GENTLEMEN,-I now recall your attention to the case of the patient whom we examined together, an hour ago, in Harrison ward. The man is 48 years of age, fair, well-built, moderately stout, and very intelligent. He is a cellarman, and has "lived well," but, as he adds, temperately. This is found to mean that he is a hearty eater of animal food, and that his daily consumption of alcohol averages about two quarts of beer, an occasional "drop" of brandy in water, and three or four glasses of any sort of wine. But he has never been "the worse for liquor"; and until eight years ago, although taking little exercise, and following his occupation almost entirely underground, he enjoyed uninterrupted health. Even now, an ordinary look at the man returns no impression of serious illness. It is only the close scrutiny of an experienced eye which detects in the patchy red and yellow of his face, in his pinched features, in his careworn expression, in his tremulous excitable manner, and in his movements shorn of the freedom characteristic of health, the signs of an organism somehow ill

at ease.

The patient's family history is exceptionally good. The father died at 70; the mother lives in tolerable health; two brothers and a sister are alive and well.

Eight years ago our patient, after a hearty supper, awoke in the middle of the night with an odd sort of nervous attack, suffering from palpitation, shortness of breath, cold sweats, trembling, and an agonising sensation of impending death. A stiff dose of brandy-and-water subdued the urgency of his distress, and in a couple of days he was at work again. But from then until now he has never been well; and yet he is unable to say exactly how he has been ill.

The burden of the man's present complaint is to this effect: -He says that he is losing strength; that he is nervous, irritable, and ofter "queer in the head"; that he has sometimes numbness, or tingling, or pains now in his arms and then in his legs; that he wakes in the early morning depressed and agonised; that although he has a good appetite his food does not strengthen him; that he is not able for his work; and that when he persists in working he flushes all over, and feels as if he would be faint or sick. He adds, with remarkable significance, that he is always better in the hospital, where twice before he has been a patient; and he ascribes his betterness to rest from work, in spite of what he considers the insufficient diet to which he is confined.

Such is the sum of the patient's complaints. Let us now endeavour to discover the cause of them. Our first thoughts suggest that it will be found in the nervous system, and we will seek it there. Head feelings, numbness and tingling in the extremities, occasional incertitude of movement, incapacity for sustained attention, and morning despondency make together an array of symptoms which seem to betoken either the approach or the existence of serious disease of some part of the nervous centres. But I am by no means sure-nay, in this case I doubt that they do. For observe, in the first place, that these symptoms have existed in greater or less degree for years; that they come and go, that they flit from place to place, that they are scarcely a whit worse now than they were at first, and that for all the gravity of their threatenings nothing serious has actually come of them. Observe, in the second place, that the symptoms under discussion are all, or at least nearly all, subjective. By none of the many means of investigation at our command can we discover and demonstrate any reliable objective evidence of disease within the regions of intelligence, sensation, or motion. And, lastly, let me sayand I say it confidently-that there is nothing in these nervous symptoms, regarded collectively as well as separately, to necessitate the conclusion that they are due to any primitive affection, either organic or functional, of the nervous system. On more than one occasion I have been enabled to furnish some of you with proofs, as conclusive as the subject will admit of, that disorders akin to those complained of by our patient may arise from pathological conditions in other parts of the organism. And in this case, unless I cannot find elsewhere a VOL. I. 1873. No. 1175.

sufficient cause for the nerve symptoms, I shall certainly not return to seek for it in any independent affection of the nervous system.

Turn we now to the digestive system, and see what we can find there. The tongue is clean; the appetite is good; there is no discomfort after meals. Beyond a habitually acid saliva, some pain in the left side plainly due to colonic distension. obstinate constipation, and a singularly scanty separation of fæces, there are no other evidences of disease in this part of the body. Here let me remark that the patient has a rooted prejudice against aperients. He says that they make his head bad; that they aggravate all his symptoms, and that they make him low and uncomfortable: wherefore he has been in the habit of leaving Nature to herself and of going for days together without relief, which, when it comes, is dark, scanty, pellety, and dry. Infrequent relief of the bowels, and a slender discharge of fæces when it comes, may seem matters of small moment and to count for nothing in the explanation of the patient's case: but it is, in fact, quite otherwise. Next to a just supply of proper food and air there is no more essential condition of health than a free separation and discharge from the body of its waste products. The retention in the blood and tissues of what ought to be separated from them, and the absorption of what ought to be cast out, are fertile sources of disease. Without a wide and free excretion our pabulum becomes our poison, and anæmia, nervousness, embolia, gout, rheumatism, and tissue degenerations are occasionally the manifest expressions of its baleful influence.

Now, I am not about to contend that this long detention of fæces in the body is a frequent cause of serious disorder; but I do contend that it is an occasional one, and that it counts for something in the explanation of cases of anomalous illhealth in which the excretory functions generally are at fault. Only last session I called your attention to two cases of what I called "fecal poisoning"-cases in which anæmia and a long array of nervous disorders were demonstrably due to a lengthened detention of fæces in the bowels. I do not doubt that many cases could be brought forward in which habitual and lengthened constipation is found to be compatible with excellent health; neither do I doubt that many persons are to be found who for successive years consume daily over a bottle of strong wine without manifest disorder. But such cases are strictly exceptional, and, whilst worthy of record in illustration of what some organisms will tolerate, they are certainly not to be held up for general example.

Returning from this digression to our patient, I am disposed to say that this fæcal retention and the consequent absorption of fecal matters into the blood is one of the conditions which together have brought about his present illness. And I think the man's statement that he is made worse by aperients no refutation of this opinion. He has been peddling with purgatives, and in cases like his you will often find that whilst small doses excite insufferable teazing and return no benefit, liberal doses of well-selected drugs act with ease and are followed by relief.

Let us inquire next into the condition of the kidney, in so far as it can be ascertained through an examination of the urine. Sundry things in the patient's history, habits, and present condition point to this organ as a probable cause of his symptoms. Viewed together and in their manner of appearance they closely resemble those which herald the approach of granular degeneration. But still, although they justify a grave suspicion, they warrant no conclusion. What does the urine tell us? Not from one examination, but from several examinations carefully repeated, I have learned several things which seem to have an obvious bearing on the case, and this is the sum of them :-The quantity of urine passed in the twenty-four hours is rather below than above the average. It is of a pale sherry colour, clear, acid, and has a variable density, which, however, at no time exceeds 1012. Occasionally it deposits, after some hours' rest, a few crystals of uric acid, together with a mucous cloud of normal appearance and size. There is not a trace of albumen, and the most careful examination of the sediment fails to reveal the presence of tubecasts, or of anything but a very small quantity of granular débris, with now and then a few crystals of uric acid and of oxalate of lime. Of the saline constituents and of the extractives I have kept no precise record; but the quantity of each is considerably below the average of health. The quantity of urea excreted in the twenty-four hours is about 280 grains, and this is an amount which, considering the weight of the patient and the quantity and quality of his food, cannot be called otherwise than flagrantly deficient. Through this constitution of the urine we clearly discern an indolent and inefficient kidney.