazel eyes, or with eyes in which the colour is much mixed or broken, in which the general effect on a distant view is green. My own observations have not confirmed this notion. Cancer, in my opinion, is most common in people who have a fairly healthy constitution in other respects. The prevailing complexion, among the subjects of cancer in this country, is dark. These figures vary from those of the surrounding non-cancerous population very decidedly in the direction of darkness. Roger Williams, who has also investi- gated this subject and on a somewhat larger scale, has kindly shown me his figures, which bear out my own conclusion. It will be remem- bered that Dr. Baxter's American statistics also agree with our own on this point. Of course it does not necessarily follow that cancer is 1 See analysis of upwards of 1000 cases in Races of Britain, pp. 222, 223. 36 SYSTEM OF MEDICINE at all more prevalent among generally swarthy than among generally blond nations; nor am I aware of any evidence in favour of such a belief. On the contrary, there is some reason for supposing it to be a disease whose development is favoured by civilisation, comfort and intellectual progress; and these are on the whole most prevalent in the races whom Huxley calls Xanthochroi, although it is the swarthy individuals among them who suffer most. John Beddoe. references 1. Obstbblbn. Handbuch der medidnischen Statistik. Tubingen, 1S75. — 2. Lom- bard. Paris, 1877. — 3. Bebtillon. Paris, 1874. — 4. Boudin. Paris, 1867. — 5. Laqnbau. Anthropologie de la France. Paris, 1879. Bordieb. Paris, 1884. — 7. Baxter. Medical Statistics of the Provost-MarshaVs Biareau. Washington, 1875. — 8. Hirsch. Handbook of Historical and Oeographical Pathology. Translated by C. Creighton, M. London, 1883. — 9. Haviland. London, 1875. ON TEMPERAMENT Temperament is usually understood to denote a certain combination of physical and mental characteristics. The two have treated the subject in differ- ent ways : the physician has considered chiefly, and often exclusively, the physical aspect of temperament ; the psychologist, on the other hand, has regarded temperament as a type of mental character with tendencies to certain forms of emotion, and has neglected the physical side. The doctrine of temperament was originally founded on a physiological basis, and physical conceptions of temperament prevailed till the end of the last century. Rant then took up the subject, and although he made use of terms derived from the character of the blood, his treat- ment was exclusively psychological. Since the time of Kant the sub- ject of temperament has been treated more fully by psychologists than by physicians, and the popular use of the term shows that the word has now come to mean a certain type of mind rather than a certain type of physical organisation. The comparative neglect of temperament by recent writers on medicine is not surprising. Medical practice has gradually been more and more influenced by the exact methods of modem physiology ; thus it is natural that the doctrine of temperament, resting on simple observation of more or less vague characters, should have fallen into disuse. At the present time, although the subject of temperament is specifically mentioned by few, its importance is being ON TEMPERAMENT 37 more recognised. The predisposition of certain individuals to certain forms of disease, and the different effects which the same dose of the same drug may have on different individuals, are well-recognised facts which show the importance of what is popularly called " constitution. " But though the importance of constitution or temperament is acknowl- edged, little has yet been done to study the subject on modern methods. Whenever it has been studied, as by Stewart in his book, Our Temperor ments, the old classification has been adhered to with far from satisfactory results. The importance of temperament is also being more recognised in relation to many problems of practical life — to such questions as the methods of education and the choice of occupation in life. Yet here again little has been done in the scientific study of the subject. The doctrine of temperament falls imder the head of individual as opposed to general psychology, under the head of that branch of psychology which deals with the differences which distinguish different minds rather than of that which deals with the laws of mind in general. Individual psychology has been comparatively neglected not only by the older school of psychologists, but also by the recent experimental school ; and it is but quite recently that a beginning has been made in the systematic investigation of the mental characters on which a scien- tific doctrine of temperaments should be based. In order to establish such a doctrine, it will first be necessary to study more closely, and by more exact methods than hitherto, the phys- ical differences which distinguish different individuals. Much has been done in this way by anthropologists ; but their investigations have been carried out chiefly from an ethnological stand-point, and it is probable that their methods will have to be modified to suit the different end in view. A second necessity is the investigation of mental differences by exact methods. This has hitherto been the greatest difficulty in the way of a scientific doctrine ; but experimental psychology is now suffi- ciently advanced not only to show how this may be done, but to have taken some steps in this direction. Up to the present time the most important work on these lines of investigation has been done by Mr. Galton. On the physical side his anthropometrical researches furnish the kind of material which is needed to establish the existence of dif- ferent groups of physical organisation. He has also made some advance on the mental side. His division of individuals according to the nature of their mental imagery, which has been further developed by Charcot and Binet, is a valuable contribution to individual psychology, and an example of the kind of distinction to be made out. At present the most important work on the mental side is being done by Professor Kraepelin of Heidelberg. He and his school work at the subject from the psychi- atrical point of view; and one important division of their work has been the investigation of certain fundamental properties of the mind which are of great importance in the study of temperament. These include the capacity for mental work, the susceptibility to fatigue from mental work, the power of recovery from such fatigue, the extent of 38 SYSTEM OF MEDICINE the influence of practice, and the power of concentration of attention. They have also investigated the relations of bodily and mental fatigue, the depth of sleep, and other questions of psychical or psycho-physical capacity. In all these investigations they have found that individual differences occur ; and it is in such differences as these, so important in relation to practical life as well as to insanity, that we may hope to find the materials for a new classification. It would be fruitless here to attempt to formulate a new system of temperaments. Such an attempt should only be made on the basis of experience gained in the investiga- tion of physical and mental characters by methods such as those of Galton and Kraepelin. A few suggestions in this direction may, however, be made. There has been singular unanimity among both medical and philosophical writers in favour of a fourfold division of temperaments. Both Kant and Lotze accepted the old division, while modifying and describing the mental characteristics more fully than had been done before. Wundt has retained the old types, but defines them on the basis of the strength of the emotions, and of the rate at which they change. Thus, in the choleric temperament the emotions are strong and change quickly ; in the melancholic, strong but change slowly ; in the sanguine, weak and quick ; in the phlegmatic, weak and slow. One recent writer goes so far as to say that the fourfold division must be approved " by all who advocate intelligently any theory upon the subject. " In spite of this consensus of opinion, it would probably be best to put the older classi- fication on one side, and to start afresh from the beginning. In one direction, however, it may be well to take advantage of previous methods ; the old doctrine had a pathological basis, and it is probable that pathological investigation may give us the clue to a more satisfactory method. It is customary to speak of certain dispositions to disease as diatheses, of which the nervous diathesis and the uric acid diathesis may be given as examples. The exact investigation of the physical and mental characters of these diatheses has yet to be carried out, and probably no more useful contribution to the doctrine of tem- perament could be made than such an investigation. Another line of inquiry which might be useful is the study of the different characters of the two sexes, and of various ages. The temper- aments of age have been most fully considered by Lotze. The reaction to disease is known to vary with the different epochs of life, and it is probable that exact investigation of the characteristics of different ages may enable us to define groups of temperament useful both from the pathological and sociological points of view. It would be especially interesting to dis- cover whether the individual who retains in adult life the mental traits which are found to be characteristic of childhood, retains also youthful characteristics in his physical organisation. ON THE LA WS OF INHERITANCE IN DISEASE 39 Another possible basis for a classification of temperaments is purely psychological. As a working hypothesis at the present time, the cus- tomary tripartite division of mind might be accepted, and an endeavour be made to find the physical and mental traits which characterise the three types of Auguste Comte — the man of thought, the man of feel- ing, and the man of action. It must be remembered that a satisfiactory doctrine of temperaments has not only to be useful in defining the nature of the more special disposition to react in certain ways to disease, but also, and perhaps more essentially, in defining the nature of the disposition to react in ains, whatever may have been their exciting causes, will in him assume a special character and lead to specialised results. Thus the offspring of generations of gouty ancestry may, in virtue of such descent, suffer from various maladies which stand in no direct relation with errors in diet, defective assimilation, or the accumulation of urates in the blood. One of these is the weakening of blood-vessels, which is the proximate cause of haemophilia, and may also find its expression in epistaxis, haemorrhagic purpura, bleeding into the vitreous, and other phenomena. In the same way inherited gout may be the parent of iritis in early life, and of various forms of joint disease at all periods of life, which are wholly unassociated with the deposit of urate of soda in the structures. It is an inheritance of tissue proclivity independently of, though usually in addition to, peculiarities of assimilation and excretion. Kor must it be forgotten that these inherited liabilities may have been inextricably 46 SYSTEM OF MEDICINE mixed with others. Feebleness of circulation, instability of nerve func- tion, scrofula, and other causes of disease, may have joined with inheri- tance of gout, and the resulting state may thus be a very complicated one. It is not necessary to say more than a few words respecting the heredity of congenitsd defects in the growth of exterruil parts. We also observe respecting them that occasionally they occur in many members of the same family ; whilst there is little or no evidence as to their occurrence in former generations. " Another important law which receives occasional illustration in these very obvious hereditary defects is that of " transmutation in transmis- sion. " By this expression is meant that the defect reproduced is not always exactly the same as that in the predecessor. Thus one child may have a superfluous digit, and another of the same family merely a deformed and overgrown one. What is hereditary is clearly a liability to disturbance in the development of a certain portion of protoplasm, but falls short of the necessary production of identity of result. This law is probably of wide application under conditions in which it is not so easy to prove its influence. In the case of various forms of skin disease it may be conjectured that a liability to defective formation of the skin in general is the antecedent rather than a definite proclivity to one single type of malady. Thus an inheritance from a parent who has suffered from psoriasis may possibly be transmitted as ichthyosis, or some form of chronic eczema or lichen. Many of the known facts as regards "family diseases" support the belief that some law of unity in variety influences their production. Jonathan Hutchinson. IVIEDICAL GEOGRAPHY OF GREAT BRITAIN That branch of medicine which has for its subject the Geographical Distribution of Disease, may be said to have had a very remote origin in the ancient Coan School of Medicine, of which the family of Hip- pocrates were the founders. In this school the study first sprang into existence as far as we can judge, and then flourished for a time under the care of the author of Airs, Places, and Waters, the head of the above distinguished family, whose genius, common-sense, and vast experience, extending over an unusually long life of active prac- tice among the isles of the Greek Archipelago, and the mainland MEDICAL GEOGRAPHY OF GREAT BRITAIN 47 of Greece, Thrace, and the Coast of Asia Minor, enabled him to accumulate a vast number of clinical facts bearing upon the relation between certain classes of disease and certain conditions of soil, water, and atmosphere. Within the circumference of his wide experience he had almost every variety of land-surface from the Mount Olympus to the paludal lakes of the plain, and the swamps alongside the river mouth ; over those lands he noted the sweep of the atmospheric currents, the different lie and aspects of their slopes towards wind and sun. The different effects of the various waters on mankind — the hard, the soft, the brackish, and paludal — were also noted by Hippocrates, and locally the effects of weather and seasons were also studied by him, whether in his reports of clinical cases, or of epidemics 1. In the etiology of disease Hippocrates evidently foresaw the great importance of the physical configuration of the land, its aspects and soils, and the influence of the two great factors of local climates, the sun and the atmosphere, — the latter ever varying in its currents, temperature, moisture, and adventitious constituents, whether of mechanical, vegetable, or animal origin. The later results of the study of medical geography justify these early anticipations of that great physician. Since the death of Hippocrates b. 480-357 the subject stood still until the publication by Dr. Alexander Keith Jolmston of his well-known FhysiocU Atlas of Natural Phenomena 2 , in which maps appeared of the geographical distribution of certain diseases. The data were gathered principally from the works of our naval, military, and mercantile marine medical officers and others, within whose stores of facts there are many that might still be profitably studied. In 1856 the eminent French physician and medical geographer, Boudin, published his Giographie MMicale, based principally on the statistics of the French army — the first statistics used in the study of medical geography. In England the data for constructing maps of disease distribution were not published in serviceable form until the late Dr. William Farr issued his Decennial Supplement for 1851-1860 to the Kegistrar- General's Major Graham 25th Annual Report in the year 1864. 48 SYSTEM OF MEDICINE The history of disease distribution is fully dealt with in my recently published work 3 ; I will now give the salient facts resulting from my own investigations from the year 1868 up to the present time. The first firm step in the study of the medical geography of Great Britain was made within a short time of the publication by Dr. William Farr, C. , of the supplement already referred to. In this important and model report the deaths from twenty-four different causes during the ten years 1851-1860, in each of the 630 registration districts of England and Wales, were arranged in two tables, one for moiXes and one for femoUes respectively. The mean populations of each sex in each district were divided into so many 17 age-periods, giving 1 the mean number of males and females living during the decennium at each age- period; and 2 the number of deaths from each of the twenty-four causes during the same time at each of the said age-periods : thus the death-rate from each cause at each age-period could be calculated — the mean populations at the different ages being given in the same column as the actual number of deaths from the different causes. With the life and death statistics so arranged the medical geography of England and Wales, and the construction of maps showing the geographical distribution of each cause of death in the 630 districts, became possible for the first time in the annals of medicine ; and future investigations into the causes of the varieties of the several distributions, as well as of the marked inequality of the distribution of each individual cause of death, found a solid basis. Such a map once constructed and coloured in varying shades, enables the student at once to compare it with other maps of the geology, physical geography, hydrography, meteorology, etc. , of the country under observation ; and lastly, with other maps of the distribution of other diseases over the same area, and of the distribution of the yield of such crops as wheat, a plant whose habits and peculiar construction I have shown to be remarkable exponents of local climates. In 1875, whilst my first folio edition was going through the press, the Kegistrar-General of Scotland issued his Supplement to the Annual Keports for the ten years 1861-1870, which contained a summary of the deaths in each of the thirty-three counties during that period from heart disease, phthisis, and cancer: he did not, however, take the precaution of separating the sexes, or of giving the number of deaths and the mean populations at each age-period. It enabled me, how- ever, to extend my inquiries and to construct sketch maps, although very imperfect ones, of the distribution of the above causes of death in that part of Great Britain. I will now give an outline of what has been achieved in the medical geography of England and Wales. Heart Disease. — The first map constructed was that of the geo- graphical distribution of heart disease and dropsy during 1851-1860, amongst a mean population of 18,996,916, or 9,278,742 males and 9,718,174 females, distributed over 630 registration districts, amongst MEDICAL GEOGRAPHY OF GREAT BRITAIN 49 whom had occurred 236,973 deaths from this cause, of whom 109,527 were males and 127,446 females. As the annual death-rates from this cause were found to differ only as 11-8 males to 131 females , a careful study of the death-rates of the two sexes in each district was made : the difference in the mortality attributable to sex was found too small to necessitate two maps, especially as the organ affected was common to both. The map, there- fore, represented the. deaths of both sexes, namely, 236,973, or nearly a quarter of a million, and at all ages. A map was constructed and coloured in accordance with the above scale, which ranged from 4-6 — the lowest rate — to 19-21, the highest ftnnnal death-rates to every 10,000 males and females living in each registration district during the ten years 1851-1860. The Map of Heart Disease, — When a map of the 630 districts in England and Wales is coloured on such a scale, and each separate district coloured with a shade of blue or red according to its death-rate, it will be found that instead of the map presenting the appearance of a " crazy-patch work," it will be characterised, according to the disease chartographed, by groups of red and blue districts, which suggest at once to the observer that some unknown general condition gives a certain measure of uniformity to the forms and positions of the groups he sees before him. The observer must now compare the disease-map, and its remarkable groups of high and low mortality, with a good map of the physical geography of the same country — such as that constructed by the late Sir A. Kamsay Stanford — and carefully note each physical feature represented on it with each group of high and low mortality. This will prove an easier task than at first it appears to be, for every country, even the smallest islands, have their water-partings and river-catchment basins, their ridges of high ground, and their valleys in the lower, through which the rivers and their tributaries take their courses to the ocean or some inland sea. Throughout Great Britain these river-catchment basins have been well defined on excellent maps which help the student at every step of his investigation. In the case of heart disease the first glance at the two maps will disclose the following remarkable coincidences : — 1 The east coast of England and the west coast of Wales — in fact, those parts of the country most exposed to the force of the sea-winds — are characterised by almost continuous groups of low mortality, red. 2 Wherever on the physical map the outlets and courses of the large rivers are seen to have their axes corresponding in direction with the prevailing winds — such as the south-west and north-east — groups of low mortality are observed on VOL. I E 50 SYSTEM OF MEDICINE the disease-map invariably to extend far into the country, as in the cases of the Tyne, the Tees, the Humber, the Norfolk and Suffolk rivers, the Thames, the Severn and Avon, the Welsh rivers, the Mersey, the Westmorland and Cumberland rivers.

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