No. 3102

FEBRUARY 10, 1883.

Presidential AddressDELIVERED AT THE

CLINICAL SOCIETY OF LONDON,On January 26th, 1883.

BY ANDREW CLARK, M.D., LL.D.,PHYSICIAN TO THE LONDON HOSPITAL.

(Concluded from p. 180.)

IF time permitted and the occasion would justify it, I couldeasily produce from the records of our common experience inevery department of medicine illustrations the most variousand cJllclu3ive of the peril of neglecting and the profit of

following minute physiological considerations in the treat-ment of disease. On this occasion I shall content myselfwith one.Some eight years ago I was summoned to a consultation

in South Kensington, where, in presence of the patient andvis family, I met Dr. Andrew Stephen and Dr. Taylor. It

appeared tint the subject of our consultation, having beenill for many weeks, and growing rapidly worse, had been.brought from Wales to London for further advice, and thatthe advice given was opposed to the feelings and convictionsof the patient and his friends. The family therefore refused,without the help of another opinion, to carry out the pro-posed treatment ; accordingly, with the acquiescence of thedoctors, I was summoned to examine the patient, and tostate my views, without previous consultation with my’colleagues, but in their presence. The patient, a tall, stoutman of about sixty, with flushed face, suffused eyes, anxiouscountenance, and swollen legs, sat leaning forward in anarm-chair, partially undressed, breathing laboriously, andapparently in much distress. He complained of shortnessof breath and palpitation, of confused sensation in his headand occasional dizziness ; of general weakness and of inde-scribable depression. The patient had a loaded tongue,with fetid breath, and, although troubled with nausea, wasable to take freely of food and drink. The abdomen wasdistended and the liver distinctly enlarged. There were

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frequent discharges of fetid gases from the bowels. Thefaeces, discharged twice or thrice daily, were dark, offensive,and unformed. The urine was scanty, pale, faintly acid, ofa density of 1010, and slightly albuminous. The heart waslarge, flabby, murmurish, frequent, quick, and irregular intime and force. The pulse was small, thready, irregular,and beating over a hundred times in a minute. The legs

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were oedematous, bluish-red, and cold. The cervical veinsremained continuously distended. Both lungs were con-gested at their bases, and there was frequent cough, withfrothy, and sometimes sanguinolent expectoration. Nothingworthy of note was discovered in the nervous system.

Inquiring now as to the treatment which was beingpursued, I was told that in the opinion of all who knewhim, and of all the doctors except the last who had beenconsulted about him, the patient was a man of naturallydelicate constitution, thst he needed constant keeping up,and that his chances of life were in direct proportion to the

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amount of support that he could take. Accordingly he wastaking food and wine every second hour, had iron, quinine,and strychnia three times daily, and, being increasinglythirsty, he drank milk-and-soda water without much regard tofrequency or amount. Questioned as to my opinion of thepatient’s malady, and urged by my colleagues to say exactlywhat I thought, I replied that he was a man with deterio-rated but not seriously diseased tissues and organs, and thathe was in peril of death, not so much from his malady asfrom the means used for its cure, that he was being poisonedby food and wine, that he was in the condition of a firehaving more coals put upon it than it could burn, and thathis chimneys being choked he was in near danger of beingsuffocated with his own smoke. My colleagues agreeingwith this view of the case, and the patient, after much dts-cussion and explanation assenting, he was placed upon apreci-te and severe regimen. He was ordered to have foursimple nursery sort of meals in the course of the day, to

I’have an ounce of brandy diluted with eight parts of waterat dinner and supper, to be restricted to two pints of liquid

in the course of the twenty-four hours, to take nothing ofany sort between meals, and as soon as he was able to moveabout the rooms in which he dwelt. In the way of drugs hewas directed to take for a week or longer a grain of calomelat night, followed by a salient aperient onwaking in the morn-ing, and to have twice or thrice daily, two hours after food,infusion of gentian with bicarbonate of potash, iodide ofpotassium, tincture of digitalis and aromatic spirits of am-monia. For the first three days he was no better for thistreatment. It tried him severely through the restriction ofhis liquids, and, declaring himself worse for it, he thleatenedto discontinue it, and to return to his former ways. But onthe fifth day he began to improve, and then, his confidencebeing gained, there was no further difficulty in continuingthe treatment, which, when digestion improved, was addedto by the administration of reduced iron with meals. At theend of three months the patient declared that he was well,and all that could be said against him was that he had aweakish heart, that he was breathless upon exertion, thathe had rather inadequate kidneys, and that to maintain hissense of well-being he was compelled to live by rule. Thisrule was a midday dinner with an ounce of brandy in halfa pint of water, a moderate breakfast and tea, with eggs, orpoultry, or fish, extreme moderation in the use of fluids,tepid sponging, warm clothing, gentle exercise, and earlyhours. Within a year I heard of the patient being in fairhealth and managing his ironworks in Wales. What I havesince heard of him from time to time is instructive. Occa-sionally, losing his faith or lacking strength Ito follow hisrules, he returns to the freedom for which he longs, fre-quents society, dines late, rejoices again in his wine, and hasall that his heart desires. For a time all goes merrily and well,and he breaks sarcastic jokes over the heads of his physicians.But sooner or later this seeming well-being ceases, and histroubles reappear. The urine diminishes in density, andbecomes albuminous ; the heart loses its strength and regu-larity ; the breathing is oppressed ; the nights are sleeplessand the days depressed; till at last, after much suffering, hisobstinacy is conquered, and reconvinced, and humbled andpenitent, he returns to his obedience and again recovers hishealth.Such cases are common enough, and my experience forbids

me to doubt that in fevers and inflammations, in haemor-rhages and acute diseases of every sort, the issue of particularcases turns oftener than we are perhaps ready to admit uponan adequate understanding of the physiological principlesapplicable to the removal of the conditions imperilling life,and upon the resolution and patience, the minuteness andfidelity, with which they are enforced. Such considerationsare true and important, not only in diseases jeopardising life,but also in common disorders, which, although devoid ofserious peril, invade our comfort, hinder our work, and dullour joy in life. I do not forget that through hereditary in-fluences and unsuitable but inevitable environments manypersons are doomed to be constantly ailing without beingreally ill ; that their normal state is one of suffering ; thatno physiological readjustments and no specific medicationcan give to them the pleasant sense of health; and thatattempts to effect what is impossible issue only in greatersuffering or in disaster. But making full allowance for suchcases, there remain countless numbers who are willing andeager to make any and every sacrifice necessary to recovery,and who are left to continue in suffering because the physio-logical principles and compensations applicable to their reliefare derided, disregarded, or denied.Reviewing anew the completed Transactions of the Society

I am struck with the inadequate representations foundtherein of that interesting and instructive group of clinicalaffections which is unconnected, except causally, withsensible structural alterations of the tissues and organs. Thegroup contains numerous members of divers sorts, and Icannot doubt that every one of them would repay thoroughinvestigation, with fresh additions to our knowledge of theorigin, the nature, and the relations of disease. Many ofthem, familiar to experienced practitioners, have no sufficient recognition in medical literature ; and a full accountof them all would contribute more than any other accountthat I can imagine to a just understanding of the relationsof dynamic to static conditions, and of physiological to

pathological processes.Let me make mention of such members of this group of

affections as lie nearest my thoughts at this moment. And,first, there is the morning agony of middle-aged nervouspeople, often the precursor of melancholia. A man awaking

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at early dawn is conscious of undefinable malaise and unrest;his mental and moral outlook become dark and gloomy ;aching pains arise in the limbs ; unable to lie still, he tossesrestlessly about his bed ; the malaise deepens into distress,and he groans ; a cold sweat breaks forth over all his body ;and then in a few minutes the attack subsides, and thepatient finds himself in his accustomed health and spirits.In the second place, I will mention the temporary in-complete hemiplegias with aphasia, which, closely alliedto migrain, occur often in women, and occasionallyin men, otherwise healthy and strong. A woman, neitherhysterical nor nervous, suddenly fails to see distinctly;the field of vision is invaded by moving zigzag lines oflight, arranged either in circles or in forms resemblingthe outlines of a fortification ; there are slight ringingnoises in the ears, and trifling confusion of thought; numb-ness follows about the tip of the tongue, on one side ofthe lips and mouth, in the right thumb, and more rarely inthe right leg ; the connexion between ideas and their corre-lated words is interrupted ; articulation falters ; there is,perhaps, passing loss of power in the right hand or arm ; thebreathing and the pulsation of the heart are quickened ; thefeet and hands become moist and cold ; and then, after aperiod of time varying from ten to thirty minutes, with orwithout a slight headache, the attack ends with a few deepsighs and a discharge of limpid urine. Curiously enough,when headache occurs early in attacks of this kind, and issevere, sickness soon follows ; disturbances of speech, sensa-tion, and motion seldom arise ; and the distinctions which,in its fully developed form, separate this affection frommigrain are obliterated. In the third place, there is thedry barking cough of boys and girls about the age of puberty.This curious but not uncommon affection is characterisedchiefly by recurring paroxysms of a dry guttural cough, whichresembles the barking and, occasionally, the howling of a dog.This affection is usually associated with various slight disordersof the nervous system, and with defects of will; it is greatlyinfluenced by the emotions, and sometimes instantaneouslycured by sudden surprise or shock ; it is occasionally sodistressing to others that servants, and even friends, cannotstay in the house in which the patient dwells ; it is only ina small degree amenable to treatment; lasts from three orfour months to as many years, and ends, in my experience,always, in complete recovery. In the fourth place, I wouldcall attention to the cases grouped under the term renal in-adequacy ; cases in which, without discernible structuralalterations of the kidneys, they are, nevertheless, incapableof producing a urine of sufficient density and of healthyconstitution ; cases in which the blood, getting charged withexcrementitious matters, and nutrition and innervation be-comingthereby disordered, thepatientssufferingeneralhealth,fall immediately into peril from attacks of acute disease, andcannot, with ordinary chances of success or of safety, undergo acommon surgical operation. In the fifth place, I will mentionthe numerous and important cases occurring among youngpersons in whom, under the strain of prolonged competitiveexaminations and great excitement of any sort, the urinetemporarily falls in density, loses its healthy characters,and becomes albuminous. Of the young men competing forplaces in the Indian Civil Service examination, I haveascertained, bv repeated personal examination, that morethan a tenth becomes albuminuric. And, not to weary youfurther with illustrations, necessarily imperfect, of this groupof affections, I will conclude with merely mentioning theglycosuric storms which, without sensibly damaging the

body or materially impairing health, come and go throughouta lengthened life; the gouty spasms of the diaphragm sooften mistaken for some affection of the heart ; and thosestrange cases of autoclithonoemia, in which the blood, whendivided into minute streams, is ready to clot on the slightestprovocation from the structures around.Next in importance to the work of the Society are the

manner and circumstances in which that work is done.Under these heads many reflections occur to me as worthyof being submitted to vour consideration; but the time atmy disposal is so short, and the list of cases for considerationso long, that I must confine myself to the setting forth of avery few of them.The general meetings of the Society have been well

attended ; but whilst the junior members have been con-spicuous by ilteir presence, the cenior members have beenconspicuous by their absence. This is much to be regrettedfor the sake of the work of the Society and the discipline ofits members. The seniors themselves suffer in manifold

ways from their non-attendance. They miss the stimuluswhich comes from contact with youthfu enthusiasm; theyslide into stereotyped habits of thought, expression, andwork; they lose their receptivity ; they cease to adjustthemselves to their ever-varying environments, and thusthey become old, and the labour which should be life istransuguredintovirtualdeath. The Societysuffers;foritneedsthe large experience, the wide views, the sharpened insight,the cautious temper, the sober judgment of disciplined age,to control, regulate, and carry to their best issues theminuteness of detail, the flow of imagination, the hastygeneralisation, the speculative passion, and the dogmaticfury of our fervid youth. The pleas of pressing occupationand of consequent fatigue are doubtless true, but neverthe-less they must be disallowed; for no good can be got withoutsacrifice ; and the sacrifice of ourselves, even at the cost ofsuffering, is the only, or at least the chief, occasion ofgetting the strength which we need for the greater purposesof our lives..........Of late years there has arisen in the domains of general

literature and of controversial theology a habit of dealingwith the relations of ideas to words which is calculated tothrow into confusion all the higher controversies of the timeand to inflict serious injury upon letters, the advancement ofknowledge, and even the moral life of man. Under cover ofa particular word, connected by long usage and by commonconsent with a sufficiently definite idea, a new idea, totallydifferent from the old, is introduced, and is then used as ifthe one had become merged into the other, and as if therewere no doubt or difference between them. For example :By a religious man most people would understand a persondevoutly loyal to his ideal of a Divine Ruler of the universe,and fervent in his endeavours to die to himself that therebyhe might live to God. But in these days all this is beingchanged: a man who is emotionally interested in anything-in art, or physics, or science-is a religious man. Hissanctity is to be measured by his fervour ; and morality hasjust this relation to this religion that, if it interferes with itsculture, so much the worse for morality, which is a defect ora disorder that forthwith must be thrust aside. Now thisjuggling with words and ideas-this throwing of dust intopeople’s eyes so that controversies which cannot be settledmay be stifled-this unpardonable sin in literature, is threat-ening to invade the realms of medicine, to confuse our dis-cussions, and to render hopeless our progress in some depart.ments of knowledge. For instance, the word tubercle is nowoften so used as to comprehend the most diverse ideas, and togive apparent reconciliation to the most conflicting views.One may not object to an author using in his works wordsin the sense, usual or unusual, in which he has defined them;but one must protest with all one’s power against the habitof a man who puts on the clothes of another man and strutsalong the common highway pretending to be him..........A few more words upon a different aspect of the working

of our Society and I will hasten to a conclusion. The casesrecorded in our Transactions are for the most part admirable.It cannot justly be said of any one of them that it isdestitute of interest or of instruction; many are fertile infresh expedients for treatment or conclusive in their bearingupon questions still contested or unsettled, and in not a fewone finds the spell of original, creative, and far-reachingthoughts. But however highly we may rate the value ofany one of those cases standing by itself, its value for everypurpose conceivable in our relation to it would be doubledstanding side by side with a record of the debate which thecase had excited. For thus we should secure various viewscorrective or confirmatory of the position taken up by thenarrator of the case, and we should obtain in this way whatwe can rarely, if ever, obtain in any other way, the ripeexperience, judgment, and wisdom of busy practical andsuccessful men. For the literary and practical faculties areseldom combined in one person, nay, in the course of timethere often arises a sort of antagonism between them. Theman who can observe, collect, classify, reason, invent, apply,is often through the direction of nature or the force of cir-cumstances deficient in the qualifications necessary in onewho is to speak and write with ease. His habit of accnmu-lating and using knowledge for practical purposes weakensthe power of methodical exposition, so that from his im-proving treasury we get fewer gifts, and the habit of con.tinuous literary effort is not only neglected but shunned.And yet these are the very men whose knowledge is in anespecial manner worth the getting; these are the men

whose halting words straight from the watching and ques’

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tioning of nature are oftentimes more precious than eloquentspeeches; these are the men whose experiences worked inton, few clear idea", packed into a few awkward sentences andspoken in so many minutes, will sometimes bring to a con-clusive close the discus-dons of many days. And when youcannot induce such men to write, you may tempt themsuccessfully to speak, and the temptation will not be mademore difficult, nor the responsibility in speaking less, by theknowledge that their words will be preserved in that store-house of facts, experiments, and reflections which this Societywill give to the generations that follow after this.And as of like, although not equal importance, I shall

venture to ask the Council to permit the publication in theTransactions of the reply made by the author of a paper tothe criticisms which it has elicited. After reading in one ofour journals the record of some interesting and importantdebate in which various, and perhaps contradictory, viewshave been advanced, we are told that " the author havingreplied, the Society adjourned." But what the authorexactly said, how he dealt with the facts, cases, andcriticisms adverse to his views, what he admitted or whathe refuted, whether the case collapsed or succeeded, we arenot informed. And thus, deprived of the most importantevidence of the most important witness, we decide the casenot according to evidence, which is incomplete, but accordingto prepossessions, which neither necessarily nor usuallyinfluence us aright.And now that our work awaits us, let us turn to it with

justly attempered minds. For surely the burden of it is notmere occupation or interest, not mere success or failure, notmere profit or loss, not mere distinction for ourselves, nor Ieven honour for the profession to which we belong. Thetrue and serious burden of our work as we smoothly say sooften, and entirely realise so seldom, is the prevention ofdisease, the relief of suffering, and the prolongation of life.And this is the burden of it, not in a loose and general sense,but in a solemn and particular sense ; it is the burden of itas it affects not merely many persons, but one person, onewith whom we have to deal as if he were the sole object ofinterest and importance in the world, as if all the momentouspossibilities of life and death, of the preservation or thedestruction of the family life, and of all the goodor evil which might issue out of recovery or of death,were centred in him, and depending upon us. Impor-tant as our work thus is to the life and welfare of the indivi-dual and the family, it is not less important to the lifeand welfare of the State and the world. For this work, asit is sound or unsound, successful or unsuccessful, affects,for good or evil, the numbers of the population and itsphysical constitution, the supply of labour and the sourcesof wealth, the education of the young and the direction oftheir energies, the moral conditions of society and theobjects of political organisations, the development of therace and the fulfilment of its destinies. Such reflections,common as they are, serve to remind us of what our fami-liarity with them makes us forget-the momentous andfar-reaching influences of our work, and of the solemnresponsibilities which lie upon us in undertaking and dis-ciiarging it. Such reflections may further help us to cherishthe spirit of self-sacrifice in active endeavours to overcomeour ignorance of disease, till at last, with fulness more orless, knowing and foreseeing, preventing or controlling,stilling pain or curing disease, repulsing death and renewingthe conditions of continuing life, we may justify the boastof our father, Hippocrates, and to men in their extremities ofneed give help like gods.

I cannot close these desultory and imperfect remarkswithout adverting to the honour which you have conferredupon me in electing me to the presidential chair. It is anhonour which, although unanticipated and unsought, is notunvalued. I regard it, indeed, as the highest honourwhich I or any physician could receive. For titular honours

may be got by Royal favour or the influence of a greatMinister, or may fall upon one through accidents of positionand of service. But this honour no favour, influence, oi

accident can purchase. It is a spontaneous gift of the pro.fession, and the recipient of the honour must be free fromgrave reproach, and at least credited with some sort of merit.

I do not deceive myself with the thought that I am suffi.ciently worthy of this great honour, nor do I forget thatthere are others before me worthier of it than 1. But 7am not here to-night to quarrel with your judgment ; humblyand gratefully accepting it, I shall strive to justify it bendeavouring in singleness of heart and fervour of purpose

to co-operate with you in the divine work which you aredoing for the relief of suffering, the advancement of know-ledge, and the higher discipliue of ourselves for the betterservice of both.

In

FOURTEEN CASES OF

DIGITAL EXPLORATION OF THE BLADDER,IN SIX OF WHICH VESICAL TUMOUR

WAS REMOVED.BY SIR HENRY THOMPSON,

SURGEON EXTRAORDINARY TO HIS MAJESTY THE KING OF THE BELGIANS,CONSULTING SURGEON AND EMERITUS PROFESSOR OF CLINICAL

SURGERY TO UNIVERSITY COLLEGE HOSPITAL, ETC. ETC.

AT the meeting of the Royal Medical and ChirurgicalSociety of January 23rd last I stated that, for the purposeof diagnosis in exceptionally obscure cases of urinary dis-ease, I had of late performed a limited incision of the peri-neum carried to the membranous urethra only, and sufficingto enable me to carry the index-finger to the neck of thebladder, after which, by supra-pubic pressure under com-

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plete ansesthesia, the whole of the interior of the bladdermight be examined by the finger, and its condition be easilydetermined. I stated in my paper, in language the mostdistinct I could adopt, that the incisions in question had beenfrequently employed for two centuries at least for stricture,retention, &c., but that they had not been employed for thepurpose of making the diagnostic examination above de-scribed, and, moreover, that such examination became pos-sible only since we have had the power to produce at willcomplete relaxation of the patient’s abdominal muscles bymeans of ether and similar agents ; and I claimed this pro-ceeding to be a new mode of diagnosing such obscure con-ditions, and also of treating them when, as has often hap-pened, the incisions made have sufficed also to enable me totake away a tumour or other source of disease, not removableotherwise than by operation. In order to illustrate and sup-port these statements I append very brief notes of every casein ivhich I have made this explomtory incision, so as toenable the profession to judge of the proceeding and of itsresults. I have during the last two years and a half metwith thirteen cases in the male of obscure disease in which Ideemed it right to employ digital examination of the bladder.I add one case of dilatation of the urethra in the female,because tumour was present and was removed, this being aproceeding which may le regarded as analogous to thatabove adopted for the male ; and I think it will be regardedas a very striking fact-to none has it been more unexpectedthan it has been to myself-that among these fourteen casesI have found and removed vesical tumour of considerablesize in no less than six of them.CASE I.-T. R-, aged twenty-nine. I crushed an

oxalate of lime calculus on Aug. 5th, 1880. Symptomswere very slightly relieved,and he became worse in theautumn. The conditionbeing obscure, I operatedon Nov. 6th by perinealurethrotomy, Mr. Ceely,of Aylesbury, and others,present. I found a fibrouspolypoid growth (Fig. 1),and removed it with theforceps. He made a rapidrecovery, and is perfectlywell now and actively en-gaged in business. He waspresent at the lecture onthe 29th ult.CASE 2. -A gentleman,

agedforty-eight. Hadbeenthe subject of painfulfrequent micturition forseveral years, and of slightbromaturia, without ob-vious cause. On June 27th,"100"1 T ................_.....l.-..J -c- ..J’:__. --

Form and situation of tumour inthe bladder. (Case 1.

r 1881, I operated, finding no specially morbid condition.) The tube was retained in the wound for a week. He was