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PRINCIPLES  OF MEDICINE:
COMPRISING
GENERAL PATHOLOGY AND THERAPEUTICS,


              AND A BRIEF GENERAL VIEW OF



      ETIOLOGY, NOSOLOGY, SEMEIOLOGY, DIAGNOSIS,

                 AND PROGNOSIS.
   CHARLES J. B. WILLIAMS, MTJ.,F.R.S.,

          FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS',
 PROFESSOR OF THE PRINCIPLES AND PRACTICE OF MEDICINE, AND OF CLINICAL MEDICINE,
     AND FIRST PHYSICIAN TO THE HOSPITAL, UNIVERSITY COLLEGE, LONDON ;
CONSULTING PHYSICIAN TO THE HOSPITAL FOR CONSUMPTION AND DISEASES OF THE CHEST, ETC.
   WITH NUMEROUS ADDITIONAL NOTES, EXPLANATORY AND CRITICAL,


                      BY


THE EDITOR OF THE SELECT MEDICAL LIBRARY AND BULLETIN

               OF MEDICAL SCIENCE.
           PMlaTrcljJhta:
ED. BARRINGTON & GEO. D. HASWELL.

              18 4 4. 
i.
W 7? 2o
 l8 + <h
  [Entered, according to act of Congress, in the year 1844, by Bakrington and
Has we li., in the Clerk's office of the District Court for the Eastern District of Penn-
sylvania.] 
               PREFACE

TO  THE AMERICAN EDITION.
  The  most correct idea of the present work, the one by which
justice will be done to the intentions of the author, and the reason-
able expectations of the reader gratified, is, to regard it as outlines,
a text book in  fact,  rather than  a comprehensive and finished
treatise.  While admitting its intrinsic merits and its additive cha-
racter, on the  subject of that part of pathology which chiefly en-
gaged the author's attention, it would be affectation not to say, that,
in some other parts, there is both meagreness and want of preci-
sion in doctrine  and language.   On pathogeny or  pathology pro-
per, as he terms it, the author has furnished data, in facts and sug-
gestions, of undoubted value and freshness, for farther elaboration
and expansion ;  nor  is there any  lack, in   the present  volume,
of frequent and available, if not actually novel therapeutical de-
ductions for practical medicine.   The revelations of the microscope
have enabled  the author to enrich his  pages by an exposition of
minute morbid changes in  the textures and fluids, explanatory of
various pathological phenomena.  It  may be objected,  however,
that he has studied the ultimate organic elements, thus revealed,
in connexion with vital properties, somewhat to the exclusion of
the proximate organic systems, or textures ;  and that he dwells on
the modifications of the properties of the bloodvessels, to the over-
sight of those of the nervous system and its  offices  of maintaining
sympathetic and associated actions.
  Therapeutical indications  cannot be deduced from  morbid ana-
tomy.  It remains to be  seen whether organic chemistry and micro-
scopy will be sources of more  certain reliance ; for, as  yet, the
indications which they have  furnished have been anticipated
by the results of experimental observation of vital actions and of
clinical trials.   In the present work, the practical deductions from
this new fashion of pathology, the histogenic and chemical, are
calculated  to  produce an impression of  novelty, which is not sus-
tained by a view of all the premises.  The general inference, for ex-
ample, drawn from the bufly and cupped appearance of the blood,
that inflammation is present, and the exceptions to this view in par-
ticular cases, were taught and acted on long  before  recent hemato-
logy revealed the proportions of fibrin in this fluid.  So, also, the ex-
cess of blood and its richness in plethora and in sthenic hemorrhages
was well known, anterior to the demonstration of a superabundance
of globules in these cases.  Poverty of the blood in asthenic hemor-
rhages, chlorosis, scurvy, and other forms of anemia, was clearly 
IV
PREFACE TO THE AMERICAN EDITION.
admitted, until  solidism,  in  its pride and exclusiveness, put the
facts aside  and set up a doctrine of its own.   Equally well ascer-
tained and  proved by long experience, was the efficacy of chaly-
beates and  a properly selected nutritive food for the cure of these
affections.                                                   .
  It is, however, a  no small gain in the progress of experimental
inquiry, to have ascertained the material origin of various patholo-
gical phenomona, and thus to be protected against future fluctua-
tions of doctrine.  We advance, also, with more confidence in the
line of therapeutical indications, when we can  positively connect
in our minds, as the result of microscopical and  chemical disco-
veries, the operation of a remedy with  an ascertained change in
the ultimate organic elements of the fluids and solids of  the body.
The present volume contributes a full share towards satisfying our
minds on these points, and gratitude  is due to  its  author  accord-
ingly.
   The title of this work  is too comprehensive for  the subjects dis-
cussed in its pages ;  and in the instance of General Pathology espe-
cially it will be a subject of regret that the author did not either nar-
row his ground, or, having marked out certain boundaries, did not
strengthen  his positions by more  abundant and  systematically
arranged materials.  These  remarks and some preceding criticisms
are proffered in this place, in order to  exonerate the  American
editor from the charges of officiousness or vanity, in his endeavours
to  supply  some of  the omissions in the text by  numerous notes,
especially  on  Etiology and  Semeiology, including Diagnosis and
Prognosis; and,  also, on Prophylaxis and Hygiene.  Familiarity
with these  subjects, embraced under the head of General Pathology
 and Hygiene, growing out  of the fact of the editor  having pre-
pared a full course  of lectures on these branches, and of his having
published  essays and volumes on some of their  more  interesting
 topics, has enabled him  to make his additions while the sheets of
 this volume were passing through the  press, and when but little
 time was afforded  for selection and  arrangement.
    The text and notes of the author have been given entire, and
 unbroken  except in a few  instances in which  a  qualifying word,
 or opinion in a few words, not of sufficient moment  or length to
 constitute  a note,  has been added in  brackets,  thus  [  ].  The
 notes of the editor are  indicated by the letters  (a) or (b); and are
 printed in the same characters with the text, by which means they
 are readily distinguishable from the notes of  the author himself.
 Most of the  notes added to this edition are explanatory; being
 either  new facts, or facts deemed pertinent to the points discussed
 in the text, or a correction and extension of some subjects not clearly
 advanced or  adequately elucidated by the author.  Even in those
 of a  critical nature, as on cold, miasm, contagion, and semei-
  ology, reference is continually made to obvious  and material pheno-
 mena, preferably to indulgence in recondite  research or ingenious
  analogies. 
       PREFACE

BY  THE   AUTHOR.
  As an apology for the appearance of this publication, it may, I
think, be  stated to be generally acknowledged, that there is  at
present  no work which fully treats of the subject of General Patho-
logy, and its application to practical medicine.  The present attempt
to supply the defect arose from my feeling the want of an elemen-
tary work on these subjects, by aid of which I could introduce  to
my pupils the science of practical medicine.   With many excellent
and elaborate treatises on the details of medicine, we have scarcely
any  which treat of those general principles in the nature and treat-
ment of disease, which are  really fundamental in the practice  of
medicine.   Even  the very able work of my distinguished friend,
Professor  Alison, (to which the following pages owe much,)  in the
last  edition, instead  of some of these general principles, embraces
some of the details of Special  Pathology.
   It may be supposed, that in subjects comparatively so modern
as those embraced in this work, little reference can  be made  to
any but recent authors ; and for a great portion  of the  facts and
illustrations, I have drawn on my own experience in the continual
observation of  disease, during upwards of twenty years, in hos-
pital and private practice.  Throughout this experience, I have
always  endeavoured to keep in mind the bearings of physiology
and pathology on practical medicine, and to render their advances
useful, by their application to  this  art.  Many original facts and
opinions have been the result of this mode of study;  and some of
these will be found in the following pages.  I cannot expect that
they will speedily receive a general assent; but I ask  for them the
test  of  clinical observation, from which they have been mainly
derived.
   It seems  quite extraordinary that,  notwithstanding  the  recent
rapid improvements and comparative perfection of the contributory
sciences, practical  medicine should still halt in the domain of em-
piricism.  A chief reason for the anomaly seems to be, that science
and practice have been rarely pursued by the same parties.  Scten-
tific men are not and cannot be practical, because they have had no
experience ; and practitioners know little of science, and therefore
derive little  good  from  it.  Instead of  working together, these
           1 
p
PREFACE BY THE AUTHOR.
parties are at issue with each other.  But it is high time to put an
end to this feud.  Philosophers must descend from their transcen-
dental positions, to consider details of practice and purposes of
utility.  Those who would be practitioners, must gain from science
that knowledge and that method which render experience instruc-
tive and useful.
  In  the  present  effort towards the  accomplishment  of these
objects, I am conscious of many deficiencies.   Want of  time has
prevented me from treating some subjects as fully as they deserve,
particularly those of the last  chapter.  In others, I have studied to
be brief, to avoid perplexing the reader with much discussion or
detail.  For this reason, doubtful facts and a variety of conflicting
opinions have been withheld ; and only the  facts best ascertained
and the views which seem  most tenable have been given.   By
this eclectic method, I have succeeded in reducing a very extensive
range of subjects within the  compass of a moderate volume.

    7,  Holies Street, Cavendish Square,
        32 Sept, 1843. 
CONTENTS.*
Preface............p. iii
Introductory Lecture on the Need of the Study of General Pathology  as
       the Foundation of Practical Medicine.
     State of  practical medicine as a study and as an  art.  Favour shown to empi-
       ricism by the public.   Irksome and difficult character of the study of medicine
       as usually taught.   Insufficiency of empirical and nosological medicine.  Some
       knowledge of general pathology at length gained in practice.   Need of general
       pathology in the study and practice of medicine.   What is general pathology 1
       Contributions from all departments of medical science, especially clinical medi-
       cine [occasional fallacies of the application  of  science to medicine].  General
       pathology the proper introduction to special pathology.   Where principles fail,
       experience must be the sole guide.   Noble nature and objects  of medicine the
       best encouragements to its careful study    -     -     -     -    - p. 13—28

                   PRINCIPLES  OF MEDICINE.
for.
 I—4  Explanation'of the Subjects of the Work   *     -     -    -    p.  29
 J, 2   Principles of medicine:  synonyms;  whence derived.  Etiology,  pathology
 3,4     proper, principles of treatment.   Other subjects stated      -    -     p. 29
 5      Definitions of disease     ...-.---  p. 30,  33
       [Division and terminology of the different branches of the Institutes of Medi-
         cine, according  to Boerhaave, Gaubius, and others.]
 6      Standard of comparison.  Definition of health.  Deviations  from health ;  in
 7        function ; in  structure.  Physiology the  standard of healthy function; ana-
         tomy, of healthy structure,
 8, 9     Definition of disease.  Variations in the  standard of health.'
      CHAPTER I.— ETIOLOGY —ON THE CAUSES  OF DISEASE.
       Section I. — Nature and Ditisioxoi  Causes         k      p. 33—37
 10    Causes of disease intrinsic and extrinsic.   Causes of disease not sure in opera-
 U       tion; except those which are very strong.  They generally require  predis-
 12       position.   Examples [common determining and specific determining causes],
 1 3    Causes divided  into remote and proximate.  Remote divided into predisposing
 14       and exciting.  Co-operation of predisposing and exciting  causes generally
 15       necessary.  Examples.   Exceptions.
 16    Predisposition generally absence of natural resisting power.   Exnmples of the
 1 7       operation of this resisting power.
 18    Predisposition  from   error  of structure.   Other  names i.of  predisposing
 19       causes [general and particular Or individual causes].
       Section II. —- Predisposing Causes of  Disease     -     -     p. 37—45
 20      Exemplification of predisposing  causes.  Debilitating causes.  Imperfect
 21—23    nourishment.   Impure  air.   Fatigue of body or  mind.    Heat  with
 24—26    moisture.   Continued  cold.   Habitual  intemperance.    Depressing pas-
 27—29    sions.  Excessive evacuations,   [Pregnancy.]   Previous disease.
 29—30  Vascular fulness  or  activity.   Previous  disease operating by change  of
 31—33    structure; by persistence of cause.  Examples.
 33—35  Organic  disease  already  existing.   Innate predispositions.    Hereditary
 36—40    tendency.   Temperament: sanguine,   bilious, phlegmatic, nervous.  Dia-
 41—44    thesis.  'Age:  infancy,  childhood,  puberty, full-growth, age, old adult
 45—48    age, exemplified in vascular and nutritive functions.
         Section III.—Exciting Causes of Disease  -                  p. 45   88
 49, 50 Operation of exciting causes.  Divisioninto cognizable  and non-cognizable.
 51        I.  Cognizable  Agents.  (1.) Mechanical  causes;  examples of  their
 52           physical  effects.   Vital operation  of severe injuries.  (2.) Chemical
 53          causes ; extrinsic, intrinsic.
 54—56   (3.) Ingesta.   Non-alimentary;  examples;  intoxicating  liquors, use and
 57,58      abuse.   [Their use habitually is abuse.   Advantages of entire abstinence.
              Dietetic value  of alcoholic liquors ; alcohol is not nutrimental]   Adul-
              terations of food.   Medicines.  Aliment ill-proportioned : a due mixture
              requisite.   [Instances of healthy nutrition maintained by simple aliment;
              all vegetable or all animal.]   Simple principles, such as sugar, gum, &C,
 59,62       insufficient.   Bread I lie staff of life.  Liebig's views on aliments.   Dr.
   * Th2 contents in brackets indicate the subjects of the notes added by the  American Editor. 
4
CONTENTS.
Par.         Prout's.  Results of familiar experience.   Excessive aliment.  Defective
63          aliment.  [Alimentary effects of salt meat and fish.]
64       (4.)  Violent exertion : effects on heart, brain, lungs, &c.   Partial exertion.
65          Exhaustion from fatigue.
66       (5.) Strong mental emotion.   Slow emotion.   Continued mental exertion.
67       (6.)  Retention, diminution, and  suppression of evacuations, alvine, urine,
68         &c.   Lower  degrees conmon in disease.  Suppression  of artificial dis-
69         charges,  cutaneous eruptions, &c.
70       (7.) Excessive evacuation.  Effects.  Syncope, cerebral  and cardiac.  Other
             effects  and resulting diseases,
71       (8.)  Temperature and changes.  Extreme  heat  and  cold ;  local  effects.
72, 73     Constitutional effects of burns ; of extreme cold.  Stimulant operation
74, 75      of heat: view  of  Liebig.  Partial heat.   Operation of moderate cold.
76          Indirect effects  of cold in the part chilled.  Operation of external cold on
77          internal parts.  [Cold, a general sedative acting simultaneously on inter-
78          nal as well as  external  parts.  Consequent indications for  its employ-
79          ment therapeutically].  Cause of " catching cold," by disordering  cir-
            culation.  Symptoms  of " cold caught."  Susceptibility to cold.   Means
            of diminishing it.  Cold bathing.   Water cure.
80        Section  IV. — II, Non-cognizable Agents     -     -     p. 73—88
81, 82      Definition and division into endemic,°epidemic,  and infectious.
83, 84      1. Endemic causes.   Proofs of their existence.   Sources.  Malaria.
85            Nature of malaria.  Its properties.   Sources  of malaria.   Its virulence
              in  proportion to heat with moisture.   Morbid   effects  of malaria,
86, 87         Kinds of malaria.  [The hypothesis of miasm or malaria not sustained
              by facts or analogy-]  Endemic diseases from cognizable causes.
88          II. Epidemic causes.  Proofs of their existence. Epidemic.   Cognizable
89, 90        causes distinguished from non-cognizable.  Epidemic constitutions or
91, 92        periods.   Nature of epidemic  influences.  Dr. Prout's observations.
              Animalcule origin of epidemic diseases.
93, 94      III.  Infectious  causes.  Proofs of their existence.   Modes of infection.
94—97       By wounds.  By contact.  By aerial  communication.   By  several
98, 99        modes.  [Infection and contagion, not synonymous.  Their difference
              explained. Fomites.  Quarantine.]  Difficulties of explaining infection.
100           Analogy of fermentation; of animal and vegetable generation; exam-
              ples.   Parasitic  view  of infection confirmed by circumstances which
              promote and  check it.   [Cold does not destroy contagion.]
101—103    Peculiarities of infectious diseases: of endemic; of  epidemic.
104          Diseases propagated in several ways.   Pestilences.
105          General operation of all these causes depressing.
       CHAPTER II.— PATHOLOGY (PROPER) OR PATHOGENY.
106         Disease composed of elements.   Analogy with  chemistry.   Primary
107           elements of structure and function ;  healthy and diseased.  Proximate
108—109     elements of  disease.  These elements  the proper  subjects of general
              pathology and therapeutics......p. 88—90
           FUNCTIONAL DISEASES.—PRIMARY ELEMENTS.
          Section I.— Diseased Irritability     ....    p. 90, 93
110—115   Natural irritability. In  excess.   Varieties: in strength; in mobility;
              in duration.  Remedies for excessive irritability.
116,  117    Defective; in force; in mobility.   Connexion  of irritability with nerves
118,119      not essential.  Remedies for defect.
          Section II.— Diseased Tonicity -----   p. 93, 96
120         Natural tonicity: distinct from irritability ; proved by different effects of
              cold and heat.   Long known empirically.
121, 122    Excessive.  Examples.   Remedial measures.
123, 124    Defective.   Examples.   Atony.  Remedial measures.
          Section  III. — Diseased Sensibility -                   p. 96,  101
125         Sensibility referable to nervous system, and divided into general and local.
126—128   General.  Excessive: from disease ;  from  temperament.   Pathological
              causes.   Remedies.
129,130    Defective.   Causes: from disease; temperament.   Remedies.
131         Perverted.  Examples; causes;  remedies.
132         Local Sensibility.   Variations illustrated  by experiment. 
                                CONTENTS.                                5
 Par.
133—136   Pathological causes.  Excessive:  in  orifices,  pain, &c.   [Sensibility
              and sympathies of valvular orifices.]
137,  138    Defective.   Remedies for diseased local sensibility.
          Section IV.—Diseased Voluntary Motion    -     -    p. 101, 104
139         Division into general and partial.
140         General voluntary motion :  in Excess ;  Examples.
141,142    Defective:  Examples.  Perverted: Examples.
143,  144    Partial.  Excessive:  rare.   Defective: causes.  Examples.
145—147   Remedies for excessive voluntary motion ; for defective local.  Perverted.
          Section V. — Diseased Reflex and Sympathetic Nervous
                 Influence........p. 104, 110
148—153   Natural reflex function. Excessive: in involuntary muscles; in  volun-
               tary  muscles.  Convulsions, centric  and eccentric.   Partial,  by re-
               flected irritation.   Irritation  of involuntary  muscles.   Pathological
               causes of inordinate excitomotion : from poisons ;  from rest.
154,155    Defective reflex motion.   In coma;  asphyxia; sinking, &c.  Remedies
               for excessive.  Narcotics.   Sedatives.  Stimulants.   Tonics.
156,157    Reflected or sympathetic sensations.  Examples.  Remedies.
          Section  VI. — Diseased  Secretion   ...     -   p. 110,117
58—160    Secretion due to a vital property, aided  by  chemical  affinity.  Changes
               due to altered supply of blood, or to nervous influences.
161 —166   Division.  Excessive.  Effects:  forwards; backwards; on the  organ
               on the blood. Examples. Remedies. Depletion. Astringents. Alteratives
167—175   Defective.    Causes.  Effects:  forwards;  backwards.   Extreme; mo-
               derate.   Remedies: through the circulation.   Specific stimulants.
              Alteratives.  Tonics.  Substitutes for defective secretion.
176, 177    Perverted secretion.  Examples.  Effects.   Remedies.
            Diseases of the Constituents  of  the Blood     -    p. 117, 118
179         Constituents of the blood diseased constitute elements of disease.
180         Enumeration of constituents and modes of disease.
181,182    Changes of the entire blood.  Chemical composition of blood.  [Propor-
               tion of its constituents in health.]
          Section VII.  — Diseases of  Red Particles-    -        p. 119, 124
183—193   Natural offices and proportions.   Excess.  [Proportion of  red globules
               (particles) in  plethora  and hemorrhages.]   Examples  and   effects.
               Defect.   Examples and effects [deficiency in ancemia and the neuro-
               ses.]  Alterations :  in colour; in size and form [fallacy from  certain
               appearance of  red  globules  in health].   Arterial change.  Structure.
               Spontaneous motion 1   Mr. W. Jones's observations  and explanation.
               Origin of red particles.  Remedies.  Excess.  Defect.
          Section  VIII.— Fibrin and  White Globules -     -    p. 124, 134
194—205   Nature of fibrin.   Purposes.   Excess.  Examples.   Increase of white
               globules.  Defect.  Examples in  fluidity  of blood.  Causes.  Effects:
               hemorrhage; congestion.  [Congestion with softening of the spleen.]
              Alterations in quality :  apparent  from character of coagulum, which
              shows properties of self-coagulation, contraction, and separation.  Self-
               coagulation : varieties and causes.  Contraction : varieties and  causes.
               Separation :  causes.  Varieties.  Causes of buffy coat.
206—213  Appearances  of  coagulated blood.  Large clot.   Small  clot.  Separated
              and cupped.   Mode  of exhibiting  these properties.   Source of fibrin.
              Increase by inflammation.  Material of coagulable lymph.  Varieties.
              White globules.  Coagulation of fibrin during life: vegetations and polypi.
214—215  Remedies for excess of fibrin.  Bloodletting.   Evacuants.  Diet, &c.
216        Remedies for defect:  diet: regimen; tonics; antiseptics, &c.
217—219   Means of altering quality of fibrin.  Depletion. Alteratives. Tonics, &c.
         Section IX.—Albumen and other Animal Principles in
                the Serum  -      -       -      -       -       -   p. 134, 135
220         Natural proportions and offices of the albumen
221,222   Excess.  Examples. Causes. Remedies. Defect  [only in cases in  which
              it is lost by the kidneys].  Examples.  Effects.
         Section X.—Oil or Fatty Matter      -       -       -  p. 135, 136
223,224    Excess.  Milky serum.  Cases.   Source of fat.   Causes of obesity.
         Section XI.—Saline Matter     -       -       -       -  p. 136, 137
225—227   Excess.  Thirst caused by salt.  Defect  in yellow  fever and cholera.
              1* 
6
CONTENTS.
Par.         Effect of saline injections.  Effect of salt in preserving the red partl^s-
           Section  XII.—Water.....P- 137' i38
228—231  Excess.   Examples and effects.  From too much drink.   Defect.   Ex-
             amples.  Symptoms.   Causes.   Effect  of abstinence  from  liquids.
             Remedies for excess and defect.  Dry diet and water cure.
     Section XIII.—Changes in  the Blood by Respiration, p. 138—143
232, 233   Analysis  of the Changes.  Excess.   Examples in disease 1
234—242  Defect; the element of asphyxia.  Effect proportioned to suddenness as
             well  as degree.  Analysis of asphyxia.  Classification  of symptoms.
             Defect gradually induced.  Hybernation. Cyanosis:  state of functions.
             Little muscle and  much fat, with defective  respiration.  Remedies for
             defect:  lowering functional activity.   Stimulants.  Promoting respi-
             ration.   Other means of arterializing the blood 1
243—244  Treatment of the congestion of apnoea.  Diet in dyspnoea.
245        Excess  of changes by frespiration:  in  rheumatism!  Respiration  of
246           oxygen gas. ' Effects explained.  Liebig's notion of action of hydro-
247           cyanic acid controverted.
         Section XIV.—Changes in the Blood by Secretion, p.  143—147
248           Defective secretion of urine.  Experiments of Prevost and Dumas.
249, 250        Effect of diseased kidneys.  Of bite.  Examples;  effects.  Defective
251             perspiration.  Vicarious action of skin and kidneys.   Rheumatism.
                [Numerous  diseases from suppressed perspiration.   Importance of
                promoting the  action of the skin,  both in acute and  chronic dis-
252             eases.]   Remedies to be directed to this element.
         Section  XV.—Changes in the  Blood from the  Transformation
             of Chyle and of the Textures        -        -       p. 147—150
253        Natural changes uncertain.   Lithic acid diseases.  Causes.
254        Morbid effects  on kidneys.  Gout.  Varieties.   Effects.
255        Formation of sugar in diabetes.  Effects and treatment in  gout and dia-
256,257     betes contrasted.  Production of urea in excess.   Remedies.
         Section  XVI.—Changed Properties of  Blood from the presence
             of Foreign Matters    ...      -       p. 150, 152
258, 259  The blood  the seat of morbid poisons : proofs :  and of germs of malignant
260        disease.  Treatment of morbific matters in the blood.
         CHAPTER III.—PROXIMATE ELEMENTS  OF DISEASE.
         Section I.—An.v.mia        ...       -       p. 152—160
261        Explanation of proximate elements of disease.
262, 263    General  Anssmia.  Nature  and symptoms.  Physical signs.  [Bellows
             sound of the heart and arteries in anaemia, always coincident with defi-
264, 265     ciency  of red globules.]   Changes in the blood.   Symptoms of excite-
266,267     ment in anaemia.' Explanation of these symptoms. Symptoms of coma,
268, 269     &c.  Cases  and  interpretation of nature in anaemic coma.   Nutrition in
270,271     anaemia. Exciting causes of anaemia.  Fatal terminations.  [Anaemia
272         in connection with the puerperal state.]  Remedial measures.  Kegimen
             and diet.  Medicines.
273         Partial Ansemia.  Examples.  Effects.
          Section II.—Hyperemia, or Excess of Blood          -      p. 160
 274          Definition and nature.   Classification of varieties.
         Section III.—Plethora—General  Excess  of  Blood,   p.  160—164
 275—278  Origin of plethora.  Subjects.   Symptoms.   Tendencies.  Causes.  Di-
 279,280     vision into sthenic and asthenic.  Symptoms of sthenic.   Subjects. As-
 281, 282     thenic.  Symptoms.  Subjects.  Results. Fever, Gout, &c.  Remedial
 283,284     measures.  Bloodletting:  where unfit. In sthenic, other measures needed.
 285, 286     In asthenic, tonics as well as evacuants-
               Local Hypeiitemia.  Excess of Blood in a  part.
          Section IV.—With Motion diminished          -        p. 164- 179
 287, 288   Congestion analyzed.  Its causes classed.
 289         Congestion from venous obstruction.  Examples in health and disease.
 290         Congestion from atony of the vessels. From  general debility ; hypostatic.
 291, 292      From over-distention.  Examples.  From intropulsive action of cold
 293, 294      and of malaria [results from a state of imperfect reaction].  From pre-
 295, 296      vious excitement or inflammation.  Examples and illustration by micro-
 297,298      scope. From  direct operation of cold.  From arrest of secretion, or of 
                                 CONTENTS.                                7
 Par.
299, 300     capillary circulation.  Atony of  vessels impedes transit of blood.  Ex-
301          periments to show neutralization of force  in flaccid vessels.  Cause  of
302          long continuance of congestion.
303, 304    Symptoms and  effects of congestion.   Effects on secretion explained.
305          Production  of flux.  Examples.   Amount  of tension and  quality  of
306—308    blood determine quality of effusion, liquid  and solid.  Albuminuria re-
309           ferred to congestion of the kidney.  Reasons.  Congestion continuing,
310, 311      causes hypertrophy of a peculiar kind.   Origin of granular disease and
312          cirrhosis.  Other instances.
313         Remedies for  congestion.  Removal of causes.  Venous obstruction and
314         causes of atony.  Posture.  Pressure.  Friction.   Exercise.  Astringents
315, 316     and tonics.  [Congestion, the effect of morbid action of the nervous system
 317         on the  bloodvessels.  Application of this view to its cure.]  When inap-
 318         plicable.  Stimulant remedies.  Operation  shown by the  microscope.
319         When  hurtful.  Depletion and other evacuants. Preceding remedies pro-
320         perly combined or alternated.  Prevention of congestions.
         Section V.— Local Hyperemia, or  Excess  of Blood in a part,
             with Motion increased—Determination of Blood, p. 179—192
 321,322    Examples in health.  In disease.  Determination to the head.  Examples,
 323, 324      with symptoms. Caused by stimuli. Physical cause of determination
 325, 326      of blood. Enlargement of arteries proved by experiment and microscope.
 327, 328      Cause of the enlargement a loss of tonicity.  [Prior change in  the ner-
 329          vous tissue.]   Opinions refuted.  Final cause of determination to supply
 330          more  blood where  wanted.   Determination  by intropulsion.  Subjects
 331          of local determination.  Determination may cause anaemia in other parts.
 332          Determination affects large arteries.
 333_335   Symptoms and effects of determination.  To the head.  Explanation of
 336          the remarkable  difference  in  different  cases.   [Connection  between
 337—339     determination and  excess  or defect of red globules.]  To the kidneys.
 340          To mucous membranes.   To  the  skin.   Other symptoms.   Deter-
 341          mination if continued causes hypertrophy.   [Determination of blood
              sometimes  the effect of sympathy from prior determination to  another
              and remote organ.]
 342, 343  Remedies.  Removal of causes.  Means to promote contraction of dilated
 344, 345    arteries.  Cold.  Astringents. Derivants.   Posture.  Evacuants. Blood-
 346         letting ; general and local;  its effect seen in the  microscope.  [Skill  in
 347         diagnosis^  guide in the selection.]   Remedies to relax the arterial sys-
 348         tern, and quiet the heart.  Measures to equalize and strengthen the circu-
 349         lation.   Tonics.
          Section VI.—Results of Hyperemia      -       -       p. 1 92—216
 350       Hemorrhage, flux, and dropsy, results short of inflammation.
 351       Hemoriuiage  from plethora.   Examples.  Epistaxis, haematemesis, &c.
 352         from congestion of venous obstruction. Examples: pulmonary, bronchial,
 353         gastric, &c.  From atony of vessels; from posture; from intropulsion of
 354         cold.  Examples. From determination of blood.   Examples; epistaxis,
 355         haematuria,  apoplexy, &c.   Additional  element  of. hemorrhage in the
 356         vessels or in the  blood.  Bloodvessels diseased ; examples.  Blood dis-
 357,358    eased; hemorrhagic diathesis.  [Different states of the blood in  hemor-
 359         rhages.  Superabundance of globules in one variety, the sthenic, or that
             with plethora.   Deficiency of fibrin in the  asthenic or  passive variety.]
             Mode in which blood is  effused, by rupture or through pores.  [May  be
 360—363   considered a bloody secretion.]  Varieties of hemorrhage.  Sthenic and
             asthenic defined.                                      .
 364       Symptoms  of  hemorrhage. Molimen  hxmorrhagicum.  Faintness.  Re-
 365         action.   Transition  to  inflammation.  Examples.  Local effects and
             symptoms.   Passive  hemorrhage.                         _
 366,367  Treatment of hemorrhage.  Remedies  for hyperaemia.   Styptics.   Active
 368, 370    or sthenic.   Passive or asthenic.  Mechanical  means.   Special styptics.
 371,372    Tonics.  Derivants.
 373,374   Flux and Dropsy.  From plethora.  Examples.
 375       From congestion.  Experiment of Lower.  Examples in disease.
 376—378 From weakness of vessels.  After excitement.  Intropulsion of cold.
 379, 380   From determination of blood.  Examples ; active flux ; active dropsy. 
CONTENTS.
Par.
381,382  Flux and dropsy vicarious.   Examples.  Circumstances  causing hype   -
383         mia  to  lead  to  these results : in the vessels:  in the  blood.  ^iseaseu
384         blood from defective excretion, especially by the kidneys.  [Intemperance
385         the most prolific cause of albuminuria.]   Examples and proofs.  ^r0Psy
386         and flux with albuminuria: why inflammatory : resemblance to rneuma-
387         tism.  Thinness of the  blood cause  of asthenic  dropsy.  Dropsj'iron,
            retention  of water and  excrementitious matter in  the blood. |>niei-
            cause of impoverishment of blood causing dropsy is loss ot  albumen Dy
388         the  kidneys.]   Malnutrition.   Proofs.  Distinctive  pathology ol  tlux
389         and  dropsy.  Causes of each.                              .    ■oamo
390       General treatment of flux and dropsy.   Remedies for hyperemia.  Keme-
391         dies  for malexcretion and malnutrition.                        .
392, 393  Treatment of fluxes.  Derivants.   Removal of causes,   t or sthenic nux.
394         For  asthenic :  astringents,  tonics.  Dry and tonic regimen.
395       Treatment of dropsy.  Means to remove effusions, and  restore  action oi
396         kidneys in sthenic dropsy.  Means  to improve the  blood  in  astnema.
397         Recurrence of dropsy requires variation of remedies.    Examples.   lAr-
398         cumstances which indicate tapping or puncture.  Cautions.
           Section VII.—Local Hyperemia, Excess of Blood in a part,
             -with  Motion partly  increased,  partly diminished—In-
                                                                  p. 216—297
FLAMMAT10N
399, 400   Inflammation not understood from not studying its elements.  Definition.
401          Causes of inflammation and mode of operation.  Predisposing.
402          Exciting divided into direct or local, and indirect or general.   Local lr-
403          ritants, mechanical, chemical, and vital.  Indirect causes produce  con-
404,405      gestion.   Causes  mixed  in operation.   Checked hemorrhage and
406'          flux.  Irritants operate first on nerves.  But inflammation sometimes
407           excited without nervous irritation.   Cause essentially acts on vessels,
408           sometimes producing congestion first, sometimes determination.  [Chief
              seat of inflammation is in the capillary tissue, through changes in the
              functions of which come the phenomena of inflammation.]
409       Phenomena and  nature of inflammation.  Difference irom conges-
410         tion.  Essential characters established.   Increase of blood  with motion
4U         increased and diminished.  [Increase of motion doubtful.]  Cause of the
412         obstruction.   Views  of Cullen, Hunter, W. Philip, Alison, considered.
413         Examination of incipient inflammation with the microscope ;  descriptions.
414         Atony of the vessels a partial cause of obstruction : examples and experi-
415         ments.  Another cause within  the vessels: adhesion of white globules ;
416         their increase. Description and production  of white globules.  Messis.
            Addison and  Gulliver's observations.  Adhesive  property of white glo-
417         bules examined.  Their presence and properties essential to inflam-
418         mation.    Conclusions as  to  obstruction  of inflammation.   [Analogy
419         of inflamed part to a  gland.—Meckel's definition, and Muller's  explana-
420         tion.] Effect of obstruction to direct force on arterial capillaries.  This op-
421         position of obstruction to force also the cause of destruction.
422       Effects nf inflammation on vital properties.   [Blood  itself is affected in
423         inflammations.]  Effusions;  general character; microscopic character.
424         Exudation  corpuscles. Elementary  solids  of  inflammatory effusions.
425         Molecules.  Granules.  Fibrils.  Lymph corpuscles.  Pus  globules.  Tu-
426         bercle. Mode of formation of  some of these.  Other effects of inflainma-
427         tion.  Softening. Suppuration.  Slough. Gangrene.  Induration.
428       Symptoms and effects of inflammation.   Division  into  local  and
            general.
429,430  Local symptoms.  Redness; cause; varieties and causes; changes.  [Dif-
            ferential characters of inflammation and local congestion.]
431,432  Heat; cause; indications.  Swelling; causes; varieties from texture.
433,434  Pain ; causes.   Degrees and varieties, and their causes.  Other sensations.
435,436    Effect of inflammation on contractility. On other functions and symptoms.
437       Constitutional  symptoms.    Inflammatory fever.   Change  in the
438         blood.   Cause  of the increase  of fibrin, and its more  contractile  pro-
439, 440    perty.  This not the cause of inflammatory fever  with an irritation or
441,442    reaction.  Symptoms of inflammatory fever.  Its varieties.  High, low.
443, 444    Type of fever from cause or seat of inflammation.   Remittent and  inter-
            mittent fever.  No fever. 
Par.
CONTENTS.
9
    Nature and Symptoms of Results of Terminations of Inflammation.
445—447   Division.   Resolution.  Its nature.   Modes of occurrence.  Local symp-
             toms.  Constitutional symptoms of resolution.  Lateritious sediments ;
             cause, &c.
449        Effusion (including adhesion).  Not always a termination.  History of
450         effusions  in  serous  membranes.  Coagulable lymph.  Varieties.  Eu-
451         plastic.  Mode  of organization.  Formation of vessels.   Cacoplastic
452—454    lymph;  varieties and effects.   Aplastic lymph.   Causes of these low
455         products. Effusion of mucous membranes.  Interstitial deposit.  Changes
456         of mucus.   Effusion in  skin; varieties  of cutaneous inflammation.
457—459    Effusion in cellular  texture. In parenchymata.   Symptoms of effusion.
460       Suppuration  and ulceration.  Nature  of pus; microscopical characters.
461, 462    Its want  of  cohesion.   Causes of suppuration.   1.  Intensity of inflam-
             mation.   2.  Access  of air.   3. Condition of the blood.  Pus in the
463         blood 1  Process of suppuration explained : absorption  of all  but pus
464         globules.   Varieties of suppuration.   Diffused.   Abscess:  pyogenic
465,466    membrane:  pointing.   Opening and healing of abscesses.  Granulation.
467,468    Ulceration.   Varieties.   Causes.   Softening of textures.  Suppuration
             a work of destruction, therefore depressing.  Symptoms of  suppuration.
469         Local : constitutional:  varieties caused by limitation, or not, of suppu-
470         ration.  Purulent deposits.  Nature and  causes.  Possibility of  absorp-
471         tion  of pus.  [Pus  globules found in the  blood of healthy  persons.]
472         Depression from suppuration.   Hectic fever.  Varieties  of pus: lauda-
             ble :  ill-conditioned.
473       Gangrene.   Process of sloughing; gangrene; sphacelus.   Causes  ofgan-
474         grenet interrupted circulation: noxious  agents.  Local  symptoms and
475         effects of gangrene :  constitutional symptoms.  Combinations and grada-
476         tions of the results of inflammation.
                          Varieties of Inflammation.
477       Sthenic and asthenic.   Symptoms : results.
478       Acute inflammation.   Sub-acute : symptoms :  products.
479       Chronic inflammation.  Symptoms:  duration: products and results.
480       Congestive inflammation: nature:  symptoms: results.
481       Phlegmonous inflammation : nature:  causes: type and symptoms.
482       Erythematic and erysipelatous : local symptoms and effects : fever: cause
483         specified.   Pellicular:  asthenic: symptoms:  low  fever.   Plastic in-
             flammation  of mucous  membranes.  Aphthous  inflammation.  Hemor-
484,485    rhagic inflammation;  causes.   Scrofulous inflammation; asthenic;
             peculiar symptoms.  Scrofulous diathesis :  its external marks : its symp-
             toms and  causes.  Course and results of inflammation in scrofulous sub-
             jects.  Condition of the blood.   Gouty and rheumatic inflammations.
486         Nature and causes.   Gonorrheal inflammation ;  seat and effects.  Syphi-
487         Utic inflammation ; seat  and effects.
488       Treatment of Inflammation, best understood  from knowledge of its
             elements,  and of counteracting measures.
489       Tabular view of constituents of inflammation.
490       Tabular view of chief elements of inflammatory disease and their remedies.
491         Comments on the principles of antiphlogistic treatment. Remedies:  l,for
492         congestion;  2, and 3, for  irritation of nerves and vessels; 4, for
493,494     determination to the part; 5, and 6,  for obstruction in the part, by atonic
             enlargement  of capillaries, and adhesion of white globules; 7, for disten-
495, 496     tion of vessels;  8, for effusions from  the vessels; 9, for increased ab-
497,498     sorption;  10, for impeded circulation in  the part.   For the increased
499         circulation around the obstructed part.
500       Treatment of inflammation-with fever.   Local remedies secondary. Chief
501         remedy, general  bloodletting: effect; tolerance in  inflammation; cause.
502         Objects and  modes  of  bloodletting; in  recent  inflammation;  in  con-
503         firmed inflammation; in inflammation with plethora.  Local bloodletting;
504, 505     uses. [What controlling power has bloodletting in  inflammatory fever 1]
506         Evacuants ; purgatives ; combinations.  Tartarized antimony : modes of
507         exhibition: mode of operation.   [Acts as a direct depressor of the  nervous
508,509     system.]   Mercury :  calomel and opium : modes of  exhibition : opera- 
10
CONTENTS.
   Par.     ation.  [Sedative effects of calomel.]   Refrigerants.  Salines.  Diuretics.
510,511     Sedatives.   Counterirritants.   Treatment  of exhaustion.   Depression
512         from poison.   Solid effusions.  Antiphlogistic regimen and diet.
                 Treatment of Varieties of Inflammation.
513—517 Sthenic.  Asthenic.  Acute.   Subacute.   Chronic.   Congestive,   rmeg-
516 (bis)     monous.    Erysipelatous.    Pellicular.   Hemorrhage.    Scrotulous.
517 (bis)     Treatment of scrofulous diathesis.  [Benefits from simplifying the diet.j
519, 520      Rheumatic and  gouty.  Gonorrhceal and syphilitic.
CHAP. IV.-STRUCTURAL DISEASES;  OR DISEASES OF NU^1™^"
        Section I.—Nature and Classification  -    -     -    ,p', 1  K1  n
521       Arrangement of structural disease.   Table of elements.  [Andral b  1 able.j
522         Structural disease.  Modifications of natural nutrition.  Material ot nutn-
523          tion : fibrin.  Modes and process of nutrition.  Variations in  nutrition.
            [Proximate elements of other tissiaes exist ready formed  in  the  blood.]
524         Causes.  Relation  to nervous influence.
         Section  II. — Increased Nutrition — Hypertrophy.  [In  what  it
                          consists],       -     •     -     -     -    P • 3°2-3<>4
525         [Sometimes general and  connected with  scrofulous  diathesis.J   Va-
526           rieties.  Simple hypertrophy;  of muscles.   Examples   of mtersti-
527           tial  textures.  Of epidermis : varieties  in  skin diseases,  Complex
528           hypertrophy:  Uterus; breasts; brain; follicles; bursa,  &c.  Liver
529           and spleen.   Treatment of hypertrophy.
          Section III__Diminished Nutrition—Atrophy     -     p.  305—307
530         Atrophy may  be general.  Emaciation.   Causes.   Drains.   Causes pre-
531           venting reparatory  nutrition.  When traced to its cause an important
532           sign.  Partial  atrophy, from defective  supply  of blood.   Examples.
533,534      Treatment of  atrophy : general ;  partial.
                         PERVERTED NUTRITION.
 535         Alterations in kind; in texture       -----     p. 308
           Section IV.—Induration and Softening     -     -      p. 308—311
 536,  537    Both  may  be  independent  of inflammation. Nature  of  induration.
               Examples.
 538         Softening.  Specific causes.  Common causes.   Nature.  Examples.
 539         Treatment of induration and softening, opposite, but parallel.
 540,  541    Treatment of softening generally tonic and supporting.  Specific causes.
           Section V.—Transformation of Textures   -     -     p. 311—313
 642         Transformation  generally degeneration.  Exceptions : skin, and mucous
 543            membrane.   Transformation  of muscle.    Fatty  transformations.
 544            Fatty degeneration of the liver; of tubercle. Osseous transformation.
 545            Treatment of transformation.
           Section VI.—Deposits in or upon textures       -      p. 313—332
 546         Definition of deposits.  Nature.  Division.
 547         Euplastic deposits.   Cicatrices.  Respiration effected  by three modes.
 548            Dr. Macartney's view of the  modelling process.  Treatment.  Union
 549            by  first  intention: adhesive inflammation.  Dr. Carpenter's aecount
 550, 551       of organization  of cicatrices.  Reparation by  blood. Remedial mea*
 552            sures to promote the euplastic process.
 553          Cacoplastic and aplastic deposits.  Examples of the former: structure:
 554           causes, general and local.  Cirrhosis.  Granular degeneration.  Semi-
 555            transparent  grey  and  tough tubercle.  A degraded kind of lymph.
 556            Connexion with other cacoplastic deposits. Tendency  of cacoplastic
 557            deposits to  contraction ;  effects ; intimate nature.  To degeneration
                into  aplastic: this common tendency of tubercle  Form of tubercle ;
 558           causes.   Opaque change indicates  aplastic degradation :  causes of this
 559           change.   Primary  aplastic  deposits;  proof of degraded nutrition.
                Yellow tubercle.  Maturation and softening ; the converse of contrac-
  560           tion.  Chemical nature.  Fat in tubercle.  Changes of tubercle from
  561           adjoining  textures.  Quiescence of tubercle ; spontaneous  changes;
                 induration ;  plastery  and petrifactive change.  Causes  of cacoplastic
  562           and  aplastic deposits :  congestion : chronic and asthenic inflammation i
  563          degraded plasma of the blood, with defect of red particles.  Symptoms.
                Seat of tubercles.   [Proportion of  in lungs to that  in other  organs.] 
                                 CONTENTS.                              11
  Par.
  ***           Reason of liability of the lungs considered.  [Doctor Barlow's observa-
               tions.]  External or  exciting causes of tubercles: operation explained.
  b"         Treatment of cacoplastic and aplastic deposits. Elements to be considered
             1. Disordered distribution of the blood and its causes. Remedial measures.
 5""         2. Disordered condition  of the  blood, and its  causes.  Remedial  and
               preventive measures.
 567         3. Deposits  already  present;  their  effects  and changes.   Medicine of
               little efficacy.  Mercury;   alkalies'  iodides;  sarza; naphtha;  tonics.
 568           External  counterirritation.   Treatment during  degeneration   and
               softening of tubercle.   Nitric and  hydrochloric acid.  Diet, &c.
             Morbid Growths........p. 332
 569         Definition.  Names and divisions.   Analogous and heterologous, &c.
           Section VII.—Non-malignant Growths                  p. 332—339
 570, 571     Definition.  Serous cysts distinguished from enlarged natural sacs.
 572           Encysted  Tumours.  Hygroma.   Steatoma.  Antheroma, &c.   Dr.
 573           Hodgkin's  view of the cystiform origin of tumours.   Sarcomatous tu-
               mours.  Vascular sarcoma.  Adipose sarcoma.   Polypus.  Neuroma.
               Choudroma.  Osteo-sarcoma.
 574       Pathological cause of morbid growths.   Parasitic 1
 575       Hydatids :  Proofs of separate vitality ;  nature  and origin ; situations ;
 576,577     death.   Echinococcus.   Cysticercus.  Distoma.
 578       Medical treatment of morbid growths, and their effects.
        Section VIII.— Malignant Growths  -    -    -    -     p. 339—348
 579       Definition.   Character of malignancy ;  varies in degree.
 380       Carcinoma the generic term.  Varieties traced to different degrees of acti-
             vity  of cancerous  matter.   Some  chronic,  some  acute.  Elementary
 581         structure of  cancer: cells; forming fibres, &c.   Disposition  to grow
 582         at expense of  nutrition : parasitic nature 1  germs or ova :  communicated
             by injection into veins.   Local origin of cancer  as  modification  of  nu-
 583         trition.  Dr.  Hodgkin's view.  Practical deductions from  pathology of
             cancer.  Mode of origin.  Varieties of cancer explained by  difference in
             quantity and activity of germs, and activity of nutrition in adjoining tex-
             tures.  Scirrhus is the chronic form.  Symptoms :  tendencies : open
             cancer : growth : destructive effects on part, and on whole frame.   Pan-
             creatic, mammary, lardaceous, and salanoid intermediate forms of can-
 584         cer :  mode of growth.  Encephaloid  cancer the  acute variety : in parts
 585         and subjects where nutrition is active.  Cause  of rapid growth  of  en-
 586         cephaloid  disease.  Colloid  cancer, the cancerous element  in a separate
             form.   Other varieties from form, &c.  [Proportion of cancer occurring
             in different organs.]
 587       Melanosis.  Varieties.  Peculiar black matter:  its nature.
 588       Treatment of malignant  growths.   Indications.  1.  To  extirpate  them.
 589—590    2. To retard their development.  3. To counteract their effects.   Means
              of attempting the fulfilment of these.
 Section IX.— Disorders of  Mechanism   -     -    -    -    -  p. 348,349
 591         Changes in mechanism,  elements of disease.  Examples.   Dilatation.
 592—594      Contraction.  Rupture  and  laceration.   Displacement  and  compres-
 595           sion.  Contortion.
  CHAPTER V. —CLASSIFICATION, SYMPTOMS, AND  DISTINCTION
                      OF  DISEASES.
           Section  T. — Nosology.....-    -   p. 349—352
 596,597     Definition of special diseases.  Methods of classification.   Symptomatic.
 598, 599       Methods of Sauvage, Cullen.  Method of Pinel.   Modes of patholo-
 600           gical classification.   Definitions of disease with reference to pathology.
           Section II..— Semeiolooy and Diagnosis -    -    -   p. 352—368
 601,602     Definition of symptoms and signs.  [Proper distinction  made between
               symptoms and sign.   Use  of these terms by the best writers, ancient
               and modern.]  Physical signs.  Examples. Those of disease known
 603           by  comparison with  healthy standards.  Modes  of learning healthy
 604,605       standards.  Standard of symmetry.   Anatomical  standard.   Physical
606           signs explained by physical laws.   Vital symptoms, called also func-
607           tional and physiological, general and rational.   Examples.  Sources
608            of symptoms.  Pulse.   Skin.  Tongue.   Stools.   Urine.  Knowledge 
12
CONTENTS.
              of pathology best key to symptoms.  Statistics a temporary substitute.
              Respective value of physical signs and vital symptoms.   Division and
              nomenclature of symptoms.
            Diagnosis defined.   How founded.  Division into general and special.
              Diagnosis, illustrated by problems, and  modes of  solution.   Need  of
              every branch of medicine in diagnosis.  The test of ability and know-
              ledge.   Methods of examination with  regard to diagnosis, prognosis,
              and practice.  [Martinet's tabular view of the method of examination to
              establish a diagnosis of the disease.  Causes of fallacy.  Comparison
              between healthy and morbid states.]
 CHAPTER VI. —PROGNOSIS :  FOREKNOWLEDGE OF  RESULTS OF
               DISEASE........P- 369-388
616         Definition.   Prognosis, empirical or rational.   Empirical that of infant
              medicine.   Prognostics of Hippocrates.  Good and bad signs.  [Atten-
              tion to prognosis by the ancients.  Their writings too much overlooked.
              Good prognosis a guide to treatment,  by restraining from the use of
617,618      needless medication.]   Rational prognosis described and exemplified.
619           Circumstances from which prognosis may be formed.  Cause of dis-
              ease.  Of the subject: age; sex ; temperament; previous disease ; pre-
620           sent diseases ;  previous habits ;  condition at the time of attack.  Of
621           the disease : situation and nature ; extent and progress.   Of the symp-
622           torn* : character.   Good symptoms.  Bad symptoms  : signs of impedi-
              ment to a  vital  function,  and approach to one of the modes  of death.
623,624      Operation of all modes of death on the blood proved.  Modes of death
              arranged in table.
625         Death by syncope : by spasm of the heart; causes ; by loss of irritability ;
              causes; poisons ; diseases.  Symptoms of approach.
626         Death by asthenia :  from diseases.  Symptoms of approach.
627         Death by asphyxia.  Distinction.  Symptoms. Causes.  Varieties.
628         Death by coma.  Causes. Symptoms.  Combined with  excitement of me-
              dulla.  How does  coma cause death ?   Medullary symptoms the most
               serious.
629         Death  by paralysis.  Injuries to the medulla; to  the  afferent nerves of
630,631      respiration; to the efferent nerves.   Examples.  Paralysis of spinal
632           nerves with and without injury to the cord.  With injury of cord itself,
              symptoms and fatal tendencies.
633         Death by necrxmia.  Explanation.  Proofs ofdeath of  the blood.   Mode
              of spreading death to other parts.  External causes of necraemia. Vital
634           resistance to its causes.   Symptoms.  Modes of elimination of causes
635           of necraemia.   Intrinsic causes of necraemia. Symptoms  ofdeath by
636—638     necraemia.  Slow deaths, equal
         CHAPTER VII. —PROPHYLAXIS  AND HYGIENICS     -   p. 389
639         Definitions.   Prophylaxis connected with  special pathology.  [Prophy-
               laxis.   Its divisions.  Its application of physiology, hygiene and  eti-
               ology.  Neglect of it  in  season.  General  ignorance on the  subject,
               and mischievous  effects  in  consequence.   True prophylaxis, adapted
              to the prevention of various hereditary  diseases.   Should be begun at
               birth.   Prophylaxis of indigenous diseases; of epidemic and of occa-
               sional or  sporadic disease.  Medicinal substances,  sometimes useful
               prophylactics.  Ought to be long persevered in.   Prophylaxis on  a
               large scale with advancing civilization.]
 640        Hygienics refers to means to resist disease generally,  and to means which
               maintain the general health.  [Hygiene not attended to as it ought to
               be in modern times.  Great neglect of its requirements in Great Britain.
               Imperfect drainage and sewerage and supply of water to the inhabitants
               of towns, and also villages and in the country.  Classification of the
               agents of  hygiene.  Subjects treated of  under each class.  Conditions
               for longevity.  Causes and  modifying  circumstances affecting health
               and generating disease.]
Par.
610

611,612
613
614
615 
ON  THE  NEED  OF  THE  STUDY

                          OF

         GENERAL PATHOLOGY,

                          AS

 THE FOUNDATION  OF PRACTICAL MEDICINE.
Extracted from an Introductory Lecture on the Principles and Practice
     of Medicine, delivered at University College, Oct. 1, 1842.
   [The following remarks may serve as an introduction to the pre-
sent work, as they were intended to be introductory to that part of
the course of lectures which embraces  the same topics.  As an
apology for the familiarity of their style, the reader may be reminded
that they are printed as delivered.]

   State of practical medicine, as  a study, and as an art — In-
       sufficiency of empirical and nosological medicine — Gene-
       ral pathology the true foundation for practical medicine
       — What is  general pathology ?— Its relations to clinical
       medicine — Noble nature and objects of medicine.
       ******
   I must farther state another circumstance which greatly upholds
my anxiety to bestow my  best exertions in teaching the subjects
of my course.   It is, the low position which  this most important
part of medical science still holds with  the public, and even  with
students.   I feel this to be a matter of such moment, that  I propose
to make the chief subject of this lecture, the state of practical me-
dicine, as a study, and as an art.
   Compare the state of the practice of medicine with that of ana-
tomy, physiology, and chemistry — the great fundamental or pre-
paratory studies.  How  minute, how precise, how connected and
definite, are these !  Yet how. loose, indefinite, uncertain, uncon-
nected, is  the practice of our art.   To the public it appears  alto-
gether vague — without any acknowledged principles.
   Is there any wonder, then, that quackery should triumph ?  that
the public show their want of faith in legitimate medicine by  their
ready belief in any novelty that  is  not legitimate ?  Thus, one
          • 2 
14
INTRODUCTORY LECTURE.
year, St. John Long's plan ; another year, homoeopathy ;  another,
Morison's pills; another, the water-cure — rules the fashion.  The
public may show their ignorance by such credulity ;  but they show-
also  the want of something plain and trustworthy in regular medi-
cine.  The public will not believe that the secret of the art is  with
a faculty which professes to follow experience only.   The quack
also  can appeal to his  experience; and  that, too, in a way more
striking and convincing  than those who express doubts and admit
difficulties.  Thus, one who cures nervous diseases can  calculate
his success by the numerical method.   In eight thousand  cases he
can count  only twenty failures.  Another tells you of an extraordi-
nary per centage of success in cases of deafness, in which the most
eminent practitioners  had failed, &c.  Hence you will  find the
partisans of quackery far more zealous in the defence of  their fa-
vourite notions  than  others are in  support of the regular art.   No
wonder that homoeopathy and the  water-cure have their royal and
noble advocates.   Then there is  a captivating simplicity in the
theories of quacks.  A certain high official personage pins  his  faith
to an empiric who was formerly a gardener, and whose notion is,
that  all diseases proceed from buttercups.   This is  the  theory :
every man,  woman, and  child, eats mutton, beef, or butter, or
drinks milk ; every cow and sheep eats buttercups with its grass;
buttercups are rank  and acrid weeds ; ergo, all diseases  proceed
from butter-cups.   How beautifully simple !   How  attractive, too,
are the comprehensive views of the hygeist and the water-curers !
They both agree in their pathology ; all diseases arise from bad
matter  in the blood;  they only differ in their mode  of expelling it
from the system.  One  purges out the peccant humour; the other
washes  and sweats it forth.  There is something, too, very fasci-
nating in the notions of homoeopathy:  similia similibus medentur.
Who cannot fail to admire the expansive genius of Hahnemann,
who discovered that the best cure for a  disease is the influence
which caused it ?
  On the other hand, the regular practitioner has nothing  so plau-
sible or  so captivating to bring forward in explanation of his me-
thod.  He either has no theory at all, and grounds his practice on
experience, (in which we have said he is matched by the empiric,)
or, if he gives a theory, it is viewed only as an opinion no better
than the hypothesis of the quack, in  an  art so little founded on
principles  as medicine.   So little favour does medicine receive from
the public in its pretensions to science !
  How is it with  the student ?  Surely to the student the practice
of physic must be as interesting as it is important — the useful ap-
plication of  all his knowledge — the winding up of the drama of
his studies — the  rehearsal of the great  performance of his  life.
Surely this must be a very attractive study ?  Quite the contrary.
I  believe  it has  been  generally considered by students as the
heaviest, most repulsive, most tedious of all  subjects (with, per-
haps, a  single exception).   Without  the constant appeal to the 
          ON THE NEED OF PRINCIPLES  IN MEDICINE.         15

senses with which anatomy attracts and  rivets attention ; without
the beautiful  connexions and adaptation of means to ends which
make physiology interesting; without the simplicity and striking
phenomena  which  give  a charm to chemistry — the practice of
medicine, as taught, is an enormous mass  of dry detail; its science,
mere glimpses  into an unknown land; its rules, irregular tracks
through a wilderness of confusion.  Practical  medicine  is studied
only from a conviction that it is  useful  and  necessary ; and not
because it is easy or agreeable.
   Further, there are a great many students, certainly not the  most
industrious, who shirk the  disagreeable  duty, pleading that  it is
neither useful nor necessary ;  and that the practice  of/ medicine
is  only to be  learnt at  the  bedside with whatever aid  books can
supply.   It would speak  more in favour of this opinion, if its advo-
cates acted up to their dogma, and proved, by their  constant and
diligent attendance in the wards of the  hospital, that they  seek
there the knowledge which they profess to be unable to obtain in
the lecture-room. But, so far as my observation has  gone,  I do
not find this to be the case.  It  is not those that neglect the lec-
tures, but those who  most regularly attend them, that prove to be
attentive students in  the hospital.
   But, although useful and necessary, it cannot be denied that the
study of the practice  of medicine, both  by books and by lectures,
is  at first very difficult and irksome — more so than  other studies.
But  why is it so ? This  is a serious matter.  Let us examine a
little into it.   Is  the fault in the imperfect state of the subject, or
in the method by which it  is  taught ?  The science of practical
medicine is undoubtedly  very imperfect; but  I  think it can be
shown that there is a still greater imperfection in the method by
which it is taught.
   As anatomy and physiology, with chemistry, are the studies pre-
paratory to medicine, one might expect that they should  be made
fundamental to that of medicine ; that, starting from the knowledge
of the healthy body, as taught by them, the transition should be
easy and intelligible to disease — first, in its  lowest degrees and
simplest form;  then to that which is more compound, pronounced,
and more removed from, but  still comparable with, the healthy
standard.  Instead of this, lecturers  and writers plunge at once
into the mazy thickets of inflammation and fever — subjects so
complicated, so changed from anything taught by previous study,
that  anatomy and physiology  afford little help: and  no won-
der that the student  (like many observers and reasoners on  the
same topics) becomes confused and bewildered in the complexity
of the subject; or, if he do make out  anything, it is something
isolated, abstract, about fever or inflammation  itself, without its
natural relations to health and to other diseases.
   This plan of proceeding may be compared  to a person begin-
ning the study of mechanics  with the  steam-engine ; or to  the
student of chemistry commencing with organic matter. 
16
INTRODUCTORY LECTURE.
  The general  result is, that where any distinct notion  of dis-
ease is acquired, it is one not at all founded on previous physiolo-
gical knowledge, but it is a  new idea of disease as an absolute,
separate thing — not a mere condition consisting  of altered func-
tion and structure, but a being, the character and history of which
are to  be detailed like that of a plant or  an animal.  And when
special diseases are treated of, the same individualizing process is
pursued through all the jargon of the schools.  Each has its noso-
logy, classification, and definition ; its predisposing, exciting, and
proximate causes ; its theory, ratio symptomatum ; its diagnosis,
prognosis, indications  of cure, fulfilment of these, juvantia et
lasdentia, and prophylaxis !
  With all this formidable  array to each disease, the practice of
physic was an arduous study in the days  of Cullen.  What must
it  be now, when the diseases of Cullen's  nosology have  been
almost doubled, and  the facts  relating to  them have been more
than doubled ?
  But let us follow the student, well crammed with his nosological
list,  their definitions, &c, to the bedside.  Let us see how  his
knowledge, so meritoriously and laboriously obtained, will serve
him in the hour of need.   In  a few cases of fully developed and
well-marked  acute diseases, such as pleurisy, scarlet-fever, or
rheumatism, he may get on pretty well; but in the commoner
description of cases, acute or chronic, in their early stages, in their
endless variations  from peculiarities of constitution, or from com-
plicating causes, he finds himself continually puzzled :  the pheno-
mena do not  correspond with  any of his defined diseases; they
frequently change their character in a way that he cannot account
for; his prognosis is falsified;  his diagnosis fails; and  his treat-
ment, although not always unsuccessful, does not answer according
to his expectations;  some patients recovering whom he expected
to die ; others dying, or  not  improving, whom he expected to
recover.
   Disappointed in the failure of his nosological learning, the young
practitioner more and more  mistrusts  it, and falls in a routine of
empirical practice.   Without troubling his head about the name
or nature of diseases, he thinks  solely of their  treatment; and
begrudging the time that he has spent with books and lectures, he
decries everything that is not practical,.
   Still he is obliged to retain some notions of the theory of dis-
ease ; but they are generally notions, and not fettered  by defini-
tions.  He still studies symptoms: he seeks in the pulse and heat
of skin indications of fever and  inflammation ;  he  looks to  the
tongue and  alvine  evacuations  for  proofs of  disorder  of  the
digestive organs; he judges  by  the  complexion and muscular
strength the state of the constitution.  Instead of troublesome
scholastic definitions, he  uses  convenient, general terms which
 may be taken in a pretty vague sense — such as irritation, con-
 gestion, constitutional weakness, cachexia,  disordered digestive 
ON THE NEED OF PRINCIPLES IN MEDICINE.        17
organs, scrofula, scorbutic habit, and the like ; and his remedial
measures are designated  in the same convenient general terms —
such as soothing, cooling, supporting, stimulating, alterative, puri-
fying, &c.
   In short, he has, in practice, learned himself, in a loose way, at
the expense of previous  studies, and sometimes, it is to be feared,
at the expense of some bad practice, what he ought to have been
properly taught as the foundation of his studies — general patho-
logy.  Thus we are  led to the presumption that  general patho-
logy is  the proper basis for practical medicine ;  and I venture to
affirm, that a chief reason why the practice of medicine has been
commonly so distasteful, and so difficult in its study, and so un-
satisfactory when tested at the bedside, is, because  its foundation,
general pathology, has not been efficiently taught.
   We have just met with a practical illustration of the truth, that
general pathology is a more efficient help at the bedside than such
knowledge of diseases as is to be obtained only from nosological
definitions and details.  Before I proceed to exemplify this truth,
by matters  of every-day experience, let  me first briefly point out
why it is so.
   Without the  connecting link of general pathology, practical
medicine derives little or no  aid from anatomy and physiology.
Instead of being founded on them, it is studied and practised quite
independent of a full knowledge of them, and is generally acquired
 in proportion as they are forgotten.  This kind of  practical medi-
 cine is  much the same as that of old women and nurses;  it con-
 sists chiefly of treating symptoms, or groups of symptoms, (called
 diseases,) by remedies that have been found useful m similar cases,
 without the trouble of inquiring about the causes of the symptoms,
 or the precise seat  of the disease.   Thus, if a person complains of
 headache and giddiness, leeches are applied, and purgatives are
 given, because they have been found useful in similar cases.  An
 intimate  knowledge of the structure and functions of the contents
 of the head would give  no further help in the use of these reme-
 dies ;  nor suggest others, if these be found to fail.  If they do
 fail, the only resource is in experiment: first one thing is tried,
 then another, until much mischief may be done, or at  least, per-
 chance, the  right remedy may be  hit upon ; and this may be the
 very opposite'of those  first used.   Long  experience may make
 the symptom-treating practitioner more successful, if  he  be an
 observing  man ;   because  it will acquaint  him with  additional
 symptoms  to  be  considered  for the guidance of the treatment,
 But there are few  of  this class of practitioners who are carefully
 observing men, who do  remember  and profit by their experience :
 they more generally, like their sisters, the nurses, keep pretty close
 to their first notions ; and although age and the  name of experi-
 rience may screen  their failures, alas for the young adventurer
 who sets sail on this tack !
    But the benefit of such experience is gained at the commence-
              2* 
IS
INTRODUCTORY LECTURE.
ment by the student of pathology.   He has learnt to trace symp-
toms to their causes.   Having been taught, by anatomy, the pecu-
liarities  of  the  circulation  in the  head —and  by physiology,
confirmed  by clinical observation, that  this  circulation  may be
similarly impeded by opposite causes, inanition as well as fulness,
— he is prepared to  find out, through other symptoms, which is
the cause of the  headache in the case before him ; and he adapts
his remedies accordingly.
  In fact, a true pathology, or  sound principles  of medicine, is
the embodiment of the result of experience in disease, with a
knowledge  of structure and function in health.  It is  the only
connecting link  between the preparatory sciences  and  practical
medicine.    Without it, these are disjecta membra;  with it, they
form  a connected body  of  science — young  yet, it is true, and
falling short of  the  objects  of  the art, but already  available for
much, and needing only  the growth and continued support of its
chief members,  especially anatomy, physiology,  and clinical  ob-
servation, to become the  perfect  and efficient director of practical
medicine.
   The great proof of the practical utility of general  pathology is,
the aid which it gives in the study of clinical medicine, and the light
which clinical medicine continually throws on it.  The states which
the practitioner  has to treat  are  often too indefinite or too mixed
to correspond with any of the definitions of special disease.  They
frequently consist of functional  disorder, varying with time and
circumstance, or changing  its  place, so as to present  no fixed
characters.  But, compared by the pathologist with the standard
of health, and analyzed from  their complexity, their nature be-
comes  intelligible, and their proper treatment obvious, so far as
 means are possessed to counteract or control that which is wrong.
 Let us take one out of many examples. The disordered  state of
 health, for treating which Mr.  Abernethy gained such  a reputa-
 tion, is one of the commonest ailments  we  have to  prescribe for :
 some  call  it, with Abernethy, "all stomach ;" others, "liver;"
 others," disordered constitution;" others," indigestion :" but how-
 ever differently they may name it, few refuse to treat it, as Aber-
 nethy did, by regulated diet, blue pill, and  mild saline  aperients,
 repeatedly administered.   Now,  the  pathologist  analyzes the
 symptoms of such a state,  and  in  the white or yellowish furred
 tongue,  morbid eructations, tender epigastrium, sometimes full
 right  hypochondrium, with extended dulness on percussion, the
 discoloured faeces, the high-coloured and  turbid urine, he finds
 proof of  congestion and disturbed secretion of the liver and upper
 part of the alimentary  canal ; and he  recognises in the remedies
 employed, means which, by increasing the secretions, relieve the
 congestion ; and if these fail, he can suggest other measures which
 he knows to be efficacious in removing congestion, and restoring
 the natural secretions.  Again, what confusion in diagnosis, as
 well  as  in practice, has  arisen from  comprehending, under the 
           ON THE NEED OF PRINCIPLES IN MEDICINE.        \Q

specific name hysteria, the most opposite and most varying con-
ditions, merely because they are consorted with some nervous
phenomena ; so that this word becomes almost synonymous with
female diseases.  But, pathologically considered, the confusion in
diagnosis, and, in some measure, the perplexity in regard to treat-
ment, cease.  In one group of  such cases, the pathologist  finds
really such signs of disordered  uterine function as would justify
the  name  ; other symptoms, however varied, taking their  origin
from this disorder ; and he thus  discovers the necessity of direct-
ing the treatment to this cause.   In another group,again, he finds
the uterine function impaired ; but this only in common with other
functions: and all this in consequence of a want of blood through-
out  the body, which want  is denoted by the waxy complexion,
the pallid lips and gums, the loose yet easily  quickened pulse, the
panting breath, the feeble limbs, &c.  Here the restoration of the
 blood is  the obvious indication;  and in proportion as  this is
effected, the symptoms of nervousness, debility, and loss of func-
 tion, disappear.  In a third group of cases, called hysterical, the
 pathologist discovers the opposite condition,  that of  sanguineous
plethora, which,  independently of any  disorder of the  uterus,
 causes trouble, sometimes in one part, sometimes in another, but
 especially in the nervous system, which,  in most females, is pecu-
 liarly liable to disorder.   Here, too, he is led to the most appro-
 priate treatment.
   This is but one instance out of many that might be adduced to
 show the great practical utility of a good knowledge of pathology.
 In fact, the leading rules of practice, those  which guide the most
 experienced men, (although many are not aware of it, and would
 not acknowledge it,) are founded  on  general views of diseased
 function  and structure—that  is, general pathology.   You will
 not find that practical men treat a disease merely according to its
 name, or according to the nature of the  local mischief.  Inflam-
 mation is not always  to be combated by bloodletting, nor hemor-
 rhage by styptics.   The condition of the system — that is, of the
 functions, is to be taken into account; and the variations of this
 condition, the states of sthenia and  asthenia, tone  and debility,
 excitement and  depression, plethora  and ansemia, are the very
 subjects  which  general pathology explains and  shows  how to
 treat.
   I say, practitioners do act more on general ideas of disease than
 on their knowledge  of particular diseases.  They feel  the  pulse
 and the skin, to guide them in  the use  of bloodletting, whether
 they  have found out the special disease or  not.   They examine
 the  tongue,  and inquire as to the state of the evacuations, to
 guide them in the use of purgatives,  under whatever complaint
 the patient labours.   They consider the complexion and  bodily
 strength in connexion with dietetic measures; and the chief treat-
 ment of convalescence depends on rules suggested by general patho-
 logical knowledge. 
20                INTRODUCTORY LECTURE.

  There are other very important departments of medicine which
are comprehended in general pathology, and  with it have  Dee
too  much neglected — I mean, the study of the causes of  dlsea*G
and their modes of operating on the living  body, (etiology,) ana
the means  by which  they  may be  avoided or counteracted,
including prophylaxis, or the prevention of disease ; and hygienics,
preservation of health.  Neither of these subjects can be satislac-
torily comprehended without a sufficient knowledge of the elements
and laws of disease.                                  .
  Is it not, therefore, most  important  that  these  general views
which are so practical and so extensive in their application, should
be  well founded and carefully studied ?  Is it right that the lead-
ing doctrines of disease, — leading, not in theory, but in practice,—-
should, as hitherto, be left to be picked up irregularly, from casual
retrospects of study or experience, when they may be  learned  as
the very groundwork of practical knowledge ?
   What, then, is  this general  pathology, which we extol  so
much as the proper foundation of practical medicine ?  Let us first
state  what it is not.  It is not  a collection of hypotheses hung  on
solitary facts, and ingeniously devised to  explain this  or that
symptom, or the modus operandi of this or that remedy.  It is not
anything floating on (I cannot say founded on) conjectural notions
in  anatomy and physiology, such as the existence and circulation
of  a nervous fluid, the presiding influence of the ganglionic system,
or  the vital attractions  and repulsions of the circulating fluids ;
notions which, however they may hereafter be substantiated, are
at  present too speculative to form a foundation for pathology. Nor
 is  it a partial set of opinions, erected on one only of the many
 pedestals of fact on which  the science of medicine should  stand.
 Healthy anatomy,  physiology, physics, chemistry,  the  study of
clinical medicine, that of materia medica,  morbid anatomy —
neither of these alone can furnish a foundation  for pathology —
 that  foundation must be  formed by  all — the facts which  all
 supply constitute the  material  of  which it is built,  and  the
 general facts  or laws of all must be brought to bear on  the
 arrangement of these materials  in the construction of a system
 of pathology.
    Some advancement in these contributory departments  is neces-
 sary before  the work  can  be  begun, and it is because they have
 advanced that the opportunity is afforded.  Why  should the science
 of medicine remain in a state of powerless infancy, when its mem-
 bers are progressively acquiring strength and  maturity ?  Why
 should the art of medicine still be a groping about in blind empiri-
 cism, and an unintelligible confusion of facts, when science even
 now can afford it the beginnings of light and of  order ?(a)
  (a) Notwithstanding this flattering prospect, promise  it may be
called, of the lights furnished by science, we must still regard her
with reasonable mistrust, changing as  she does her dress and her 
          ON THE NEED OF PRINCIPLES IN MEDICINE.        21

  I have just said that the  contributory sciences are sufficiently
advanced to  be generally applicable to practical medicine.  The
proofs of this in detail will,  I trust, appear in  the progress of the
course; but I will  adduce  here a few examples of a prominent
kind.  Disease, in so far as  it is the result of mechanical change,
or  in part made up of mechanical elements, may be properly

signals from  time to time, and holding out hopes falsified by sub-
sequent  experience.  Equally confident were the promises made
in her name nearly a century ago, when Boerhaave  was authority
through  his Institutiones Medicae, and subsequently  Gaubius in his
Institutiones Pathologicas Medicae.  Mechanics, general physics,
and chemistry, were then, as now, appealed to, for the support of
medicine.  They failed  in  their  promises.  Will they be truer,
hereafter, to the trust now reposed in them ?   The fact is, that, so
far as medicine is demonstrable through, it is merged in them, and
ceases to be the science of a living body.   It  may  have  recourse
to them, as aids for illustrating some of the phenomena, and fur-
nishing hints for their modification ; but if it takes them as guides
or directors, it will inevitably be lost and become a wanderer from
its legitimate field of investigation.  Have  we arrived at the know-
ledge of a single function ? have we cured a single disease, by all
the aids  of mere science, in the strict sense of the word ; that is, by
mechanics, general physics, and chemistry  ? That we have derived
aid in our attempts at a solution of  these recondite problems, as in
the  instances of respiration and  digestion, will  not be denied,—
but this  is not meeting the main question.
   Even  on the score of hygiene, and particularly that division of
it relating to dietetics, chemistry is far from having  furnished  "a
key to the most important rules,"  as asserted  by the author in
another  paragraph of this introductory lecture.  It aids us to group
and classify the materia alimentaria, and gives us many useful
approximative views, but, as yet, it has not furnished us with fun-
damental principles.  One  of the most notable deductions from
chemical knowledge, applied  on a large scale, was  that made by
D'Arcet, in his recommendation of the use of gelatin procured from
bones, for the food of the needy and destitute poor in Paris and other
places;  but experience did not bear out  the theory here without
considerable qualifications, for acquaintance with which latter  we
were indebted ultimately to physiological observation  of the vital
 and characteristic phenomena of digestion and nutrition.
   In these remarks we must not be supposed to intend the slightest
 disparagement of the exact or demonstrative  branches of science,
 but merely to designate their  real  value.  For  ourselves, we  are
 too much accustomed to press continually on  the  minds of  the
student, an  extended and  liberal  course of  inquiry  and obser-
vation in all the collaterals of medicine, to be in  any danger of ad-
vocating an undue  restriction  in these particulars  at  the present
time. 
22
INTRODUCTORY LECTURE.
treated by mechanical means.  It was the knowledge of this fact
which  led Dr. Arnott to  invent  that admirable  contrivance, the
water-bed, by which disease is  often prevented and removed ;
and  he has lately made another application of physical science,
in modes  of applying pressure to parts with such equality as to
control  to any degree the circulation of the blood through them,
and  thus  to relieve pain, remove congestion, subdue inflamma-
tion, heal ulcers, disperse swellings and arrest the growth, if not
to effect the removal, of tumours and other morbid productions.
Disease, so far as it is physical in its nature  and in its effects, is to
be investigated by  physical  means.  Hence  the advantage  of
acoustic science in  assisting  us  in diagnosis of internal disease,
and of optical science in enabling us to witness the minutiae of its
operations and its products.  I need scarcely add, that the treat-
ment of disease  is  in some  instances  founded  on, and in most
cases guided by, knowledge thus obtained.
  As an example of improvements in anatomy and physiology
oearing on practical medicine, I  may mention the late researches
on  the nervous system, and especially those  of Dr.  Hall.   By
these, much that before  was  unintelligible in diseases of the ner-
vous system has been satisfactorily explained, and their diagnosis
and  treatment have received proportionate aid.  Considerable
light has been thrown on diseases  of the liver and  of the heart,
by  recent anatomical and physiological investigations of these
organs.
  The aids afforded by chemistry to the materia medica have been
long acknowledged, and continue to increase; but chemistry is
growing in  importance  in its applications to every department of
practical medicine.  It is now directly useful in the diagnosis and
treatment  of diseases of the  urinary organs.   It furnishes a key
to the most important rules  of  diet, in health as well as in dis-
ease, and  bids fair to supply much that is wanting in explanation
of the origin of many maladies,  and the most direct mode  of pre-
venting them.   It is through the aid of organic  chemistry, now
far advanced — advanced, too, mainly by the labours  and genius
of an illustrious chemist, who this  day honours us with his pre-
sence, (Professor Liebig) — that we may hope that experimental
physiologists and clinical observers will be enabled to solve some
of the dark problems of the operation of medicines ; a subject re-
plete with practical importance, yet one that still lies chiefly in
the  region of conjecture.
   It will not be disputed that clinical observation has lately done
much  for the advancement of the science of medicine ; and this
not  only because it is the test by which the contributions of other
 branches  are tried, but  also because in itself it is carried on with
the  minuteness and  precision  which  are  essential  to science.
This precision must apply, not only to  the  modes of calculating
facts, but also and most particularly to the correct determination
and classification of these facts.  The accuracy of counting is a 
          ON THE NEED OF PRINCIPLES IN MEDICINE.        23

mere facility in common arithmetic.  The accuracy of observing
and  arranging  the facts to be counted  is the higher  and rarer
quality.   Both are required in the prosecution of clinical research.
  The whole department of practical medicine teems with exam-
ples  of the benefits which  it has  derived from morbid anatomy.
What should we know of the nature, products, and tendencies of
inflammations, and other diseases which alter the structure, but
for the scalpel revealing them to our very sight and touch ? The
minuteness with which it (morbid anatomy) has been pursued in
connexion with clinical observation, in regard to  diseases of the
lungs, heart, liver, kidneys, and alimentary canal, deserves especi-
ally  to be mentioned as the great  source  of our improved  theory
and  practice in these complaints.
  It  is not a general  or superficial knowledge of any of these
fundamental sciences that will avail to  make  them profitable to
medicine.  It  is where their facts and laws have been carefully
studied, in relation to the  living  body, that  the  advantage has
become practical;  and this  study has in many instances developed
new phenomena,  which reflect light also on  the  contributory
science.  The  application of  hearing to the distinction of diseases
has given rise  to a more intimate  knowledge  of acoustic science.
Some of the most interesting facts and laws of organic chemistry
have resulted   from researches instituted with reference  to the
investigation of disease; as, for example, those of  Prout, Wohler,
and  Liebig.   In regard to anatomy and physiology, the instances
are  abundant.   For  example, the researches  of Charles Bell,
Foville, and M. Hall, on the nervous system, and  those of Astley
Cooper on the  testicle and  mamma, were conducted with express
reference to diseases of these  organs, and were  often suggested
by  the knowledge previously possessed of these diseases.  In
this  respect they followed John Hunter, who throughout his ana-
tomical labours had an eye to pathology, and by observing dis-
ease, was continually guided to objects for these labours.
  So we shall find, as we  proceed  to the details of pathology,
that  subjects which require  further research are continually pre-
sented to us in  a practicable form; and  I shall  take  occasion to.
point out some  of these, in the hope that  some among  you may
be induced to cultivate  ground which is rich in  promise  of im-
portant practical results.
  Do not suppose, because  I insist strongly on general pathology
being the proper basis of practical medicine, that this will  lead us
to neglect the superstructure, special pathology.   Individual dis-
eases will be the chief subjects  of the  course,occupying 100 out
of 130 lectures; and I trust that their details  will become much
more comprehensible  by the arrangement  into  which  general
pathology will enable us to distribute them.   It is because  I feel
the vast importance and extent of our knowledge of individual
disease, that I  would endeavour to introduce  you to it from the
most advantageous and commanding position ; and that position 
24
INTRODUCTORY LECTURE.
is afforded by a  previous acquaintance with the general features
of disease.   In fact, individual diseases are like the leaves and
boughs  of the  tree, of  which general pathology constitutes the
trunk and great  branches—all preserving an  identity and con-
nexion, yet each portion having peculiarities  of character which
require separate study.   Or medicine may be compared to a great
edifice, the foundation and great entrances of which  represent pa-
thology,  which generally give the proper approach to the separate
rooms, special diseases.  To some of these, in the imperfect state
of the structure, there may be access only by the dark back ways
of blind experience, which there must not  be  neglected ;  but this
is no reason for making these dark back ways the only entrance.
  Throughout our examination of the details of disease, we shall
find the principles of general pathology continually exemplified ;
and through these principles the mind can master the details to an
extent wholly unattainable  by those who pursue  them as uncon-
nected matters of fact.   Those who begin the study of practical
medicine by attempting  to  learn the details of  diseases, are like
those  who would endeavour  to master all the facts of chemistry
without any knowledge  of  the general facts or  laws of chemical
action, affinity, and definite proportions ; yet even in  practical che-
mistry, or chemistry applied to the arts and manufactures, the most
extensive and important services have  been obtained from  these
very principles, applied to the details.
  But in treating of individual diseases, although we  shall find our
previous pathological principles of great use  in explaining and
simplifying the details, we are not to be tied to them whensoever
experience varies from those principles, or goes beyond them;
there, experience must be carefully followed.  There is no subject
in which this simple statement of fact is more frequently necessary
than in regard to the modus operandi of medicines.  It is  quite
true, that many curious  speculations have  been offered on this
subject.   In fact, it  seems to be quite the hobby, or  the Pegasus,
of a very speculative class  of men who call themselves practical.
These can tell you to a  nicety how  mercury cures syphilis;  how
opium causes sleep ; on  what precise parts of the intestinal tube
each variety of purgative acts, &c.   But, as in most of such hypo-
theses, there is much more of fancy than of fact;  and as the fancy,
if erroneous, may be mischievous in a strictly practical matter, I
shall be excused if I prefer  giving you the naked matters of fact.
  The purpose  of lectures on the practice of medicine  is not
merely to convey knowledge of disease  and  its treatment, but
also   to direct the mind in the  ways  of using this knowledge
and of acquiring more.   Books will supply details which cannot
be given in the lectures; but the more important additional source
of information   is clinical instruction.  This is  an  essential
part of the teaching of practical medicine.   It is its demonstrative
part,  and is essential,  not  only because, like  other witnessed
phenomena, it appeals  to  the senses, but also  because  it is ne- 
          ON THE NEED OF PRINCIPLES IN MEDICINE.         25

cessary to practise those senses in the examination of the signs of
disease, and to exercise the reasoning powers in the interpretation
of those  signs, and in  the further application of previously  ac-
quired knowledge.  As general  pathology is the connecting link
between  the preparatory studies and practical medicine, so clinical
instruction is the step  between the knowledge of medicine and
the personal application of that knowledge in actual practice.  I
need not say that each of these is most necessary to the formation
of a good practitioner : but there are especial reasons why clini-
cal study, connected   with the  practice of medicine,  is  more
indispensable now than it ever  was.  In former days, medicine
was little more than a matter of  routine ;  and the examination of
a  patient was summed  up in feeling  the pulse, looking  at  the
tongue, and asking a few questions as to the feelings and functions,
and this  was often done for the sake more of form than of informa-
tion ; for the pills and draughts were much the same in most cases.
This was little better than quackery,  and  required no great prepa-
ratory study.  That it sometimes succeeded to win the favour of
the public is not surprising, seeing that quackery often had a simi-
lar or greater success.   Then the ignorant practitioner could  dis-
guise his emptiness by a cloak of mystery, and a solemnity of
manner, and could command confidence  by dropping a hint about
his experience, tact, and intuitive perception of disease.  But igno-
rant as people still are in medical matters, they are not so dull as
to be deceived by these means.   They have a smattering of phy-
 siology  and the  use  of remedies, and they are  become  trouble-
 somely inquisitive; and if they are  taken in, it is by the clever
quack, who is ready with his theories and persuasive proportion
 of cures, and not by the unsatisfactory-regular, who examines but
 little, and cannot explain his views or  his practice.  In short, the
public look for what they have a right to expect,  thoroughly edu-
cated practitioners, who prove their  qualifications by their care-
ful method of investigating disease, the clearness  with which
they  give  their  opinions, and  the general correctness of those
 opinions.
   This,  then, is another reason for thoroughly availing yourselves
of practical instruction, especially in the clinical department.   The
great importance of this department has  occasioned the adoption
of extended measures for teaching it.  1 trust that you will prove,
 by the assiduity and  success of your  practical  studies,  that  the
 college has not adopted these means in vain : but that, as in  the
 preparatory branches, so  in the  finishing  of  your medical educa-
 tion, you will obtain that high standard of qualification that must
 insure the confidence and esteem of those among whom you  may
 exercise your calling.
   Gentlemen, we have great pleasure  in meeting you again for
 the session—those who  have favoured us before,as old triends ;
 new-comers we welcome to  the work, which, although  arduous,
 is not one of drudgery.  I almost envy the pleasure, in young and
            3 
26
INTRODUCTORY LECTURE.
ardent minds, of rising step by step in knowledge, and delighting
in the wonders and beauties of the enlarging view.  I admit that
the ascent is arduous — that it requires hard labour, and no little
self-denial.  But is there no compensation in the delight of ac-
quiring knowledge and intellectual power?  No gratification in
learning and'contemplating the intricate beauties of the most per-
fect part of the creation?  Is there no moral  and  religious go^d
to our own minds in tracing out and unveiling its frailties, weak-
ness,  decay, and death?    No satisfaction in learning of means
which a gracious Providence supplies for preventing and removing
the ills which flesh is  heir to ;  for relief  of  pain, suffering, and
weakness, and restoration of health and strength ?   And  if from
present studies you carry your anticipations onwards to their final
object in practice — under  Heaven,  yourselves  to ease suffering
humanity, and to invigorate and prolong life —  is the pursuit less
noble, or less worthy of your highest thought ?   Need I say more
for the intellectual and moral greatness of our art ?
   Is a study noble in  proportion to  the  breadth, and depth, and
diversity of the knowledge on which it is founded ?  Then, think
of medicine ; how  she levies her contributions from every branch
of knowledge.  The human body exhibits a machinery so perfect,
that the  most skilful  mechanical philosopher may take  lessons
from  studying  it.   It contains  a  laboratory so  diversified,  and
chemical processes so subtle, that therein  the ability of the most
expert chemist is far surpassed.  But the knowledge of the student
of medicine  must go beyond that of  the mechanical and chemical
philosopher.  He must study those vital properties of which they
can tell him  nothing.  He must become acquainted with the attri-
butes  of life operating  in matter.  In animal generation, nutrition,
growth, secretion, motion, and sensation, in the variations of these
processes, in their decay, and in their cessation, which is  death,
he has a complicated study, peculiarly his own, in addition to those
of a more  elementary nature.   He  has, besides, to  contemplate
the body under disease, and to bring  to his aid the three kingdoms
of nature, and almost every art and every science, for agents and
means to counteract and control that which disturbs its well-being.
But is the  body the only object of his  care ?   No'.  Mind and
matter are  too  closely combined to be studied or treated apart.
To medicine alone it belongs to  contemplate and to treat the
ENTIRE MAN--PHYSICAL, MORAL, AND INTELLECTUAL.   What Call  I
say more of the intellectual greatness of our art ?
  Neither  shall I strain your thoughts far to remind you of its
moral worth.  See its effect on masses of mankind displayed in
the progress of the happy discovery of Jenner !   See how even
barbarous people and idolators, Mussulmen, Hindoos, and Chinese,
respect our nation  only for the medical aid which it  can supply.
So that it has happened that medicine has become  the  handmaid
of religion—a bond between countries, a peace-maker between
nations. 
          ON THE NEED OF PRINCIPLES IN  MEDICINE.        27

  But let  us not  vaunt ourselves.  Listen to one who speaks of
our art — and that one the eloquent ambassador from the United
States, the Honourable Edward Everett.  I quote from the Times
of the day before yesterday: — " For what was that which consti-
tuted the chief pride and glory of the British nation ?  They had
heard of the intercepted letter from one Chinese chieftain to another;
and what was the characteristic which had excited the admiration
of the mandarin  of a great and important empire, reeling at  the
time under the blows of the British government ?  Was it the mili-
tary prowess of their countrymen?  Was it the steam-vessels of
war reaching coasts in defiance of the desolating simoon ?  Was
it their arms — their artillery — their  skill of engineering, which
civilized nations  now brought to the strategy of war?  Was it
this, or any of these, which had struck  with wonder, and awe, and
admiration, the barbarians of China ?  No !   It was the humanity
of British physicians and surgeons—their managementof hospitals,
and the generous kindness  which was extended to the sick and
wounded, even of a hostile nation — which  moved them with
astonishment,  and excited their sympathy and  regard.   These
were some of the arts of peace which extorted the admiration of
an  enemy, and which other states would do well  to imitate." (a)
   But if you would see the moral influence of medicine depicted
in its  liveliest hues, I would ask  you to contemplate a domestic
scene — a family whose hearts are wrung with a dreadful anxiety
for  one  vibrating between  life and death.  What a  ministering
angel does the physician seem!  How they watch his every look !
With what breathless earnestness do they hang on his words! and
those words, how they wing themselves to the souls of the hearers
for sorrow or for joy ! Yet such scenes are passing daily and hourly
in every class of society — in the mansion and in the cottage :  they
open the hearts of all; for the moral influence of medicine is bound
up with the treasures of life and health, and with all those endear-
ing ties that make these treasures  doubly precious.  Nay, how
often,  with the hopes, or fears, of a blessed or an awful eternity !
   Do not think me too euthusiastic, nor that  I overrate the profes-
sion you have chosen.  Morally and  intellectually I cannot over-
rate it: and now, at the commencement of  a new epoch of your
studies, when toil and exertion  are required, I would cheer  and
encourage you, by reminding  and convincing you of  the intrinsic
gratification which these studies may afford, and of the nobleness
of the objects for which they prepare you.
   It is the fashion to  decry our profession — to call it a poor pro-
fession, a degraded profession.  If it be poor and degraded, is that
the fault of the calling, or of  those who practise it;  or rather of

   (a) So deeply impressed with this truth are the different religious
 bodies, associated for  missionary purposes,  that every encourage-
ment is now given to young medical men to join with the clerical
ones sent abroad for the conversion of the heathen. 
28                 INTRODUCTORY LECTURE.

those who should have governed and protected it ?  Is the art of
healing in itself less noble, because  its  practitioners, unsupported
by the  arm  of  civil power, and too often  unsustained  by a con-
sciousness of their own dignity, have not raised it to the  place in
society which it ought to hold ?  Poor it may be, but degraded it
cannot, shall not  be, so  long as its foundation is science, and its
end the good of mankind. 
PRINCIPLES  OF   MEDICINE.
 EXPLANATION OF THE SUBJECTS OF  THE WORK.

  1.  The Principles, Elements, or Institutes of Medicine
comprise those leading and general facts and doctrines regarding
disease and its treatment, which are applicable, not to individual
cases only, but to groups or classes of diseases.  The same branch
of medical knowledge is also designated by the term General
Pathology  and Therapeutics, to distinguish  it from  special
pathology and therapeutics, or the theory and practice of medicine
in relation to individual diseases.
  2. The principles of medicine  may be deduced in part from a
knowledge of animal structure and function, anatomy and physio-
logy, conjoined with an acquaintance with the agents which cause
and remove  disease ;  but chiefly they are derived from a general-
ization of facts observed in an extensive study of disease itself, and
its effects, in the living and in the dead body.  But so far as they
have been ascertained, they become more intelligible to the student
if explained synthetically, by first describing the causes of disease,
then their operation on the body, and lastly, the resulting changes
in function or  structure which constitute disease  in  its more ele-
mentary forms.                                           .
  3. Etiology, or a knowledge of the causes of disease, will in
troduce us to their effect — disease ; the nature and constitution ot
which will  then be considered under the head of pathogeny, or
pathology  proper.  As this  last subject  is the chief one to be
treated, it will form the greater part of the work, and it will be
combined with such an elementary view  of the principles of
treatment as reason and experience may supply.
  4. A short general view will afterwards  be given  of the pheno-
mena of disease, (semeiology,)  the division and classification of
disease, (nosology,) their distinction,  (diagnosis,) their result,
(prognosis,) and  their prevention,  (prophylaxis and hygie-
nics.) (a)__________________________
 ~la) The division and terminology^FthoTifferent branches oT
the Institutes of Medicine  have undergone little  change with suc-
cessive writers, from Boerhaave's time  down to the^present day.
That which has taken place is  more  the  result of carelessness
            3* 
30           WILLIAMS'S PRINCIPLES OF  MEDICINE.
                    DEFINITION OF DISEASE.
  5. The reader is supposed to be  acquainted with anatomy and
physiology: without a  knowledge  of these, we cannot proceed

of the author in defining, than  from any exigency of the  case
from advancing  knowledge, or a  larger number  of premises.
Boerhaave recognised five chief parts in the Institutes: 1. Physi-
ology;  2.  Pathology;  3.  Semeiotics;  4. Hygiene;  5. Thera-
peutics.  Under the second head, or Pathology, he ranks, etiology
and  symptomatology; — as under  Semeiotics  he  includes  the
signs both of health and disease; and under Hygiene, he speaks
of prophylaxis, or the  art  of warding off disease when it is im
minent.   Belonging to Therapeutics, are the  results of  obser
vation, by the physician, of the existing deviations  from health,
and  the subsequent reasoning as to their  extent and the means, in
general, for their removal, alfof which are designated  by the terms
indications, or curative indications.  The rules  or conditions by
which these  indications are revealed, constitute the plan of cure
(methodus  medendi), and of course  an appreciation of the nature
and  direction, for their use, of the different classes of medicine and
regimen for the sick.  See Institutiones Medicae (Lugduni, 1713).
  Gaubius, the disciple and successor of Boerhaave  in the  Ley-
den  school, defines medicine  to be a knowledge  and prudent
direction of the powers of the human economy for the preservation
of life and of health from  diseases and death.   He divides  the
Institutes of Medicine into two great parts: the first of which em-
braces the whole doctrine of all the circumstances in man conform-
able with nature; and the second, whatever operates in  him
against  nature.   Tbe former  he designates as  Hygiene,—the
latter latrike or  Iatrics.  He defines hygiene, in its  comprehen-
sive  sense,  to  include the entire duty of the physician  towards a
person in health.   It embraces — 1. Physiology.  2. Physiological
Semeiotics, or the signs by  which we recognise life and health in
general, and its various states and degrees in each individual.   3.
Dietetics, or the aids and rules by which life and  health may be
preserved,  uninjured, for the longest period.
  Iatrics is also  tripartite—viz. 1. Pathology.  2.  Pathological
Semeiotics, or the doctrine of signs  by which we detect whatever,
present, past or to come, is obscure  in disease.   3.  Therapeutics,
which furnishes  the aids against, disease and the correct manner of
employing  them.  General Pathology, according to Gaubius, in-
cludes observation of  and inquiry into the nature, differences,
causes, and effects of diseases ; and, accordingly, he  discusses this
division under the sub-heads: De naturd morbi; de  causa morbi
(etiology);  de symptomate  (symptomatology).  (Institutiones
Pathologise Medicae.)   In  common with Boerhaave, he separates
symptomatology, the  doctrine of symptoms, from semeiotics or
semeiology, the doctrine of signs.  In reference to the application 
DEFINITION OF DISEASE.
31
even to a definition of disease.   Disease is known only by compa-
ring it with the standard of health, which it is the object of anatomy
and physiology to describe.
  6. Health consists in a natural and proper condition and pro-
portion in the functions and structures of the several parts of which
of the term symptom, Gaubius declares expressly, that, whatever
latitude the ancients may have taken in their application of this
word, certain it is that symptom, at the  present day, can be only
predicated of a sick man.   Semeiotics, we have seen, is made, both
by Boerhaave  and his successor, to  include  the characteristic
manifestations both of health and disease.   We pray the reader's
attention to this point, as it will come up  again when the author
gives his definition  of the differences  between symptom  and
sign.
   The author, in  the present work, has separated etiology from
pathology proper (page 29) ;  but not, as it seems to us, very ad-
visedly or happily.   The study of the causes  of  disease  forms
an integral part of that of pathology, as distinctly laid down by
the eminent teachers  just  referred to.  Chomel, in his valuable
work (Elemens de Pathologic.  Generate), following  in the path
of Gaubius, describes, under the general head of pathology, the
definition and nomenclature of diseases,  equivalent to the nature
of disease, touched on by Gaubius, then etiology,symptomatology,
and semeiology, in the  divisions of diagnosis and prognosis; the two
last corresponding with the difference  and effects of diseases, as
stated by the Dutch professor.   But among the effects to be noted
are, the organic changes  revealed  by post-mortem examination,
and  to which Chomel devotes a chapter.  This writer  is faulty,
however, in speaking  of  Therapeutics as  a part of pathology.
For all practical purposes  they ought to be closely connected ; but
neither can be properly declared to be a  division of the other.
The two conjointly constitute a very important share of the Insti-
tutes or Principles of Medicine.  Chomel is correct in the initiatory
announcement of his  first chapter; that  all which relates to man
in a state of sickness belongs to pathology,—just as all that relates
to man in a state of health comes within the domain of physio-
logy.   But although pathology applies to all the derangements of
health, it cannot rightfully include the means adapted for  their
removal, or therapeutics ( Therapeia).
   The order in describing  his subjects pursued  by Dr. Williams
as indicated in paragraph 4, p. 29, is not  as natural a one as could
be desired.  Semeiology, including diagnosis and prognosis, though
not identical with symptomatology, yet  as made up in a great
measure of symptoms, ought to follow this latter and precede the
treatment.   The  phraseology is  lacking in definiteness, which
makes semeiology synonymous with the " phenomena of disease"
and confounds it wi'th  symptomatology, or  confounds either signs
or symptoms with phenomena. 
32
WILLIAMS'S PRINCIPLES OF MEDICINE.
the body is composed.   From physiology we learn that these func-
tions and structures have to each other  and to external agents
certain felations, which  are most conducive to their well-being
and permanency ; these constitute the  condition of health.  But
the same knowledge also implies that function and structure may
be in states not conducive to  their permanency and well-being;.
states which disturb the due balance between  the several proper-
ties or parts of the animal frame ; and these  states are  those ot
disease.   For example, physiology, as well as experience, teaches
us, that in health the digestion of food  is easy and without annoy-
ance.   But when, after food is taken, there is pain, sickness, eruc-
tation, flatulence, or the like, we know that the function  of diges-
tion is changed from the healthy standard — is diseased; and  if
this diseased function continues long in spite  of remedies which
usually  correct it, and  if on examining  the abdomen we find at or
near the epigastrium a hard tumour, which anatomy teaches us is
not there in health, we know that there is also diseased structure.
  7. We find, then, (§ 6,) that  there isdisease offunction,known
by its deviation from  a standard furnished by physiology; and
disease of structure, which we recognise by a standard  supplied
by anatomy (§ 5).  These varieties  of disease may be, and very
commonly  are,  combined:  there is  seldom structural disease-
without some disorder of function ;  and in  many instances func-
tional disease is, or will be, accompanied by change of structure.
  8. Looking, then, to anatomy and physiology as standards, we
may define disease to  be, a  changed condition or proportion  of
function or structure, in one or more parts of the body, (a)
  9. The standard of  health is not, however,the same in all indi-
viduals  : that which is health to one may be  disease to  another.
Thus if we instance individual functions.   The healthy  pulse in
adults averages from 70 to 80;  yet there are some in whom  90
or 100 is a healthy pulse.  Some persons fatten on a  quantity of
food on which others would starve.  The animal functions, mus-
cular  strength and  activity, nervous  sensibility, and the  sensorial
powers, vary still more in different individuals, yet all within the
limits of health : but what  is health in  one would be decidedly

   (a) That  state or condition  of the  living body  taking  away
the ability to exercise  any function, is called disease.  (Boerhaave,
op. cit.)
   That state of the human body, in which the functions proper  to
man cannot be performed conformably with the laws of health, is
called disease.  (Gaubius, op. cit.) This writer properly  adds : —
Imperfections, however, of  functions depending on age, sex, tem-
perament, &c, when they are  within the range of health, are not
included in this category. Chomel (op.  cit.) defines disease to be, a
notable disorder, supervening either  in the  material arrangement
of the constituent parts of the  human body or in the exercise of its
functions. 
              NATURE AND DIVISION OF CAUSES.             33

morbid in another.  Such unusual proportions of certain structures
or functions constitute varieties of temperament ;  and although
they can scarcely be called morbid, yet they certainly give, as we
shall afterwards see, a proclivity to disease.
                       CHAPTER I.

          ETIOLOGY — ON THE CAUSES OF DISEASE.

                         SECTION T.

               nature and division of causes.
  10. Disease sometimes originates within the body from a change
in some of the component parts of the animal frame, without any
obvious external influence : thus disorder may arise from an undue
proportion or predominance of  a function, as that of the nervous
system ; or of a constituent of the body, as in the case of sangui-
neous plethora.  Such states, however,  constitute more commonly
proclivity to disease than  disease  itself; and generally  disease
arises from causes extraneous  to the body, although in many in-
stances we may fail to  detect these causes.
  11. A great variety of agents and circumstances may act on the
body so as to produce disease;  but in  most instances there is not
that uniform and constant relation between  these  as causes, and
the diseases as effects, which we might expect from the analogy
of causation in  the simpler sciences.   In chemistry or in mechanics
effects certainly and uniformly follow  causes;  in  physiology or
pathology, no doubt, effects also ensue ; but  whether these effects
shall be manifest as disease or  not, will depend  on many circum-
stances, of which we often cannot take cognizance.  It is true that
when the causes resemble and act like those of physics or chemis-
try, their proper effects will not fail to ensue.  Thus, a cutting in-
strument, a  red-hot iron, or a corrosive liquid, will not fail  to pro-
duce disease, beeause it overcomes vital properties by physical and
chemical, and  disorder  must follow.   Further, certain poisons  and
other energetic agents, which act on without destroying the vital
properties of living parts, may also, if of sufficient strength, pretty
constantly produce  morbid effects.  Thus, opium  causes somno-
lency; tartar emetic excites nausea, vomiting, &c.(a)

  (a)  The  causes above mentioned in  the  text,  have been
called  common determining.    The list might be extended by
instancing  certain  gases  unfitted for respiration, the foul  air
evolved by the exhumation of dead bodies, the odorous principles
of certain flowers and fruits, very high or very low temperature,
excess of lisht or of noise, electricity.
  Specific determining causes are the necessary  and sole causes of
certain diseases, which, as  they acknowledge, severally, but  one 
34
tWILLIAMS'S PRINCIPLES OF  MEDICINE.
  12. But the common causes  of disease are seldom of this de-
cided and positive character ;  they are often present without dis-
ease ensuing; and  they are known  to be  causes  only because
disease  is observed to ensue in a greater number of cases when
they are present  than  when  they are absent.  Thus,  improper
food is a cause of indigestion, and exposure to cold is a cause of
catarrh; yet many persons eat unwholesome food without suffer-
ing from  indigestion, and  many are exposed  to  cold without
" taking cold."  But those who do suffer from indigestion observe
that they do  so  more  after taking improper  food ;  and those
who  are  affected with  catarrh  can often trace it to exposure to
cold.  The reason of this uncertainty of  action  is chiefly in vari-
ous powers by which  the body resists  the morbific  influence ;
which powers vary  much  under different  circumstances.   The
failure of this power constitutes a predisposition to  disease.
   13.  Causes of disease were formerly divided  into remote and
proximate: the remote include both the predisposing and the
exciting causes, the only circumstances now considered as causes.
They were called remote, not because they are distant or not in
the body, but because they are not, like  the proximate cause, a
constant and present part of the disease.  The term proximate
cause was used by Cullen (after Gaubius) to represent the patho-
 logical  condition, or  essential bodily change, on which the symp-
 toms depended ;  and it was called a cause of the disease, because
 diseases were by him defined to be an assemblage  of symptoms.
 But this  essential bodily change is rather a part  of  the disease
 than a cause, and must be considered under the head of pathology.
 Discarding, then, the term proximate cause, we have only to con-
 sider the predisponent and exciting causes.
    14. The co-operation of both these kinds of causes is generally
 necessary to produce disease.  A number of persons are exposed
 to cold: one gets a sore throat; another, a pleurisy ;  another, a
 diarrhoea; and a fourth  escapes without any- disease.  All four
 were exposed to the  same cause, yet it acted differently on all.
 The three  first were predisposed to the disease, which attacked
 them as soon as  it was excited by the cold.  The  fourth had  no
cause and have their peculiar characters, may be also called spe-
cific.  They have  been (vide  Chomel), subdivided into common
specific causes, such as certain metallic emanations, some poisons,
miasmatic exhalations  and the poisonous virus of certain ani-
mals ; and into contagious principles, such as variola, scarlatina,
measles,  and syphilis.   The  first of these,  or  common  specific
causes, do not extend their operation beyond the  individuals sub-
jected to  their influence: the second, or the contagious principles,
multiply  and extend themselves  in the progress of the disease, so
that the individual who receives any one of them into his system,
engenders them in  his turn  to  a  great  extent, and  may transmit
them to other  individuals. 
NATURE OF PREDISPOSING CAUSES.
35
predisposition; the  exciting  cause was therefore  powerless; it
was insufficient without the  predisposing  cause;  as in the other
cases, the predisposition was insufficient, until the  exciting cause,
the cold, was applied.
   15. In some  cases, however, where sufficiently  strong, what is
in a smaller degree a predisposition, in a greater degree constitutes
a sole cause  of disease (§11): thus  a person  with  a very weak
stomach always  has indigestion, whether an  exciting cause be
applied or not.  So likewise exciting causes, if sufficiently strong,
may produce disease without predisposition: thus a person not
predisposed to indigestion may be pretty sure to earn it, if he
take a  sufficient quantity  of raw cucumber, pickled  salmon, or
any such indigestible matter.  Take another example.  A healthy
person living in a marshy district may not get an ague, until he
becomes debilitated by any cause, such as cold, or fatigue : then
the poison will act.   But without his being thus weakened, if the
exciting cause be  made stronger by his sleeping  on the  very
marshy ground itself, then the poison may act without  predisposi-
tion, and the  ague begins (§ 12).
   16. The consideration of these facts throws some light on the
nature  of many predisponent causes.   There is  in organized
beings a certain conservative power which opposes the operation
of noxious agents, and labours to expel them when they are intro-
duced.   The existence of this power has  long been  recognised,
and in  former days  it  was impersonated.  It was the  archaeus of
Van Helmoilt; the anima of Stahl; the vis medicatrix naturae
of Cullen.  But without supposing  it to be aught distinct  from
the ordinary attributes of living matter, we see its  frequent opera-
tion in the common  performance  of excretion; in  the careful
manner in  which the noxious products of the body, and offending
substances in food, are ejected from  the system; in  the flow of
tears to wash a grain of dust from the eye ;  in  the act of sneezing
and coughing to discharge irritating matters from the air passages ;
and in the slower, more complicated, but not less obvious example
of inflammation, effusion of  lymph, and suppuration,  by which a
thorn or other extraneous object is removed  from  the flesh.
   17. This vis conservatrix  (§ 16) is alive  to the  exciting causes
of disease; and in persons in full health it is generally competent
to resist them.  How it resists them will depend on what they are.
For instance: — Is cold the cause ?  It throws the blood inwardly ;
this, by  increasing the secretions, and exciting the heart to reaction,
establishes  a  calorific  process, which  removes the cold.  Is the
cause improper food ?  The preserving power operates by  dis-
charging this speedily  by vomiting or by stool.  Is it a malarious
or contagious poison?   It carries it off in an increase of some of
the secretions.   But if this  resisting power  (§ 16) be weakened,
locally or generally, or if the exciting cause be too strong  for it,
then the cause acts,  and disease begins (§ 15).
   IS. In the cases hitherto noticed, predisponent causes consist in 
 36           WILLIAxMS'S  PRINCIPLES OF MEDICINE.

 absence or deficiency of power (§  16), rather than the existence of
 anything positive : but sometimes  predispositions depend on some-
 thing positively wrong in the organization ;  and this error may be
 congenital, or hereditary, or acquired from previous disease.
   19. It must be observed that predisponent causes operate chiefly
 through the constitution, or some of its powers; hence they are
 often called constitutional or  internal causes, in contradistinction
 to the exciting causes, which are more commonly external, (a)
 But these terms are objectionable, because not always applicable.
 Sometimes the term predisposing  is also inappropriate, as in the
 following instance.  Several persons are exposed  to a malarious
 or infectious poison :  some of these  afterwards suffer much from

   (a) Predisposing causes  have been divided  into  general and
 particular or individual.  General predisposing causes are those
 which depend,chiefly, on various states of the atmosphere or on sub-
 stances diffused through it, and  also  on certain circumstances of
 locality.  W^e may add, also, agencies which, although operating
 by the production of disease on  individuals, exert often a marked
 influence on men in masses, and often from the  very circumstance
 of their being thus congregated.  Examples of this variety of causes
 are seen when the inhabitants of a besieged city, or the crews of
 fleets in time of war  or on long voyages, suffer  from defective or
 damaged food and bad water; and, also, during  a disastrous war,
 when moral emotions of a depressing kind contribute to the pro-
 duction and aggravation of disease, both among  the troops and
 the inhabitants of an invaded or conquered country.  Under other
 and  apparently  more  favourable  states of society, the people,
 subjected to strong and varied excitement, by political, commer-
 cial, and religious freedom and latitude without restraint, are
 found to suffer more from insanity and  its accessory phenomena
 of hypochondriasis, &c, than a people idle, ignorant and enslaved.
   Individual predisposing causes  are  more numerous than the
general ones, as there are a multitude  of agencies influential on
 individuals in their  separate state,  which cannot be common to a
 large number ; and, besides the general predisposing causes already
 specified, may, at the same time, become individual predisponents.
 These are divided by Chomel into — 1, causes peculiar to many of
them, inherent in each individual; — and 2, external causes, which
 predispose, with more or less activity, to the development of disease.
The first series of causes, or those peculiar to  the individual, he de-
signates by the very fitting and yet familiar and colloquial term apti-
tudes.  These are, birth, age, sex, temperament, constitution, habits
profession, degree of comfort or destitution, the state of the disease'
convalescence, and health even, and pregnancy, all of which  states
 and conditions render  a person  apt  to be attacked by some one
disease rather than directly produce them.
  Most of these causes are described in the text, and hence  they
need not be enlarged on in this note. 
PREDISPOSING CAUSES OF DISEASE.
37
fatigue  or privation; they then  begin to  show the effects of the
poison; others, who have not suffered this second trial,  escape
unhurt.  The poison has entered the system of both ; the last resist
its influence ; the subsequent weakening reduces the powers of re-
sistance in the  first class, and exposes the system to the exciting
cause ; but occurring after, it cannot be said to predispose.  Hence,
under such  circumstance, the fatigue or privation is called the de-
termining cause.
                         SECTION II.

              predisposing  causes  of disease.
  20. It will be useful to illustrate, by a few examples and expla-
nations, the chief predisposing causes of disease.   In doing this,
I shall enlarge on a list supplied in Dr. Alison's  " Outlines of Pa-
thology."

  I.  Debilitating Causes of Predisposition are the most numer-
ous of any.   So we might expect from  the fact that constitutional
strength  generally implies power of resisting disease (§  16, 17).
The weakness which renders the body liable to disease is that espe-
cially which enfeebles  the heart, and impairs the tone of  the arte-
ries :  it is often accompanied with an unusual susceptibility of the
nervous system, which increases the liability of the  body to suffer.
The following are the chief of this class.
  21.  (1.) Imperfect  nourishment, whether from defect in the
quantity or quality of the food, or from  incapacity of the digestive
powers.   This in itself may cause many diseases,  particularly  of
the digestive organs;  but it also produces a  liability to low fevers
and inflammations, epidemic and contagious disorders.  Thus the
susceptibility of the body to infection  when fasting, is  generally
acknowledged; and  the  rapid  propagation  of  infectious diseases
among an ill-fed  population, such as the poor Irish, is  too well
known.
  22. (2.) Confinement  in impure air.  The  injurious effects  of
this are apparent in the pallid, cachectic complexion of the inhabi-
tants  of crowded cities, even  those who live well and regularly.
How do they contrast with the ruddy countenances of the hardy
and coarsely-fed mountaineer!  So do  they also in their  liability
to diseases, particularly to those of the nervous and  nutritive func-
tions.
  23.  (3.) Excessive exertion of mind or body without sufficient
sleep.  Exercise is beneficial to both body and mind ; but when
it exceeds what  the  strength can bear, or  rest can  recruit, the
animal functions are exhausted, and lose their balance, tone is im-
paired, nervous excitability takes the place of strength, congestions
ensue, and various organs are on the brink of disease.  It is thus
           4 
38           WILLIAMS'S PRINCIPLES OF MEDICINE.

that the fatigued mind or  body is peculiarly prone to suffer from
causes of disease.
  24. (4.) Long continued heat, particularly when combined with
moisture, and unrelieved by the invigorating  influence of occa-
sional cold.   The debilitating effects of this agent are remarkably
exemplified  in  warm climates and seasons.   The  muscles, and
with  them the  heart  and arteries, lose power  and  tone ; vessels
become relaxed ; perspiration  is profuse ; and internal  organs,
especially the liver, are too much stimulated by  blood that has lost
more than usual of  its water, and less of its oxygen.  Hence the
disposition to bilious and liver complaints, dysentery, and  cholera.
Overheated rooms and excessive clothing likewise  predispose to
disease by their weakening and relaxing influence.
  25.  (5.) Long continued cold, not sufficiently counteracted by
artificial protection and by muscular exertion.  Cold applied oc-
casionally, invigorates, because it is  followed by a  healthy reaction,
in which  the vital properties are exercised and exalted.   But when
long continued, its sedative and debilitating effects are permanent;
it weakens the  circulation, especially that of the surface, causes in-
ternal congestions, and directly lowers all the vital energies. Hence
the most  malignant forms of epidemic fever in this country are ob-
 served to prevail towards the close  of very severe winters ; and  all
diseases may then assume a typhoid type.  This is observed chiefly
 among the lower orders, whose means do not enable them to pro-
tect themselves sufficiently against  the inclemencies of the season.
 We have before adverted to the striking manner in which cold dis-
 poses the body to suffer from malaria.
   26. (6.) Habitual  intemperance  with  intoxicating liquors.
 There  is  probably,  in this country,  no source of disease more fer-
 tile than  this.  Besides many winch  it excites, it also predisposes
 the body to attacks of fever, erysipelas, dysentery, cholera, dropsy,
 rheumatic and urinary diseases ; and if it do not increase the  prone-
 ness to inflammatory disorders, the  habit of intemperance  certainly
 disposes  them  to  unfavourable terminations, and causes many a
 victim to sink  after accidents and operations, which would be com-
 paratively trifling in  a sober subject.  Nor can we wonder at  the
 pernicious effects of this kind of excess, when we consider the un-
 sound state of function  and structure which stimulating  drinks
 induce, especially in  the organs which they most directly affect,
 the stomach, the liver, and the kidneys.  We  shall soon have to
  explain how such an unsound state of these organs  peculiarly  im-
  pairs the powers of the body to resist or throw off disease (§ 17).
    27. (7.)  Depressing passions of the mind,  such  as fear, grief,
  and despondency.   Many are the  instances in which numbers as
  well as individuals have escaped a prevalent disease,until depressed
  by some unhappy event or apprehension, and then they have fallen
  victims.   Such was instanced in the ill-fated Walcheron expedition,
  and in many passages in the history of armies in pestilential coun-
  tries.  A defeat, a failure, or even  bad news, made many succumb 
PREDISPOSING CAUSES OF DISEASE.
39
to the pestilence who had before escaped.   It is a common remark,
that when a contagious or epidemic  disease prevails, those who
take most precautions frequently suffer, because they are timid and
fearful, whilst the stout-hearted and reckless are unscathed.
  28. (8.) Excessive and repealed evacuations, either of the blood
or  of some  secretion from it.   The weakening effect of a large
loss of blood needs no explanation; but. the injurious influence of
habitual losses, if they be more than the system can repair, is still
greater; for the functions then  become depraved, a state of ca-
chexia as well as anaemia is induced, and a little cause may suffice
to determine many states of disease.  Various hemorrhages and
discharges, menorrhagia, diarrhoea, and other fluxes,  if in excess,
reduce the powers  of  life and the capacity to resist disease.  No
secretion, however, weakens so  much or so irreparably, when in
excess, as that of semen.  In many of the lower tribes of animals,
the males live till they copulate, and then die : the reproduction of
the species is at the expense of the individual.  That our species
is not wholly exempt from this law of organized  nature, is appa-
rent from the fact that immoderate venery is known  to induce ex-
treme debility and  premature decay, and to dispose  the body and
mind to various diseases, (a)
   29.  (9.) Previous debilitating diseases, and the treatment used
 to  remove  them.   It  is well  known that the body is unusually
 liable to disorder during  convalescence, from serious maladies.
 It  is weak in all  its parts; and  improper food, exertion, excite-
 ment, or exposure to cold, may readily produce the former or some
 new complaint.  Hence convalescence from a severe disease is  a
 condition of health that requires  peculiar care. The  functions
 are but just resuming  their balance, and have neither the capacity

    (a) Among the individual predisposing causes or aptitude to
 diseases, pregnancy merits a distinct notice.  In  order to attain a
 solution of the problem of the causative influence of this stale, we
 must take into account the elements of ageand of vascular fulness.
  It is only within a certain period of life that a woman can become
 pregnant, and the development of the foetus in utero is necessa-
 rily^attended by irregular determination of blood to some organs
 more than others, owing to mechanical obstruction by pressure on
 the aorta and vena cava descendens.  In addition to palpitations,
 headache, singing  in  the ears,  &.C., attributable  to local plethora
 at least, we meet  with  various derangements  of  the  digestive
 functions and acute nervous disorders, which must  be referred to
 sympathies induced between  the uterus and other organs, by the
  growth and peculiar functional  activity of the former.  The com-
  pletion of the  period of pregnancy by parturition, singularly pre-
  disposes to disease in  various forms, — of which  the  most frequent
  are inflammation of the uterus and its appendages,  and irritation,
  often converted into inflammation, of the mammas, — before the
  secretion of milk is fully established. 
40
WILLIAMS'S PRINCIPLES OF MEDICINE.
 to act nor the power of resistance which is the attribute of robust
 health.(a)
    30. II.  Hitherto we have  considered only those  circumstances
 which predispose to disease  by their weakening  influence (§ 16,
 17, 20).   There  are  others  of a somewhat opposite character,
 which favour the production  of disease by vascular fulness or
 activity.  Thus full living with  insufficient  exercise, and other
 causes of plethora, predispose the body to apoplexy, hemorrhages,
 and gout; and although it is doubtful  that they increase the ten-
 dency to inflammation, yet they make it  more  intense when it
 does occur.  So,  also, undue fulness  of bloodvessels in  a part,
 when insufficient  to produce  disease, renders the part more liable
 to suffer from external causes.  Thus the  periodic determination
 of blood to the uterus and mammae renders them liable to  disease
 at that time.  Violent exertion makes the  muscles or their fasciae
 peculiarly liable to rheumatic inflammation on  exposure  to cold.
 Excessive indulgence  in  a stimulant  diuretic beverage, such as
 punch, renders the kidneys liable to disorder on exposure to cold.
 Inflammation or irritation of the intestines is not a common effect
 of cold, except when these viscera are  under  the exciting influ-
 ence of a purgative.
   31. III.  Proclivity  to  disease  is not unfrequently caused  by
 previous disease, independently of the weakening influence before
 noticed (§ 29).   This is  particularly the case with  some  inflam-
 matory and nervous disorders.  Thus, a child who  has once had
 croup is very liable to its recurrence.   One attack of enteritis fre-
 quently<predisposes to its recurrence.  Convulsive disorders, such
 as chorea, hysteria, and epilepsy, are extremely apt to recur; and
 the longer they have existed,  the more difficult are they to remove,
 and the more ready are they to reappear on the application of any
 exciting cause.   This is what  may be called  a habit of disease,
 which it is most important to prevent.   There can be little doubt
 that the previous attack in  all such cases leaves some changes of
 structure or function, (§ 18,) which constitutes the predisposition,
 although this change may elude our means of detection.
  32. Under this head  we  may arrange many constitutional pre-
 dispositions to disease which are to be ascribed, not  to a previous
 attack, but to the persistence in the system of  a cause of that at-
 tack.  Rheumatism, gout, gravel, many cutaneous diseases, dropsy,
jaundice, and many others, may be quoted as examples.  A person
who has once suffered from any of these is very liable to a recur-
rence on the application of an  exciting cause ; and this is, because
although free from the first attack, he may  not be  free from some
functional or structural imperfection (§ IS) which  was the  predis-

   (a)  These remarks are peculiarly applicable to the convales-
cents from acute disease, who are predisposed to phthisis pulmo
nalis.  In these persons, it is very desirable to remove as quickly
as  possible, by nutritive  and  non-stimulating  tonics, the  debility
 resulting from disease. 
PREDISPOSING CAUSES OF  DISEASE.
41
 ponent to that attack, and which may again be brought into ope-
 ration by the addition of an  exciting cause.   In most of these
 cases the constitutional defect is in some of the processes of assimi-
 lation or excretion, this defect  being  generally functional, but  in
 some cases it is also attended  with change of structure, especially
 in the great eliminating organs, the liver and the kidneys.   When
 the  tendency to the  diseases under notice is acquired, it  may  be
 often  traced to causes which  peculiarly affect  these organs, such
 as intemperance or irregularities of diet, and scarlet fever.
   33. Nor can we separate from this class of constitutional causes
 (§  31) the predispositions  to  many  structural diseases, such  as
 tuberculous and malignant  formations.   Where  such  have  once
 appeared,  there is a tendency to the production of more, although
 this tendency may be latent until brought  into activity by an ex-
 citing cause.  In the following  pages  many arguments will  be
 found in favour of the view that the disposition  to these diseases
 is connected with errors in the functions of assimilation and excre-
 tion (§ 32).
   34.  IV.  Organic disease  already  existing in  the  body,
 even when itself latent, often predisposes to other disorders, inde-
 pendently of its weakening effect (§ 20).  Thus tubercles and other
 tumours, structural lesions of the heart and other  organs, often in-
 duce irritations or obstructions of bloodvessels, which, if not them-
 selves causing open disease, render them ripe for mischief inflicted
 by other causes.  Thus a person on the occasion of violent bodily
 or vocal exertion is seized with profuse spitting  of  blood, which
 causes his death: on opening  the body many tubercles are found
 in the lungs, although there had been  no  obvious  symptoms of
 their existence  before the violent effort.   Again, disease  of the
 heart causing accumulation in the veins often leads to congestion
 of the lungs  and liver; and it may only require  the addition  of
 an exciting cause, such as sudden exertion or an excess in diet, to
 bring about an attack of asthma or jaundice.
  35. The predisposing causes hitherto considered may be called
 accidental  or acquired.  There are others which are born with
 the individual ; and others which arise from circumstances of age
 or growth.   All these may be supposed to depend on  something
 defective or ill-balanced in the organization, (^ 18,) which is insuffi-
 cient to manifest itself until  wrought upon by an external exciting
 cause.
  36. V. Of the predispositions born with the individual, the most
 generally acknowledged  is  hereditary tendency  to disease.
 It is well known that scrofula,  gout, leprosy, epilepsy,  mania,
 asthma, blindness, and deafness, run in families.  That this depends
 on individual peculiarities transmitted from  parents to offspring,
appears from the fact that all children do not partake, or not alike,
of the disposition.  Nay, sometimes a whole generation is passed
over, and the disease appears in a third,  Sq too we  see external 
 42          WILLIAMS'S PRINCIPLES OF MEDICINE.

 organization,  family  likeness,  differently stamped on  different
 children of the same family.
   It  must not  be  supposed that  hereditary proclivity to disease
 commences at birth.   In a few instances  it is congenital ;  but in
 the greater number it is developed by growth or some other cir-
 cumstances  in  life.  Gout, for  example, is acknowledged to be
 hereditary.  A parent has  it in middle  or advanced life : his son
 does not get it until abbut the same period, sooner or later, accord-
 ing to whether he  lives freely or  not.   Here  is something trans-
 mitted from father to son, yet not  manifest in the son for forty or
 fifty years.
   37. VI. Frequently but not essentially connected with here-
 ditary conformation is the peculiarity of constitution called tem-
 perament, which certainly predisposes to  particular  diseases.
 Temperament is constituted by a predominance  or defect of some
 function (9).
   38. Thus the sanguine temperament  implies an activity of the
 system  which circulates red  blood, and a rich proportion of red
 particles, manifest in the  excitable pulse and flushing cheek of
 those of this  temperament; and  further evinced in their quick
 movements and lively disposition.   This temperament gives a
 disposition to  inflammation, determination  of blood, and active
 hemorrhage (30).
   39. In the bilious ox melancholic temperament, which is com-
 monly met with in persons of dark complexion  and gloomy dis-
 position, there is probably a defective action in some of the biliary
 or digestive organs, which are therefore  the more liable to de-
 rangement (9).
   40. In the phlegmatic or lymphatic temperament, which gene-
 rally occurs in those with weak pulse and languid circulation, cold
 extremities, and pallid skin, — there is a  deficiency of red blood
 and of vascular action and tone, (§ 9,) and  the proclivity is to
 watery fluxes, dropsy, and other chronic affections.
   41. The nervous temperament  is externally manifest  only by
 agitation or hurry of manner: it seems to depend on an excess or
 want of proportion of some properties of the nervous system, (§ 9,)
and it predisposes to the disorders  called nervous, such as hysteria
nervous pains,spasms, &c.   These  temperaments may be variously
combined.
   The term diathesis is often used to  express a particular morbid
tendency ; thus we hear of the inflammatory diathesis, the scrofu-
lous diathesis, &c.  It is merely a  name, signifying predisposition
without affording any clue to its true cause.(a)

  (a) Room is not allowed us for engaging, just now, in the ques-
tion of Temperament.  We would refer the reader, who desires to
have a more satisfactory view than that furnished in the text to
Miiller's Physiology, Chapter on  Temperament, p.  803,  Be'll's
edition,  and in  a  highly interesting essay on  temperaments by
 Dr. Caldwell.                                               y 
PREDISPOSING CAUSES OF DISEASE.
43
  42. VII. The last head of predisponent causes to be noticed is
age.  The several changes in organization as well as in external
circumstance which the animal frame undergoes at different periods
of life, may naturally be expected to be attended with correspond-
ing proclivities to disease.  I proceed to enumerate a few of these,
premising that some of the examples may be entitled to rank under
the head of exciting causes of disease, as well as under that of
predispositions.                         %
  43. (1.)  In  early infancy, the low calorific power of the body
disposes it to  suffer from  the  bad effects of cold, (§ 17,) whence
the tendency to visceral  inflammations.  The skin is particularly
liable to various eruptions in consequence of its tenderness and the
new and drying medium  in which  it is placed.  The redness of
new-born children is obviously the result of the action of  the air;
it is  often  a  vivid  erythema, followed by  desquamation of the
cuticle, and a yellow stain of the skin from extravasated hematosin,
which is erroneously thought to be a kind of jaundice.  Strophulus
and other  papular eruptions often  succeed.   The comparatively
virgin state of the alimentary canal at birth  renders it peculiarly
susceptible of disorder ; and a similar trial may occur at the period
of  weaning;  hence arise diarrhoea, vomiting, colic, waterbrash,
atrophy, and other ailments connected with disordered digestion.
  The brain, excited by the novelties of the  external world, be-
comes rapidly developed, and in its increased activity and growth
is liable to various diseases (§ 30) ;  hence the proclivity to hydro-
cephalus, convulsions, &c.
  The  process  of  teething adds an irritation, which, by its influ-
ence on the head, the bowels, and the air passages, disposes them
to disorder.
  44.   (2.) Childhood,or the age from  infancy to puberty.  The
functions most active are those which administer to growth: the
organs  of digestion and  assimilation are therefore obnoxious to
disorder (§ 30) ;  hence derangements  of the stomach and bowels,
worms, infantile remittent, &c.
  The activity of the nutritive function gives a preponderance to
the fibrinous or proteine constituent of the blood ;  and inflamma-
tions  which may occur are often attended with the effusion of
much plastic or albuminous matter; hence the products of croup,
tubercle, mesenteric disease, &c.
  The natural mobility (or activity of the excitomotory system) of
childhood predisposes to  chorea and kindred affections (§ 30).
  45.   (3.)  Puberty brings with it many morbid susceptibilities,
chiefly  in  the  female  sex,  in  which  the important function of
menstruation  is  to  be  established.  Many and serious  are the
evils  that are liable to  be produced  by external causes,  which
check the development of this function.  So also when  established,
this function  has its nervous as well  as  its vascular relations ;
and where it  is irregular or disordered, a  predisposition is given
to many maladies, affecting the  bloodvessels  and  their contents,
the secreting organs, and the nervous  system. 
44
WILLIAMS'S PRINCIPLES OF MEDICINE.
  46.  (4.) At the termination of growth, there is another critical
period.   The cessation of that appropriation of nourishment for
the increase  of the body, that had  hitherto been going on, may
cause fulness, and a disposition to hemorrhage  and  inflammation
in the more robust; and  in  the  cachectic, to morbid depositions,
especially of the tuberculous kind (§  47).
  47.  (5.) Adult age can  hardly be said  to predispose  to  any
diseases,  unless it be #hose arising out of occupation, and those
connected with  the generative function,  for which  this age is
obviously the natural period.  When this function  fails, at what
is termed the change1 of life, there  is a remarkable tendency to
various diseases, generally connected either with vascular plethora,
or with morbid growths of various kinds, particularly in the uterus,
ovaries, mammse, testes, prostate, rectum, &c.
  48.  (6.) As old age  approaches,  habits are more established ;
and unless they are such as are calculated to  maintain the balance
of the functions, (§ 6,) they gradually affect the  organization,  and
accelerate those  changes, in  the  fabric, by which  our existence is
limited to a span of years.   It would occupy too much space to
enter into the details of all these changes, but some of the prin-
cipal may be briefly  noticed.
  The nutritive  function becomes impaired ;  and  instead of mus-
cles, fat, and integuments being  nourished in the equal propor-
tions that give  beauty as well as strength  to  the  form in early
adult age, the deposition of fat becomes scanty, partial,  or in ex-
cess ; the muscles become  thinner and more  sinewy ; and   the
integuments are loose and  wrinkled, or  fat and flabby.   The
bloodvessels,  too, lose  their proportion and mutual  adaptation.
The arteries  become less elastic, and transmit the heart's pulse
unsoftened to  the capillaries.  The  veins  become distended  and
tortuous ; particularly in persons whose employment has required
much muscular  exertion.   The capillaries  have no longer  the
vital susceptibility which  is evinced in the blush of  youth.  This
altered proportion of the bloodvessels brings with it morbid  ten-
dencies,  the nature of which will  depend  much  on the great
moving power,  the heart;  now  more than ever the prime asent
in the  circulation.    If the heart be moderately strong, a  fair
balance  may long be sustained ; although hemorrhoids, varicose
veins, and  such irregularities from local obstructions, may occur.
If the heart be  too strong, (which is often the case  after a life of
much muscular exertion,) the  small  arteries  may suffer from  the
unsoftened force of its pulses, particularly in the  brain, and there
is a  liability to apoplexy or  palsy: and  in mucous  membranes
there is a disposition  to active fluxes and  hemorrhages ; hence
catarrh, asthma, and  affections of the  urinary organs.   If the heart
be weak or diseased, there will be an imperfect  circulation  and
tendency to venous congestions, dropsical effusions,  imperfect and
disordered  secretions, and a  general failure of ail  the  functions,
which depend on a sufficient supply of arterial blood : hence  may
arise diseases of the liver, stomach, kidneys, lungs, and in fact any 
EXCITING CAUSES  OF DISEASE.
45
of the viscera : in extreme cases the lower extremities actually die
for  want of circulation.
  If instead of the organs of circulation we were to take  the  ali-
mentary, the respiratory, or the urinary apparatus, we should here
too find changes induced  by  age,  which  show the necessarily
limited time that man's organization is intended to last.   Old  age
is thus attended with increasing infirmities and liabilities to disease
(§ 16, 18).  The very strength and activity which some functions
retain, may, from their partiality, endanger life ; and their gradual
and more equal  failure degrades the physical and often the mental
frame of man to a lower  scale of existence, until he  sinks  into
second childhood, dotage, and  imbecility.
SECTION III.
EXCITING CAUSES OF DISEASE.
  49. We now pass to the consideration of exciting or occasional
causes of disease, or those circumstances and agents which, oper-
ating on the body, especially when predisposed, (§ 14,) may excite
disease  in it.  It has been stated before, (§ 11, 15,) that certain
powerful  agents, such as irritants or  poisons, pretty surely cause
disease, independently of constitution or predisposition ; but con-
stitution or predisposition may much modify the character of this
disease in different cases ; and where  the agents are less powerful,
as in the case of common causes of disease, the effects will depend
still more on the predisposition, and may be null where this is not
strong (§  15, 19).
  50. Exciting causes may be divided  into the  cognizable and
noncognizable.  The former class comprehend  physical and
mental agents, of whose existence we can  take  cognizance, inde-
pendently of their operation in producing disease;  thus cold we
know by its effect on our  instruments  and sensations;  muscular
exertion by our witnessing or  performing it ;  and mental emotion
by  our consciousness  of it.   The noncognizable causes, on the
other hand, elude our senses, and we infer their existence  only
from their morbific effects : thus malaria and infection we know
by  no other property but that  in  question.    The subjoined  table
includes both classes.
                                 1. Mechanical.
                                2. Chemical.
                                3. lngesta.
              f 1. Cognizable   J 4. Bodily exertion.
              I     Arronto     ">  .1. Mpntal emotion.
Exciting Causes i
       of
    Disease.
                   Mental emotion.
                 6. Suppressed or defective evacuation.
                 7. Excessive evacuation.
               (_ 8. Temperature and changes.

tt m     •   ,, f  *• Endemic ~)
II. Noncognizable \  2  Kpidemic CPoisons.
    Agents.     ^  3> lnfeCtj0U33 
46
WILLIAMS'S PRINCIPLES OF MEDICINE.
                    I.  COGNIZABLE AGENTS.
  51. (1.) Mechanical causes, which injure structure, or impede
or derange function.   Besides the obvious instances of tearing,
cutting, pinching, striking, and straining, which  produce  at  once
diseases which fall under  the provinces  of the  surgeon, the phy-
sician finds many mechanical causes of diseases which he  has to
treat.  Long-continuef pressure of articles of clothing may produce
disease.  Tight neckcloths may cause apoplexy, by impeding the
flow of blood from the head.  Tight stays may cause fainting, by
pressure on the heart and great vessels ;  or colic and costiveness,
by  obstructing  the  free  passage  through the great  intestines.
Pressure on the epigastrium by sitting at a  desk after  a  meal
may cause indigestion.  Long continuance in one position, whether
standing, sitting or lying, will partially  obstruct  circulation and
innervation, and produce swelling and paralysis of the lower parts,
or those beyond  the seat  of pressure,  and  in time may cause
inflammation and death of the parts pressed upon.  Mechanical
causes also operate within the body.   A stone in the bladder irri-
tates by its mechanical properties, especially if it  be of the mul-
berry kind;  or  it  mechanically stops  the  flow of urine: so also
may a gall-stone  that of the bile.  The  intestinal canal  is  often
mechanically stopped by hardened fasces, and irritation and  inflam-
mation may  ensue.  The stomach is often irritated by the  me-
chanical qualities, bulk,  hardness or asperities of its contents;
thence  may ensue vomiting, indigestion, or inflammation of the
organ.  The air-passages  of needle-pointers, stone  masons, &c,
are irritated  and inflamed, and  at length altered in structure, in
consequence of the mechanical action of particles of stone or  other
substances, which these men are continually inhaling  in the course
of their employment.
  Instances are endless;  and the further effects of disease are also
in  great measure mechanical.  For example: the  influence of
tumours, of diseases of the  heart  and vessels, the lungs and air-
passages, intestines, and urinary apparatus, injuries and  diseases
of  the bones and ligaments, &c, &c, is  in great part mechanical,
interfering with the natural mechanism.
  52.  Besides their  simple mechanical effects on structures and
functions, (§ 51,)  some  mechanical  injuries, when  extensive,
directly depress the vital powers ; thus crushing or  tearing off  a
limb, or a blow on the epigastrium, causes fainting and extreme
weakness  of the heart's  action, and  may thus cause  death.
Slighter mechanical injuries are causes of irritation or excitement,
which may be local or general, according to circumstances.
  53.  (2.) Chemical causes of disease are even more varied than
mechanical, because chemical agents are more numerous.  We
are acquainted less with  the chemistry than  with the mechanism
of  the animal body,  and therefore can  less distinguish causes
which act by chemical properties  from those which have complex
relations to vital properties.   But we recognise chemical  irritants 
EXCITING CAUSES OF  DISEASE.
47
in acids  and alkalies and  many salts, whether applied liquid, or
inhaled in  form of gas  or vapour.   So, what are called chemical
poisons,  such  as corrosive  sublimate and other metallic salts, the
strong acids and alkalies, iodine, chlorine, &c, produce disease by
their known powerful  chemical affinities, which tend to decom-
pose tissues and disorder functions.
   We cannot  doubt that many of the matters which cause disease
in the alimentary canal, do so by virtue of their chemical qualities.
The process of digestion, although always in part chemical, is so
under the superintendent  influence  of a  superior vital  power:
no sooner does this power fail, or the chemical agencies or de-
compositions become too strong for it, than we have fermentation
and putrefaction, which cause eructation  of gas  or sour liquid
from the mouth, and there may follow the discharge of ill-coloured
and unusually fetid matter by stool ;  then, too, may arise a num-
ber of disorders, which may in great part be  referred to the influ-
ence of these injurious  chemical processes.
   There can be little doubt, too, that the chemical composition of
the different constituents of the body is subject to variations which
may themselves become causes of disease.  The  altered state of
the  blood which we see in malignant cholera, scurvy, typhous and
inflammatory fevers, is a  proof that there is a great difference in
this fluid ; but  how far this is  a  simply chemical, or a vital and
chemical change, is as uncertain as  is the  question of the vital
 properties of the blood in health.
   54. (3.) The solid  and liquid ingesta are a fertile source of
disease,  and in various ways.  Their mechanical  and chemical
properties have been already noticed (§ 51, 53).   But further, the
 ingesta  may cause disease —
   a. By non-alimentary matters acting injuriously.
   (l  By aliment defective, or ill proportioned in quantity.
   y By aliment defective, or excessive in quantity.
   55.  (*) Of the non-alimentary matters contained in the ingesta,
salt, spices, pickles, and other condiments, and spirituous or fer-
mented  liquors, are frequent exciting causes of disease.  They are
all more or less  irritating or stimulating to the  digestive appa-
ratus ; and it' used indiscreetly may  induce  inflammations,  con-
gestions, and  functional disorders of these  organs, and, in  some
instances, irritation of  other parts, and of the whole system.  Salt
in excess irritates the  stomach, causes feverishness  with  thirst,
 and, according  to Liebig, impedes the deposition of fat.   Animals
 will not fatten on salt food ; —a hint for the corpulent.(a)

   (a) It would have  been  as  well for the  author to add a  fact,
known to every grazier and cattle-feeder, viz., that all the  domes-
 tic  herbivora thrive best when a  portion of  salt is added to their
 food, or given to them separately.   All the bovine tribe especially,
 will lick it up, when thus given to them, with great avidity.  They
 drink greedily,  also, from the « salt licks" so common in  the  west
 and south of the United States. 
48
WILLIAMS'S PRINCIPLES  OF MEDICINE.
  56. But the operation of intoxicating liquors is more extended :
being soon absorbed, their stimulant action is directly felt on distant
parts, especially on the vascular and  nervous system.   Being ab-
sorbed by the veins, they pass by the portal vein into the liver, the
function and structure of which is particularly apt to suffer when
spirits have been  freely indulged in.   So too the kidneys, which
are the natural emunctories through which such extraneous matters
are eliminated from the system, are often over-stimulated, and are
injured in their secreting power, and ultimately in structure also.
The heart and vessels  are over-excited at the time, and afterwards
lose their tone; and the processes of secretion and nutrition become
variously disordered.  The nervous system is an  especial subject
of the disordering influence of intoxicating liquors.   A large quan-
tity taken at  a time is a narcotic poison, inducing, first, cerebral
excitement, then intoxication, and insensibility.  The functions of
the brain are  more or  less impaired, and at last those of the spinal
marrow ; and if the influence be insufficient to stop  respiration,
yet it may be imperfectly performed, and congestions  are formed
in the brain and  other organs.  Hence apoplexy, palsy, phrenitis,
delirium  tremens, may follow, and  the  whole  frame  may suffer
from the effects of the poison.  Even when less excessive quantities
are taken, and their first effect is mere intoxication, the headache,
sickness, and  inappetency, and the feelings of  wretchedness and
depression which often ensue, sufficiently prove that disorder has
been  produced,  and  that such  artificial excitements cannot  be
abused with impunity.
  Yet these and  other adjuncts to food, when taken  with  modera-
tion and discrimination, often prove useful, to  aid  the digestion
where it is weak, and to  counteract various exhausting and de-
pressing  influences, which are frequently arising  out of the arti-
ficial condition and employments of society, especially  in  large
towns.  Total abstinence, therefore, is preferable to moderation,
only because  it is morally easier to practise, not because it is more
salutary in its physical effects, (a)

  (a) The assertions and doctrine advanced in this paragraph we
cannot but regard as untenable and unsound; equally wrong in phy-
siology as in  morals.  Total abstinence is put by the author on a
footing with  entire seclusion from the world, a monastic life in
fact, which is a  thing in itself  not commendable but only to be
justified  as a means  of avoiding the many temptations incident
to  intercourse with  mankind,  and  in  itself easier  to  practice
than  the every day active duties of life.  We  claim, on the con-
trary, for total  abstinence from intoxicating drinks  all the ad-
vantages which   accrue from the avoidance of a poison to the
body, a disturber of  the mind, and a perverter and  degrader of
the moral sense, without its  causing  any diminution  but on the
contrary an augmentation of the vigorous exercise of all the func-
tions, in all climates and localities, in city as in  country, amonCT 
EXCITING CAUSES OF DISEASE.
49
  57. Disease may be excited by unwholesome articles with which
the food is adulterated.  To this class of causes belong various

the rich as among the poor, among the intellectual and educated
as among the weak-minded and ignorant.
  This proposition is susceptible in all its parts of the fullest de-
monstration and proof, whether we examine it chemico-physiolo-
gically, pathologically, or on the broad basis of practical hygiene.
As germain to the subject we will repeat here  the facts and argu-
ments which we have elsewhere advanced  in the
  " Dietetic value of Alcoholic  Liquors. — One of the claims most
strongly urged in favour of alcoholic liquors as drink, is that they
aid digestion both directly and by correcting disorders of this func-
tion.  There is not a particle of proof of this allegation, which, on
the contrary, is  opposed to  chemistry, physiology,  and general
observation and experience.  The end and object of  digestion is,
first, the solution of  the food, since nothing can  be  taken up by
the absorbent vessels, by them to be carried into  the blood, which
is not in solution ; and secondly, the reduction  of the different
ingredients of the food, already enumerated, into the  most simple
material of the animal processes, namely, albumen, which is found
to be contained in the fluid resulting from the digestion of the food,
partly in the state of solution and partly in globules.   This, with
slight additions, is  the  clear statement  of the  case by Muller.
(Elements of Physiology, p. 479.)   Let  us  see, next, how far
alcohol or alcoholic liquors contribute to fulfil  the indication  laid
down.  Has it any reducing property, such  as water has and weak
acids have,  when aided by heat ?  So far from this, alcohol coagu-
lates  albumen and hardens the  muscular  fibre, and  does not dis-
solve casein.  It is on account of its being opposed to  the reduc-
tion of animal matter, either into a homogeneous pulp, such as is
required for its  conversion  into chyme, or into a homogeneous
fluid, as we see  in chyle, that  alcohol is employed by anatomists
and naturalists to preserve  animal substances and objects in natu-
ral  history unchanged.
  " Digestion, or the conversion of food into the somewhat homo-
geneous, pulpy mass, called chyme, is brought about  in the  sto-
mach by water, by  warmth, and by an acid, the muriatic, and
sometimes  by another, the  acetic, mixed with  some  mucus.   Al-
cohol is no ingredient in this mass, is no part of the secretion from
the stomach, or  of gastric  juice with  its acids and  mucus.  Its
presence,  by introduction from without, retards the change or
reduction of  the several  articles of food into  chyme, and conse-
quently interferes with, by retarding, the farther change or con-
version of the fluid portion  of this chyme into chyle,  or the mate-
rials of chyle, which soon becomes blood.  The  chief component
parts  of chyme are albumen and casein, to the solution  of both of
which alcohol is opposed.
  " Farther observations made,  of late years, on the gastric fluids,
           5 
50           WILLIAMS'S PRINCIPLES OF MEDICINE.

poisons : the operation of some of these will be noticed under the
head of causes of death ; but for further details, works on toxico-

by Eberle, Schwann and Miiller, all  German physiologists, have
almost rendered it certain,that the active animal matter in gastric
digestion is a modification of mucus, termed pepsin, or the diges-
tive principle.  The activity in  pepsin is increased by its solution
in acids, and they cause a change in  substances analogous to that
of digestion  in the stomach.  The  combination of pepsin and
acid seems indeed to be  necessary for  digestion.  Very different
is the  case with alcohol.  Miiller says expressly, 'alcohol and
the boiling temperature render the digestive  principle inert.'  It
may be replied to these and some preceding observations, that it
is pure alcohol on which  the experiments were made ; and  that,
in common  drinks  this fluid is  greatly diluted.  This objection,
however, at the very farthest, is  merely in extenuation ; alcohol,
as far as it reaches "the particles of food' in the stomach, retards
digestion ; and if not greatly deleterious when drunk in the shape
of spirits,  wine or beer, this  is owing to the smaller quantity, but
not to any change or modification of its mischievous properties.
  " In confirmation of these chemico-physiological views and ex-
periments, we have  direct proof, derived from the changes which
have been noted in  the stomach of a  living person, after drinking
alcoholic liquors.   Many of my readers have heard  of the man
who received a  wound, which, though  it  healed, left an opening
into his stomach, so  large that a portion of the cavity of this organ
could be examined by another person  at will.  Dr. Beaumont had
this man in his keeping for a long time, and made a great many
exceedingly interesting  and valuable experiments on him, in  illus-
tration of  digestion  generally, as well  as of  the relative digesti-
bility of different articles of food.  Want of time and space pre-
vents me from noticing many of these, which are recorded by Dr.
Beaumont in his Experiments  and Observations on the Gastric
Juice.  Among his observations were those respecting the effects
of alcoholic  drinks on the stomach  and digestion  of this  man
(Alexis St.  Martin).   He found, that  they invariably interfered
with the regularity and completeness of digestion ; and, in  refer-
ence to the morbid appearances of  the mucous  or  lining mem-
brane  of  the stomach, he tells us expressly : ' The free use  of
ardent, spirits, wines, beer, or any intoxicating liquor, when con-
tinued for some  days, has  invariably produced these  morbid
changes.'  p. 239.   There  are not always unpleasant feelings nor
even diminished appetite at first, with these diseased states of the
stomach ;  and hence, a person will deny for a while that he suffers
from his alcoholic potations ; but, ere long, disease manifests itself
in various ways, and by  various symptoms, many of which indi-
cate disorder of parts remote from tiie  stomach, although the injury
done to it was the primary and the chief cause.
  k-Equally fallacious with  the  belief  of alcoholic liquors aiding 
EXCITING CAUSES OF DISEASE.               51
logy and materia must be consulted.  There are  some noxious
matters occasionally mixed  with food, which gradually produce

digestion, is that of their efficacy in  enabling those  who  drink
them to encounter more fatigue, and to incur greater exposures of
temperature and weather generally, than they could otherwise do.
The very reverse of all this  is true.  The recorded experience of
men in all situations and climates, — under all kinds of labour and
exposure, prove that abstinence from these drinks gives increased
ability to go through the labours of the farm and the workshop, to
resist heat  and cold, and to  encounter hardships on sea and land,
beyond what has ever been  done under the unnatural excitement
of  alcohol, followed, as it always is, by depression and debility, if
not by fever and other diseases.  The  observations of naval  and
military surgeons and commanders are  now  pretty uniformly to
the same purport, and  their testimony is adverse to the issue of
rations of  spirits, or of alcoholic drinks generally, to men in the
army and  navy.
   " As respects the common use of wine, the subject is thus briefly
yet clearly and  pertinently dismissed in  a  few  words  by  Dr.
Pereira : — 'To persons in  health, the dietetical  employment of
wine  is either useless or pernicious.'  As a  'medicinal agent it
 must be directed by a physician with a  knowledge of all the cir-
cumstances in  the case of his patient, and of the composition,  pro-
 perties and effects of wine, similar to that which is expected of him
 in  the prescribing other medicines.  He must not evade his heavy
 responsibility under the cover of poetry or jest, or in compliance
 with  fashion; or the appetite  of his patient.  If he have studied
 the effects of  vinous liquors, he will have learned  that they keep
 up, if they do not bring on, gout, rheumatism, disorders  of  the
stomach, and of the kidneys and skin; and that the change from
one kind of wine to another is only a change in the morbid agent.
    "Malt liquors, though of less alcoholic strength than spirits and
 most wines, are capable of  causing drunkenness, and  this is quite
 a common effect of their use in England.   At first apparently more
 favourable to nutrition than the other classes  of alcoholic liquors,
 by the fulness and  corpulency of frame which  they induce, they
 are found to  be after a while adverse to a ready and active dis-
 charge of  the  functions.  The brain suffers, and the faculties are
 dull  and sodden, or apoplexy strikes  down the beer-bibber:  the
 heart suffers, and there is hypertrophy, and retarded and irregular
 circulation, and danger of sudden death from this cause; the lungs
 suffer, and there is congestion, pneumonia, and not seldom dropsy
 of the chest.   Other forms  of  dropsy also  succeed to  the free use
 of malt liquors, which kill more speedily, and  with  preceding
 symptoms of greater degradation —reduction of man to the mere
 brute, than even after the habitual use of ardent spirits.  Some of
 the English writers, while they admit and deplore these deleterious
 effects of drinking malt liquors, attribute them to adulteration. 
52           WILLIAMS'S PRINCIPLES OF  MEDICINE.
deleterious effects.   Thus salted provisions too long used will cause
scurvy ; ergoted corn  has been  known to produce dry gangrene.

They add, however, that the taste of the  people generally is  so
vitiated by the adulterated, in fact poisonous beer and  ale  and
porter, that even if the brewers were all honest, they would not
find customers for their purer liquors.
  "A slight retrospect of the history of beer, — barley-wine, as it
was called by the  Egyptians, — will  show, that  long anterior  to
modern inventions, by the introduction into it of cocculus indicus,
or Indian berry, black  extract, or this  berry with opium and other
ingredients, nux vomica, or St. Ignatius's bean, henbane, extract
of poppies, copperas,  capsicum,  wormwood, aloes,  quassia, &c.
&c, this favourite English beverage was also a highly intoxicating
one.  The  Germans in the time of Tacitus could get drunk on
beer,  and fight,  and shed each other's  blood, very much  in the
same  fashion  in which our North American Indans enact similar
scenes under  the delirium caused by whiskey and rum.  German
bravery was  of no avail against a foreign foe, when  subdued by
drink; and in this state, as when the  Marsi were surprised by
Germanicus,  they  became an easy prey to  their disciplined  and
vigilant enemies, the Romans.
  " The descendants of these people, the Anglo-Saxons in England,
did not abate  much in  their convivial  and intemperate habits kept
up by beer : and we may suppose that the revelry and dissipation
in Harold's camp, on the  night preceding the fatal battle of Has-
tings, was maintained  by potations of the national beverage.
  "In our climate, even more than in that of England, the habitual
use of malt liquors is decidedly injurious.  The free acid, though
partially disguised  to the taste, is detrimental to digestion, and to
all the assimilating functions; it is particularly inimical to the skin
and the  kidneys." — Bell on Regimen and Longevity, p.  355-61.
  Alcohol is not nutrimental, it cannot of itself  form tissues, nor,
as we have seen in the preceding extract, can it contribute even
indirectly  to  the renovation  of  tissues by  its  accelerating the
changes  in  healthy  assimilation,  through  which materials are
procured for their formation or renovation.  Unlike the stimulus of
oxygen, alcohol cannot become fixed in the tissues, nor does it, like
light,  contribute to  chemical and vital changes of fluid and tissue
in organized  bodies, promotive of functional vigour.  It neither
gives power  by  nutriment, nor salutary action by simple  excite-
ment.   It is neither a  nutrimental nor a vital stimulus.  The ex-
citement which it causes is blended with and soon runs into nar-
cotism;  and  hence  it  is only in peculiar morbid states of  the sys-
tem that we  can have recourse to it, as we have to some other
admitted poisons,  with   the  hope  of  producing  therapeutical
effects.
  Dr. Pereira does  indeed (Treatise on Food and Diet) put in  an
indirect claim to alcohol  being considered an alimentary principle, 
EXCITING CAUSES OF DISEASE.
53
Lead gradually introduced causes constipation, colic, paralysis,
and  atrophy.   I fear, too, that under  this head we must confess
that medicines are fertile sources of disease, and that, not only when
injudiciously administered ; the remedies necessary to cure or re-
lieve  many diseases are  not uncommonly necessary evils; they
remove one disorder by inducing another, and are entitled to rank
among the causes of disease.
  58. (0)  Aliment ill proportioned in  quality is another article of
the ingesta that may cause disease.  Man is by nature and habit
an omnivorous animal; and in general  his health is best maintained
by mixed proportions of animal and vegetable food.  The insalu-
brity of the simpler constituents of food, when separate, even those
supposed to be most nutritive, has been well shown  by the numer-
ous  experiments of Magendie, Gmelin,  and others.  They fed
dogs, geese and donkeys, and other animals, on articles which are
generally  considered highly nutritive, as sugar, gum, oil, or butter :
the animals died with symptoms of starvation  almost  as soon as
if they had been kept without food.(a)   Even bread, when too

on  the  plea, that it  is  burnt in the lungs, and converted thereby
into carbonic acid and water, and that this  process, as a kind of
oxidation, must evolve caloric, and thus  contribute  to support the
temperature of the body.   He  admits, however, that it  is an ob-
noxious fuel.   " Its  volatility, and the facility with which it per-
meates membranes and tissues, enable it  to be rapidly absorbed,
and  when it gets into the blood, exerts a  most injurious operation,
before it is burnt in the lungs, on the brain and the liver.   Though
by  its combustion  heat is  evolved, yet, under ordinary circum-
stances, there  are  other, better, safer,  and  less  injurious  com-
bustibles to be burned  in  the vital lamp."   The effects  of alco-
hol on  the nervous and capillary systems  are of  a  debilitating
nature ; and such as to interfere not a little  with the evolution of
caloric, a  process, the completeness and  regularity  of which de-
pends mainly on the conjoined healthy action of these two systems.
  (a) In  a communication recently made to the French Academy
of Sciences, by M. Chosat, experiments are  referred to  which, if
they do not entirely invalidate, at least modify very considerably
the conclusions mentioned in the text, as to the effects of an ex-
clusively sugar diet on certain animals.  M.  C. states that he made
seventeen experiments on dogs, and ascertained that, in some cases,
the sugar tended to fatten the animal, and in others turned to bile.
In the first case there was  a general tendency to constipation; in
the other the  bowels were relaxed.  Like  differences had  been
noticed by him when milk was taken as  aliment, according to the
different constitutions of the persons using it exclusively, or making
it the chief article of food.  Where bile  was created, a diarrhoea
ensued, which caused a wasting  of  the solids and  emaciation.
Among the few well-attested instances of persons who have lived
for any great length of time on sugar alone, is that of the cele-
           5* 
54           WILLIAMS'S PRINCIPLES OF MEDICINE.

fine, is insufficient for nutriment.  A dog fed on pure white bread
lived only fifty days, whereas another fed with the coarsest brown
bread was well nourished, and seemed capable of living an indefi-
nite  period.  According to the researches of a commission of the
French  Institute, (the report  of which  was published  in  1841,)
gluten, or vegetable albumen, is the only simple principle which
will alone maintain  life, and the nutritious qualities of  vegetable
food depend chiefly on the  quantity of  this azotised  principle
which they contain.   Bread may therefore be well called the staff
of life.
  Animal albumen and fibrin  require mixture with vegetable mat-
ter to make them  properly nutritious  as well as wholesome ; and

brated Colombian chief,  Bolivar.  It has  been stated, that, by
fatigue and privation, he had  so injured  the tone of  the stomach,
that he was  unable, at times,  to take  any other  food  than  sugar,
which, in his case, was easy of digestion.   Some of his personal
friends relate, that, in some of his last campaigns, he would live
for weeks together upon sugar alone as  a solid, with pure water
as a liquid.
  Reference  has  been made often to the fac tof the  improved
bodily condition of the West  India negroes on the sugar planta-
tions, during the period of converting the  cane-juice into sugar,
owing  to  their  large  use, and what, according  to dietetic rules,
would be called excessive, of the former. "During the sugar season
in the West India Islands, every negro, says Wright, (Med. Plants
of Jamaica,) on the plantations, and every animal, even the  dogs,
grow fat.  The negro children have a certain allowance of sugar-
cane at  this season, which  they suck with avidity, and with the
same good effects as is noticed in their parents." — Regimen and
Longevity, p. 216.   The chemical deduction, from his experiments
by Magendie, that non-azoted substances are unfitted to nourish,
is not tenable in practical hygiene.  For, even though we admit
the somewhat compound nature of the cane-juice compared with
simple sugar, still, neither in the composition of the former, nor of
other vegetable substances used by the people on the sugar planta-
tions, can  we detect  azote either at all, or if present, in quantity
adequate to  explain  the chemical theory of Magendie.
  Opposed also to this theory and to  the assertion in the text, is
the following experiment contained in the "Fifth Report of the
Inspectors of Prisons of Scotland," &c, by Frederick Hall, 1840 —
and introduced with other trials made on different kinds of food
into the work just cited (Regimen and Longevity, p. 310).
  " Eighth  Diet.— Cost, including cooking, lid.
  " Breakfast. — Two pounds of potatoes, boiled.
  " Dinner. — Three pounds of potatoes, boiled.
  " Supper. — One pound of potatoes, boiled.
  " A class of ten young men and boys was put on this diet.  All
had been in confinement for short periods only, and all  were em- 
EXCITING CAUSES OF DISEASE.
55
gelatin  and oily matters are still less  available for  nourishment
without much combination.
   59. Liebig has recently advanced some novel views with regard
to the purpose of the different  proximate elements of food.  He
considers that the albuminous principle alone nourishes the body;
all other proximate elements go to  supply the  excretions; their
carbon and hydrogen being united with the oxygen  absorbed in
respiration and thrown off in the form of carbonic acid and water ;
and  the nitrogen with the remainder of hydrogen and carbon being
separated in the constituents of bile and urine.  The  union of the
combustible constituents  of the food with the oxygen inhaled, he
considers to be  the great  source of animal heat, which is raised  by
oily  or saccharine matters in the food, together with the increased
supply of oxygen afforded by cold air or exercise.  Thus the Lap-
lander eats train oil  for fuel ;  whilst the Italian, under  a  sunny
sky, delights in maccaroni,  which  nourishes without heating him.
If the inhabitant of a  warm climate  indulges in rich, greasy food,
he loads his blood  with hydrocarbon, which the scanty oxygen of
the rarer air which he breathes is  insufficient to  remove; the liver
is overtasked to eliminate the superfluous matter, and is therefore
liable to derangement.  These and other views of this distinguished
chemist are highly interesting, but as yet they seem too speculative
to become the basis of pathological reasoning.
   60. The views of Dr. Prout* on the due proportion of alimentary
matters, although also in  some measure hypothetical, are more in
accordance with common experience.  He considers milk to be the
great prototype of all food: as its nutritious part consists of albu-
men, oil, and sugar, so all our wholesome meals, or artificial com-

ployed at light work, teasing hair.   At the beginning  of the expe-
riment eight were  in  good health and two in indifferent health;
at the end, the eight  continued in good  health,  and the two who
had  been in indifferent health had improved.  There was, on an
average, a gain in  weight of nearly three and a half pounds per
prisoner, the greatest gain being eight and a quarter pounds, by a
young man, whose health had been  indifferent at the beginning of
the experiment.  Only two prisoners lost at all in weight, and the
quantity in each case was trifling.  The prisoners all expressed
themselves quite satisfied with this diet, and regretted the change
back again to the ordinary  diet."
   Equally difficult, though not impossible in all circumstances, is
nutrition maintained  by the injection of substances, albuminous  or
fibrinous, which are purely  azotic.   We have heard a gentleman,
(Gen. Ashley, of Missouri,) tell of himself and his troop of hunters
and  traders'for  furs, living for weeks in the enjoyment of excel-
lent  health on buffalo  flesh alone —their drink water alone.

   ♦ « On Stomach and Urinary Diseases." 1843.  P. 362.  Amer. Edit. 
56           WILLIAMS'S PRINCIPLES OF MEDICINE.

binations of food, comprise these three ingredients ; albumen being
isomeric with fibrin and gluten, (that is, identical in ultimate  com-
position,) and starch  with sugar.
  61. Every  day's experience  may teach us that disorder is apt to
occur if we do  not duly proportion the articles of food : thus if we
take too much butter or fat, we become sick and  bilious ; if we
subsist too much on farinaceous food, we become costive, for want
of bile ; if we eat meat too freely, we become bloated and heated,
the urine becomes high coloured, and if we persist, we may become
the subjects of plethora, inflammation, gout, or calculous disorders:
if, on the other hand, we  feed  too exclusively on vegetable food,
we lose colour and muscular  strength.  The appetite and taste
generally instruct us pretty safely as to the best proportions of differ-
ent kinds of food ;  but  then they must not be perverted and pam-
pered by condiments  and elaborate modes of cooking.   These are
expedients to coax and deceive the appetite and taste ;  and if these
guardians of the  nutritive department are cheated, it is no wonder
that the department becomes deranged.
  62. (y) Aliment may be excessive or deficient  in quantity.
Sometimes  the appetite is inordinate ; more frequently it is pam-
pered; in either  case, more food is taken than the expenditure of
the system requires.  If the digestive organs  fail  in appropriating
the nourishment, they become  distended, irritated, and otherwise
disorded  by  what they cannot digest.  If they are  strong and
digest the excess, they send too much  chyle  into the  blood, and
this may cause plethora, apoplexy, gout, gravel, or  some  conges-
tive  or inflammatory disorder  to  which the individual is predis-
posed (§14).  (a)
  63. Defective nourishment may  excite various disorders.  In the
extreme case  of privation of food the cravings of hunger are alter-
nated with  nausea  and  a sense  of sinking ; then follow fever,  deli-
rium, and general disorder of both body and mind, with increasing
feebleness.  It is a curious fact, that in this state the stomach be-
comes inflamed ; probably from the irritating  action of its secretion
on  its unrelieved  vessels.   Even  in less degrees of abstinence
enjoined  in the  treatment of disease, symptoms  of vascular and
nervous irritation often arise in the midst of general weakness.
By many practitioners of the Broussaian school,  these  symptoms
are erroneously taken as indications for an  increase of the anti-
phlogistic plan, when a judicious return  to  nourishing food will
really prove the  best  cure.  Deficiency of food, if long continued
causes general weakness of all  the  functions and wasting of all the

  (a) We would refer the reader  for excellent descriptions of the
origin of various diseases from excessive alimentation, to  the sec-
tion  in Broussais's Physiology, on Abnormal Assimilation, and
to Prout's Stomach and  Renal Diseases, Sect, e., on the General
Pathology of the  Primary and  Secondary Assimilating  Pro-
cesses, p.  3S0-S. 
EXCITING CAUSES OF DISEASE.
57
textures.  The blood becomes thin and easily extravasated ;  the
gums spongy and bleeding ;  the  legs ©edematous ; diarrhoea often
occurs; ulcers appear in the cornea and  other parts; a state of
scurvy or cachexy  is induced, from which, if advanced, an  im-
proved diet may now fail to  restore.   In less extreme cases, poor
living may excite scrofulous and tuberculous disease, and  other
kindred forms of degeneration of organs.  The bad  influence of
poor living is much more felt in  those who are confined in close
habitations, as in prisons, poor-houses, the cabins of ships, and be-
seiged towns, than in  those who are at  large (§ 22) : and  it is
under such  circumstances that the insalubrity of some kinds of
food, however nutritious, becomes apparent.  Thus  even bread
with meat or broth  will  not exclude scurvy; but a sufficient addi-
tion of fresh vegetables, and even  of potatoes, prevents this dis-
ease from occurring. — (Dr. Baly, Bled. Gaz., Feb., 1843.) (a)
   64.  (4.) Violent bodily exertion of various kind is a common
exciting cause of disease.  General muscular efforts, as in running,
walking up hill, rowing, &c, hurries  the movement of the blood
back to the heart, and resists its distribution through the arteries
   (a)  We will quote here our opinions on this subject, as given in
 another work: —
   " The alimentary effects  of  salt meat  and fish will vary with
 the quantity of vegetable food  taken at the same time, and the
 state of atmosphere in which the persons using it habitually live.
 The disease of scurvy, which was  at  one time attributed almost
 entirely to a diet  of salted animal  matters, is fully as much deve-
 loped  by a  humid  atmosphere and  defective or faulty vegetable
 aliment, as  by the  cause  popularly assigned.  On board  ship, if
 the crews have dry and well aired quarters, there  is great proba-
 bility of their being exempt from scurvy, even though their food
 should be, as far  as relates to the animal portion of it, entirely of
 salt  meat.   My  own observation induces  me  to believe, very
 firmly, that  if the crews of vessels be  supplied  with fresh water
 in abundance, biscuit of good quality, and the customary allow-
 ance of beans or peas, with a modicum of molasses and vinegar,
 they may eat daily, for a  twelvemonth, of salt beef or salt fish,
 without suffering  from scurvy, provided all  the conditions before
 mentioned, of dry hammocks and dry clothing, when  they  turn in,
 be complied with.  I  have been on  board a vessel which had a
 six months passage, all but seven days, from  the Mediterranean to
 China, without my having had to treat a single case of scurvy, or
 even of disease complicated with scorbutic symptoms.   The return
 passage in  another vessel,  with another crew,  from  Canton to
 Cowes, England,  was five months  and  a  half;  but we  were
 equally clear  of  scurvy as  before.   In both  instances, the men
 were  well fed and well  treated — in the manner which  I  have
just indicated," — Regimen and Longevity, p. 303-4. 
5S           WILLIAMS'S PRINCIPLES OF  MEDICINE.

in such a degree, that the heart, the lungs, the  brain, and other
organs, have  an unusual pressure of blood upon them (§ 51).
  The heart is excited to inordinate action, is often strained and
distended, and its function, or even its  structure, and  that of the
great  vessels, may be impaired  in consequence.  This is  especi-
ally apt to happen if there is anything already imperfect in the
structure of the organ, its valves or vessels ; and there are natu-
rally very various degrees of perfection and strength in these parts.
  The brain is particularly liable to  suffer from violent exertion,
especially if joined with  a stooping or constrained posture ;  for its
vessels are not, like  those of the  limbs and trunk, supported  by
muscular pressure upon  them, and the excited heart can therefore
send its blood into them  with  more force.  Hence giddiness, noise
in the ears, deafness, defective vision, convulsions, palsy, and apo-
plexy, have been brought on  by violent exertion.
  The lungs  are also apt to suffer  ; for the blood being returned to
them faster than they can arterialise it, they become greatly con-
gested ; hence cough, dyspnoea, hemoptysis, or inflammation of the
lungs, may ensue ; and the texture of the lungs  may  also sustain
injury in consequence of the violent strain to which it  is subjected
by the increased exertions for breath.
  Other internal organs sometimes are disordered by the blood
thrown or retained in their vessels by the pressure of external mus-
cular action.  Derangement of the liver, hematemesis, hemorrhoids,
and hematuria, have been brought on by such a cause.   The sharp
pains or stitches  felt in  the sides or  abdomen on running fast are
commonly supposed to be in the liver or spleen  ; but more proba-
bly they are  spasms of the intestines — temporary  colic, produced
by irregular pressure on them,  when their sensibility  is raised by
the blood unduly thrown into them.
  Some kinds of muscular exertion peculiarly effect certain organs.
Thus loud  reading  or  speaking, or blowing  wind instruments,
especially try the organs of respiration and the voice, and may
cause  hemorrhage, inflammation, and  various diseases  of these
organs.  Excessive or  rough riding  or leaping may injuriously
affect the kidneys and  organs of generation.  Straining  to lift  a
heavy weight, or at stool, or in any continued effort, which implies
holding the breath, endangers the structure of the vessels of the
chest and brain, on  which there is no equally counteracting mus-
cular pressure.
   65. Bodily exertion  may also  cause disease  by its exhausting
effects.  In extreme degrees this exhaustion may  amount  to syn-
cope, and even death : short of this, it may cause  great weakness
of muscles and of the heart, with corresponding depression of other
functions.   A low typhoid or  adynamic fever  sometimes follows
prolonged fatigue.   In other cases, giddiness, nausea, loss  of appe-
tite,  indigestion, costiveness, amenorrhcea, and other varieties of
injured function.
   66. (5 .) Strong menial emotion or acute sensation, is a  common
I 
EXCITING CAUSES OF DISEASE.
59
cause of disease.  Closely knit together as the mind and body are
— so closely, that their great common organ, the nervous system,
seems  to have double offices for both — it is not  surprising that
they should ever be  ready to  affect each other, and  that when
the  impression is strong, the  affection  should  not be  slight  or
transient.   The heart most remarkably suffers from such causes.
Thus a sudden shock, whether of grief, surprise, fear, or even joy,
may cause fainting, partial suspension of the action of  the heart ;
nay, even  death has ensued ; and the expressions  "frightened to
death," and "killed with joy," are not always mere figures of
speech.  Sudden acute pain often cause fainting.   Palpitation and
irregular action of the heart are very common effects of emotions.
   Other parts also suffer from  strong moral impressions.   Spas-
modic asthma and spasmodic  affections  of the throat are some-
times  thus induced.  Apoplexy,  palsy, inflammation of the brain,
epilepsy, and insanity, have been caused by excessive anger, terror,
surprise, and joy.
   Very commonly, mental  emotions affect the secreting  organs,
and especially the functions of  the alimentary canal.  A piece of
very bad news takes  away appetite, or  impairs digestion.  Fright
or anxiety often loosens the bowels, or brings on a bilious attack,
or jaundice.   The  uterine periodic  function  is  remarkably sub-
ject to the influence of moral emotions, and many  of its disorders
may often be traced to this source.
   The slower emotions of the mind and over-exertion of its facul-
ties are also exciting causes of disease.   Long-continued depres-
sion or anxiety sometimes induces dyspepsia, costiveness, or diar-
rhoea, asthma, and functional disorders of the heart, menorrhagia,
and clysmenorrhoea ; and  in time structural diseases of the same
parts occasionally follow these functional affections.  Over-exer-
tion of the faculties, or excitement of the passions  of the mind, is
chiefly felt in its own functions, or  in its own organ the nervous
system [brain].  Hence may arise congestions of the brain and
exhaustion of nervous power, with giddiness,  stupor, headache,
dull and disordered sensation, and even apoplexy  and palsy.   Or
the  disease may be  inflammatory,  with symptoms of irregular
excitement, nervousness, delirium, tremor, convulsion, partial para-
lysis, &c.   Sometimes the effects of excessive mental exertion or
moral  emotion are apparent only in the phenomena of the mind,
the  powers of which  are injured or disordered, and various forms
of insanity are produced.  When  we  consider the variety  and
amount of food and condiment, employment and excitement, that
pass into the minds of persons in the  busy and worrying scene  of
civilized life, it is not extraordinary that the mind, as well as the
digestion, or other function, should occasionally be disordered  by
such causes.
   67.  (6.)  Diseases are frequently excited by the retention, dimi-
nution, or  suppression, ot evacuations, natural or  habitual, espe-
cially if the  change  be  sudden.  The  operation  of this  class is 
60
WILLIAMS'S PRINCIPLES OF MEDICINE.
  somewhat diversified, causing  disease,  some  by the  positively
  noxious influence of matter retained  in the system, which is the
  case of the excretions of urine and fasces ;  others, by causing ful-
  ness  of the vessels, and the various disorders  which  this  may
  induce.  To  the latter cases belong sudden  suppression of hemor-
  rhages, or other discharges which  have become habitual.
    The matter of alvine and renal excretions is essentially perni-
  cious, and cannot be long retained  even  in their natural reposito-
  ries  without  causing mischief.    Feculent  matter, when  it has
  reached  the  large intestine, is  still acted on by the  absorbents,
  which take up its more fluid parts,  and with them, if long retained,
  fetid  matter,  which ought to be  excreted.   The solid residue
  becomes hard  and scybalous, and may remain lodged in  the cells
  of the colon,  a  cause of irritation, distension, and  obstruction
  (§ 51).  Sometimes the  system suffers  before the intestine itself;
  at length, however, or sometimes  at first, this part becomes irri-
  tated,  colic, diarrhoea, and  inflammation may  ensue—nay, in
 some instances, where efficient remedies have been neglected, even
 ulceration and other  structural  changes take place, before  the
 offending matter has been dislodged.
   The retention of  urine has even more pernicious effects.   Be-
 sides  mechanical  distention,  and irritation,  and rupture, which
 may follow from  the  constantly accumulating  secretion, (§ 51,)
 the fluid is partially  reabsorbed, giving a  urinous  smell  to the
 breath  and perspiration, and sometimes causing typhoid  symp-
 toms, which in extreme cases prove fatal,  with delirium or con-
 vulsions, and coma ; and effusions of serum, containing urea, are
 found  in the brain, chest, and other  parts.  These are effects more
 commonly  of suppression  than of mere  retention: but, in  fact,
 suppression often follows retention : the  retained urine is prone to
 decomposition (§ 53);  highly irritating and  offensive matters are
 produced, which cause injury to the  bladder,  rapidly extending up
 the ureters to the kidneys, whose function then becomes impaired
 or suppressed.
   6S. The preceding are  extreme  results;  but the attentive ob-
 server will find that smaller degrees of the same causes, insuffi-
 cient secretion, or insufficient evacuation of excrementitious matters,
are among the commonest sources of disorder ; and it is by a pro-
 per restoration of these  functions that the almost universal domestic
 remedies, as well  as  the  common pills  and  draughts  of  the
 surgery, prove so useful in  preventing as well as m removing
disease.
  Numberless maladies arise from suppression or irregularity of
 the catamenial  discharge; and diseases are not unfrequently ex-
cited or rendered active at the period of  its total cessation.  The
same may be said of the secretion of milk.  The  disorders' which
these  produce  are commonly connected  with local  or general
plethora.
  69.  An artificial or diseased discharge or secretion as that of a 
EXCITING CAUSES OF DISEASE.
61
seton or issue, or from  an ulcer or diseased membrane, or an
unnaturally profuse flow of an ordinary secretion — such as loose-
ness of the  bowels, if so long established as to have become habitual
— cannot be suddenly suppressed without great risk  of exciting
disease.  The same may be said of habitual hemorrhages, as from
the nose or rectum, and of the practice of periodical bloodletting.
The maladies which result will  vary with the predisposition ;  but
generally they are of the nature  of local or  general vascular ful-
ness, or some disorder of secretion or of the nervous system, arising
from disturbances in the circulation.   As exa'mples may be named
—congestion of the brain, apoplexy, congestion of the liver, various
hemorrhages and inflammations, gout, epilepsy, palsy, hysteria,
hypochondriasis, mania, &c.
  The suppression or too rapid removal of some cutaneous  erup-
tions may  be appended to this class.   The diseases  which it ex-
cites are sometimes inflammatory or  profluvial, as gout, rheuma-
tism, diarrhoea, &c.; sometimes more nervous, as chorea, epilepsy,
asthma, dyspepsia, hysteria, &c.
  70. (7.)  Opposed to the group  we have  just considered, is
excessive evacuation or loss either of blood or  of some secretion.
This was formerly noticed (§28) as a cause of debility which pre-
disposes to other diseases ; but if the loss be great or sudden, it may
produce immediate disease.  A certain fulness of the heart and
bloodvessels is  required for their healthy functions, as well as for
those of all the organs which they supply.  If a moderate quantity
of blood be suddenly withdrawn, or a large quantity less suddenly,
the heart's action will be impaired, rendered irregular, and may be
interrupted, and the brain not receiving a  supply sufficient for its
functions,  there  may  be fainting,  with  loss  of consciousness,
accompanied or followed  by disordered function, palpitation, de-
lirium, convulsion, or  by death.   The sudden impression in these
cases is exercised more on the brain than on the heart;  for  these
effects may be induced by the loss of a much smaller  quantity of
blood in an erect or sitting posture than in a horizontal posture.
Similar results have been found to ensue from the sudden removal
of pressure from the vessels in any considerable part of the body,
as by the discharge of the fluid of ascites, or by enclosing a limb
in an exhausting tube. (Dr. Arnott.)   Lower mentions a case of
extensive varix (enlargement) of the veins of the  lower extremi-
ties, in which the patient could  not stand without fainting, until
the  legs were  bandaged.  In these  cases, much of  the  blood,
although not removed from the system,  gravitates into vessels,
where it becomes unavailable for the  general  circulation.   The
fainting which  occurs  in  these  cases is called  cerebral syncope,
because  the functions of the brain are suspended, consciousness is
lost before the heart's action is  interrupted ; but the disorder  of
the brain reacts on the heart, and adds another influence to impair
its action also.   This is Dr. Alison's  explanation.  On the  other
hand, if the hemorrhage is gradual, and  the posture  horizontal,
           6 
62
WILLIAMS'S PRINCIPLES OF MEDICINE.
other functions fail before the consciousness is lost — the chief
symptoms being " feebleness of muscular action,paleness and col-
lapse of the countenance, coldness, beginning at the extremities,
cold sweat, beginning on the face, the pulse imperceptible,"  and
the heart's action becoming so.  The true nature of these effects,
and of the reaction and nervous symptoms with which  they are
often  followed, will  be considered hereafter in connexion with the
subject of anemia.
  Not only bloodletting,  but other evacuations, purging, sweating
and vomiting, the catamenial and seniinal  discharges  in  excess,
are capable of producing syncope and general debility.  The  de-
pression and faintness induced by these,  although less prompt, are
often  more permanent than  those  from bloodletting ;  for such,
evacuations  imply, not only reduction in the  mass of  blood,  but
also an exhaustion of the vital energies in the secretionsand func-
tions concerned in producing them.
  The diseases gradually induced by these several causes of evacua-
tion are seldom of a simple kind.  General debility  of the muscles
and functions is commonly a result; but this is  often complicated
by  symptoms of partial reaction, palpitation, spasm, noises in the
head, images in the sight, pains in different parts, sometimes very
acute, but seldom long  fixed, partial  paralysis, and a  defective
and disordered state of the excretions.
  71. (S.) Of all the exciting causes of disease,  there are none so
common as  temperature in  extremes, or in  sudden transitions;
cold, heat, and sudden transitions from cold to hot, or hot to cold.
Both heat and cold  have different modes of operation, and cause
disease in different ways.
  Extreme heat  and extreme  cold are directly destructive to  life.
Heat above  ISO0 coagulates the albumen of the blood, and  thus
obstructs the bloodvessels, and may cause other chemical changes
of a disorganizing nature  (§ 53): a pait  that  has been raised to
this temperature, therefore, necessarily dies; it cannot live again.
It  is true that we occasionally  see boiling water at 212°, boiling-
oil at  600°, and red hot  iron at  1000°, produce no other effect than
violent inflammation and blistering of a  part; but that is because
these  bodies have been applied for too short a  time to do more
than violently stimulate the  part, nor time  enough to raise it to
the decomposing temperature ;  a few seconds more, and the part
would be killed.
  Cold below  32° freezes the water of  the fluids ; and as it de-
stroys the life of tender plants, so it kills  parts of animals, whether
by  the expansion of the ice injuring the  delicate organization  (Sir
B. Brodie), or whether  from  the  mere stoppage of the circulation
or other cause, is unknown.  The part may be afterwards separated
from  the  living  parts  by a  vital process of inflammation  and
sloughing.
  72. A disorganizing degree of heat extensively applied acts like
a violent mechanical injury — such  as tearing  off or crushing a 
                EXCITING CAUSES OF DISEASE.               63

limb (§ 52).   It directly depresses all the functions :  the  pulse  is
very weak, frequent, and irregular ; the muscular strength almost
annihilated, and consciousness may be nearly or quite suspended.
In this state, notwithstanding the stimulant properties of heat, and
the inflammation which it generally excites, patients require stimu-
lants, and they often die in a state of complete collapse, without
any rallying or reaction.  Extreme cold, also, if for some time
applied to the whole body, depresses and paralyzes all its powers,
even that of generating heat, and, therefore,  of resisting cold.   Sir
Astley  Cooper observed, that  on  plunging kittens  into ice-cold
water, the arterial blood did not become venous in the veins ; and
Chossat found, in animals killed by cold, arterial blood in the left
cavities of the heart.   From a similar cause,  the limbs become
benumbed by extreme or continued cold : thus persons are drowned
in cold weather much more speedily than in  warm.   With less in-
tense degrees of cold, on the other hand, which do not destroy
the vital processes, more oxygen is absorbed, more carbonic acid
formed, and heat generated, which  are the  means by which ani-
mals resist cold.
   73. Heat which is insufficient to decompose is directly stimulant.
 It excites the function of parts, and when generally applied induces
 a state of fever.  Thus when a person is in a vapour bath, or hot-
 air bath, the pulse quickens, the whole surface becomes  red, full,
 and hot; there may be throbbing  and pain  in the  temples, and a
 feeling of feverish oppression, until a sweat breaks out, which  re-
 lieves the superficial tension and fulness, and soon reduces the  in-
 creased heat.  Similar  results  may  ensue  from confinement in
 overheated rooms : and if there be any tendency to  local conges-
 tion  or inflammation, particularly in the head, this excitement.may
 be enough  to produce  it.  The  continuance  of heat enervates,
 reduces the strength and appetite, and may  excite a feverish state,
 with disorders of the liver.  The oppressed  breathing which is
 often felt in heated rooms may, according to the view of Liebig,
 be ascribed to the smaller amount of oxygen in the air rarefied by
 the heat;  but it is probable that this is not the only cause.
   74. A more partial  exposure  of  the body to heat may produce
 still more disordering  effects, if  the part  overheated be capable of
 suffering from the excitement.   Thus solar  or artificial heat to the
 head may cause severe headache, apoplexy, or inflammation of the
 brain.  Heat to the spine, as on sitting with the back near a large
 fire, is very apt to cause sickness and faintness, and  if continued,
 may induce convulsions.   More local inflammations, as of the eye,
 ear, and  skin, are frequently caused  by exposure of the  parts  to
 heat.  Gout may sometimes be excited in  the feet  by the  same
 stimulus, and this is often attempted purposely.
    75. Cold, on the  other  hand, is  directly  sedative.  It contracts
 tissues and vessels, especially the arteries, and thus at first renders
 parts pale and shrunk.   In persons of feeble circulation, after 
 64            WILLIAMS'S PRINCIPLES OF MEDICINE.

 bathing, the fingers are sometimes quite bloodless and numb from
 this cause ;  the cold having quite closed up the arteries.*   But
 cold also retards  the passage of blood in the capillaries; the vis-
 cidity of the liquor sanguinis seems to be increased : globules stick
 to the sides or move but slowly, and the part soon becomes purple
 or blue from the congestion  of blood in it.  This purple colour is
 chiefly seen  in parts much exposed, and where the blood  habitually
 enters with freedom, as the  cheeks, ears, nose and hands.  There
 is also much internal congestion from the intropulsive operation of
 the cold—that is, the  external parts being constricted and ob-
 structed, blood accumulates  more in internal parts, and the heart's
 force is more expended on these.  This  may in part account for
 the degree of stupor and ultimate  insensibility into which persons
 exposed to extreme cold are apt to fall.  In some such cases there
 has been a flow of blood from the  nostrils or ears : the stupor has
 continued for hours after the heat  and circulation have  been  re-
 stored ; and, in fatal cases, much serous effusion has been found in
 the brain.t
  76.  Hitherto we have considered  the immediate  operation of
 cold (§73, 75).  But its indirect effects are more commonly known :
 these are, reaction,irritation, inflammation, and their consequences;
 and they will be more  manifest where the cold  has  been partial,
 and the strength of the circulation generally not  reduced.  Thus,
 after a part has been exposed to  severe cold, when restored to
 warmth, it  becomes  the seat  of increased  flow  of blood, whieh
 causes redness, pain and more  heat; and various forms  of inflam-
 mation may  ensue, generally modified by the specific effect which
 the previous cold has exerted on the vessels and  nerves ; varying
 also with the strength of the general circulation.  Thus, as the in-
 direct effects of cold in  a part, we may have chilblain, gangrenous
 or erysipelatous inflammation, and paralysis, or altered  sensation.
 As much of the disease in  these partial effects of cold arises from
 the violence of the reaction and inflammation, and this depends on
 the sudden return  of heat and circulation  in the  part, it becomes
 an obvious indication, for  frost-bitten limbs, to retard this return
 by cold applications.  But Dr. Alison well remarks, that this pre-
 caution is not needed, where the sedative effects of cold have been
 more general;  here warmth  and  stimulants may be used freelv,
for there is no fear of partial  injurious reaction.

  *A similar effect may be seen under the microscope, on applying i«e-cold water
 to the frog's web: the arteries contract to obliteration.  This  is contrary to the
 assertion of Poiseuille. (See my Gulstonian Lectures, Med. Gaz., July 16,  1841,
 p. 639.)  It must be remarked, that the elementary action of cold on the arteries
is strictly stimulant, exciting their  vital property of contraction ; but its operation
on textures and organs is sedative, because it impairs the circulation which sup-
ports their functions.  So too, we have found, that where it reaches the heart it
paralyses its powers (§ 73).
  f Kellie, Ed. Med. Journal, vol.  i., p. 304, quoted by Dr. Alison. 
EXCITING CAUSES OF DISEASE.
65
  77. We have hitherto chiefly considered the manner in which
cold causes disorder  in the parts to which  it is applied ; but this
is not the most common mode in which cold excites disease.  A
person gets  his feet  wet, stands in a draught of cold air, or is ex-
posed to cold when insufficiently clothed;  he afterwards becomes
diseased — not in the feet, or the parts chilled, but in some inter-
nal part.  He gets a sore throat, a "cold in the head" or chest,an
inflammation  of the lungs, a rheumatism in the limbs, a looseness
of  the  bowels, a catarrh  of the bladder, or any  other disease to
which he may be predisposed (§ 14).  Now how does the external
cold cause internal disease ?   How is  the  effect  transferred from
external to internal parts ?
   Dr. Alison supposes that the cold operates chiefly on the nerves,
and that the sensation which it excites isconveyed also by the nerves
to the internal organs, where its morbid effects become  manifest.
But it must be objected that the morbific effects of cold are by no
means proportioned  to the sensation, or known nervous impression
which it excites.   A person may have his limbs aching and  be-
numbed with  general cold ; yet internal disease  does not result.
But if he has  been exerting himself, is perspiring, and then gets his
feet wet, or is otherwise exposed to cold,especially partial, without
continuing his exercise, although he  may  scarcely feel the cold,
yet he will be pretty sure to catch cold, and  to exhibit some one
or other of its internal morbid effects.
    It would seem more probable, therefore, that external cold ex-
cites internal  disease by deranging the circulation, particularly that
in the capillaries.  Cold checks the external secretion, the perspi-
ration ;  it constricts and obstructs the vessels of the surface (§  75),
and must thus throw  more  blood  inwardly, so that internal con-
gestions are  produced — these internal congestions maybe  the
commencement of  disease.   This  intropulsive effect of cold  will
take place more  readily and  to a  greater extent in proportion to
the weakness  or relaxed state of the capillary circulation. This
may be weak naturally (§ 20) ; in this case there is a constant lia-
bility to " take cold."  * Or it may  be weak, and  relaxed from pre-
 vious excitement, during fatigue (§ 23,24), or during sleep.  Hence
persons are more apt to catch cold after being in a hot room, after
exertion, or when asleep,   On the other hand, the injurious effect
of cold is lessened or prevented by a vigorous state of the capillary
circulation, whether that vigour be natural, or excited by continued
exertion, stimulating drinks, or by  febrile excitement (§ 17).
    On  this view  we  can  understand  why partial  but continued
cold, such  as from  draughts of cold  air, wearing  damp clothes,
 standing on cold stones and the like, should be  particularly inju-
rious, even  when the sensation of cold excited is not great. Such
 causes of cold, acting long on the  same  part, more completely
constrict its vessels, check  its  secretions, thus more  surely injure
the balance of the  circulation, and by throwing a  corresponding
            6* 
66           WILLIAMS'S PRINCIPLES OF MEDICINE.

amount of congestion inwardly, fix it in some part predisposed to
disease (§ 14). (a)

  (a) We cannot but regret that the author, who, in opposition to
the views still  entertained by some writers, declares, most cor-
rectly, as we think, cold to be " directly sedative" (p. 63), should
still adhere to the popular hypothetical explanation of the manner
in which it  affects the internal  tissues and organs, and  should
speak of more blood  being thrown inwardly, — at the time that
the cutaneous vessels are constricted, or rather  measurably torpid
and  collapsed  by cold.  Early  convinced of  the fallacy of this
notion, which partakes more of hydraulics than of pure physiology,
we took occasion at different times to enter our protest against it,
and to describe the phenomena  as they actually occur.   In 1825,
in a paper on Miasm, in Dr. Chapman's Journal (vol. xi.),  after
showing the  numerous fallacies and contradictions in the received
doctrine of the  agency of miasm in the  production of periodical
fever, we sketched briefly the operation on the animal economy of
the different sensible states  and mutations of the  atmosphere.
Respecting the  topic  now under notice, we find the following lan-
guage :
  " The operation of cold on the body generally is of a decidedly
sedative nature, though, when speaking of its  morbid effects, we
must generally  hold in mind  that these latter are compounded of
the first application of cold, and secondary one of heat, and other
stimuli.  Still, we are justifiable in speaking of cold as producing
such and such effects, since it is the causa sine  qua non.   On the
surface of the body, cold, in extreme, causes chops, chilblains, and
even gangrene of the  extremities — fingers, toes, ears, nose. When
continued for a still longer period it strikes at the sources of vita-
lity.   The torpor of the capillaries represents that of the larger
vessels, the heart, and the brain.   There is lethargy and apoplexy,
particularly  venous,, from the congestion of blood, and hence the
great and at  times irresistible propensity to sleep, in those who are
exposed to great cold.   We  are  not to conceive  of a  reflux of
blood to the great cavities  or the internal surfaces from cold out-
wardly applied.  The torpor  of  the former immediately succeeds
or is synchronous with that of the latter : and the  reaction in both
is simultaneous, or with little interval.   The rest of torpor and the
excitement of reaction may then be said to constitute this state of
things.   What is seen to take place in the skin is repeated in the
other surfaces,  mucous,  serous, and synovial ; and the alterations
in the one will serve to give us an idea  of the  changes in the
others, which cannot, however, we know, be effected with equal
impunity.   The skin after exposure to intense cold, may speedily
recover the  rhythm of its  functions : but not so with the internal
sympathizing membranes, lining or investing, which evince their
disorder in  catarrhs, pleurisies, rheumatisms, anginas,  &c.  The
blush  of the skin, heated after being immersed  in cold water or 
EXCITING CAUSES OF DISEASE.
67
  78. When a person has  thus  taken cold, which  he knows by
general sensations of coldness  and weak circulation, rather than

long acted on by cold air, is often  no more than sensation.  The
same blush in  the  parts already specified is irritation and pain,
productive of fever."
  On a subsequent occasion, when investigating the effects of cold,
in connexion with the operation and use  in health and disease of
the cold bath, we took some pains  to demonstrate  the futility of
the  common hypothesis of its modus operandi on internal organs.
  "  Swayed by hypothesis, rather  than observant of faets, medi-
cal writers have generally  supposed that the  blood  arrested in its
free course through the vessels of the skin and parts immediately
subjacent, was driven in increased amount into the internal organs;
and hence fears  expressed, and cautions given, not  justified  by
the  actual state  of the  case.   A  brief enumeration of the phe-
nomena which occur will serve to dispel this illusion.  We cannot
indeed see what changes are produced internally,  but we are able
to measure them  with tolerable accuracy by particular symptoms,
universally recognized as  indicative of the real condition of the
organs.  First, then,  as  to the manner in which  the lungs are
affected.  A warm, and, still more, hot vapour given out during
respiration indicates  an active, and in  the latter case* highly ex-
cited  state  of the  pulmonary circulation, and especially of the
capillaries of the lining mucous membrane.  Now, if a person
 whose lungs  are in  this state of  strong functional exercise, goes
 into a cold bath, we discover very speedily that  the air which is
 expired is  no longer hot  or even  near so warm as in common,
 nor so abundant in vapour.  In other words, the  air taken into
 the lungs is  returned without undergoing changes to the  same
 extent as  before the cold immersion ; and this is direct evidence
 of the diminished  activity of the  pulmonary circulation and  of
 the secreting function  of  the respiratory mucous surface, which
 latter is in fact similarly, though not to the same extent, affected
 as  the skin.   Secondly, as to  what transpires in  the digestive
 canal; the changes in  it are tolerably well  represented  by
 the corresponding alterations  of appearance in  the tongue and
 lining membrane  of the  mouth and fauces.  It is well  known,
 that when the stomach is highly excited, irritated  or inflamed,
 the amount of blood circulating  through, and  contained  in  its
 vessels, is greater than  before : there is a sensation of heat in the
 parts, and  thirst;  the  mouth is dry and parched, and the tongue
 is in the same state, and  in general, preternaturally red.   Let a
 person thus suffering, use  the cold bath, and what results?   lhe
 mouth loses  its  dryness, the tongue  much of its redness, if  it do
 not become actually pale,  thirst is  no longer felt, and the sensation
 of  inward heat  complained of, as well in the stomach  as  m the
 chest, has disappeared.   Surely these  two  series  of phenomena
 in  the pulmonary and digestive apparatus, for changes similar to 
68
WILLIAMS'S PRINCIPLES  OF MEDICINE.
by any feelings in the part chilled, powerful measures which tend
to restore the balance  of  the circulation, such as violent exertion,

those above described in  the state of the stomach take place also
in the course of the intestinal canal, afford no evidence of an un-
usual determination of blood to the organs of which they consist.
On  the contrary, we have  an intimate conviction, from  the feel-
ings and symptoms, that  there is now less blood, and a less active
circulation, as well as diminished sensibility in  these parts, such
as we know there is in the skin.   If, in the third place, we ask
whether  the paleness of the face, and the obviously diminished
activity of the external vessels of the neck and head be replaced,
in the" cold bath, by an  accumulation of  blood in the brain, we
cannot, on examination,  but  answer in the negative.  The func-
tions of the brain  are vigorous in proportion to the amount of
blood distributed to this organ; and it is only when the supply is
excessive  that  the  mentaf faculties, for  a while preternatnrally
active, become  perturbed and weakened, as in the state preceding
delirium and apoplexy, and  pending these maladies.   But  no
symptoms  analogous to  these  are discovered on immersion in the
cold bath, and when the presumed determination of blood to the
brain is supposed to exist.  From the first application of the cold
fluid, there  follows impaired  mental  vivacity; the  person  feels
dull, has his range  of ideas limited, and perceptions blunted ;  he
is torpid, but it  is the torpor of gradually  abated cerebral circula-
tion, unaccompanied by those sensations of fulness, and singing in
the ears, which  would be caused byundue determination of blood
to the part.  Restoration of the accustomed activity of the faculties
and senses generally, in the case of the cold bath, is performed by
means the very  opposite  of those which we would have  recourse
to  where   undue determination of  blood existed.   External
warmth, and a mild stimulating drink, are sufficient to relieve  the
 torpor  from cold;  they would  aggravate the state  of a brain,
 where undue determination of the blood has been the cause.
   " With the diminished activity of the  brain  and nervous sys-
 tem generally, there is, as an  unavoidable consequence, less mus-
cular power.  The  muscles deprived of the accustomed stimulus
 of  the nerves, and also  of the  blood  in  their capillaries, which
 sympathise with those of the skin, are thrown into a state of inac-
 tion : their fibres approximate passively, owing to  the distending
 fluids being withdrawn,  and they are less bulky than usual.  But
 we must not confound  this approximation, any more than occa-
 sional  or  irregular spasm or cramp  in portions  of them, with
 increased contraction and  increase of tonicity.   The irregularity
 with which they may be  supposed to be deprived of the stimulating
 influences of the blood  in the capillaries, and of the nerves dis-
 tributed to  them, owing to their  different degrees of  sympathy
 with the skin, will sufficiently explain the feeling of partial  con-
 traction, or peculiar creeping movement occasionally experienced 
EXCITING CAUSES OF DISEASE.
69
a hot or vapour bath, or stimulant drinks, may often yet prevent
the further progress of disease.  The general application of cold,

by a person in the cold bath.   If this last be  continued, the com-
plete torpor of the nervous system, and  of the capillaries through-
out the body insures that of  the  muscles, which eventually be-
come powerless and motionless, however inordinate  and irregular
may have been their contractions previously.
  " The effects of cold bathing on the circulation, as evinced by
the contractions of the heart  and the pulsations at  the wrist, are
somewhat dependent on the sensibility of the individual immersed.
At times,  where  the impression on the  sentient  surface of  the
skin is prompt  and powerful, and that by consensus or sympathy
on  the  pulmonary mucous  surface equally sudden  and strong,
the interruption to the capillary circulation in the lungs calls on
the sensorium or cerebral centre for increased efforts of the respi-
ratory muscles to  heave and expand the chest; hence the breath-
ing is panting and hurried,  and  the  heart, struggling to  clear
itself of the blood thus hastily returned  to it in a smaller circle,
contracts  with  increased frequency.   After a  while,  however
when the central portions of the  nervous system, cerebro-spinal?
and ganglionic, participate with  the sentient expansions in the
enfeebling influence of cold, the  heart  beats slower and feebler,
and the number   of pulsations, from being  more  frequent and
hurried, now become slower and  more  uniform.  We cannot for
a moment confound this  hurried respiration of some bathers on
first entering a cold bath, with that which is produced by a real
augmentation of  blood in the lungs,  and its  rapid circulation
through them, as after great exercise and the ingestion of nutritive
and diffusible stimulants.
  " That the cold  bath diminishes the frequency of the  pulse, is a
point positively affirmed by Marcard  and Currie.   The former,
indeed,  says that  his experience is chiefly confined to what he
calls cool baths, in which the water was of the  temperature of
60° to 63° of Fahrenheit.  Buchan (Observations an Cold Bathing)
asserts,  that in all whom he had any opportunities of making ob-
servations, it was  at first accelerated; but he adds, that in the ex-
periments instituted by Dr. Currie, the  pulsations of the person,
who was  the subject of them, were found to decrease  uniformly
from ten to  fifteen beats per  minute, becoming at the same time
firm,  regular and small.   Athill, though   he expressly  states
that the pulse is greatly hurried during cold immersion, admits its
subsequent retardation, and  tells  us that it  is diminished in  fre-
quency from seventy-six to  sixty beats  in a minute, in water of
52° Fahrenheit.
  " But whatever doubts might have existed respecting the  direct
sedative and depressing effects of  the cold bath, must be dispelled
by a knowledge of its effects  on  the calorification or the forma-
tion of  animal heat.  When we  discover that the evolution of 
70           WILLIAMS'S PRINCIPLES OF  MEDICINE.

if not  long  continued, is less injurious than that which is partial,
both because it disturbs less the balance of the circulation, and be-

caloric is less, and the ability to furnish  it is diminished, we  are
satisfied at once of the feeble functions of the  three systems, pul-
monary, capillary, and nervous, since it is on the combined energy
of these that the formation of animal heat in the economy maimy
depends.  Not only are we apprized  of this diminished tempera-
ture by our  sensations, but we also iearn  the  fact by the applica-
tion of the thermometer to a part of the body, under the tongue,
to which the water has not access.  Even for some  time after
leaving the bath, and when we feel aglow of pleasurable warmth,
the  temperature  is still less than before  immersion (Currie),
showing how profound was the sedative impression on the ner-
vous system produced by the cold of the water.
  " The first or direct effects of the cold bath, whether we regard
the phenomena evinced on  the'skin and  membranes with which
it directly sympathises, or those in the senses, and  the brain and
heart, are unequivocally sedative, and, under  longer continuance,
enfeebling and stupifying.  Some have referred  much  of the first
effects of cold immersion  or affusion to the shock or suddenness of
impression on the nervous system.  But we know, that, if a person
immersed in  a  warm bath of 98° be gradually subjected to the
 operation of cold by lowering the temperature of the bath by the
introduction of cold water, the customary effects of cold bathing
will  be experienced,  although the  individual in question  was
barely sensible of the change,  and certainly experienced no shock.
 (Gia'nnini,toin. i., p. 65.)" — Bell on Baths and Mineral Waters,
p. 98-104.
   After no  other view of the  modus operandi of cold, or that by
 which it is regarded not only as a partial or local, but also a gene-
 ral sedative, can we reach  the proper indications for its employ-
 ment therapeutically.  If, consequent upon and owing to its seda-
 tive operation on the skin, there should be accumulation or partial
 congestion of blood in the viscera and  internal organs  generally,
 with what show of reason could we direct cold  bathing in its vari-
 ous fashions, in the exacerbations of  fever, intermittent, remittent,
 and  typhous, in  all of which we  should  deprecate any  the
 slightest  augmentation of  congestion which  we  may fear exists
 already to  a greater  or less  extent in  these diseases ?  But if,
 while removing the morbid excitement  of the  skin by cold bathing,
 we hope and design to mitigate, and it may  be remove, the  syn-
 chronous morbid  excitement of the  digestive and  respiratory
 mucous membranes, and of the meninges of the brain and spinal
 marrow, and with them the irritation of the heart  and circulatory
 system generally,  our therapeutics  harmonise with  our  patho-
 logy.
   If the popular hypothetical explanation of  the immediate effects
 of cold on the animal economy generally, be received, how can
 its advocates apply cold to the epigastric region to allay the inor- 
EXCITING CAUSES OF DISEASE.
71
cause also it supplies the lungs with denser air, and therefore more
oxygen ; and its impression on i\vi nerves of the face and chest
excites  more  energetic respiratory movements, which  maintain
the heat and the vigour of the circulation.  Healthy persons rarely
take cold when travelling on the top of a coach  or in a perfectly
open carriage, but they frequently suffer  in a close carriage par-
tially open.

dinate heat of the skin of this part, and while doing  so  to  allay
the thirst and internal heat, the effects of gastric excitation, which
keeps the patient in a state of continued restlessness and suffering;
or, how  apply cold (ice and cold cloths)  to the scalp in cerebritis,
or  in delirium and  maniacal raving  depending  on  meningitis?
Dare we, by this hypothesis, apply cold externally in any of the
varieties of hemorrhage of internal organs ?  But take the expla-
nation which we have offered of the synchronous sedative effects
of  cold on all the organs, and we  do not hesitate to adopt that
which experience has shown to  be safe and salutary practice, viz.,
the application of cold water to  the entire  skin, or to some portion
of  it,  in order to arrest the internal  hemorrhage, by inducing a
state of the capillaries from which  it takes place analogous to those
of  the skin at the time and for a while after the cold is applied to
 this latter.
   In scarlatina, most physicians, entertaining a false notion of the
 real effects of cold on the entire system, and alarmed by the idea
 of determination to  internal parts, if not  positive congestion from
 the use  of the cold and cool bathing, deprive themselves  of one of
 the best, most expeditious and safe remedies  in  this  so often for-
 midable disease.  In using this language of eulogy of the efficacy
 of the cold bath  in  scarlet fever, we  speak advisedly, after much
 and long experience.  But, for the remedy to be of service, we
 should  employ it when the cutaneous excitement is  considerable
 and  uniform, and  the anginose  and pulmonary symptoms, with
 irritation  of the  nervous system, correspondingly  great — at a
 juncture, in fine, when general sedation is  most required, and
 stimulants are most hurtful.  As the disease declines in  intensity,
 or the excitement becomes less and irregular, we must withhold
 cold bathing, and substitute tepid in its stead.
    We have  not thought it worth  while to argue formally against
 the hypothesis of cold being a stimulant, contradicted directly as
 this view  is both by nearly all  the phenomena already described,
 and by  its therapeutical employment, even under the direction of
 those who hold to  its being a stimulus.   To  have recourse  to a
 stimulus in various phlegmasia,  in  active hemorrhages, in  the
 paroxysms of fever, in the first stage  or  that of  excitement of the
 exanthemata), must seem to be odd practice, and is, in fact, opposed
 by the  whole tenor of the treatment in  these cases.  But, on the
 other hand, to use  a sedative or contrastimuiant under these cir-
 cumstances, is in harmony with the etiology which  we advocate,
 and the therapeutics almost universally adopted. 
72           WILLIAMS'S PRINCIPLES OF MEDICINE.
   79. Susceptibility to the morbid effects of cold is to be. diminished
 by  means  which  invigorate the capillary circulation, especially
 those which  promote that  process  of reaction  by  which cold is
 naturally resisted.   Now nothing tends to increase this more than
 sudden artificial applications of cold, as by cold bathing or spong-
 ing, followed by friction, exercise, heat, or stimulant applications,
 which promote the reaction (§ 16).  The great art in usefully ap-
 plying cold with these intentions, consists in using the cold in such
 manner and  degree, and having the  body in  such a state before
 and alter the application, that the reaction  or  glow, which is the
 sign of vigour in the capillary circulation, shall be most fully pro-
 duced.  If, on  the other hand, the cold be applied too long, or
 when the  body is  exhausted by fatigue, exertion, or other cause
 (§ 20), or is naturally too weak, depressing effects of cold will con-
 tinue, there will be little or  no reaction, the sensations of languor
 and chilliness show that the cold  has been injurious instead of be*
 neficial.  The addition of salt to  the water of baths gives it a sti-
 mulant property which promotes reaction, and  a  similar influence
 results from the force or shock with which the  water is  applied.
 This shock  excites deep  and forcible respirations through an im-
 pression on the incident nerves; and these  are probably  the effi-
 cient cause of the process of reaction which follows.
   The reaction which follows the judicious use  of cold as  a thera-
 peutic agent, may prove serviceable, not only in resisting  the fur-
 ther influence of cold, but also to remove congestions and irregu-
 larities in the circulation from other causes, and  to excite in the
 capillaries and secernents  new actions, which may supersede  those
 of disease.(a)  It is thus that the " water cure" of Priessnitz chiefly
 operates; and although  too powerful  an agent to be entrusted to
 unskilled and unscientific hands, it promises to become a valuable
 addition  to  the means of combating  diseases, particularly of a
 chronic kind.
   In the preceding remarks on cold, it must be  borne in mind that
 the term cold is applied relatively, not absolutely ; cold is not a fixed
 temperature or range of temperature ; but something considerably
 below the temperature of the body.   Thus  a body that has been
 warmed  throughout to a heat of 9S°, and kept in  an excited  state by
 that temperature, would suffer from a draught of air at 70°, which
 would be cold to the body, and produce the physiological  and pa-
 thological effects of cold.  But if the  body had not been previously
 warmed, so that the temperature of most parts of the surface mi<mt
 not exceed S5°, or if,  although lately warmed, the energies of the
body had not been exhausted by it, then air at 70°  would feel plea-
sant, and produce none of the effects of cold.   This is one of many
facts which  distinguish vital from physical  properties.  Physical
or chemical properties are generally affected by fixed temperatures,

  (a) With  the  understanding that  as the sedation was general,
that  is, in all the membranes and viscera, so shall  the reaction be. 
EXCITING CAUSES OF DISEASE.
73
independent of previous circumstances: but vital properties are
variously affected, through that power of adaptation by which they
are enabled to maintain the same function in varying external
circumstances.
                          SECTION IV.

                  II.  NONCOGNIZABLE AGENTS.
   80. We now proceed to notice those causes of disease, the ex-
istence of which is inferred only from the fact that disease prevails
under certain circumstances not well explained, unless we assume
that such  causes do exist (§ 12), although we cannot  prove there
existence  in any other way (§53).   These comprise the endemic,
epidemic, and infections causes of disease.

                     I. ENDEMIC CAUSES.
   SI. Persons living in  a marshy district are often afflicted by a
disease called ague, which does  not attack those inhabiting dry
lands.   Again, the inhabitants of certain deep valleys  are often
affected with the swelling in the neck, called bronchocele or goitre :
the neighbouring mountaineers are not so affected ; and when those
from below remove their  residence to the mountains, they often
lose the disease.   These are instances of diseases which  may be
said to dwell among the residents  in particular spots;  hence they
are called endemic, in the people («' JVec).
   82. In some cases, much doubt still  hangs over  the precise
source of endemic influence ;  some supposing it to be in the water,
others in emanations from the soil ;  but this doubt does not apply
to the cause of agues, intermittent and remittent fevers, which have
been clearly  traced to  effluvia from marshes, rice-grounds, &c.
It has been found that when the wind blows across these marshes,
the disease appears chiefly in persons residing to leeward of them,
and not  to windward  ;  and it  has been  abundantly proved,
that when the marshes are drained the ague ceases.  From these
and similar facts, it is concluded that the cause of the ague is an
effluvium, miasm, malaria, or bad air ;  an  aerial poison, which
is supposed to be inhaled with the breath, and absorbed into the
system.
   83. The true nature of marsh malaria  has not been determined.
It  has  never  been  detected by chemical  analysis.   Professor
Daniel conjectured that the malaria causing the destructive ende-
mic  fevers of  Western  Africa, might  be sulphuretted hydrogen
evolved from  the sea water by the decomposing vegetable matter
brought down by the rivers ; but  I am informed by Dr. D. B.
Reid, that experiments made in the late unfortunate expedition to
the Niger  have negatived this notion.  The microscope, rather 
74
WILLIAMS'S PRINCIPLES OF MEDICINE.
than chemical analysis, may be expected to discover t he nature of
malaria.
  Although hitherto unknown in its nature, some  knowledge of
the general properties of marsh malaria has been obtained through
its morbific effects.   It seems to be heavier than air; for persons
occupying a ground floor  suffer more than those living in upper
apartments.  Water seems to absorb or  destroy it; for persons on
board ship, or on an  opposite  side  of  a lake, are not affected;
whilst  at a greater distance a favourable wind will convey the
pernicious influence over land.   A damp  state  of the air, how-
ever, favours its  production ; good fires in a house give marked
protection to  the inmates.  It seems to  be attracted by trees;  for
the vicinity of trees is doubly  dangerous, whilst places beyond
trees are  more free from  its effects than  others at the same dis-
tance.
  84.  The chief points  known with  regard to  the source  of
malaria are, that it arises from the operation of  the sun's heat on
marshy ground, or on the banks  or deltas of tideless rivers, after
evaporation has proceeded to some extent; putrefaction of organic
matter not being an essential part of the process.*  The virulence
of the  malaria, as shown  in the severity of  the disease excited,
and in  the number which it affects, seems to  bear some propor-
tion to the heat which has led to its development.  Thus the ague
of this country,  the  pernicious  intermittent  of Italy, and the
malignant remittent of Western Africa and the West Indies, seem
to arise  from  similar endemic causes, but differing in their viru-
lence according to the degree of heat.   A certain amount of mois-
ture  is, however, required: for a very  dry season, which  desic-
cates a marsh, stops the malaria ; and the deposit of  the evening
dew always favours its  production (§ 83).    Again, excess  of
moisture  checks its development, so  that a very  wet season, as
well as  a  very dry  one,  may  render  a marsh less unhealthy
(§ 83).  Extreme heat will not, however, diminish the malaria
from the  banks of rivers, since portions  of these  are never dry.
  It is not only marshy or low grounds that engender malaria,
although these are the situations commonly most favourable for its
production.   All that seems to be requisite is the continued opera-
tion of the sun's heat on moisture stagnant at or near the surface
of the ground.  I know instances in which ague has attacked per-
sons living on a height of mountain limestone, forming a small
table land  below greater  heights.  So  also  some swampy lands
are not malarious, particularly peat bogs, which show a remark-
able exemption from decomposition and effluvia of all kinds.
  S5. The  morbid effects of marsh miasms are several:  intermit-
tent  and  remittent fevers of various types are the most remarkable
of these, and they particularly  affect the new residents ; but the

  * Chisholm and Ferguson, Ed. Med. and Sur. Journal, vol. vi.; Trans. Roy.
Soc. Edin., vol. ix. 
EXCITING CAUSES OF DISEASE.
75
older inhabitants suffer from diseases of the liver and spleen, ner-
vous affections, rheumatisms, dropsy, and cachectic complaints,and
are generally short lived.
  One of the most remarkable characters in the diseases resulting
from malaria, is the periodicity of their attacks, and the diminution
or cessation of the symptoms in the interval.
  86. There can  be little doubt that there are different kinds of
malaria besides that which causes intermittent and remittent fever
(§ 79, 81).   Thus yellow fever and plague are  endemic diseases,
probably arising from  peculiar aerial poisons.  The propagation
and mortality of the latter, perhaps its very existence, is very much
to be ascribed to the filth and impurities of  the towns where it
prevails.  There is now abundant evidence that drains, cesspools,
and other  repositories  for effete and putrefying organic matter,
evolve exhalations which, when concentrated,  may generate low
fevers;  and  when  more diluted,  may considerably  impair the
health of those exposed to them* (§ 22). (a)
  (a) Hasty generalization, attempting to define the complex before
a faithful study of the simple, has  led into abstractions, and the
assumption of  essences,  without any clear perception, because,
without any adequate knowledge of the separate parts and pro-
perties, which, collectively, have been  thus represented by abstract
terms.   Instances of this faulty reasoning occur in all  the depart-
ments of science, except perhaps, geometry ; and  in medicine they
are most obvious in the writings of those who profess to explain the
causes of many diseases.   Terms of familiar use are  unfortunately
the strongest examples of the evil; such as endemic or endemial, epi-
demic, miasm, infection, atmospherical constitution, &c.  Locke,
(Human Understanding, Book III, Chap.  10,  Sect. 14,)  alter
having given instances of the use of terms, purely conventional
and arbitrary, and without definite meaning, by the Peripatetics,
Platonists, and Epicureans, remarks :  " There is scarce any sect in
philosophy that has not a distinct set of terms, that  others under-
stand not; but yet this gibberish, which, in the weakness of human
understanding serves so well to palliate men's ignorance and cover
their errors, comes, by familiar use  among those of the same tribe,
to seem the most important part of language, and of all others the
most significant.  And should aerial and  ethereal vehicles come
once, by  the prevalency of that doctrine, to be generally received
any where, no doubt those terms would make impressions on men's
minds, so as to establish them in the  persuasion of the reality of
such things, as  much as  peripatetic forms and intentional species
have heretofore done."
  The application of these strictures to the sect of medical philo-
sophers is too readily and  closely made for the gratification of the
vanity of teaching or of authorship.  In the case of endemic causes

  * Sanitary Report of the Poor-Law Commissioners, by Mr. E.Chadwick, 1842. 
76           WILLIAMS'S PRINCIPLES  OF MEDICINE.

  S7. Some other endemic diseases can be traced to more cogniza-
ble causes ;  as the Guinea worm, to drinking water containing its

treated of in a summary way by the author in the preceding section,
there is scarcely any one of his propositions, although all of them
are in conformity with the  prevailing  tenets  of the  schools, that
might not be successfully controverted.  The term endemic con-
veys, by  its  derivatives, "no  definite meaning as to cause,  opera-
tion  or general results.  It certainly ought not to designate an unit
idea; but rather to  be regarded as a general  term on which  the
mind pauses, in attention but not instructed,  for ulterior descrip-
tions and details.  It is resulting,not causative ; and hence it is and
has been more fittingly used for diseases than for their causes.   It
is more correct  language to  say endemic diseases than  endemic
causes.   That the inhabitants of certain localities, distinguished by
fixed peculiar sensible conditions of atmosphere, soil, and  water,
are liable to diseases  marked and recognisable  by symptoms, dif-
ferent from  those which affect the inhabitants of localities of a
different  nature, is a proposition rendered evident by observation,
from the age of Hippocrates to the  present  time.   This cele-
brated  writer, in his works on Air, Water, and  Situation, and on
Epidemics, pointed out this fact, in its various relations, with a sim-
plicity yet distinctness of narrative equalled by few of his succes-
sors  ; and if we say that he  made no approach to explanation of
cause beyond the extremes and alternations of obvious atmosphe-
rical  and topographical states and qualities, we shall be obliged to
add that a no nearer solution of the problem, by the revelation of a
cause occult to him, has been made up to the  present day.
  We cannot regard the arbitrary application of the term miasm,
or malaria, as, at all, either indicating or giving facilities to a better
knowledge of the cause of those fevers that occur most frequently al-
though not exclusively in paludal districts. Miasm does not express
the idea of anything appreciable by our senses,  aided by any form or
fashion of chemical or philosophical apparatus  and manipulation.
It  is  not pretended to be a property inherent in  the soil or its pro-
ductions, in  the water, or the air of the region  in which it is alleged
to manifest its operation by inducing disease.  It is not the product
of any one of these, severally or  conjointly,  although for  a  long
time it was confidently said  to be evolved in the process of or-
ganic, and especially vegetable  decay, and  decomposition.   To
speak of miasm as an effluvium or emanation is pure hypothesis,
since we cannot, with any show of common logic, speak  of  the
motion of that of the existence of which, to say nothing of  its dis-
tinctive properties, we are entirely ignorant.
   Not  only  does the  miasmatic  hypothesis fail to advance us in
the theory of the causation of fevers and some other  diseases and
in pointing out means of prevention  and  cure, but it has,  on the
contrary, retarded  us in these particulars.  Speculating  on an
imaginary cause, modern writers have failed  to exhibit In detail 
EXCITING CAUSES  OF DISEASE.
77
ova;  the pellagra of Northern Italy, and the  plica of Poland, to
neglect of cleanliness, and healthy modes of living.

                     II. EPIDEMIC  CAUSES.

  88. There is another class of diseases, which, in their affecting
many persons in  the same place  and at the same time, resemble
 the series of common and obvious causes except in forced and, as
 it were, adventitious connexion with miasm; and hence  our  me-
 dical  topography  and geography has not been  enlarged  at all
 commensurate with our minuter  acquaintance with  meteorology
 and geology, and the extended sphere for observation in so many
 regions of the earth, to which  the people of civilized nations have
 been carried by the thirst  of dominion or  of commercial gain, or
 the better motive of religious  enlightenment and conversion.  If
 due attention be paid to an avoidance of the extremes and vicissi-
 tudes of the known and appreciable conditions of the atmosphere,
 such as great heats by day and coolness and dew by night, to a
 proper protection by lodging and clothing, a substantial and well re-
 gulated diet, including  wholesome water for drink, a due  division
 of the sleeping and waking periods, and well-balanced exercise of
 the mental faculties, the inhabitant of so-called miasmatic regions
 need not  fear miasm nor its alleged effects, periodical fevers.  He
 avoids the substantive causes:  he  need  not care for imaginary es-
 sences or abstractions.
   Stress has been laid on a supposed peculiarity or distinctive trait
 of the diseases  of reputed  malarious  origin, mentioned by  the
 author in the text — viz.: " One of the most remarkable characters
 resulting  from malaria, is the periodicity of their attacks, and the
 diminution or cessation of symptoms in the interval."  It will be
 sufficient  reply, in proof of the fallacy of this opinion, to advert — 1,
 to physiological phenomena, as manifested  in the periodicity of all
 the functions of animal life, by the regular and necessary alterna-
 tion of waking and sleep, and of those of organic life, by the return
 of the catamenia at regular periods: and 2, to pathological phe-
 nomena, in the  periodicity of  many hemorrhages, and still  more
 evidently of various diseases of the nervous system, epilepsy,  &c.
 The periodicity of fevers that originate in certain conditions  of lo-
 cality, is owing to the lesion  of the nervous system, and not to  the
 specific nature of the supposed exciting cause, or miasm.
  We have restricted ourselves in  this note to a simple exposition
 of the prominent fallacies of the miasmatic doctrine. Detailed  argu-
 ment and proofs would be not quite in place here.  Elsewhere (Chap-
 man's Journal,volxi., and Stokes and Bell's Lectures, vol. ii.)  when
 treating of Miasm and Intermittent Fever, we have enlarged  more
 fully on this topic.   Dr. Pritchett, in his Account of the African Re-
mittent Fever, to which the crews of the vessels sent out in the Niger
Expedition were subjected, is also, we are glad to see, distinctly
adverse to the miasmatic hypothesis.
           7* 
78          WILLIAMS'S  PRINCIPLES  OF MEDICINE.
the endemic (§ 81).   But they differ in  this respect, that they do
not regularly return at stated seasons, (§ 84.) nor are they confined
to particular localities, (§ 82,) although they infest some more than
others; but they attack a whole district, a  whole country— nay,
almost a whole hemisphere — within  a  very short lime; often
coming on without obvious cause ; prevailing for some time, then
disappearing for an uncertain  period ; perhaps recurring within a
few months, or years, or not within the  memory of man.  These
are called epidemics,  (wn/^cc,) like a blight or pernicious influence
blowing on  the people; and therefore affecting a whole country
at once.
   89. The cause of these diseases is supposed to be something in
the atmosphere ; because the atmosphere is the only thing common
to all the places so affected;  but  the nature of the cause  is not
known,  It is true that some diseases, which seem to  prevail epi-
demically, may be traced to the cognizable  qualities, cold, heat,
dryness, and moisture of,the air  (§ 72, el seq.).  Thus  diseases ex-
cited by cold sometimes prevail, like an epidemic, in the winter;
those by heat, in the summer ;  catarrhs and quinsies abound in
cold damp weather; croup and rheumatism become common during
the prevalence of a cold east wind, in  the spring ; diarrhoea and
dysentery are rife in the fruit  season  of the autumn.  Others,
again, such  as  dysenteries, fevers, scurvies, &c, have  in some in-
stances obviously arisen from deficient or  contaminated  food, bed
water, or some distinctly cognizable cause  (§ 60, 66).   And as
these causes belong to the class of cognizable agents before noticed
(§ 51, et seq.), it is unnecessary to advert to them here.
   90.  But there are diseases  occurring epidemically without any
discoverable connexion with season or temperature.  Thus an
epidemic influenza  may come  on at any season  of  the  year,
rapidly spread through a country, and cease as unaccountably as it
began.  So, too, diseases that are usually excited by other causes,
infectious and others — such as typhus and scarlet fevers, measles,
small-pox, erysipelas, &c. — sometimes prevail throughout a coun-
try so generally, and often with such peculiar characters,  that some
influence besides their  common causes must, be concerned in their
sudden increase.  The nature of this influence is unknown ; but it
is called epidemic (§  88).
   91. Lastly:  various diseases,  fevers, and inflammations, and
almost all sorts of ailment, at some periods assume a remarkable
character in common, or type (as it is called); for example, being
attended with unusual weakness,  or  unusual  excitement,  or  a
tendency to hemorrhage.  This is called an epidemic or prevail-
ing diathesis,  or constitution.   Thus  at uncertain times, fevers,
wherever arising, and from whatever source, are more  low,
typhoid, or  adynamic, than usual; at the same time, exanthema-
tous  diseases generally partake of the  same character ; and even
patients affected with  inflammations do  not well bear the usual
depletions.  Of late  years, this constitution has more or less pre- 
EXCITING CAUSES  OF DISEASE.
79
vailed, and  may be contrasted with a period of twenty years ago,
when  an inflammatory diathesis  existed, and bloodletting was
advantageously employed even in continued fever.
  92.  It  has  been before stated (§ S9), that we are quite in the
dark as to the nature  of epidemic influences, or causes of disease.
Many conjectures have been advanced, some of them with much
plausibility, but without  any  substantial  support.   Dr.  Prout
states, that shortly before and during the prevalence of the malig-
nant  cholera   in  this country,  he  noticed a  small  but decided
increase in  the average weight of  the atmosphere, as if from the
addition of some ponderous gas.  At the same time, he remarked
an  unusual acidity in  the  saliva  even of healthy persons, and
such an absence of lithic acid  from the urine, that he seems  in-
clined to suppose that a disposition to form oxalic acid was  re-
ferrible to the  same  unknown cause which was  then  producing
cholera (§ 56).
  Many analogical arguments may be  adduced  in favour of  the
notion  that epidemic  diseases are caused by animalcule  tribes.
This hypothesis  has been  ably advocated by Dr. Holland* and
Dr. Henle.t   Before  I had seen the opinions of these authors, I
had stated in  my lectures some arguments in favour of this notion,
which will  be given under the head of infection.   The chief facts
which  countenance  this view are  the  following: — 1.  Epidemic
diseases in  the uncertain periods and places in which their visita-
tions occur (§ 88), resemble those  of blights, or tribes of insects,
which are known to  appear and disappear without evident cause.
2.  Proofs are accumulating of the occasional existence of parasitic
animals and  plants in living animals,  and in some instances as
causes of disease (as  in  the case of worms and other entozoa,
acari in itch, the rot-worm in sheep, the myco-dermatous vegeta-
tions in  porrigo,J conferva? in impetigo, aphtha?, &c).   3. The
history and symptoms of some epidemic diseases, such as cholera
and influenza, are not inconsistent with the hypothesis that they
are caused  by the sudden development of animalcules  from  ova
in  the blood.'   But there is  a total want of direct observation in
support  of the hypothesis;  and, perhaps,  it may be objected
against it, that the" seasons at which epidemics sometimes appear
(as cholera  in winter), are not always those most favourable  to the
development of animalcule  life.§

  * Medical Notes and Reflections, 1840, p. 597.  Republished in the Select Me-
dical Library.
  t Pathological Researches, British and  Foreign Medical Review, April, 1840.
  % Gruby, Comptes Rendus, t. xiii.  Bennett, Trans. Royal Soc. Edin., 1842.
  § The prevalence of  the south-east wind was  observed  to be particularly
favourable to the increase of both cholera and influenza ; and 1 cannot but think
that this had some connexion with the general tendency exhibited by the former
to spread chiefly from east to west. Has the morbific property of this wind aught
to do with the haziness of the air when it prevails —a haziness seen in the
country, remote from smoke, and quite distinct from fog]  What is this hazel
In the west of England, a hazy day in spring is called a blight. 
SO            WILLIAMS'S PRINCIPLES OF MEDICINE.
                    III.  INFECTIOUS CAUSES.

   93.  The terms infection and contagion are applied to the pro-
duction of a disease by a morbid matter proceeding from the body
of another person who  is, or  has been, the  subject of the same
disease.   The proofs that disease is thus propagated from one indi-
vidual to another are, first, the general one, that those who have
intercourse with  the sick are affected in much greater numbers
than  those who  have  not  (§ 12) ; and, secondly, the direct and
individual proof of infecting  a healthy person with matter taken
from a person in disease.   This, although available only in some
modes of infection, may be considered as a  proof of the fact of
contagion in general — that is, of disease propagating its kind.
   94. I have just alluded (§ 93)  to differences in modes of infec-
tion :  they may be further enumerated as follows: —
   (1.)  Infection through wounds, or  an abraded surface ; as in
hydrophobia, the morbid matter being contained in  the saliva, or
guttural  mucus of the rabid animal; and in cow-pox, the matter
being contained in the specific vesicle, and acting on  a puncture
or abraded surface.
   95.  (2.) Infection by contact, different parts of the  body being
susceptible in different diseases ; as the urethra and conjunctiva in
gonorrhoea, the vicinity of the external openings of the passages in
syphilis,  the skin in scabies,  the scalp in  porrigo—the morbid
matter generally proceeding from similar parts.
  96. (3.) Infection by exhalation  from the breath, perspiration, or
other secretion, conveyed through the air to the mouth and air-
passages  ; as in  the  case of  measles, scarlatina,  hooping-cough,
typhus, and  other infectious fevers.
  97.  Some  diseases may be propagated in several of these modes;
small-pox, for instance, may be communicated by punctures in the
skin (§ 94), by inoculation — application to the eye (§ 95), — and
by diffusion through the air (§ 96):  and probably  the same might
be effected with other febrile poisons, if their precise source in the
body were as clear as it is in  small-pox.  These  different modes
of infection merely show that  the infecting  matter can exist sus-
pended in the air, as well as  in  a  fluid or solid state ; and ac-
cording to these conditions, it  may get access to the system by dif-
ferent avenues, (a)
  (a) The author regards infection and contagion as synonymous
and convertible terms; and this view is sustained by most English
writers of authority.   As, however, these terms have had different
significations attached to them, and may, it seems to us, very pro-
perly be made to  designate two  different and distinct series of
morbid  agencies, we shall devote a few lines to the subject.  The
student  will be better able  to appreciate the value of the separa-
tion when he sees it made in other quarters, and even if it be con- 
EXCITING CAUSES OF DISEASE.
81
  98. Many of those who are skeptical as to the reality of infec-
tion, aim their objections only against aerial infection, and do not

ventional it will  aid him  to classify more satisfactorily a large
number of diseases usually spoken of indiscriminately under the
epithet of infectious or contagious.
  Dr. Copland (Diet. Pract. Med.) uses the word infection  in its
generic  and  extensive  appellation, to  indicate  whatever may
affect, so as ultimately  to taint, pollute, or corrupt  the body.
Contagion he regards as an infection by immediate or mediate
contact — as a pollution by the touch.  " The word contamination
may (he  thinks)  with justice be applied to the deterioration or
morbid change which takes place in the fluids of the body during
the course of  infectious maladies."  This and  other terms repre-
sent species arranged under the generic  appellation of infection.
" In other words the frame may be infected, 1st, by the morbid im-
pression of agents — internal or self-generated, or external and
mephitic, the infection being  limited to the individual  and inca-
ble  of  propagating its  kind;  2dly, by  the contamination  pro-
 duced by animal  effluvia, the infection being capable of propagating
itself in certain ascertained circumstances, and of spreading to the
healthy  from those  affected by these agents ; 3dly, by the morbid
impression ox contamination  of specific emanations  and secre-
tions, — the infection presenting certain specific effects, or dissemi-
 nating and perpetuating specific maladies."  Dr.  Copland's large
 acceptation of the term  infection is  still further manifested by his
 defining  infecting  agents to consist " almost entirely  of decayed
 or  diseased organized substances, and of animal emanations or
 secretions."
   We believe that the two  parts of this definition ought  to be
 separate; and that the  first series of agents, or  those consisting
 almost entirely of decayed or diseased organized substances and
certain animal emanations, give rise to infection ;  and  that animal
 secretions alone are the true contagious agents.   If it can be shown
that some of  the diseases  reputed to be contagious are not really
 so,  but  are the  product  of infection alone ; and that these are
 rarely if ever transmitted by contact or through the application
 of a healthy body,  of a distinct secreted virus in the  person dis-
 eased,  then will  the propriety of a separation  be  more  readily
 admitted.  Contagions proper should be regarded as of two kinds:
 1st, specific, not arising sporadically or spontaneously, but always
 the result of  a distinct animal secretion,  capable  by contact with
 previously healthy  bodies to generate their like, and  in this way
 indefinitely transmissible.  Under this head will come syphilis,
 small-pox, measles, and scarlatina.  2d, occasional or sporadic,
 marked by distinct animal  secretion, and also transmissible by
 contact, as hydrophobia,  exanthemata?,  typhus fever, malignant
 pustules, itch, glanders.
   Infection, on the other hand, is the result of a contaminated air 
82           WILLIAMS'S PRINCIPLES OF .MEDICINE.

question the other modes.  But the difficult problem is, not that
the infectious matter may be diffused through the air — our smell
by the decomposition of organized bodies, as decayed wood, vege-
tables, and sometimes animals, separate, and on the surface of the
soil, or mixed with recent vegetable mould or newly made earth; as
in embankments, wharves, &c, and by emanations from living
bodies crowded together without adequate renewal of respirable or
atmospheric air, as  in hospitals, prisons, camps, besieged towns,
underground apartments, &c.   The air under these circumstances
is contaminated by effluvia and emanations which deteriorate and
render it poisonous to such a  degree as to cause disease of great
violence to  those who come  within  its  influence, that is, who
are obliged  to respire it.  The healthy visiting  the sick in  the
infected places are  liable to be seized with disease similar in its
features to those attacking the inmates, and hence are said to  be
victims  of contagion, and to  have taken the  disease from those
first attacked ; whereas, in fact, all have suffered in a similar way
from  a  common primary cause.   If the sick in  an infected  dis-
trict  are  removed  into a healthy residence  and  have separate
lodgings, ventilated with  pure air, their  visiters  and attendants
need  not have any apprehension of taking the disease.  As  the
chief danger from infecting agents consists in  the air with which
they are mixed being stationary or stagnant, so that they acquire,
by concentration, additional power, so, the best means for neutral-
izing them  is a free introduction  of  pure atmospheric air from
without,  if  the  foci of infection be  confined  by walls or other
inclosure, or a  change and  reduction of temperature by which
winds rise and sweep across the soil of an open  infected district,
carrying off and diluting  its accidentally poisonous ingredients.
   Among diseases the product of infection, in the sense which we
now  desire  to consider it, may be enumerated  some of the worst
forms of gastro-hepatic and gastro-cerebral, or remittent and yellow
fevers,  also  common typhous  fever, dysentery, erysipelas  in  hos-
 pitals and in particular  localities, and probably plague and  epi-
demic cholera.  We have reason to believe that the atmosphere
becomes  at  times deteriorated by some foreign or adventitious
impregnation to immense distances, and  in this  condition gives
 rise to  certain diseases which may be called infectious, such as
 influenza, and probably epidemic cholera may come in this cate-
gory.  But although people in large numbers sicken in quick suc-
cession with these  diseases, the latter cannot be said to be conta-
gious, since they are not  transmissible from person to person, nor
is there any specific secretion or virus, formed in their progress,
 which  would lead  to a suspicion of their  possessing a contagious
 character.
   Infectious diseases, although we may suppose  them to  be uni-
 formly  traceable to a contaminated or poisoned  air, are however 
EXCITING  CAUSES OF DISEASE.
83
informs us that that animal effluvia are constantly so diffused —
but the difficulty lies in the fact of infection by any mode ;  that is,

modified  not a little by changes  in  the  common states  of the
atmosphere ; as heat or cold, dryness or moisture, calms or winds,
all of which, by their modifying the common atmosphere, tend to
modify the virulence of infection, in the manner already explained ;
and they also, by their influence on the people living in the infected
region  or visiting  it, modify not a little their  susceptibility to be
impressed by the infection.
   Contagion, on the other hand, is independent of  atmospheric
changes,  which are never found to alter its essential  and charac-
teristic features.  In all climates, seasons and localities, small-pox
is ever the same — whereas no infectious disease can exist except
under a  particular  condition  of  the  air within, or the common
atmosphere without. The plague, remittent, bilious and  yellow
fevers, cholera, influenza,  never prevail the year through, as
small-pox and other contagious  diseases  are  known to  have
prevailed.                                     .     ,    ,,   ■,
   This is not  the  place  to enter into an  inquiry into the alleged
 fact of simple being at  times converted into contagious fever, and
 the collateral question of the existence occasionally of anomalous
 animal poisons generated independently of contagion.  Onesot tne
 most difficult problems, is, to determine how far, if at all, a disease
 relatively harmless  in its sporadic form becomes contagious  when
 it presents itself as an epidemic.  Our own opinion is in the negative
 of these suppositions ; and on different occasions, as when  treating
 of cholera and influenza, we have argued  the point at some length
   Any notice, however brief, of contagion and infection, would be
 incomplete without allusion to fomites, or contagious matter and
 effluvia  imbibed in and retained by  certain substances, wh ch be-
 come, in consequence, capable, subsequently  of communcaing
 disease, by imparting, on exposure to  the air, their latentxontag on
 Woollens'and silk  and cotton cloths and feathers, &c., are the chief
 recipients of contagion in this way.   The ^™^™J™T0°el
 the contagiousness  of some diseases rest mainly on then■alleged
           UStieSS Ol &U111C uiocacn-c iv^x ------j            -  i
transmission by means of fomites, when the proofs from.personal
intercourse and contact are either wanting or very defect veana
      lusive.   Quarantine regulations and restrictions are justified
             V means ui  iuuhi^o,  >.uv..---r--    ./■'■„ nnr\
             d contact are either  wanting or very defective and
inconclusive.  Quarantine regulations and restrictions.are justified
by their advocates on account of the danger to be ^^&^
fomites, and the  necessity of warding it  off  by these.  mans.
Bales of cotton, for example, or silk or woollen goods nought fro
a country or a city in which the plague is  endemic, may be sur,
posed, according to" the belief in fomites, to be ^e^
the pestilential Influence or emanations or even morbid secreturns
from those who have sickened and died with this d sea e and to
be, on this account, materials or  agents for H™?™}1™*.™^
pe sons, at the port of arrival, who. in the pursuit of their bi sinss,
would be brought in contact with the cargo.  This, under the cir 
 84           WILLIAMS'S PRINCIPLES OF MEDICINE.

 that disease should propagate its kind.  There are only two parallel
 cases in nature, in which analogous  properties are possessed by

 cumstances, is now dreaded as fomites, and those exposed to it are,
 in  consequence, liable to inhale the poison alleged  to be hitherto
 latent in the merchandize, but now developed by exposure  to the
 air, which becomes the medium for the transmission of the conta-
 gion.  Danger is apprehended also from inhalation of the air of the
 hold, or the between-decks of a vessel in which such a cargo was
 stored, as whatever contagion could  escape from the latter would
 remain fixed in a concentrated state of virulence during the whole
 voyage.
   But if the prohibition of intercourse between such vessel and
 the shore or any of the inhabitants of the port at which she arrives,
 be proper, in the premises, it  may be asked, when  are the restric-
 tions of this nature imposed upon her  and her passengers, and crew
 and cargo, and constituting a  state of quarantine, to cease, and she
 and they to procure pratique and  a clean bill of health.   The an-
 swer, and its practical enforcement, in quarantine establishments,
 are based on the supposition or belief, that, after a certain period,
 the matter of contagion becomes inert, and of course fomites lose
 their power.   The period of detention of the vessel  before she can
 unload is regulated according  to  this  creed, but not with unani-
 mity in different places.  In  most of the  great  quarantine  esta-
 blishments of the Mediterranean ports, there are extensive  ware-
 houses, in a measure  open  to the atmosphere, in which  the cargo
 is stored, and in which, by its free  exposure  to  the air, it is sup-
 posed to part more  readily with  its adherent contagion or efflu-
 vium, and by dilution  have its virulence abated.  The vessel can
 also, so soon as her cargo is discharged, be thoroughly ventilated
 and purified, and all danger from this source earlier removed, than
 could possibly have been done  if the cargo had been kept in her,
 or slowly discharged.  The passengers land and  are  placed in
 rooms or suite of apartments, separate  from  those  in which per-
 sons circumstanced like themselves,  but whose arrival was  at an
 earlier date, are lodged; and here they remain, with the privilege
 of walking in a  common court or yard during the day, but ex-
 pressly prohibited, under severe penalty, from touching those who
 did not enter the lazaretto with  them.
  The organization of those establishments in the Mediterranean
 is very complete : but there is one thing wanting tocommand our re-
 spect and confidence in them, viz.: to be convinced that the diseases,
 the plague,for example, of Egypt and Turkey,or the yellow fever of
 the West Indiesorof our southern cities, are really contagious in their
 natal spots, those in which they prevail endemically.  Until these
 questions be answered in  the affirmative,  we  may reasonably
 doubt, at least, the wisdom of  those who have  contrived such a
 complex machinery at an immense expense, one of the undoubted
 effects of which  is to trammel commercial intercourse, and give
despotism a plea for suspending the relations between the people 
EXCITING CAUSES OF DISEASE.
S5
matter.  One is the case of what is called septic matter, leaven, or
ferment;  a little of which introduced into  organised  matter will
promote changes and decompositions — " A little leaven leaveneth
the whole lump."  This property is supposed, by Liebig and other
chemists, to be chemical, operating in  the manner of heat, by alter-
ing the molecular relations of compound matter; but by Cagniard
De la Tour and other microscopic observers, it is  stated, that fer-
mentation is caused by the production and growth of living mole-
cules or vegetables, and that  it spreads by the propagating power
of these.  This would transfer this case, that of leaven or ferment,
into the next category (§ 99).
   99.  The other case analogous to propagation of disease by in-
fection, is the vital power of generation ;  in this case, as in that of
contagion, matter propagates its own  kind  in the animal and  in
the vegetable world.   Does the matter of contagion consist of ani-
mal ova or vegetable  seeds ?   Are  infectious diseases  the  results
of the  invasions  and  operations  of living parasites disturbing  in
sundry ways the functions and structures of the body, each  after
its own kind, until the vital powers either fail, or  succeed  in ex-
pelling the invading tribes from the system (§ 16) ?  Suchanopinion
has been many times proposed, and is, in a degree, implied in the
term  incubation (sitting  on  eggs to hatch  them), commonly
applied to the period between the  reception of the infection and
the first appearance of  the symptoms.   In support of this notion
may be adduced the  case of itch, which  certainly infects by its
cause, the  itch-mite,  and spreads by  this animal's propagation ;
and the case  of porrigo, or  favus, which  probably depends on a
parasitic vegetable, and  infects  through the seeds or sporules of
this vegetable.*   But these, it may be objected, are  instances  of
mere local disease, and  by no means like  the cases of infectious
fevers and syphilis, which affect the whole system.
  The case of small-pox and cow-pox might seem to  be more in-
telligible, because the infectious matter is found  to reside  in the
incipient pustule ; but this throws no further light  on the subject;
for the lymph of these vesicles has not been hitherto found to con-

of contiguous countries.  The quarantine restrictions in the ports
of the Mediterranean  imposed upon American vessels leaving the
United States, on the plea of shutting our the yellow fever, seem to
our physicians generally, to be absurd.   Recent observations and in-
quiry render it quite probable, that similar restrictions imposed on
vessels sailing from Smyrna and Alexandria, under  the fear of their
being the bearers of the plague, are as little sustained by sound
medical logic; and that  the  contagiousness of the plague is as
difficult of demonstration as that of yellow fever.

  * Schonlein, Miiller's Archiv. 1839, p. 82.  Gruby, Gazette Medicale, Juillet
17, 1811.
           8 
 S6           WILLIAMS'S PRINCIPLES OF MEDICINE.

 tain anything which  can account for its  disseminating property.
 The microscope should solve this problem, by detecting the germs
 and growths of these infecting organisms, if such exist.   Until this
 be accomplished, the nature of contagion must remain a matter of
 speculation.
   100.  The parasitic nature  of  infectious  matters may  receive
 some support from the little that  is known of their general pro-
 perties, which further deserve to be mentioned on account of their
 practical importance.  Infectious  matter  is destroyed by  a  tem-
 perature above 120° Fahr., and by strong chemical agents, espe-
 cially chlorine :  its activity is impaired by cold ; and in  case of
 aerial infection, by intense cold and free ventilation it is rendered
 harmless.  Hence infectious  diseases usually cease when hard
 frost sets in.(a)  On the other hand, warmth, closeness, and filth,

   (a) This assertion is certainly made inadvertently.   It is incor-
 rect.  Extreme cold may, indeed,  impair the activity of contagion  :
 but it is in cold weather and  in northern  latitudes  that some of
 the most virulent contagious diseases, small-pox, for example, are
 often most prevalent.   The reason  is obvious: ventilation is not
 procured in cold as it is  in warm seasons, — both because  the
 atmosphere is less in motion in the former than in the latter, and
 because nearly all classes, and particularly the poor and the destitute,
 exclude carefully the  outer air in winter, in  order to avoid  the
 dreaded cold, and to enable them to make the most of their scanty
 supply of fuel.   Under these circumstances, therefore, the condi-
 tions, mentioned by the author for increasing the virulence of conta-
 gion, viz., warmth, closeness,  and  filth, are most commonly pre-
 sent.  It would have been more correct to add, that these remarks
 are intended to apply to febrile contagions, the  exanthemata?, for
 example.
  The severest  visitation of the small-pox in Philadelphia, since
 the beginning of the present century, was  during the winter and
 spring months of 1823-4.  A  full  and detailed account of the dis-
 ease was prepared and published by us in the North American
 Medical and Surgical Journal, under the names of the  writer and
 his associate  in  the  Small-pox Hospital,  Dr. John K. Mitchell.
 We there remark, in describing  the progress  of the  disease, —
" The first return of death from small-pox, furnished by the Board
of Health, was in the week between the 13th and 20th  September
 [1823].   The next was between the 4th and 11th October.  From
this time to the end of the year, there was a  progressive increase
of mortality, and  the annual return for 1823  presented no fewer
than one hundred  and sixty deaths by small-pox.  The greatest
 mortality in any one week was thirty-three, from December20th to
 27th.  During the months of January, February, and March, 1824,
 the disease prevailed extensively, and was  fatal to many.   In the
following months its violence subsided, and in the month of June 
EXCITING CAUSES OF DISEASE.
87
increase  the virulence  of contagion, and become, as it were, a
hotbed of pestilence.  Nothing tends to promote the spread of an
infectious disease more than crowding together several who are
suffering under it.  Each one  is  a separate source of contagion;
and if these sources are multiplied in an  apartment, the air will
be contaminated in proportion.   I  believe this to  be the chief
reason why, in fever hospitals and fever wards, medical attend-
ants and nurses escape infection  much more rarely than in hospi-
tals where the fever patients are widely distributed among other
patients.
   It may be useful again to point out the peculiarities which dis-
tinguish  infections from endemic and epidemic diseases ; for these
peculiarities are proofs  of the reality of  infection as a separate
cause of disease.
   101. Infectious [contagious?]  diseases first attack individuals
in any locality, then gradually spread in  the vicinity of those dis-
eased, or in the direction where there is most  human intercourse.
Where care is taken, early and completely to separate the diseased
from the healthy, disease does not appear among  the latter.
   102. Endemic diseases may simultaneously attack  many indi-
viduals  in certain localities only  (§  81); they  do  not spread

our  attendance on the temporary hospital was discontinued, in
consequence  of a resolution of the Managers of  the Alms-house
to close  it."   Typhous fever  is  much more  frequently a disease
of winter than of summer.
   But while correcting the mistake of the author  in the text, that
infectious diseases usually cease when hard frost sets in, let  us not
assume the converse, and say that they disappear uniformly  in
warm weather.   On the last occasion of  the small-pox prevailing
with epidemic aggravations  in England,  the disease began  in
London  in November,  1837, reached its  height in June, 1838,
and  finally ceased in January, 1839.  Of the  two agencies, how-
ever, heat and cold, the former is unqustionably the least favour-
able to the contagious matter retaining its virulence ; and if it be
atmospheric  heat implying more or less perflation, it checks  its
diffusion by the dilution of the poison.  The difficulty of preserv-
ing vaccine virus, for example, in a heat which is far from being
high or uncommon, and the direct power of that, at a more elevated
degree, of neutralizing  any contagion, as mentioned in  the text,
may be adduced in confirmation  of this view.   We do not, in dis-
cussing this question, think it necessary to speak of the effects of
the  possible extremes of temperature ;  as  of cold below  the
point of  congelation, and heat such as would ensue on exposure
to a tropical sun;  for both of these would destroy, or, perhaps,
in the case of the  former, suspend the power  of contagion.  The
practical reference  must be to that thermometrical range of the
atmosphere, and of the air of dwellings in which persons live who
are liable to be exposed to febrile contagions of various kinds. 
88
WILLIAMS'S PRINCIPLES OF MEDICINE.
beyond these localities; no separation of the sick from the healthy
will save the latter, but removing the healthy to another spot gives
them security.
  103. Epidemic diseases simultaneously attack numbers  in any
locality  (§ 88):  they  increase not peculiarly  in  the vicinity  of
those first affected, nor in proportion to intercourse with them, but
rather in proportion to the prevalence of other causes that may be
called predisposing or determining causes (§ 19).
  104. It, must not be forgotten that some diseases are suspected
to originate and spread in two or even  all of these modes.  Per-
haps this may be said of typhus fever, plague, cholera and  dysen-
tery.   It has been already  mentioned that  infectious  diseases,
as small-pox, scarlatina, and measles,  are  occasionally increased
and modified by epidemic  influences (§ 90, 91); and  the same
thing  may be said of some endemic maladies.   So also the aggra-
vation of contagious and epidemic complaints by endemic impuri-
ties, (§ 85,) makes it plain that all the class of causes may operate
conjointly.  It is under such circumstances of aggravation,  or
under those of strongly prevailing predispositions,  as from famine,
(§ 21,) fatigue, (§ 23,) confinement, (§ 22,) or mental depression,
(§ 27,) that this class of diseases become so destructive  as to be
called pestilential or malignant.
  105. The direct operation of most of this  class of causes is
depressing, and  where they are strongest and  prevail most, the
resulting disease  is one of depression,  adynamia, asthenia, or
prostration of the vital powers.  These causes are therefore com-
monly designated specific poisons.  But there  is the antagonist
principle of vital resistance  in the system, (§ 16,)  which leads to
various processes of reaction, which may be exhibited in different
degrees,  according to the relative strengths  of  the poison  and of
this resisting power; and likewise often according to various cogni-
zable agents which simultaneously act as predisposing,determining,
or co-operating causes.  For instance, in warm weather the poi-
sonous influences are generally strong, (§ 84, 100,) and the bodily
powers weak (§ 24); the  resulting disease is one of more com-
plete  adynamia.   In moderately cold weather, on the other hand,
the specific poison is less active, and the system is ready to react,
not only against it, but against the cold with  which it may be
combined; this causes a  more inflammatory type in the  conse-
quent disease (§ 76, 77).
                      CHAPTER II.

   PATHOLOGY (PROPER)—THE NATURE ASD CONSTITUTION OF
                          DISEASE.

  106.  Disease is a change from the  natural condition of the
function or structure of the body (§ 6,  et seq.) ;  but the change is 
       ULTIMATE AND PROXIMATE ELEMENTS OF DISEASE.     89

generally more or less compound, involving  several elementary
functions or structures; and it  is obvious  that we cannot  obtain
an  accurate knowledge  of the nature  of disease until we have
ascertained that  of  its component parts.  As the anatomist and
physiologist examine structure and functions by  separating  or
analyzing them into their constituent parts, before  he  contemplates
them in combination, so should the pathologist study these  con-
stituent  parts, or elements, in  disease, before  he can understand
their combinations/                                 '*•
  The  chemist,  in  the  examination of his  subjects, finds  that
there are some principles or elements that cannot be analyzed  or
divided  further; these  he calls ultimate  or  primary elements:
others,  again,  are simple  compounds, which  may be analysed ;
but  they occur  so constantly, and  act  so  singly in compounding
and giving properties to complex matter, that they are called proxi •
mate principles or secondary elements.  A parallel case might be
shown of physical science.
  107.   So  it should be with physiology and  pathology.t   There
are the healthy and diseased primary or  ultimate elements  of
structure — muscular fibre, nervous matter, vascular fibre, and the
elementary tissues of  membranes, glands, skin, and  other  parts ;
and there "areprimary elements, healthy and diseased, of function
of these  same structures— irritability, tonicity, nervous properties,
to which may be added, because at present we cannot  analyze  it,
the power of secretion and nutrition; and lastly, the constituents
of the blood.  And there are the secondary or proximate elements
of disease, composed of the preceding primary elements, but still
simple in comparison with the complex conditions of disease which
they combine to produce.
  108.  The following are the chief of these proximate elements:
the bloodvessels and their different conditions, anasmia, plethora,
congestion, determination of blood, and inflammation; the nervous
system,  with its different functions, sensation, volition, reflected
excitement, sympathy, and irritation;  the secreting organs and
membranes, with their relations to the vessels, the nerves,  and to

  * A neglect of this precept has greatly retarded the advancement, nay, even the
formation, of  pathological science.   Men have begun with the very complex
problems of inflammation and fever, before they have made themselves acquainted
with the elementary properties of textures,  or even of vessels.  The result has
been, that the most profound reasoning and ingenious speculations have been
wasted on nonentities, such as spasm  of the extreme vessels, increased action of
the capillaries, &c.; and even observation has been confused by the complexity
of the subjects brought under it.
  f I have pursued  this synthetic mode of teaching general pathology, in my
lectures, during the last  three years.   1 am not aware that it has been fully used
by any other writer, although  several  (as Andral and Carswell) have partially
recognized it in their divisions of the objects of morbid anatomy ; and my friend,
Dr.  Symonds, has adverted to  the parallel of chemistry, and actually employed
the term, proximate principles of disease, in the same sense in which I use it. —
Library of Practical Medicine, vol. i., Pathological Introduction. 
90
WfLLIAMS'S PRINCIPLES OF MEDICINE.
the purposes which the secretions serve  in the animal economy :
lastly, (and here we must drop physiology,) for the subject is pecu-
liar to pathology, the elements of structural diseases, new forma-
tions, and parasitic creatures.
   These, with a  few  more of  less  importance, constitute  the
secondary or proximate elements of physiology and  pathology:
webave to consider them in relation to pathology only.
   103. These primary and secondary elements of disease are the
especial stffcjects of general pathology.  By the study of them we
become acquainted with the materials of disease, and  their rela-
tions to each  other; we learn  how special  diseases arise, and of
what they consist ;  how they  produce their phenomena  and
effects, how they are to  be known, distinguished, and classified.
Out of such a knowledge,  where it is correct, sufficient, and com-
bined with an ample acquaintance with the properties of remedial
agents, arises the rational method of relieving, curing, and  pre-
venting disease, the great ends of the art of medicine.
   I readily admit that our knowledge  of  these  elements, these
principles in pathology, is as yet too limited to be  entitled to rank
as a science ; but I think that the attempt to describe and illustrate
them will be  useful, not only by making available all that is known
on the subject,  but also by showing what is not known, and needs
investigation  : thus suggesting fit subjects for further research.
FUNCTIONAL  OR  DYNAMIC  DISEASES.


               PRIMARY  ELEMENTS.
                          SECTION  I.

       PROPERTIES OP THE MOVING FIBRE.--IRRITABILITY.

   110.  Irritability, irritable  contractility, or the  property of
contracting on the  application of a stimulus  or  exciting agent, is
the distinctive property of muscular fibre.   Although  some  phy-
siologists maintain that this property is derived from some part of
the nervous system, they have not produced any conclusive proof;
it is therefore more philosophical to retain the Hallerian view of
intrinsic irritability.*

   * Dr. M. Hall ascribes irritability to the spinal marrow; but he mentions an
experiment which is conclusive against this view : — " During the half lethargic
condition of  the frog in winter, the entire cerebrum  and spinal marrow may be
removed, by  slow degrees, at considerable intervals ; the circulation is neverthe-
less good." — Gulstonian Lectures, 1842, p. GO.  The irritability of the heart,
 herefore, is  unimpaired.  The late experiments of Dr. John Reid, on muscular
irritability, are strongly in support of the Hallerian doctrine. 
ULTIMATE ELEMENTS OF DISEASE.
91
  1H. It may become  excessive, so that the contraction  is too
violent for the welfare of the part or of the system.  This consti-
tutes  spasm or  convulsion.   The  excess of  irritability may be
manifest in three ways:— 1.  By an excessive strength and de-
gree ; 2. By an inordinate quickness or promptitude; 3. By the
unusual duration of the contractions.
  112. (l.)  Excessive strength of muscular  contraction is exem-
plified in the violent action of the heart during exertion  or other
excitement; and in the extraordinary  muscular  poweTn>f a, deli-
rious patient, who  can master persons naturally stronger than him-
self.  This exaltation of the natural property may depend on the
excessive stimulus, as of blood in the heart, or of nervous excite-
ment in the case of the delirious patient; or it may arise from the
muscles being over-fed  with blood.
  113. (2.)  Inordinate readiness or quickness  of contraction con-
stitutes mobility of muscle, a slight  stimulus causing it to contract.
This often co-exists with want of power or completeness  in the
contractions.   It  is exemplified  in the irritable heart, which,
although  acting very frequently, does not  expel its contents so
vigorously as in health.  It is seen in the quick nervous  move-
ments of irritable persons, who are  at the same time weak.  The
bowels show it in  that  irritable looseness formerly called lientery,
in which food is quickly passed little altered ; and it is instanced
in the irritable bladder, which  will not hold even an ounce of urine.
The pathological cause of this kind of inordinate irritability is either
an  undue flow of  blood to the  muscle, which exalts  its natural
property, or a predominance of irregular nervous influence,  which
unduly excites this property :  thus it is often excited by irritations
of the motor nerves, or  of their  columns or fibres.  But the most
remarkable examples are given  in the extreme case of convulsions
or  clonic spasms — that is, sudden contraction, alternating with
relaxation, as  seen in  chorea, epilepsy, and convulsive  hysteria,
where it  affects the voluntary  muscles;  and in the  palpitating
heart, which beats irregularly, and  out of rhythm.
   114.  (3.) An unusual duration of muscular contraction  consti-
tutes tonic spasm  or cramp, in which the contraction is strong, and
not alternated, as usual, with relaxation.  Such spasms are not un-
frequently felt in the calves of the legs : and the different muscular
canals, the gullet,  stomach, the intestines, and the glottis, occasion-
ally present this state of continued contraction.   In most of these
cases, it is accompanied by pain more or less severe, and may lead
to serious obstruction to the function of the organ.   When in a
more moderate degree  affecting the voluntary muscles  generally,
it constitutes catalepsy,  in which, from  the muscles remaining con-
tracted, the limbs will retain whatsoever attitude they are  placed
in,  until the spasm is over.   But the extreme example  is tetanus,
in which the spasms are so violent and so enduring, that they
may be said to squeeze the patient to death.   The pathological 
92            WILLIAMS'S PRINCIPLES OF MEDICINE.

cause may be, as in other  modifications of irritability, either an
irregular supply of blood to the part, or irritation, direct or indirect,
of the motor nerves by which the muscles are excited.
  115. Remedial measures. — These must depend on the cause
of the excessive irritability.   Where there is  increased  flow of
blood to  the  part, bloodletting, derivants, sedatives, and other
remedies for determination of  blood, may be proper.  Where the
cause is nervous irritation, narcotics  are the  most effectual;  and
some of these, from their peculiar efficacy in allaying spasm, are
called antispasmodics.   The most powerful of  these are stramo-
nium, belladonna,  sulphuric aether,  opium,  and  Indian hemp.
Where irritability is combined with  weakness, tonics are often
serviceable, especially the metallic tonics, and bark.
  116. Muscular contractility may  be  defective chiefly in two
modes.   1. In  force (§112);  as in  the weakness of voluntary
muscles during  severe  illness, after fatigue (§ 68); or under the
influence of a depressing poison or shock (§ 55); and in the weak-
ness of the heart under similar circumstances, and in faintness, or
in the sinking which precedes death.  This weakness is caused  by
the  exhaustion  of  previous exertion, or  by  want of a due  supply
of blood, which is necessary to maintain all functions; or it may
proceed from an influence positively depressing or destroying the
muscular power, as in the case  of sedative poisons, as  tobacco,
sulphuretted hydrogen,  &c, and  probably concussion and other
violent injuries to the organization.   The extreme effect of these
agents is to cause paralysis, or complete  loss of irritability, which,
affecting  the heart, constitutes  death by  syncope.   Muscles some-
times lose their irritability by more gradual causes, such as rheu-
matic inflammation, the action of lead, &c.   Various muscles are
reduced in power by over-excitement  or exertion :  this  is exem-
plified in the paralysis of the sphincter after over-distension of the
bladder, torpor of the bowels after the operation of an active pur-
gative, &c.
  117. (2.) Muscular irritability  may  be deficient in readiness to
contract (§113), as in the sluggish movements  of a person whose
irritability has been lowered by opium; and  in the slow pulse
caused by digitalis, and  by some cerebral affections; and in some
cases by  bloodletting or low diet.  It is by no means clear why the
same agents should lower in some cases the strength, and in others
the  promptitude in contraction ;  and  in many other respects, the
laws of irritability require further investigation.
  118. Although it has never been proved that muscular irritabi-
lity is derived from the nervous system, yet the illustrations already
given plainly point out that it is much under  its influence.  The
nerves are the proper medium by which the voluntary muscles are
made to act, and through the nerves the motions of the involun-
tary muscles are influenced, as instanced in the operation of men-
tal emotion on the action of the  heart (§ 69).  Hence diseases of
muscular action generally rank with nervous diseases.  Thus dis- 
ULTIMATE ELEMENTS OF DISEASE.
93
ease of the  brain may cause a cessation of muscular  motion by
suspending volition ; and disease of the spinal  marrow or nerves
may do so by intercepting the influence of the will:  in either case,
muscular motion ceases,  not from disease in itself, but for  want of
its proper stimulus, the will.   In fact, under  these circumstances,
muscular irritability sometimes accumulates (§ 111), and is  brought
into action, by slight impressions reflected from the spinal marrow.
Thus, in complete paraplegia, or loss of motion of the lower half
of the body, convulsive  movements may be excited in the lower
extremities  by tickling  the soles of the feet:  in other cases  of
paralysis, they may be produced by electricity.
   119. Remedial measures.— As usual, these  will vary with the
cause of the defective irritability ; where it proceeds from  exhaus-
tion, repose is the obvious  indication.  But even here, in  extreme
cases, and more particularly in those of the second head (§ 117), it
may be necessary at once  to excite the defective irritability by
stimulants, especially those of the more diffusible kind, as ammo-
nia, brandy, and other spirits and essential oils;  whilst the feeble
circulation may be aided by heat and frictions.  The large  quantity
of  stimulants borne  by patients whose  irritability is  reduced by
accident or  disease, is a remarkable feature in their history.  A
person faint from great loss of blood (§ 71), a crushed limb (§ 55),
or a sedative poison, will  bear four or five times  more  brandy
than would be  sufficient  to intoxicate  him under other circum-
stances.  Electricity  and the dash  of  cold water should  be  men*
tioned among temporary means of  exciting  defective  irritability.
Strychnia and cantharides [and ergot] are reputed to restore powev
to paralysed muscles.
                          SECTION II.

                           TONICITY.

  120. Tonicity, or  tone, is a property possessed by all muscular
structures, and by some which  are hardly accounted  muscular.
It is a tendency to slow, moderate contraction, not essentially ter-
minating in  relaxation ; but it keeps the parts in which it resides
in a certain  degree of tension.   This tone keeps muscles and limbs
in their places when at rest, and out of their places when dislo-
cated : if one set  of muscles is paralysed, the tone of their antago-
nists draws  the parts in an opposite direction, as we see  in para-
lysis of the portio dura on one  side of the face.  A similar pro-
perty is possessed by the intestinal tube, the urinary bladder, the
air-tubes,  and the middle  coat  of the arteries, and  gives them a
constant tendency to  contract on  their contents.   In  these, but
particularly in the arteries, it performs  an  important part, both in
health and in disease.  By this  the arteries contract, when they
cease to receive blood from the heart, and thus are found empty 
94           WILLIAMS'S  PRINCIPLES OF  MEDICINE.
after  death.   It adapts them to different degrees of fulness, yet
maintains a certain tension  favourable to equality in  the motion
of the blood.
   It has been asserted, that  tonicity is quite distinct from irrita-
bility; and although irritable fibres possess tone, tonic textures are
not irritable.  This is not true  with regard to the arteries ;  tor 1
have many times distinctly seen them slowly contract, and remain
contracted, at a  point to which an irritant, mechanical, chemical,
or electric, has been applied.  The late discovery, by Henle, of  a
structure distinctly muscular in arteries, confirms this observation.
I  have  proved, in  like  manner, the  irritability of the air-tubes,
which move  more  readily under  a stimulus than  the  arteries;
whilst that of the intestines is still higher in degree, but still  infe-
rior to that of the oesophagus and voluntary muscles, the contrac-
tions  of  which, on the application of a stimulus, are abrupt, and
immediately followed by relaxation.   So  far, then, it appears, that
tonicity is influenced by the same  agents  which excite irritability;
but another  agent, temperature, seems to  affect  them differently
(§ 74, 75).  Cold increases  tonicity and impairs irritability, whilst
heat diminishes tonicity and increases irritability.  Under the in-
fluence of cold, arteries shrink in size very remarkably ;*  and the
muscles and other textures present  a firmness and contraction which
impede the quickness of motion characterizing the highest degrees
of  irritability.   Under the  influence of  heat, on  the other hand,
although muscles are relaxed, they are more irritable, and the pul-
sations of the heart are more frequent.
   Cold and heat, therefore, become the best tests for tonicity; and
by their means  we find this property to  be possessed  by  textures
which have never been proved to be irritable ; I mean, the  veins
and the  cutis, which  contract with cold, and become relaxed with
heat.
   Now this property, tonicity, is a very  important one in the ani-
mal economy, its natural condition  being very necessary for the
preservation  of health, and its modifications being concerned  in
causing and constituting  disease.   Practical  men have long ad-
mitted the existence of something of this  kind, without defining  or
localizing it;  and the terms tone  and atony,  bracing and relaxa-
tion, tonic and  relaxing  remedies, become quite appropriate  in
connexion with this property.   Let us notice some of  the charac-
ters of its excess and defect.
   121. Where there is an  excess  of tonicity, the muscles are  so
firm  that there is scarcely room for free motion ; the pulse is strong,
tense, and often slow, yet there is scarcely any interval  between

   * This fact must be familiar to every one who has noticed the difference of the
 pulse when a limb is cold and  when it is  warm. But I have seen it more forcibly
 illustrated by experiment. On plunging into cold water the aorta of an ass just
 dead, it contracted so  closely as  to  obliterate its cavity; and it  required some
 force to pass the little finger into it.  The crimping of the flesh of fish is referable
 to the same principle. 
ULTIMATE ELEMENTS OF DISEASE.
95
 the heart's beat and the radial pulse.  The capillary circulation is
 active, and the extremities warm; but owing to the tense state of
 the vessels and of the skin, the  secreting organs do not act freely,
 the urine is high coloured, the bowels are  disposed  to be costive,
 and the skin to be  dry and hot.  This is  a condition  leading to
 sthenic plethora or local congestion, active  hemorrhage or inflam-
 mation, apoplexy and gout; but there is  less than usual proclivity
 to infectious diseases and others of a depressing character.
   122. Remedial measures. — In such a state bloodletting is but
 a temporary remedy.   As long as the tonic fibres are  too  much
 braced, the  secretions  will  be defective, and the vessels will fill
 again  and renew the danger.  The measures best  suited for this
 state of excessive tone are  those tending to relax the tonic fibre,
 and increase the  secretions, such as warm bathing, exercise, sudo-
 rifics,  aperients, and diureties, with moderate diet.  It is probable
 that some remedies, such as antimony, reduce directly the tone
 of the vascular fibre, acting as relaxants.  We shall have to advert
 to this subject again  under the head of inflammatory fever, of
 which the element, excessive tone of the  vascular  system, is  a
 chief constituent.
   123. Where tonicity is defective, the muscles are flabby and in-
 capable of continued exertion, but sometimes are too irritable, with
 the tremulousness of debility  (§ 113).  The heart likewise is irri-
 table,  and often exhausts its strength in palpitation ; the pulse is
 soft and  unsteady; it  may be full when slow, but  it is without
 strength,  and easily accelerated.  Its  most distinctive  character,
 however, is  its retardation, increasing the interval  between the
 heart's beat and distant pulses; so that the radial pulse is often
 felt after  the second sound of the heart is heard (§ 121):  the tubes
 being  less tense,  the pulsewave  is slower than  usual (§  120).  So
 too the loose relaxed state of the vessels  renders the circulation in
 distant parts  weak, so that the extremities are  cold, whilst the
 head  may be congested.  Sudden exertion or change of posture
 may disturb  the circulation  and cause faintings or  giddiness.
 Want  of tone also in the stomach and intestines causes indigestion
 and costiveness, and permits them to become distended with wind
and accumulating fasces.  The secreting organs, irregularly sup-
 plied with blood, are also liable  to disorder, being either scanty,
 depraved, or profuse and watery.
  It is quite obvious that a  person  in such  a condition  must be
 prone to various diseases.  He has no resisting power (§ 16) against
 malaria, infection, or other depressing agents.   If he  is exposed to
 cold, the blood is  readily driven  through  the weak vessels into the
 interior (§ 77), where it causes congestion or inflammation.   The
 weak intestines have  no power to expel offending  matter from
them (§ 57).   Thus the system in a state of atony is open to the
action  of many exciting causes of disease ;  besides being itself in
many respects on the verge  of disease.
  124. Remedial measures. — The proper remedies in such a con- 
96           WILLIAMS'S PRINCIPLES OF MEDICINE.

dition are tonics, or those agents that tend to increase  the tone of
the system (§ 120), particularly of its muscular and vascular parts.
We  "have  already  stated  that cold  has  this effect  in a marked
degree (§ 79); and in truth, cold, properly applied, is one of the
best tonics which  we  possess.  For this  purpose its  application
should be sudden and  too brief to cause  depression or any of its
morbid effects.   The shower-bath and  plunge-bath  are  the  most
effectual forms ; and free sponging, with cold  salt water, is appli-
cable even to weak subjects.   A pure bracing air and much expo-
sure to it have also  useful  tonic effects.  There are  many medici-
nal tonics, the most effectual of which  are bark  and its prepara-
tions, medicines containing iron, and the mineral acids.  Generous
living may be considered a part of a tonic plan, in so far as it tends
to supply blood, which is the pabulum of  tonicity as well as of
other vital properties.
                         SECTION III.

          PROPERTIES OF THE NERVES. -- SENSIBILITY.

  125. Certain parts of the nervous system being known to be the
instruments of sensation, we have no difficulty in tracing diseased
sensibility to this system : and as this system consists of a medul-
lary centre, and of nerves converging from various  parts to it, so
we  find that alterations in the property may  depend either on dis-
ease of  the centre, causing disorder  of general sensibility, or of
disease of one  or more of the nerves, causing disorder of local sen-
sibility.   These we shall now notice.

               DISEASES OP GENERAL SENSIBILITY.

  These may consist in — 1, excess ; 2, defect; 3, perversion.
  126.   (1.) Excessive sensibility is more or less  present when
the  nervous centres are excited in the early  stage of their inflam-
mation or of determination of blood  to the head; where there is
intolerance of light, noise, and motion.  A similar condition exists
in hydrophobia and tetanus from mere excitement, without inflam-
mation.  But short of these, sensibility is excessive in some per-
sons,  either congenitally, (§ 44,) or  as a consequence of disease
(§ 31, 34).  Such persons are commonly called nervous;  they are
worried  with  trifles:  startled at shadows; distracted by noise or
bustle ;  never free from some ache or pain ;  for almost every feel-
ing is suffering; and what in others would be slight pain, in these
amounts to agony.  Hence they are perpetual invalids, quite unfit
for  the rugged path of life, over which they, as it were, walk bare-
footed and thin-skinned.   If real disease attack them, its nervous
symptoms  are so much exaggerated, that a  medical attendant is
apt to fall into the error of either ascribing all to "the nerves," or 
ULTIMATE ELEMENTS OF DISEASE.
97
of measuring the disease by the severity of the symptoms.   This
over sensibility is generally conjoined with excess of irritability,
and want of  tone (§ 113, 123).  Other nervous functions, such as
sympathy and reflex action, are also often augmented or in dis-
order.   The symptoms  connected with sensation most frequently
present are neuralgic pains of various  parts, excessive sensibility
of the surface, headache, pain in the back, an'd spinal tenderness.
   127.  The pathological cause of increased general sensibility is
probably a slighter degree of the same cause which  induces it in
the early stage of encephalitis, an undue  supply of blood to the
posterior columns of the spinal marrow, the corpora restiformia,
and the parts of the cerebral mass concerned in sensation.  This
local determination of blood may result from original development;
but it may also be a  consequence of inflammatory affections of the
encephalon, of irregularities in the  menstrual functions, or of the
reaction ensuing after great losses of blood, all of which are known
to be sometimes the  precursors of morbid sensibility.  On a future
occasion, in connexion  with the subject of irregular distribution of
blood, we shall  endeavour to point out why great losses of  blood
and other causes of sudden weakness  are  sometimes followed
by excessive  sensibility.  The  over refinements  and  luxurious
 habits of the upper classes, with more excitement for the mind than
 for the body, and for the feelings than for the understanding, are
 well calculated  to foster morbid sensibility (§ 69).
   128. Remedial measures. — The medicines  most  in opposition
 to this element of disease are narcotics or anodynes, such as opium,
 henbane,  hemlock,  Indian  hemp,  &c, administered internally.
 These  diminish  nervous sensibility; and  in proportion as this is
 exalted, (§ 126,) the system will bear  larger doses.  But where
 the increased sensibility depends on inflammation or vascular ex-
 citement of the  nervous centres, (§ 127,) the proper treatment will
 obviously be that to be hereafter described as antiphlogistic. Again :
 where the excessive sensibility arises from nervous excitement and
 irregular circulation, with general weakness, (§ 116,) and atony,
 (§ 123,) (by no means an uncommon  combination,) tonics, (124,)
 and stimulants, (119,) as well as narcotics, are the proper remedies.
 Weakness and  slow transmission of the arterial pulse, (123,) and
 absence of flush or heat of skin, are the chief symptoms of such a
 condition.  In these and other common cases of morbid sensibility,
 country air and exercise, plain food for both mind  and body, early
 hours, and an  avoidance of all enervating habits, are often more
 conducive to the cure than any medicines.
   129.  (2.) Defective  general sensibility in  its extreme degree  is
 exemplified in coma from the circulation  in the sensitive centre of
 the nervous system being impeded in consequence of pressure,
 congestion, or other obstruction, (§ 54,) or of narcotic influence.
 Thus  a person  in a fit of apoplexy,  or  poisoned by opium, has
 lost all feeling, as well as voluntary motion.   When  the  blood
 becomes impure by retention of excrementitious matter, as in sup-
            9 
98            WILLIAMS'S PRINCIPLES OF MEDICINE.

pression of urine, a like stupor occurs (70).  Very rarely anaesthe-
sia exists — that is, loss of sensation, without loss of motion.  But
short of these  degrees, there  are  some  who congenitally (§ 44),
from disease (§ 31, 34), or from age (§ 51), are  deficient in sensi-
bility—feel less  than other folk.  All their feelings are  obtuse
and their actions  slow : they have no intense  suffering or plea-
sure.  Such persons have also little irritability, but much tone of
fibre, and are remarkable for their immunity from many diseases.
But they are the more liable to others, such as  fulness of blood,
apoplexy, gout, costiveness, and  the  various  evils  which these
may bring.  They contrast well  with the over-sensitive  in this,
that disease when it occurs may advance far  and become dan-
gerous before it is felt;  and may  imperceptibly increase until it is
past removal, or until sudden death ensues.
  130. Remedial measures. — When obtuseness of feeling arises
from fulness, obstruction  or pressure   of blood in the nervous
centres, the treatment will consist in attempts to remove these by
depletion, derivation, and  other  means  to be  mentioned  under
the head of disordered circulation.   Where there  is no  actual
disease  present, but merely a torpor  of the sensitive  function,
mental excitements and bodily exertion, cold bathing and friction,
are the  best means  of preventing a gradual descent into a state
of  lethargy.    It  is  doubtful  whether  we  have  any  medicine
capable of directly increasing  sensibility.   Strong tea and coffee
perhaps have the  best  claim to  such a property.   What effect
would arise from  electrifying the spine and  occiput ?  Stupor
and impaired  sensibility may arise in  a  state  of anaemia, as  in
cerebral syncope, and in children  or females who have lost much
blood; this is from  stagnation of the blood in the brain.   Under
such circumstances,  the pallor of the skin and weakness of pulse
would indicate stimulants as the best means of restoring sensibility.
  131.  (3.) Perverted  general sensibility is often manifested by
those in whom there is also increased  sensibility (§ 126), but its
character is in the peculiarity of the sensations  which are experi-
enced.  Thus  sensations of tingling, prickly  heat, trickling cold,
in various parts ;  feelings of a lump  in the throat, a  hot ball in
the side, a fluttering at the stomach, and illusions of the special
senses, may severally and variously  affect persons whose sensi-
bility is modified more in  kind  than  in  degree.   Such persons
may also have  a depraved appetite, craving for sour things, cin-
ders, mortar, and all manner of filth.   These symptoms generally
occur in females,  often  in  connexion  with irregular menstrua-
tion, therefore  they  are called hysterical ;  but  their pathological
cause must be sought  in  the nervous system, the functions of
which, probably from irregular supply  or bad quality of the blood
which supports them, become disordered.(a)  The remedial mea-

   (a) Excessive and perverted sensibility are often manifested in
anemic subjects.   The remedial course  will consist of nutritive and
chalybeate tonics,  rather than of anodynes or narcotics generally. 
ULTIMATE ELEMENTS OF DISEASE.
99
sures indicated for this condition are  therefore those calculated to
remove its  cause: chalybeates and  other tonics, with pure air,
nourishing food, and other means which improve the quality, and
equalize the distribution of the blood.  Narcotics and  sedatives
may be useful as temporary palliatives.   In  rare cases,  the gene-
ral sensibility is perverted by  structural change in the  nervous
centres, such as softening of the cerebral structure.

              DISEASES OP SENSIBILITY  OF PARTS.

   132.  The  feeling of a part may be excessive, defective, ox per-
verted.  This may be illustrated by experiment.   By irritating or
strikinganerve, pain isproducedinthe part to which it is distributed,
and the sensibility of the  part remains exalted — that is, it feels
tender afterwards.  By pressing on  the nerve, anew and perverted
sensation  of  tingling and  pricking,  with numbness, is caused.
By pressing  more strongly, or  dividing  the  nerve, the feeling  is
further  impaired or altogether destroyed.  Similar effects may be
produced  by a tumour, ligature, effusion, or other cause pressing
on a nerve in its course.   Disease of the nerve, or of a part of the
spinal or  cerebral matter connected with it,  may likewise modify
the sensation of parts.   Thus  inflammation  of the sheath of the
ischiatic or trifacial nerves  may cause  first, neuralgic pain, and
afterwards numbness in the parts  to  which the nerve is supplied.
There are other  painful affections which are to be considered,
andtreatedas cases of exaltedsensibility, such as the irritable (as Dr.
Billing  observes, erroneously so called) breast, testicle, uterus, &c.
   133.  But the function of sensation, as other functions, depends
on the supply of blood to the  extreme distribution, as well  as to
the trunk and origin  of the  nerves.  Hence if  blood  does not
circulate freely through a limb, the sensations are impaired ; and
if it passes too freely, the sensibility is exalted, and there may
be itching, tenderness, or even pain.  In organs of special  sen-
sation, the senses  are  modified, together with the common feel-
ing :  thus in disease of the optic  nerve or retina, there will be
intolerance of light, or  specks and clouded vision, or even blind-
ness ; in the ear, ringing and beating noises, or deafness, besides the
affections  of common sensibility, itching, tenderness, and pain.
   134. At the orifices of passages into the interior, there are pecu-
liar kinds  of  sensibility connected with the functions  of  ingestion
and  egestion ; these modified are elements of disease.   As exam-
ples of such excessive sensibility, may be enumerated thirst, craving,
nausea, tenesmus, and painful micturition : of impaired sensibility,
anorexia,  and paralysis of the rectum and urethra.(a)
   (a) The sensibility and sympathies of the orifices and valvular
openings — such as the isthmus faucium, glottis, cardia, pylorus,
ileo-ceecal valve,anus,neckof the bladder,and os tincae, constitute
an interesting branch of pathological study, and furnish not a few
hints to theurapeutics. 
100
WILLIAMS'S PRINCIPLES OF  MEDICINE.
   135.  WThen we come to internal parts, we have only to consider
their sensibility when exalted by disease.   We do not know that
they naturally possess any feeling.  Of the ordinary processes, as
of the passage of food and faeces in the alimentary canal, of the
movements of the lungs, of the heart, and of  the  blood through
the vessels, we are not conscious;  but under the influence of dis-
ease we become painfully sensible of several  of these motions.
This excessive sensibility is  developed by  inflammation, as  in
pleurisy, peritonitis, meningitis, &c, or by irritation, by  mechani-
cal or  other  means, as in  colic, biliary and urinary calculi, gas-
tralgia, perforation of the stomach  or intestines. &c.  It is very
remarkable that pain from these, which is perhaps severer  than
any, should arise so suddenly in parts which give no evidence of
common feeling.
  136.  In  many instances  we  are  to regard  pain merely as  a
symptom to be removed only by means which remove  its cause,
the lesion which  produces it (§  132, 133) ; but in many cases, on
the other hand, although a symptom, it constitutes a chief element
of the disease, and one against which  remedies must be expressly
directed.   Thus it  is in neuralgia, gastralgia, nephralgia, colic,
dysmenorrhcea, and perforated intestine.   So long as the  exces-
sive pain lasts, all the functions  suffer,  (§ 69,) faintness and ex-
haustion ensue, and if no relief comes,  the prostration may be fatal.
Here to mitigate or remove the  pain is a first  and pressing  indi-
cation.   Again :  in  some other cases where the pain is less severe,
it may be  very hurtful  by interfering with important functions.
Thus the stitch of pleurisy impedes the breathing :  the pain of
tenesmus and the  irritation  of the stomach or windpipe  cause
efforts at straining,  vomiting, and  coughing, so violent,1 that the
functions are  thereby  kept in  a state  of "disturbance, and the
strength  is exhausted.   Here it  may  be  necessary to  treat
promptly for the pain on account  of  its immediately pernicious
effects.
  137. Remedial measures. — Where  excessive sensibility de-
pends on inflammation,  antiphlogistic  measures  will  generally
soon remove  it.   Where it  lingers after the  inflammation, is out
of proportion to  it, or  is independent  of it, then anodynes be-
come the chief remedy.  The most powerful  of these are opium
and its active principles ; but  these have morbid effects, (impair-
ing the secretions,) (§ 70,) which sometimes render  opiates less
eligible  than the weaker but safer narcotics,  hemlock, henbane,
stramonium, belladonna, Indian hemp, and aconite.  These differ-
ent anodynes are used both internally  and externally.*   Counter-
irritation and warmth are also means of relieving pain.   The pain
of gastrodynia may  often be removed  by a sinapism to  the pit of

  * Painful affections occurring with a weak circulation are sometimes removed
by tonics: thus neuralgia has been successfully treated with iron, hemicrania
with quinine, &c. 
ULTIMATE ELEMENTS OF DISEASE.
101
the stomach — that of colic and dysmenorrhea by hot  fomenta-
tions, or  bags of hot  sand or salt, &c.   In other cases, painful
feelings may be  relieved by such pressure on the part as will coun-
teract tension, and diminish without  stopping  the flow  of  blood
through the part.
   138. We are not possessed of equal means of restoring lost sen-
sibility.   Stimulant  applications  and frictions are  serviceable
where the  defect arises from deficiency of circulation in  the part;
and strychnia or cantharides given internally, and electricity used
topically, perhaps may have some little effect in exciting  the func-
tions  of the  nerves, but  more doubtfully in regard to  sensation
than to motion.
                        SECTION IV.

DISEASED VOLUNTARY MOTION  OR EXCITOMOTION BY THE WILL.

  139. The function by which certain nerves convey the impulses
of the will to voluntary muscles, may become disordered, and  its
phenomena constitute an element of disease.  Some of these have
already been noticed under the head of diseased irritability (§113);
and it was there observed that the error is more commonly in the
nervous influence which excites the muscles, than in the property
of the muscles themselves.  This  is the case in  most convulsive
diseases, and in those cases of paralysis  which depend on injuries
of the voluntary nerves, or  of those parts of the spinal and cere-
bral system which are the channels of volition.  A brief illustra-
tion of these diseases will suffice to correspond with those of dis-
eased sensation.

          DISEASES OF  GENERAL VOLUNTARY POWER.

  140. Voluntary motion may  be said to be generally in excess
when the brain is excited  by strong emotions or feelings, (§ 66,)
by stimulating liquors, (§ 55,) and by the hurried circulation of
phrensy or phrenitic delirium.  Hysteria, as usual, can supply like
examples.   The strength and rapidity of movements displayed in
hysterical cases are sometimes astonishing:  yet they are obviously
voluntary movements, for they  are often performed  rhythmically,
or to a time, as in dancing.   The dancing of tarantulism, and the
extravagant exertions of the fanatics  called jumpers, would seem
to arise from an erethism of the part of the nervous system  con-
cerned in voluntary motion.  Short  of  disease, a naturally high
voluntary power is  evinced in the energetic and active movements
of some  persons, who excel  and delight  in feats  of strength  or
agility.   Mere muscular strength will not suffice without nervous
energy to act on it.
  141. General  volition is more  or less defective in apoplectic
            9* 
102
WILLIAMS'S PRINCIPLES OF MEDICINE.
coma, stupor from various causes, pressure, congestion, narcotism,
&c, where other nervous properties are also impaired (§ 129); in
trance, catalepsy, and nightmare ; in a less degree also in cases ot
lethargy and weakness  from over-exertion (§ 68).  This  defect
may be sometimes suddenly induced by terror, surprise, &c, (§ 69,)
which for a time take  away the power  of motion.   Hence  the
fabulous power of the Gorgon's head ; and the signification of the
expressions,petrified with astonishment, motionless with terror,
fascinated, and the  like.  The muscular power (§ 110)  is not lost
in these cases, but only the influence of the mind over it —  that is,
volition.
   142.  Examples of perverted voluntary power may be -found in
chorea, delirium  tremens, and some analogous  affections called
hysterical.  In these volition may be often also defective, (§ 141,)
but it is not always so ;  only each act of  the will is perverted in
its performance.   The will sets muscles in motion, but the wrong
muscles, or too many, too forcibly, or  irregularly, so that  the re-
sulting action  is not in accordance with the will.

            PARTIALLY DISEASED VOLUNTARY POWER.

   143. We can  scarcely point out examples of  partial  excess of
voluntary motion.   The convulsive movements of voluntary mus-
cles are quite  involuntary, and have been noticed under the head
of diseased  muscular action (§ 113); but it was  there mentioned
that they may arise  from irritation of  the nerves, independent of
 the will.   Hysteria does, however, furnish examples of excessive
 movements of one limb or  part of the body, so  far amenable to
 mental influence as to be excited and timed by ideas in the patient's
 mind.  These cannot be said to be wholly involuntary ;  but are
 the result of  a wilful  impulse, perhaps  too  strong to  be easily
 resisted.
    144. Partial  defect of voluntary power is very common, and,
 like local defect of sensibility, may be traced to partial disease of
 the motor (anterior) columns of the  medulla and  prolongations;
 or to disease of, or  pressure on, a motor nerve  in its  course ; or
 to a  disordered condition  of the ultimate  distribution  of the
 nerve, or  of  the   circulation  supporting  its  function.    Thus
 paralysis of voluntary  motion  in an  extremity  of  a  whole side,
 (hemiplegia,) may arise from disease in the optic thalamus or
 corpus striatum of the opposite side : these being the channels of
 communication between the cortical seat of the sensorial functions
 and will, and the  motory columns and nerves. Lesions of the
 motory (anterior) columns  within the spine may intercept more
 or less the voluntary power over those parts supplied with spinal
 nerves from below the diseased  point.  Thus a lesion in the lower
 cervical  portion may paralyse the  upper and  lower  extremities
 and whole trunk  (except  the diaphragm, which is  supplied by
 the phrenic nerve): a lesion in the dorsal or lumbar portion para- 
ULTIMATE ELEMENTS OF DISEASE.
103
lyses only the lower half of  the  body, (paraplegia,) or lower ex-
tremities.   Or the disease may be  more  partial, paralysing one
nerve only, as the portio dura, causing distortion of the features;
or the ninth nerve, causing difficult articulation, &c.  The lesion
of the nervous textures here alluded to may be structural change,
as tumours, effusions, or hemorrhage, or  only an altered state of
the bloodvessels  of the part.  Severe cold or continued pressure
will impair voluntary power  in a limb, by checking the free flow
of blood, which is essential to the proper function of the nerves as
well as of the muscles.  Hysteria affords numerous examples of
volition impaired in parts, as in loss of voice and power of articu-
lation, retention of urine, paralysis of limbs, &c. : these affections
may come on quite suddenly, and as suddenly cease.
   145.  Remedial measures.— Excessive voluntary power is rarely
an element of disease for separate treatment.  As part of the excite-
ment of the nervous  centres, it  may be reduced by sedatives of
different  kinds — depletion,  antimonials, and cold to the  head,
being the most effectual where the excitement  is attended with
determination of blood; morphia, and other  narcotics, where the
excitement is more purely  nervous.  The violent exertions  of
maniacs are wonderfully controlled by the cold douche to the head
 [and spine], sometimes with nauseating doses of tartar emetic.
   146. The treatment  of defective volition will consist  in means
 calculated to  excite the nervous centres  directly, or  through the
 medium of the circulation.   Agents which restore free circulation
 of healthy blood through the nervous centres and branches gene-
 rally improve voluntary power.   Thus a  stimulant draught may
 raise the failing  strength  of a person fainting.   By warmth and
 friction, one who is benumbed with cold recovers  the use of  his
 limbs.   Sleep or rest will restore  voluntary power exhausted by
 fatigue.  Sudden and powerful mental excitement, as by a fright,
 has been known to restore voluntary power which had been long
 lost.   A  lady who for  several years had lost the use of  her lower
 extremities, was startled by a rat  running near her  : having an
 extreme  antipathy to the animal, she made an effort, and sprang
 on a table near;  the power, however, did  not remain, for  she
 could not get down again.   A more  permanent cure  of impaired
 volition has been effected by the excitement of religious fanaticism,
 as in the cases of the supposed miracles of Prince  Hohenloe, Miss
 Fancourt, &c.  As we have found that such  mental excitement
 sometimes causes  excessive voluntary motion  in  healthy persons
 (§ 140), so we  perceive that, suddenly applied, it may restore it
 where defective.
    But sometimes volition is defective from pressure on, or con-
 gestion in, the brain,  which  prevents the due motion  of the blood
 through it,as in plethoric lethargy,or apoplectic coma: here depletion
 and derivation may sometimes restore the  power.  In the lethargy
 of narcotism  and asphyxia, the volition is often restored by means
 which excite strong sensations and reflex actions, as  dashing cold 
104          WILLIAMS'S PRINCIPLES OF MEDICINE.
 water on the face and chest, ammonia or other stimulating vapours
 to  the nostrils, electric  shocks, stinging  with nettles, &c.  The
 trance or coma of hysteria may often be removed by a turpentine
 injection, or croton oil  purgative, which acts both as a revulsive
 to the vessels and a stimulant to the nerves.
   Perverted volition will require various  treatment  according to
 its kind ; that of delirium  tremens being corrected  by narcotics,
 especially opium;  that of  chorea, by nervous tonics, especially
 iron and zinc.
   147. The treatment of locally diseased voluntary power will
 generally commence with attempts to remove its cause, which we
 have found to vary too much  both in seat and nature to admit of
 an  elementary statement  of remedial measures.  Those for defec-
 tive voluntary power comprehend the complex subject of the treat-
 ment of paralysis, which commonly  comprises means  calculated
 to restore to its  proper state  the circulation through the affected
 part of the nervous system,  and sometimes, also, means which sti-
mulate this part by exciting agents, such as electricity, stimulating
frictions, and  blisters ; and strychnia  and cantharides [and ergot],
given internally, which are supposed  to have a directly stimulant
action on the motory columns and nerves.
                         SECTION V.

      DISEASES OF REFLECTED  AND  SYMPATHETIC  NERVOUS
                         INFLUENCE.

   148.  The nervous  property by which various movements and
 processes connected with organic  life are  excited, may be  disor-
 dered, and its alterations are remarkable constituents of many dis-
 eases.  The contractions of all the sphincters, of the oesophagus,
 the glottis, the iris, the eyelid, and the regular action of the mus-
 cles of respiration, seem to be sustained, independently of the will,
 by a nervous influence conveyed by afferent nerves from the respec-
 tive parts or  surfaces to the spinal marrow, and reflected from it
 through the efferent nerves to the  muscles connected with  these
 parts.   The full establishment of this  physiological principle we
 owe to  Dr. Marshall Hall.
   149.  The increase of this involuntary excitomotory power is
 instanced in the spasm of the throat, and sometimes of the sphinc-
 ters, in  hydrophobia, tetanus, and some hysterical affections.   The
 hurried respiration, the convulsive cough, violent retching and
 hiccup,  which are occasionally presented in these and other ner-
 vous diseases, may also be in part traced to an undue  influence of
 the excitomotory  nerves of organic life.  These actions are some-
 times excited by sensations (§ 134), as the .breathing by feeling  of
 want  of breath, cough by tickling in the air-passages, retching by
nausea, &c.; but  it is where  either there are no such sensations, or 
ULTIMATE ELEMENTS OF DISEASE.
105
where they bear no proportion to the violence of the actions, that
we are warranted to conclude that the excitomotory function  is
itself exalted.
   A similar exaltation of  the excitomotory function, independent
of sensation and volition, is exemplified in the voluntary muscles,
when they are deprived  of sensation and voluntary motion by dis-
ease in the brain itself, or cutting off communication between the
brain and spinal cord, without materially injuring  the  cord itself
(§ US).   Thus, in paraplegia from injury of the upper  part of the
spine, the excitomotory power of the nerves of the  lower extremi-
ties is exalted, and tickling, or mere touching the soles  of the feet
or legs, will produce convulsive motions, although  all  voluntary
power and sensation be  wholly lost.*   This phenomenon is some-
times so readily produced  as to be a cause of much disturbance  to
the patient, the mere touch of the  bedclothes exciting troublesome
startings.  Tho same  thing occurs  in  hemiplegia, but less dis-
tinctly, as the cerebral influence is rarely here so completely inter-
cepted.  I have known, however, the convulsive motions of  a para-
lysed  limb  so violent, in a hemiplegic patient, that it was neces-
sary every night to fasten  it down to the bedstead to  enable the
patient to get sleep.
   Another  instance  of involuntary  excitement  of the muscles
occurs in the symptom of  " fidgets," which  often arises from irri-
tation reflected from the lower part of the intestinal canal, or from
the uterus.
   150. Under this head we must also glance at convulsions, which,
according to Dr. M. Hall's views, and consistently with the phe-
nomena of disease, must be referred to an irritation of the true spi-
nal system.  This  irritation may be centric, as  in epileptic and
apoplectic convulsions from disease in the  head,  and  those from
loss of blood ; in which cases, the spinal and prolonged medulla
being excited, the  excitomotory influence radiates  to the limbs
and muscles generally ;  or it may be eccentric, commencing with
irritation of the extremities of some  afferent nerve, which trans-
fers it to the spinal centre, whence it is again  reflected generally or
partially.  Such are the convulsions arising from teething, uterine,
intestinal, and renal irritation ; and a slighter degree  is exempli-
fied in the rigor caused  by the sudden impression of cold  on the
surface,  or  by  passing  a  bougie  into the  urethra of  a nervous
person.
   151. Partial spasms  caused by reflected irritation are exem-
plified in  cramp  in the legs, from acrid  matter  in the colon, in
diarrhoea and cholera;  retraction of  the testicle from  calculus  or

   ♦The same phenomenon is exhibited in a high degree in the decapitated frog,
in which  touching the surface excites convulsive movements.  A still more inte-
resting illustration sometimes occurs in animals or persons whose cerebral power
(sensation and voluntary motion) is impaired by opium or other narcotics ; spasms
or convulsive actions of the muscles being induced by tickling or pinching the
skin, which shows the excited state of the reflex or spinal function. 
106
WILLIAMS'S PRINCIPLES OF MEDICINE.
inflammation of the kidney;  spasm of the glottis from a bone
sticking in the  pharynx, &c.  More familiar  examples of the
same class of reflected irritation are found in sneezing from irri-
tation of  the nares, winking from irritation of the  conjunctiva,
coughing  from  irritation of the glottis, retching from irritation
of the fauces, efforts to evacuate the rectum and the bladder from
irritation  of these  parts respectively.  But  it must not be for-
gotten that all these latter examples are  connected with obvious
sensations ; and they imply increased excitomotory influence only
in those cases in which they are out of proportion to these sensa-
tions.
   152. But  some  of the most remarkable instances of reflected
irritation are displayed in the  involuntary muscles, the  heart, and
the muscular fibres of the air  tubes and intestinal canal.  Thus,
inordinate action of the heart (palpitation)  is commonly caused by
irritating matters in the stomach or intestines, kidneys, or other
viscera (§ 51, 54);  nay, we shall afterwards find, that the heart is
liable to be excited by considerable irritation in  any part of the
body, as in fever and constitutional disorder.  The spasm of the
intestines  in colic  is induced  by  reflex  irritation resulting from
acrid matter in them ; for if it were from  direct  irritation alone,
the spasm would  only affect  the part touched  by  the  offending
matter.*  The  spasm  of the  bronchi, so suddenly occurring in
spasmodic asthma, also sometimes arises from intestinal irritation.
  It has long been supposed,  and is still a common opinion, that
these morbid sympathetic movements are due to the direct ner-
vous connexion  which  the great sympathetic  nerve  establishes
between the respective organs;  but this supposition assumes,
what experiment has not proved, that the ganglia  of this  nerve
are either centres  of reflection,! or  sources of nervous influence,
which is still more inconsistent with the latest researches.  So far
as we yet know, the spinal marrow is the centre of reflection in
these as in all other examples of reflex action which we have been
considering, although the sympathetic be  the medium of commu-
nication.!                                    *
   153. When phenomena of inordinate reflex actions are general
or extensive, as  in convulsions, tetanus, and paraplegia, we must
refer them to an undue excitement or erethism of the spinal and
prolonged medulla ; but the more partial examples may arise from
similar excitement of a small portion of it only, or of the incident
(afferent)  nerve of the part which occasions the  phenomenon, or
of the excitomotory (efferent) nerve of the part which exhibits the
phenomenon.
   If we seek to know the causes of this  excitement, we shall find
that, as in excess of other vital properties, it is sometimes refer-

  * Muller's Physiology (Bell's edit.), p. 551.    f Volkman, MUller, p. 567.
  J; Valentin,  Carpenter's Human Physiology, p. 150. 
ULTIMATE ELEMENTS  OF DISEASE.
107
able to an increased flow of blood through the spinal marrow or
its nerves, or the branches of the sympathetic nerve.   Thus the
early stage of inflammation of the spinal cord, or of its sheath, is
attended with convulsions or tetanic spasm.   It is very probable,
that the spinal excitement (convulsions) occurring  in epilepsy and
apoplexy, is in part due to the flow through the medulla  being
increased in proportion as  that through the brain is  impeded: a
consideration of the causes of convulsive paroxysms, and of the
distribution of the vertebral arteries, much countenances this sup-
position.  But  in  many cases, the excitement seems to be of a
more direct nature.   Strychnia in a poisonous dose  excites the
medulla so speedily, causing tetanic spasm, that its effect can
scarcely be  due to increased  flow of  blood.  So, too, we know,
that mechanical irritation  of the spinal marrow or of its  nerves
will cause convulsive motions; and we find this exemplified in
the effect of tumours and spicula of bone in  the spinal canal, in
the  head, or in the course  of nerves.   But nothing  exhibits this
element  of nervous irritation (apart, so far as is yet known, from
vascular influence) so fearfully as traumatic tetanus.   The  irrita-
tion here begins in a distant nervous branch, and is propagated to
the  medullary  centre,  the excitomotory function of  which  at
length exhibits  a state of erethism,  which destroys life   either
directly by tonic spasm (§114) of the muscles of respiration, or  by
exhaustion.  Another  cause, which  may be fairly  assigned for
increase of the  involuntary excitomotory property, is accumula-
tion by rest.  This causes the augmentation of this property in the
medulla in  narcotism, and in injuries  of the spine (§149), which
suspend the exhausting influence of volition on the whole or part
of the marrow, in which the nervous energy therefore accumulates,
and becomes unusually abundant.  There can be little doubt that
sedentary habits, and too much indulgence of sleep, likewise may
cause an accumulation and morbid excess of nervous power, and
develope  convulsive  and  spasmodic symptoms,  which are  the
result of its overflow.
   154. Defect of the reflex, or involuntary excitomotory function,
is exemplified in  the  paralysis which affects the sphincters, the
eyelids, the muscles of respiration, and others whose normal action
depends on this function (148).  When this is generally and con-
siderably impaired, the result will be fatal, because the respiration,
deglutition, and other actions essential  to life, suffer.  It  is  by
affecting these actions that apoplectic coma and narcotism  prove
fatal; and the  state of sinking from excessive weakness  or  de-
pressing causes, also exhibits the failure of the reflex power, when
the urine and fasces are voided involuntarily, and the  breathing is
irregular and gasping, being  forced by voluntary effort.   From
failure of the same power, coughing and expectoration become
inefficient in clearing the air passages of  mucus ; hence the bron-
chial and tracheal  rattles which precede  death.  As  these move-
ments are the last to fail, so in recovery  from asphyxia, syncope, 
108          WILLIAMS'S PRINCIPLES OF MEDICINE.

and  other  similar states of partially suspended  animation, the
actions connected with  the  reflex function are the first to return
with  the restoration of life ;  and thus vomiting, coughing  and
sneezing, are among the early signs of reaction.
   155. Remedial measures. — As with other instances of exalted
nervous function, so with excessive reflex action, when dependent
on inflammation, or determination, or congestion  of blood  in the
medulla, the remedies for these are appropriate against this effect:
and the same measures in  smaller degrees are often useful in hys-
terical affections when these occur with fulness of habit, and spinal
tenderness.  In  case of irritation  of the  nervous centres,  more
purely nervous, as  that of tetanus, hydrophobia, poisoning with
strychnia, &c, a narcotic  or sedative, which may lower the ex-
alted function, is the desideratum.  We possess some agents which
powerfully reduce the power of the spinal system, and cause general
relaxation  of the muscles,  such as  hydrocyanic  acid, woorara,
Indian  hemp  resin, and coniuin : these  drugs may  themselves
destroy life by arresting the function of the medulla oblongata in
maintaining respiration ; but this very poisonous  action, and the
sedative effect which one (hydrocyanic acid) also has on the heart,
render  the remedy  almost  as dangerous as the  disease.*   For
slighter irritation of the  medulla, however, these medicines in
moderate doses, and a few others like them, are often beneficial.
Thus hydrocyanic  acid is a very  efficacious  remedy  in vomiting,
nervous palpitation, and  hiccup; it is  also  useful in convulsive
cough, in which, however, the extracts of belladonna  and stramo-
 nium are still more effectual, as they also are in spasmodic asthma.
 The  same  medicines and  opium are often beneficial  in  relieving
 the spasms of colic, dysentery, and dysuria.
   Some medicines, which act as  stimulants to the heart and vessels,
 and  to the cerebral functions, seem  to operate as sedatives to the
 medullary system : these are the stimulant  antispasmodics, such
 as aether, ammonia, musk,  essential oils, gum — resins, creosote,
 alcohol, &c, which are useful remedies in spasmodic and convul-
 sive affections in weak subjects, without inflammation ;  they pro-
 bably operate  by giving  vigour and equality to the circulation.
 External heat and  counter-irritation act in a similar way.
   There is another class of remedies which have some  power in
 reducing  the  excitability of the spinal  excitomotory system —
 namely,  tonics, especially those prepared from  metals ; but the
 operation of these is gradual, and therefore probably indirect. The
 sesquioxide and other preparations of iron are efficacious in chorea,
 and perhaps in the more chronic forms of tetanus.   Nitrate of silver,
 sulphate and oxide of zinc, and sulphate of copper, have been found
 to diminish the attacks of epilepsy, hysterical convulsions, spasmo-

   * From the late accounts of Dr. O'Shaughnessy and others, the resin of the
 Indian hemp seems to  be more powerful than any other remedy in relaxing tetanic
 spasm, and in at least alleviating the symptoms of hydrophobia. 
ULTIMATE ELEMENTS OF DISEASE.
109
die asthma, and cough, and other convulsive affections.  The more
obvious operation of these remedies  is on the vascular system, to
which they prove astringent and tonic, and it is uncertain whether
their beneficial action in  nervous  diseases is  of this kind mily,
equalizing the circulation, or whether they exercise  any more
direct influence  on the  nervous system.  The  same  question is
open with regard to certain regiminal means of reducing nervous
excitability, such as cold bathing, country air, and change of  air,
and exercise.  The latter, however,  no doubt  may  be useful by
exhausting  the  superfluous  nervous  power (§  153)  by another
channel, voluntary motion.                 '   -

            REFLECTED  OR SYMPATHETIC SENSATIONS.

  156.  Clinical observation teaches us that not merely motory
impressions, but those  also which cause sensations, may be re-
flected, so that when the impression is made on one  part, the sen-
sation is experienced  in another.   I  do not allude to the  fact that
a stroke  on the nervous trunk produces feelings  referred to its
branches, but  I advert to impressions on the ultimate distribution
of one nerve  producing sensations  in  parts supplied by another
nerve, or by another branch of the same nerve.   The following are
examples of this kind.  Touching  the  external auditory meatus
causes a tickling sensation in the glottis.  A calcilus in the blad-
der produces pain referred to the extremity of the penis.  Asca-
rides in the  rectum cause itcliing  of the anus, and  sometimes of
the  pudendum.   Congestion of  the  liver sometimes is accom-
panied  by pain  in the  right shoulder-blade ;  and  a  disordered
state of the stomach, occasionally  with pain in the  left shoulder-
blade.   The pains of angina and gastrodynia often  extend to the
whole chest, and  the former especially radiates to the left arm.
Severe  frontal headache is  almost instantly caused in some per-
sons by acid  ingesta, in others by eating ice.   Irritation of the
intestines, as  in  cholera  and colic,  (especially painters' colic)
frequently causes pain and tenderness  in the legs and feet, even
when there  has been no cramp or other excitomotory phenomena.
Temporary  neuralgic affections seem to be due to similar causes.
  In these and other instances that might be cited, the sensations
cannot  be referred to direct nervous communication, but to  an
influence reflected, probably from the spinal centre only.
  The sympathies subsisting between  some  organs are very re-
markable, and none more so than between the breasts  and  the
uterus.   Applying the infant to the  breast often induces uterine
pains in women  recently delivered  ; and the catamenial discharge
has been excited in some instances by stimulating applications to
the breasts.
  157. The  remedies  most effectual  in relieving reflected sensa-
tions are —  1st, those  that remove their irritating cause; and 2d,
those  that deaden sensibility (§ 137), anodynes.   The  peculiar
            10 
110           WILLIAMS'S PRINCIPLES ,OF MEDICINE.

efficacy of trisnitrate  of bismuth and hydrocyanic acid in reliev-
ing gastrodynia  and some kinds of angina, is, however, not ex-
plicable by any narcotic quality.
                         SECTION VI.

                   DISEASES OF  SECRETION.

   158.  The power of secretion appears to be a vital endowment
of the ultimate cells or molecules of secreting structures.*   It  is
uncertain whether the process comprises  the formation as we 1
as the separation  from the blood of  the  peculiar matter of the
secretion.  In the  case  of the urine  and bile, it would seem that
they may be formed in the blood without the aid of the secreting
organs ; for urea is found in the blood of animals whose kidneys
have  been prevented from acting by ligature  of their bloodvessels,
or by extirpation ; and both urea and  some  of the  principles of
the bile (colouring matter and cholesterine) are found in the blood
and in various parts of the body when  the kidneys and the liver
respectively  have been  disabled by  disease.  But  whether the
secreting structures assist  in the formation, or only effect the sepa-
ration, of the matters which  they eliminate, their elective power
is equally a peculiar attribute of life, and is  at present inexplicable
by any physical  or chemical  law.  I  have  for  the last twenty
years! advocated the  opinion recently advanced by Dumas and
Liebig, that the formation of the principles of the chief secretions
takes  place through chemical affinities, especially  those of the ab-
sorbed oxygen and the constituents of the blood, controlled by vital
agencies ; but this view leaves still as a vital property the power
which the liver has to separate bile;  the kidneys, urine; mucous
membranes, mucus, &c.
  We are thus led to consider secretion as  a peculiar property of
the secernent structures, just  as  irritability is  of muscular fibre
(§  110) ; and as such its disorder  constitutes a primary element of
disease.  In doing this we avoid the hypothesis of some physiolo-
gists,  who ascribe secretion to nervous  influence, a  notion by no
means accordant with numerous facts.
  159. In reviewing the disorders of other vital properties, we have
found that many of them  are plainly referable to  changes in  the
supply of blood to their respective textures (§ 113, 127,  131, 133,
&c).  The same cause may be found still more decidedly to ope-
rate in producing variations in the process of secretion.  The blood
being the material from which  the  secreted matter is  supplied,

 + Miiller, De Glandularum penitiori structural.  Henle, Allegemeine Anatomie.
Goodsir,  Trans.  Royal Society of Edinburgh, 1842.  Bowman, Phil. Trans.,
1842.
 fin a thesis, De sanguine ejusque mutationibus, Edin. 1824.  See also Med.
Gaz. September and October, 1835. 
ULTIMATE ELEMENTS OF DISEASE.
Ill
variations in the quantity or quality of the blood will surely alter
the quantity or quality of this product.   Thus when an increased
flow of blood takes place to a mucous membrane, its secretion is
increased, and sometimes rendered more acrid than usual; whilst
a  congested state of  the same membrane or of the liver may
impair the secretion.   Hence the most, common causes of altered
secretion are those which operate on  the sanguiferous system and
its contents.
   160. But affections of the nervous system, and of the mind, which
acts through that system, may also affect  the secreting process, as
shown by the mouth  watering at the sight or thought of a good
meal;  the bilious diarrhoea that mental agitation will cause in some
persons ; the large flow of limpid urine after nervous excitement;
the tears excited by grief or other strong emotion;  the unwhole-
some quality of a nurse's milk when she is in a state of anxiety or
apprehension.  We do not know whether these influences act by
altering the flow of blood, (§ 159,) or by  more directly modifying
the vital property of the secreting organ  (§ 158).
   161. The importance of this element ofdisease may be estimated,
from the ubiquity of  the process of secretion, which includes both
excremenlitious (only to be voided out of the system) and recre-
mentitious products,  (those concerned in digestion, assimilation,
and nutrition,) and also from  the extent of its effects in relation
both to the destination of  the  secretion, and to the  blood from
which it is separated.   These may severally be excessive, defec-
tive, AND  PERVERTED.
   162. Excessive  secretion of any kind, whether  bile, urine,
mucus, &c, may  weaken by the  drain which  it causes from the
mass of blood (§  2S, 71); and this effect will be in proportion to
its quantity, and  especially to the animal matter which it contains.
Thus an excessive secretion of bile weakens more than that of thin
mucus.  But  each secretion  may have  peculiar effects connected
with its office and composition; and these effects may he forwards,
on the parts to which the secretion goes, and backwards, on the
organ  and the blood from which it is formed.
   163.  The forward  effects of an excessive secretion of bile depend
on its stimulating properties.  It irritates the intestinal tube, causing
a bilious diarrhoea or  cholera.   The symptoms of this consist inan
exaggeration  of  those  properties  of the alimentary canal which
have already been described as elements  of disease.  Thus the bile
irritating causes increased irritability (§ 113), and more rapid  mo-
tion of the matter through the tube;  pain from exalted sensibility
(§ 134,135);  vomiting, straining, and cramps, from exalted excito-
motory function  (§ 149,  151);  profuse  mucous  secretion  from
excited secernent function (§ 162).   An  excessive  secretion of
mucus in the  intestines may cause only simple  diarrhoea; but in
the bronchi it may occasion dyspnoea and  cough, and, if not ex-
pectorated, may  suffocate.   Excessive  secretion in  the stomach
may cause pyrosis or waterbrash,  the  liquid  being sometimes 
112          WILLIAMS'S PRINCIPLES OF  MEDICINE

acrid, and occasions nausea and vomiting as well  as eructation.
The  excessive secretions of secreting organs generally may amount
to a  flux or profluvium;  and  those from  internal enclosed serous
surfaces or cellular texture constitute various  dropsies.  These
produce different effects according to their situation.
   164. But excessive secretion may also  have effects backwards,
on the organs, and on  the blood from which  it proceeds.  Exces-
sive,  secretion often weakens the vital properties of the organ, so
that, in its proper function, it subsequently becomes torpid.  Thus
after diarrhoea the bowels often become torpid from  defective se-
cretion.  So, too, in cases where an  excessive secretion continues
for a long  time, it generally is  impaired in its  quality from a simi-
lar cause.
   165. Excessive secretions, if abounding in animal matter, may
not only reduce  the mass of the blood, but also  affect  its compo-
sition.   Thus  bile  and urine, which differ  much  in composition
from the blood,  if separated  in unusual  proportions, must  leave
the.  blood modified.  Urine contains a  great preponderance  of
azote;  and its excessive formation from the principles of the blood
would leave a predominance of hydrogen  and carbon in this fluid.
The  bile, again, abounds in  hydrocarbon, the copious removal of
which would leave a superfluity of azote.  It may be objected to
this statement, that, according to the opinion of some chemists, the
urine and  the bile are not formed from the constant elements  of
the blood, but from materials derived from the food,  and from the
decay or transformation of the tissues.  To this it may be replied,
that  this opinion  is at  present  no more  than hypothetical;  and
should it prove to be true, it would not affect  the undoubted fact,
that  the secretions of the  liver  and of the  kidneys are intended to
balance one another, and the removal of  carbon from the lungs;
and that whether the materials from  which these eliminating pro-
cesses  are supplied  be the principles of  the  blood  itself, or  the
decayed constituents of tissues, or matters derived from the food,
the co-operation  of all  these  processes will be generally required
to maintain a uniformity in the composition of the circulating fluid:
so, too, if one of these processes is more active than the others, the
blood must suffer by the excess of those  matters which  the less
active  processes  allow  to accumulate in it (§ 70, 71).   A clinical
illustration of this position may be found  in cases of bilious diar-
rhoea or cholera.  This flux of bile  is either accompanied by a
highly loaded state of the urine, or by fever; in the latter case, the
fever does  not subside until  the  urine becomes very copious, or
deposits an abundant sediment.  The most probable interpretation
of this fact  is, that the excessive  secretion  of bile  disorders the
composition of the blood ; so long as the  kidneys rectify this dis-
order by separating in  greater abundance  the solid contents of the
urine, no fever results ; but if  the kidneys fail in this task, fever
ensues, and continues until they accomplish  it ; then a free secre-
tion  and copious deposit is symptomatic of the decline of the fever. 
ULTIMATE ELEMENTS OF DISEASE.            113
   166. The remedial measures  that are serviceable in cases of
excessive secretion well illustrate the view that has just been given
of the balancing office which the secretions all fulfil.  In so far as
excessive secretion is dependent on the quantity and quality of the
blood, (§  159,) the treatment should be addressed to this element:
by depletion, derivation, and evacuation, in cases of congestion or
determination of blood ;  and in such cases the excessive secretion
should not  be hastily checked, as it may be a natural  means of
relief; nay, in some  cases, it may be  most speedily  arrested by
means which for the time increase it: thus a large dose of calomel
will sometimes, after first  purging, stop  a  bilious  diarrhoea  con-
nected with an engorged  liver, which  astringents fail  to  check.
But where the excessive secretion proceeds more from nervous and
other sources of irritation, (§ 160,) and  causes weakness and dis-
turbance  of the functions, it becomes a more immediate indication
to check it.   Secretions are to be diminished by means  which act
as general tonics or astringents, (§ 124,) and by others which ope-
rate only  on particular organs.   Of the former class are cold ap-
plied  to  the  part, and common astringents, such as alum, super-
acetate of lead, sulphates of zinc and copper, gallic acid and tannin,
and substances which contain them, as nutgalls, oak bark, rhatany
root, catechu, &c, mineral acids, &c.   These  act most  surely by
direct application, as in their use for diarrhoea, leucorrhoea, &c.; but
they seem to have some  effect also through the medium  of the cir-
culation,  as when taken  internally they reduce the secretion in the
air-passages  and skin.   Of the agents which, without  a general
astringent effect, more especially diminish  the  secretion of  par-
ticular organs, may be mentioned opium, which remarkably lessens
the secretion of the liver, and sometimes that of the kidneys.
   If an  excessive secretion have already caused febrile disturb-
ance, great advantage will  be found to result from the use of means
which increase other secretions, and thus restore the balance  be-
fore explained (§ 165).   Thus in  bilious cholera, saline  diuretics
and diaphoretics are  highly serviceable.   In renal  irritation with
copious secretion of lithic acid, blue pill, which augments the secre-
tion of bile, is often beneficial.  These means may be supposed  to
operate partly as derivants; but the manner in which they remove
the febrile irritation, after the reduction of the  excessive  secretion,
renders it most probable that they act also by  removing from the
blood dregs left by the inordinate separation of the matter  of the
single secretion which has been  in excess (§ 165).  No practical
physician can doubt  that we possess medicines which often aug-
ment  the secretions of particular organs, (mercury that of the liver
and salivary glands, colchicum that of the kidneys, &c.,) yet there
is a limit  to the operation of these agents; but this limit may be
increased  by simultaneously acting on other organs which  main-
tain the balance.   Thus in any disturbance of  the secretions, espe-
cially if it continue long, combinations of medicines are much more
useful  than those  fulfilling one indication only;  and  thus  expe-
           10* 
114          WILLIAMS'S PRINCIPLES OF MEDICINE.

rience has sanctioned the  practice of  conjoining mercurials with
diuretics, and antimonials with salines, &c.
  167. Defective secretion of any natural or habitual discharge
(§ 70) may cause a fulness of the bloodvessels;  a general fulness
if the secretion be naturally copious ; a local fulness if it be trifling
in quantify.  Thus defective secretion of urine  or bile may cause
general  plethora, or extensive local congestions, which  may end
in dropsical effusions, fluxes, hemorrhages, or inflammations.  Di-
minished secretion of tears or  saliva would merely cause fulness
and dryness of the parts immediately concerned.
  The morbid effects of defective secretion may  be both forwards,
on the parts for which the secretion is intended, and backwards,
on the organ and  on the blood from which it  should  be elimi-
nated (§ 162).
  16S. Defective  secretion of bile  causes  disorder in the latter
stages of digestion.   The neutralization of the acid in the chyme
and the separation of the chyle, to  which the bile seems to contri-
bute, are imperfectly performed ; sometimes colic  and diarrhoea,
sometimes  costiveness, results from the defect.   Deficient  secretion
of mucus in the intestinal  canal  and bladder would expose their
membranes to more irritation from their contents.  Probably de-
ficient secretion of mucus on the respiratory membrane may lessen
the facility with which the air and the  blood act  on each other.
Insufficient secretion of cerumen  in the ear, or of saliva in the
mouth, impair respectively the  hearing and the process of masti-
cation.   A want of synovia in the joints has been supposed  to be
a cause of  their imperfect motion and  subsequent inflammation.
  169. The effect of defective secretion in causing congestion  of
its respective organ,  has been already noticed : the concomitance
of congestion with defective secretion, in the case of the  liver, the
kidneys, and mucous membranes, is well known ;  but either may
be viewed  in the  light of both cause and effect.
  170. The most remarkable of the backward effects of defective
secretion are instanced in case of the  secretions (§ 70).   The dis-
tinctive materials of the secretions of urine and  bile appear  to
be positively noxious, and poison the system if not separated from
the blood.   Thus the sudden suppression of urine or bile  causes
typhoid symptoms, extreme depression, and coma, which speedily
end in death ; and in such cases, urea, or the colouring matter  of
the bile, has been found in various organs.  Where the suppression
is incomplete, the poisoning process is more tardy : various func-
tional and  visceral derangements are  produced, such  as delirium
or  lethargy, dyspnoea, palpitation, vomiting, diarrhoea,  dropsical
effusions, structural  degenerations, &c, which  always prove fatal,
sooner or later, if the defective excretion be not restored.  In these
gradual  cases, still more remarkably than in those of more sudden
suppression, some of the excrementitious matters may be detected
in the blood and  in other  fluids and solids of the body.   Thus in
some structural diseases of the liver, the colour of the bile becomes 
ULTIMATE ELEMENTS OF DISEASE.
115
manifest first in a yellow, and by accumulating, in a deep greenish
colour in all the  textures, constituting the  yellow and  the  black
jaundice.   In  granular degeneration of  the kidneys, in which
scarcely any urea is excreted by  these  glands, this principle  is
found in the blood and various fluids of the body.*
   171. The excretions are defective in many  idiopathic and symp-
tomatic fevers; and there can be but little doubt that many of the
constitutional effects of these fevers are in great measure due to
this important element.   The positively noxious properties which
excrementitious matter retained in the blood  is known to  possess,
(§ 170,) must  be taken into account when we attempt to  explain
the states of constitutional irritation and depression, with perver-
sion of functions, which fevers so generally present.  The  changes
in the blood, manifest in some such cases by its fluidity and  by
petechial appearances, may also be in part referred  to defective
elimination of effete matter ;f and it is when  the  secreting organs
recover their power, and a diarrhoea occurs, or a copious discharge
of highly loaded urine, that these appearances cease.   It is a ques-
tion how far severe  mechanical injuries or shocks, (§ 52,)  and ani-
mal and other poisons, (§ 105,57, &c.,) may operate by thus injuring
the vital powers by which the blood is continually  purified  from
its own noxious products; but that this is a part of  their  mode of
action seems almost certain from their effect in suppressing or im-
pairing the natural excretions.
   There can be little doubt that a morbid element, which in its ex-
tremes act so  injuriously as to cause serious disorder, and  even
speedy death, must in slighter degrees be an  important cause and
constituent of disease ; and I  believe  that  gout, rheumatism, and
many cachectic states leading to diseases of nutrition, degenerations,
dropsies, &c,  are essentially connected with defective excretion.
   172. Remedial measures. — Defective secretion may be caused
by deficient or excessive supply of blood to the part, as in various
cases of anaemia, congestion, and inflammation (§ 159).   In  such
cases it must   be  treated by  the  proper remedies for these  con-
ditions :  thus  stimulants may restore  secretions scanty  through
a defective supply of blood ;  and  depletion and  derivatives  may
be the best remedies, when they are stopped  by inflammation or
congestion.
   173. But sometimes the first disorder  is  in the secreting struc-
ture itself, (§  15S,) and  may  best be removed  by agents which
specifically increase the secretion,  which  common stimulants will
not do.  Thus mercury increases the secretion of the liver; colchi-

  * In the case of a patient of mine affected with ascites  from disease of the  heart,
liver, -and kidneys, Mr. Garrod obtained nearly four grains of nitrate of urea from
an ounce of the  peritoneal fluid, and a considerable quantity of bright yellow
solid matter, probably bilious.
  f Purpura 1 have found to be often connected with hepatic congestion, and im-
perfect excretion  of bile, and to be most effectually removed by  remedies which
promote the restoration of the proper secretion. 
116          WILLIAMS'S PRINCIPLES OF MEDICINE.
cum, nitre, and other diuretics, that of the kidneys; croton  oil,
jalap, sulphate of magnesia, and other purgatives, that of the in-
testines; and this they do, however introduced into the system,
whether by the mouth, through  the skin, or  injected into vessels
or textures.  These are important practical facts, however difficult
they may be to explain;  and their application to restore defective
secretions is abundantly obvious.
   174. But these specific stimuli  of the secreting organs, (§ 173,)
if used in excess, or too long, may not only cause  general weakness,
but also  exhaust  the  vital properties which  they excite (§  159);
and the result may be a diminution either of  the secreted fluid, or
of its most characteristic constituents. Hence the long or excessive
use of mercury causes torpidity of the liver; that of purgatives,
imperfect action of the bowels; that of diuretics, scanty urine, or
albuminous or watery urine, defective in urea.  These facts  point
out the expediency  of alternating or conjoining  these  different
agents with others calculated to  improve the  vital properties of
the textures generally, which may often  be effected by  the  medi-
cines  called tonic, and by regiminal means  which improve and
equalize  the state of the circulation,  (§  124,)  and preserve  the
digestive and assimilative functions in the best order.  In illustra-
tion of this position, I may refer  to the acknowledged advantage
of giving bitters with  or after mercurial courses; chalybeates with
or after saline aperients, and  diuretics, when  these  are long  used;
and these additions, which alone, or used at first, would check the
secretion to  be increased, now sustain it and  render it permanent.
Some medicines  which are  inferior in efficacy to  those already
named, are  yet, in some  instances, more eligible for chronic cases
of defective secretion  ; because they are less exhausting, and com-
bine some measure of tonic influence with that of  increasing the
secretions.  As examples of  this  kind may be named taraxacum,
preparations of iodine, sarsaparilla, nitric and  nitro-muriatic  acids.
Courses of these medicines are sometimes of great efficacy in  keep-
ing free the secretions after they  have been  restored by  more
powerful means  (§ 173); and they likewise often improve  the
functions of digestion and nutrition.
   175. Where  defective secretions  are  not  readily restored, the
forward disorder  (§  168) arising  from their deficiency maybe
sometimes remedied by artificial substitutes.   Thus, in defective
secretion of bile, the action of the intestines has been promoted by
exhibiting ox-gall.  Aloes and soap combined have been thought
to supply the  place  of bile in some cases.   Toasted  bacon  at
breakfast has been supposed  to have a similar effect; but it more
probably excites  the liver to increased secretion, as other fat mat-
ters do.
   Imperfect lubrication of the throat and  larynx, and other mu-
cous membranes, from defect of mucus, may be remedied by  muci-
laginous and demulcent matters.  A dry state of the skin may be
relieved  by applications of oil or honey. 
ULTIMATE ELEMENTS OF DISEASE.
117
  176. Perversion of secretion often accompanies  excess and
defect of this process.   In febrile diseases, the  secretions  of the
kidneys and alimentary canal are altered as well as  diminished.
Inflammation and determination of blood change  as  well  as in-
crease the secretion from mucous membranes, rendering it more
saline, and sometimes albuminous.  The urine exhibits remarkable
changes in quality : full living, stimulating beverages, and irrita-
tions of the digestive  organs or  kidneys, rendering it unusually
strong and acid ;  whilst low diet, great fatigue  of body or mind,
and chronic inflammation of the kidneys, generally make  it pale
and alkaline.  Out of these  morbid conditions may arise various
further decompositions, with sediments and calculous  concretions
of  different kinds (§51,  53).   Concretions  are  likewise  formed
from  an  altered state of the bile.  The perspiration is also some-
times changed;  thus  it is very  acid  in rheumatism,  and fetid in
delirium tremens.
   177.  Secretions which serve particular purposes, when  altered
may  become unfit for these, and thus cause disorder : thus a thin
acrid mucus irritates instead of protecting the membrane which
secretes it, as in  coryza and mucous diarrhoea; a viscid dry mucus
clogs up and obstructs tubes which it was intended to lubricate ;
altered gastric juice causes indigestion ; sebaceous matter  of the
skin  may accumulate  in  its follicles, and cause irritation  and
inflammation, &c.
   17S. The remedies for perverted secretions (§  176)^are  usually
 those which likewise increase  secretion (§ 172, 173).'* Thus de-
 praved secretions of  the intestinal canal are often  satisfactorily
 altered by continued purging; a turbid state of the urine is sometimes
 removedby diuretics ; too thick a state  of the mucus of  the air-
 passages is modified by expectorants, &c.   But where the  change
depends on altered circulation in the part, the  remedies must be
 suited accordingly.   In some cases,  tonics restore a healthy state
 of secretions ; and in most instances of long-continued perversion,
 tonics may be  advantageously  combined with  medicines which
increase secretion (§  174).   Such a  combination  is presented  in
 most of those remedial agents which have obtained  the appella-
tion of alterative, and which would seem to be  especially suited
 to  oppose to the  diseased element  under consideration, if they
 really possessed the virtues ascribed  to them.
   Nutrition is also effected by the property of secretion (§ 158) ;
 but inasmuch as its changes cannot be understood without a pre-
 vious knowledge of  the  blood  and   its  constituents, and  involve
 the complex subject  of structural disease, their consideration will
 be deferred.

         DISEASES OF THE CONSTITUENTS OF THE BLOOD.
    179. The pathological elements (§ 107) which we have hitherto
 considered are those of the vital properties of the elementary solids.
 We now proceed to  examine the morbid changes of the  blood. 
118           WILLIAMS'S PRINCIPLES  OF MEDICINE.
 These, like those of the solids, may be often traced to individual
 elements, of which the blood is composed, the changes of which
 must be viewed as ultimate elements of disease, and are therefore
 properly included in  the  present division.  But as the blood also
 operates as a whole,  compound indeed in itself, but simple in  its
 influence on vital functions and structures, it forms a proper  con-
 necting link between  ultimate and proximate elements of disease.
 So, also, inasmuch as it  is, in some  respects,  an organized com-
 pound, the  materials  of which are changed, together with its func-
 tions, and contributes to  the production of change of structure in
 the solids of the body, the consideration  of  its changes will be  a
 proper introduction to that of alterations  in the circulation, which
 induce changes of structure, and thus  lead  to structural  diseases
 themselves.
   180.  We  have found that  blood is the support of all the vital
 properties ;  and in describing their variations, we have been obliged
 to refer frequently to  differences  in the supply or quality of this
 fluid, both as causes and as consequences of these variations (§ 113,
 127, 131, 159, &c).   WTe have now  to examine the properties of
 the blood itself, and, first, those which are most elementary, or re-
 ferable to its respective constituents.
   The circulating blood  consists of  red  particles, colourless glo-
bules and liquor sanguinis; but as the latter  is compound in
function as well as  in constitution,  it  is necessary to specify its
 chief constituents.  We have, then, to consider —

         1.  The red particles,           "^
         2. Fibrin and colourless globules,
         3.  Albumen and  other dissolved
             animal matters,            V- *" """"j"0' "_">»-*">«■"•
         4  qji                       f     alteration.
         5.  Salts,                    |
         6.  Water,                   J

   181.  Other changes affecting the entire blood are —
                  7.  Changes by respiration.
                  8.    —   by secretion.
                  9.    —   by nutrition.
                  10.    —   by foreign matters.

   182.  The average natural proportions of the chief constituents
of the blood, according to Lecanu, and adopted by Andral and Ga-
varret as a  standard, are 127 red  globules; 3 fibrin; 72 animal
matter in the serum;  8 salts ; 790  water.* (a)

   (a)  The range, within the limits of health, of some of these
constituents, are from 110 to 140 red globules ; 2.5 to 3.5 fibrin  ;
6S  to  70 pure albumen; 725  to 915 water. — (Andral, Essai
d'Hdmatologie Pathologique.)
in avnaac* no fa ot onrl
* Annales de Chimie et Physique, Nov. 1840, p. 229. 
ULTIMATE ELEMENTS OF DISEASE.
119
                         SECTION VII.

                     RED  PARTICLES.

   183. The red blood-discs appear to be the part of the blood on
which its vivifying and calorific properties chiefly depend.  Thus
Prevost and Dumas found that animals bled almost to death could
be restored by injecting into their veins a mixture of red particles
and serum, even when the fibrin had been removed ; yet the serum
alone failed to produce any such effect.   It is therefore to be sup-
posed that the red particles are the part of  the blood  required in
transfusion in cases of hemorrhage.   Andral, Gavarret, and  Dela-
fond, remarked that in domestic animals the vigour and beauty of
the animal were proportioned more to the amount of red particles
in the blood of the animal than to any other constituent ; and that
improvement of a breed  by crossing was marked by an increased
proportion of this  element.*  The red particles are supposed, by
Liebig, to be the means by which oxygen is carried throughout the
circulation, and brought to act on the various textures.(a)  Their
proportion varies considerably in  health ; it may  be stated gene-
rally at 120 or 130 in 1000 of blood.
   184. Excess of the red particles might therefore be expected to
cause a  general excitement of the vital properties of the body
(§ 183).   Accordingly, Lecanu found that they exist in larger pro-
portion in persons of sanguine temperament (§ 38) than in others,
and more in  males than  in females.  Andral and Gavarret de-
tected an excess in the early stage of inflammations and fevers,
especially eruptive fevers, as measles and scarlatina.  In sangui-
neous plethora, also, and in hemorrhagic diseases before much
blood  is lost, they were in excess, in  some instances rising to 185
in 1000 of blood.(b)    The obvious sign of the abundance of red
   (a) The reader might be led to believe that this is a recent opi-
nion, originating with Liebig.  It has been advanced by different
writers long before.  Sir Humphry Davy, among others, supposed
that  the air pervading the  membranes of the lungs, in respiration,
is decomposed in consequence of the affinity of the oxygen for the
red particles. — (Midler's  Physiology, Bell's edition, p. 308.)
  (b) The mean proportion of red globules in thirty-one plethoric
subjects, from  whom blood was drawn, as stated  by M. Andral in
the latest and most authoritative outline of his views and experi-
ments (Essai 8,-c. ), to be 141 parts in 1000,— the extremes being
131  and 154.
  In the hemorrhagic diathesis the peculiarity consists more in the
disproportion between the  red  particles and the  fibrin, the  latter
being less than its  normal quantity, than in the  excess of the
former.   One of the effects of hemorrhages is to diminish  notably
the proportion of red particles (op. cit.).  In scurvy characterised
              * Ann. de Chimie et Physique, Juillet, 1842. 
120          WILLIAMS'S PRINCIPLES OF MEDICINE.

particles is the florid colour apparent in the lips, cheeks, gums, and
other vascular parts ; the deep blue colour of the superficial veins ;
and the fine deep crimson which a thin film of blood gives on a white
plate.  The functions, animal heat, and muscular irritability are in
an elevated state, bordering on or passing into febrile excitement.
  185. The red particles are defective in persons of the lymphatic
or  leucophlegmatic  temperament (§ 40);  after great losses of
blood (artificial or from disease); in chlorosis, and in other anaemic
states, as those connected with advanced stages of cancer, diabetes,
scurvy [?], and other cachectic diseases; in scrofulous and tubercu-
lous diseases ;  in the latter periods of  fevers, and after severe in-
flammations ;  in granular degeneration  of  the kidney, and other
organic diseases attended with dropsy ;  in  diseases of the spleen,
and  others of malarious origin  (§ 85).  In  extreme cases of chlo-
rosis, the  proportion of the  red  particles was found,  by Andral,
reduced to 27  in 1000 of blood.(a)

by hemorrhage their proportion is, at times, not materially differ-
ent from that  in health.
  M. Lheritier confirms the accuracy  of  many of MM. Andral
and  Gavarret's statements  respecting the changes that the blood
undergoes in acute diseases, and dwells especially upon one result
of their experiments, viz., that the proportion of the red globules
becomes decidedly diminished, when an acute disease  has lasted
for some time.  This fact explains some phenomena that are other-
wise not  very intelligible.  Enfeebled and weakly persons  are
more liable to  inflammatory attacks  than those who  are  more
robust and plethoric, in consequence  of the proportion of the fibrin
to that of the red globules in their blood being relatively,although
not  actually,  greater than  in  health. — (Joum. des Connaiss.—
Bull, of Med. Science, p. 261, vol. i.)
  (a) We shall repeat here the words, which we have elsewhere
used (Bulletin of Med. Science, June, 1843, p. 210), in an analy-
tical notice of Andral's essay on pathological hematology, already
quoted :
  " In anemia a state of the blood is met with the very reverse of
that in plethora, viz., in there  being  a deficiency of red  globules.
In 16 cases  of incipient  anemia, the proportion was 109, and in
24 confirmed  cases, 65 parts in 1000.  The fibrin in the first class
was  3;  and  in  the second,  3.3.  In  spontaneous  or primary
anemia, the globules are alone deficient; whilst in that following
hemorrhages, although at first  the change  is mainly in  the  less
proportion of globules, yet, with  the repetition  of the discharge,
there is, also, a diminution of the fibrin and albumen.  Thus for
example, in   a woman, subjected to abundant menorrhagia, the
blood contained only 21 parts of globules,  1.8 of fibrin, and 61 of
solid materials of serum in 1000.   The water was in the enormous
proportion of 915."
   In most of the neuroses the blood is remarkably poor in red
globules. 
ULTIMATE ELEMENTS OF DISEASE.
121
  The signs of the defect are, paleness of parts naturally coloured
with blood, pallid or sallow hue of the skin, pink colour of super-
ficial veins, and a pinkish or light purplish hue of a film of blood
on a white plate.   The symptoms  of such a  condition are those
which will be more fully described under  the head of anaemia ;
a weak state of the functions generally, of circulation, calorification,
digestion, and nutrition, constituting their summary.
  186. The red particles are evidently altered in some diseases, the
colouring matter being much darker than usual, as  in  the worst
forms of scurvy, in which the blood is said, by Mead, to be changed
to a dark brown  or green colour; in the Walcheren and other
malignant fevers it  has  been described as pitchy black.  Some
change seems to occur in congestive  typhoid fevers, in which  the
bloodvessels become stained or dyed of a deep claret colour ; this
imbibition implies an unnatural solution of the  red particles.  Pro-
bably the occurrence  of petechias and ecchymosed patches  in these
diseases  is partly dependent  on  a similar change.   The readiness
with which the textures  become stained in scorbutic subjects, and
in secondary  syphilis, seems to  indicate an  alteration   in  the
colouring matter;  all inflammations and ecchymoses in the skin
being  followed by livid, purple, or copper-coloured stains.  The
black matter of melanosis seems to  be the colouring part of the
blood in  an altered state :  this  is certainly true of the spurious
melanosis of the intestines.
  187. Besides changes in colour, the  red particles may probably
be  subject to alterations in their  form, size, and other properties in
connexion with the  medium  in which they are placed.   It was
first observed by  Hewson, that  pure water causes them to swell,
become  globular,  and burst; whilst saline solutions, containing
more salts than serum does,  make them shrink in  size.   These
changes are now generally understood to arise from endosmosis and
exosinosis : the saline matter drawing the water into or out of the
little cell which constitutes the red  particle.   It has not been ascer-
tained, but it is highly probable  that similar  changes  may take
place in  the living  body, from circumstances  which greatly alter
the proportion  of saline  matter and water in the blood.(a)  May

  (a) M. Andral (op. cit., p. 52-3) relates the  results of microsco-
pical  observations made on  the blood of two chlorotic subjects,
showing the red particles to be  smaller than common,  and  at
the same time  some  of  an  abnormal figure,  being  broken, and,
as it were, fragmentary, in  the field of the microscope.   One of
these  patients recovered her  health  entirely  in a period  of two
months afterwards.  He  does not, however, lay any great stress
on these cases.
  This careful  and conscientious observer points  out  sources  of
fallacy, in regarding, as morbid,  certain accidental appearances of
red  globules, viz., that their granulated or raspberry-like  appear-
ance, seen so commonly in the blood of the dead subject, or even,
           11 
122          WILLIAMS'S  PRINCIPLES OF MEDICINE.

such change contribute to  produce the serious symptoms, and even
sudden death, which have ensued on drinking a  large quantity of
water after great exertion ?  Has  it aught to  do with the reac-
tion  and irregular excitement sometimes  occurring  after  exces-
sive  losses of blood ?  Or  with  the  symptoms of suffering which
animals  manifest at  the  instant  of injecting water  into  their
veins ?
  188. The change  of the blood from dark to florid, on the addition
of saline matter, appears to depend  on  the  increased density and
opacity  given to the red particles or their nuclei, and  to the colour-
less globules, whereby they  reflect  light  more abundantly,  and
are also rendered less transparent.*   Probably the action of oxygen
in reddening venous blood is of a similar character.
  189. The red  particles are  distinct structures, living cells, (pro-
bably nucleated,) although isolated and  floating in a lifeless fluid.
Like other nucleated cells, they probably possess the  power of se-
cretion  and reproduction  ; but the  office and mode of these have
not been ascertained ; and we can  therefore say nothing of their
modifications.   It has been conjectured  that they have other vital
properties, such as spontaneous motion, and attractions and repul-
sions;  but  there are no  unequivocal  facts  in support  of such
notions.   The  motions  described  by  Treviranus, Schultz,  and
others,  may be  accounted for on purely physical  principles.   It
is said, that  a systolic and diastolic movement in  blood  particles
has been lately observed,  by  Dr. Martin  Barry, in the fallopian
tube of  a recently impregnated  rabbit; but this  needs  confirma-
tion.
  190. Mr. Wharton Jones hasdescribed changes in recently drawn
blood, which he considers to arise from  peculiar attractions sub-
sisting between the particles.t  Hewson, Prevost,  Dumas,  and
others, remarked  that red  particles  of new drawn blood cohere
together in  piles or  rouleaus.   Mr. W.  Jones adds, that  this cohe-
sion  in   healthy  blood  is temporary only ; and  that,  in a few
seconds, the discs may be  seen loose and confused; but in blood
drawn from  a  person affected with inflammation,  the cohesion
takes place earlier, is more firm, and lasts longer than usual ;  and
he  considers this  the chief  cause  of  the  separation  of the red
at times, in fresh blood examined  soon after its abstraction from a
living  one, are owing to the breaking up of these globules.  M.
Andral's investigations have led him to the belief, that this appear-
ance of being festooned with smaller bodies is really  owing to the
agglomeration of white corpuscles, and their  agglutination to the
circumference of the red globules.   He shows these white corpus-
cles  to be fibrin  held  in  solution by serum. — (Bulletin of Med.
Science, ui supra, p. 208.)

              * Medical Gazette, Sept. 1835.
              }  British and Foreign Medical Review, Oct. 1842. 
ULTIMATE ELEMENTS OF DISEASE.
123
particles from the fibrin, which leads to the formation of the buffy
coat.  We shall  notice the  relation  of this phenomenon to  the
buffy coat under the  head of fibrin;  but of the cohesion of  the
red particles we would remark, that it is not certain that it is more
than one of mechanical aggregation induced by change in the re-
lative dilution  of the liquor sanguinis, or serum,  without and
within  the  blood corpuscles.(o)  The momentary  exposure  of
so  thin a film  of blood to  the  air  causes evaporation, which
affects the serum  before it  can reach the  interior of the blood
particles.   At this time they  cohere; but  the  exosmosis pro-
ceeding from the individual particles  again  detaches them from
each  other.    But,  without dwelling  on  this  or  the  equally
hypothetical  notion  that the cohesion is due  to a vital  attrac-
tion, it  is  not  unimportant  to observe this  property, and  the
variety  which is presented in inflammatory disease.  But Mr. W.
Jones is premature in assuming that a similar  aggregation of the
blood corpuscles occurs within  the bloodvessels, and is the cause
of obstruction in  the capillaries in inflammation and other cases
of impeded circulation.  No such cohesion is seen in the large ves-
sels of  a  frog's web, when the motion of the  blood  is  arrested
by  pressure on a vein; and although the blood does coagulate in
some of the vessels  of an inflamed  part, this will  be  hereafter
shown to begin  with  the colourless, rather than with the red par-
ticles.   (See Inflammation.)
   191.  Our inquiries as to the  pathological causes of changes in
quantity and quality  of the red pariicles are baffled by our igno-
rance as  to  the  origin of these  particles.   The most  plausible
hypothesis is that advocated  by Dr.  Martin Barry, that  they re-
produce themselves.   This does not altogether supersede the older
notion that the lungs and the spleen may be the chief seats of
their formation, nor that of Mr.  Gulliver, that some may be formed
from the globules of  chyle.  Certain it is that in serious and long
continued diseases of the lungs or spleen, their quantity is remark-
ably diminished.   But the same diminution  is  still more remark-
able in chlorosis without any visceral disease.
  192. Remedial agents. — Excess of the red particles may be
speedily removed by  bloodletting, which  reduces  these  much
more than the other constituents of the blood.  Low or vegetable
diet, and the antiphlogistic regimen generally, produce a similar
effect more tardily.    It is not  certain whether any medicines di-
rectly act  in  a  similar way ; but probably the continued use of
mercury, colchicum,  and  other  medicines which  largely increase
the excretions (§ 173), ultimately reduce this  element.   The re-
markable  pallidity which accompanies the occurrence of extensive
suppuration would also point to the formation of  pus as a means
of diminishing the red particles, which means may be used artifi-
cially in the form of setons and suppurating counter-irritants.
(a) See preceding note. 
124
WILLIAMS'S PRINCIPLES OF MEDICINE.
  193. To promote the increase of the red particles, where defec-
tive, we might expect  nourishing food, especially meat, exposure
to invigorating air and  light, with tonics  generally, to  be  the
proper means.   But without experience we could not have anti-
cipated  that  medicines containing iron  should possess such re-
markable efficacy in relation to  this element of disease.  In many
cases of chlorosis, under  the use  of any suitable preparation of
iron, the complexion will change from waxy to ruddy, in three or
four weeks' time.  This  subject will again come under our con-
sideration  in connexion with anaemia.
  It has been supposed by Dr. Stevens that saline medicines have
great power in restoring  to  their natural condition the red parti-
cles which are changed in typhoid and malignant remittent fevers
(§ 186); but if  these remedies have any power in such maladies,
it is very  doubtful how  much  is to  be ascribed to this mode of
action.
                        SECTION VIII.

                            FIBRIN.

  194. The trifling difference in composition between fibrin and
albumen (a minute addition of sulphur in the first) would scarcely
distinguish them; but the self-coagulating  property of fibrin is
that which makes  the distinction obvious, and most important in
pathology.  Being  the part which  causes the coagulation of the
blood, with all the varieties which that process exhibits ; being the
part which constitutes the buffy coat and coagulable lymph; and
being probably the material  by which textures  are  chiefly  nou-
rished and repaired, its changes must constitute an important ele-
ment of disease.  Although probably not so immediately concerned
as the red particles in maintaining the vital processes of respiration,
circulation, and innervation, it is yet a representative  of the active
state of these processes, and of  the nutritive and reparative func-
tion ;  and it therefore exists in  larger proportion in  arterial than
in venous blood.   It is  deficient in new-born animals, but abun-
dant in children and in persons who have been well fed, and are in
robust health.  The  average proportion in health is three in one
thousand of blood. (Andral.)
  195. An excess of fibrin, and of the colourless or lymph-globules,
exists in inflammatory diseases, especially  those of a sthenic cha-
racter and acute rheumatism.   In  some cases, MM. Andral and
Gavarret found  it as high as ten per thousand.   The proportion
of fibrin is also increased during the latter months of pregnancy.*
These facts have been long known ; but in addition to these, MM.

  *In domestic animals the fibrin is diminished before, and increased after, par-
turition.  (Ann. de Chim. 1842.) 
ULTIMATE ELEMENTS OF DISEASE.
125
 Andral and Gavarret found an excess of fibrin in tuberculous dis-
 eases,  [when the tubercle or cancer  becomes softened,] in which
 we have noticed there is a defect of red particles (§ 185).   Mr.
 Gulliver has observed the increase  of white globules in blood
 drawn in inflammation ; and I have noticed this as occurring in
 the vessels.  (See Inflammation.) (a)
    196. Deficiency of fibrin is of frequent occurrence in many dis-
 eases and temporary conditions bordering on disease.   Its sign is
 fluidity or imperfect coagulation of the blood when drawn.  As
 venous blood contains less fibrin than arterial, so the quantity is
 absolutely diminished when the blood is more venous than usual,
 as in cases of asphyxia or impeded  breathing; and in those of
 cyanosis, in which the venous blood becomes mixed with the arte-
 terial through an unnatural opening.*   Excessive  bodily fatigue

   (a)  M. Andral (op.  cit.) tells  us, that in strongly  developed
 acute inflammation  fibrin is present  in the blood, in the  propor-
 tion of from 6 to S parts in 1000.  The  two  diseases in which he
 has seen  it most abundant, are pneumonia and  acute articular
 rheumatism ; they are the only  ones in which  it  rises to 10.
 Excess of fibrin was met with in cellular inflammation or  shnple
 phlegmon, phlegmasia? of the mucous membrane of the respiratory
 and digestive apparatus, mercurial stomatitis, acute cystitis, either
 separate or combined with nephritis,  acute inflammations  of the
 skin, as in burns, erysipelas.  But no augmentation is found to fol-
 low the pustules of small-pox, or  the  exantheme of  measles or
 scarlatina, any more than the patches in dothinenteritis.  All the
 phlegmasia? of the serous membranes are marked by an increase
 of fibrin.   The same maybe said of inflammation of the lym-
 phatic  glands and softening  of the brain.  In the only case of
 acute hepatitis which M. Andral met with, also in jaundice and
 cirrhosis of the liver, there was no change in the normal propor-
 tion of the fibrin.
   Increase of the fibrin in the blood is manifested so soon as  the
 inflammation begins. As to the order of sequence, M. Andral is
 inclined to believe,  from  what he has  observed in  the cases of
 burns, that the  disease of the  solid precedes the  change  in  the
 blood ;  and that the  occurrence of this latter explains, and is proof
 of inflammation being a general  and constitutional disease.  The
 sympathetic fever in  the phlegmasia? is, he thinks', due to the alter-
 ation in the blood by excess of its fibrin.
   In reference to the variable proportions of fibrin in the blood of
 pregnant  women, M. Andral  found that, during  the first  six
 months  of utero-gestation, it was commonly  below the  physiolo-
 gical  standard;  and  during  the last  three months  as  uniformly
 above it — the greatest augmentation  being in the last month.

 * Poor  food, or that defective in protein principles, fibrin, albumen and casein,
lowers the quantity of fibrin ({ 63). 
126          WILLIAMS'S PRINCIPLES OF MEDICINE.

and want of sleep expend the fibrin : hence the blood  remains
fluid in animals hunted  to death (§ 65).  It was stated  by John
Hunter that the same thing is observed in animals killed by light-
ning ; but  this is  not  always the case.   In many instances the
blood is found fluid in cases of death from poisoning and other
sudden causes.  In some of these the  absence of  fibrin may be
attributed to the impeded respiration which is the immediate cause
ofdeath, as in some cases of death from hydrocyanic acid, opium,
strychnia, apoplexy, dividing  the pneumogastric,  (Dupuy,) &c.
There is, however/some uncertainty about these facts.  (See Mr.
Blake's experiments mentioned further on.)  But in others, as  in
poisoning with arsenic, sulphuretted hydrogen, and some other
pernicious agents, the  fluid state of the  blood must  be ascribed  to
a more direct operation on the  blood itself.  So likewise in ady-
namic fevers, which arise from  a peculiar  poison,  the fluidity  or
imperfect coagulation  of the blood is one of the most remarkable
conditions, and seems to be a chief cause of  the  hemorrhages,
petechia?, and vibices, which sometimes occur in these fevers.   In
a case  of very low typhoid fever, Andral  found the proportion
below  one in one thousand.  The artificial imitations  of these
fevers produced in dogs inoculated with  various morbid or putrid
matters,  or confined over their exhalations, in the experiments of
Gaspard, Magendie, Gendrin,  Leuret,  and Hamon, exhibited  a
similar absence of fibrin in the blood (§  194).
   The addition of some neutral and alkaline salts to the blood out
of the body will diminish its coagulating property ; and it has been
stated  that subsisting on salted food will  produce  a dissolved or
nonfibrinous state of the blood during life; but this  statement does
not  appear to  be founded on any well  ascertained facts, and is
perhaps  connected with the notions that salt food is the cause of
sea scurvy, (§ 63,) [note to page 57,] and that  the  blood  does not
coagulate in this disease, both of which are erroneous.   (See Lib.
of Pract. Med., Art. Scurvy, by Dr. G. Budd.)
   197. Besides the sign already mentioned, permanent fluidity or
little coagulation  of the blood when drawn, a defect of fibrin causes
a tendency to hemorrhages, generally of the asthenic kind, and to
an unmanageable oozing of blood from any accidental wound or
breach of texture.  In the same cases, too, wounds do not readily
heal, nor fractures unite.   In fact, the plastic or reparative process
is defective  for want of its material (§ 194); and  for a similar
reason, the nutrition  of textures which  consist chiefly of fibrin,
such as  muscle, is ill  maintained.
   198.  Magendie found that animals, from whose blood fibrin had
been abstracted,  were affected with  congestions and effusions in
 the  lungs, brain,  and other organs, which he  ascribes to a cause
 supposed by M. Poisseuille to be a general physical fact; that very
 thin fluids pass with greater difficulty through capillary tubes than
 those of somewhat greater spissitude.   But his experiments were
 too  rude and his  deductions too  hasty  to  merit confidence;  and 
ULTIMATE ELEMENTS  OF DISEASE.
127
the obstructions and congestions alluded to  might be equally due
to the cohesion of colourless or blood  particles, or even to little
clots of fibrin left by the coarse process employed.(a)
  There can, however, be no doubt that a certain spissitude in the
blood is favourable to its transit through the hydraulic  apparatus
of the circulation;  and that when  this is  deficient, various irre-
gularities in the  distribution of the blood  may occur.   Some of
these will be mentioned under the  head of ana?mia : but  I may
mention here that thin blood is easily thrown into  sonorous vibra-
tion, and various unnatural sounds or  murmurs in the heart, arte-
ries, and veins, may be thus produced.  As these are sometimes
met with in cases in which  the complexion does not indicate  a
deficiency of red particles, and they are  sometimes absent in  the
most pallid subjects, lam inclined to connect them as much with
defect of the fibrin and albumen as with that of the red particles
of the blood.
   199. Alterations in the quality of the fibrin introduce to  our
notice the important morbid appearances  presented  by the buffy
coat and contraction of the clot of blood.
   As the  consolidation of the fibrin is the cause of the coagulation
of the blood, so  differences in the coagulum represent variations in
the properties of the fibrin.
   200. A large  firm coagulum indicates an abundance of fibrin,
as well as of red particles, and is commonly presented by healthy
blood.  A loose coagulum implies  a deficiency of fibrin.   A small
firm clot betokens a proportion of fibrin exceeding that of the red
particles; but the smallness of the clot points to another property
of the fibrin, which is in excess, that of contraction during  and
after its consolidation. Again  : in this case as in others, the upper
part of the clot is commonly more  contracted than the lower por-
tion :  i^, is also firmer and contains more fibrin, whilst the lower
abounds more in red particles. Here  there is evidently a tendency
to a separation of the red particles from the fibrin.  In other cases,
again, the separation is to some extent complete, the red  particles
subsiding, whilst the fibrin rises to the surface, and on coagulating
forms at the top of the clot a layer of  a light yellow or buff'colour,
commonly known by the name of the buffy coat.
   201. It may  be  inferred, then,  that, besides self-coagulation,
(§ 194,)  fibrin possesses a  property of contraction, and  another
 of separation from  the red  particles;  and  these properties are
 presented in  different degrees in  different states of the system,

   (a)  M. Andral's  observations are  confirmatory of the experi-
ments of  Magendie.  Congestions, we learn from the former, fol-
low uniformly a diminution in  the fibrin  of  the blood.  This is
manifested  in a  remarkable  manner in the case of congestion with
 softening of the spleen, which is almost symptomatic of, or, at any
 rate, found almost exclusively in,  the typhoid state. 
 128          WILLIAMS'S PRINCIPLES OF MEDICINE.

 Let us consider these  properties, first separately, afterwards  in
 combination.
   202. Self-coagulation is generally retarded in inflammatory dis-
 eases, and in other cases in which the fibrin is abundant (§ 195);
 its amount is indicated by the firmness and size of the clot.  Other
 circumstances,however,maymake the coagulation slow,as warmth
 and seclusion from the air;  whereas cooling quickly, and expo-
 sure to the air, as when the blood trickles from the vein, or is drawn
 into a shallow vessel, hasten the coagulation.  The addition  of
 some saline matters, such as common salt, carbonate or sulphate  of
 soda, also retards the  coagulation of the blood.
   203. The contraction of the clot evidently depends on the attrac-
 tion of the particles of fibrin  for one  another after the coagulation
 has begun.   By the contraction, the red particles entangled in the
 fibrin are also "drawn together whilst a portion  of the  serum  is
 squeezed out.   The  more slow the  coagulation is, generally the
 greater will be the contraction.   Hence the upper  surface of the
 clot is often formed more quickly, (§ 202,) and is therefore larger
 than that below, whilst  the middle portions of this large upper film
 being drawn downwards by  the contraction of that below, cause
 the concave or cupped appearance in  the clot, so commonly seen
 in  buffed blood  (§ 200).   By drawing  blood  slowly, or in  a
 shallow vessel, the coagulum is speedily formed  in all parts, and
 adhering to the sides  it is not cupped (§ 202).  The  contraction
 and cupping of the clot  being due to  the fibrin, might be expected
 to be in proportion to its quantity; and this is the  case in inflam-
 matory diseases.  But there is  also  great contraction  and often
 cupping in chlorosis and some analogous states, in which the fibrin
 is not absolutely increased ; but the  red particles being  much di-
 minished, the contractile  property of the fibrin  is  not  impeded.
 For a similar reason the contraction is greatest where the quantity
 of fibrin is greatest, and  most completely separated from the red
 particles.   On the other  hand, there is little or no contraction where
 the red particles are in great  abundance, as  in sanguineous  ple-
 thora, (§ 184,) or where the aggregation of the fibrin is  impaired
 by the addition of saline matter (§ 196).
   204. The separation of the fibrin from the red particles, (§ 200,)
 as exhibited in the buffy coat, has attracted much attention, and
 has been ascribed to various causes.   As the fibrin  always rises  to
 the surface, and the red particles sink, it is obvious  that a chief
 cause of the separation is the  greater  weight of the latter, which
 subside entirely  from  the upper layer of fibrin before it  has  time
 to coagulate.   Now, this subsidence will be favoured by three cir-
 cumstances— 1, the tardy coagulation of the fibrin  giving more
 time for the separation ; 2, increased specific gravity of the  red
particles ;  3, diminished spissitude of  the liquor sanguinis.  Now
all these  three conditions may be fulfilled by adding a  little salt
 to healthy blood as it flows from the vein; and this addition really 
ULTIMATE ELEMENTS OF DISEASE.
129
does produce a separation of the fibrin ;  but the fibrin thus rising
to the surface has neither the contraction (§ 203) nor the firmness
of the inflammatory buff, but  is gelatinous, like size, and rather
resembles  the sizy blood sometimes exhibited  in scurvy and
diabetes.  Further : although  blood in inflammation is generally
slow to coagulate, it is not so  always ; and in  extreme cases, as
in acute rheumatism, the buff appears even where the coagulation
is speedy, and accordingto Schroeder Van der Kolk, is seen in
patches and thin films where gravitation would not have promoted
the separation.*  There  must, then, be some other cause for the
formation of the buffy coat besides those above  mentioned.  The
great firmness and contraction of the surface of inflamed blood may
be ascribed  to the  increased proportion  of fibrin, which  is con-
stantly present.
   205. Dr. Alison considers the separation of the fibrillin inflam-
mation to be due to a vital repulsion  between  the fibrin and the
colouring matter.t   Mr. Wharton Jones thinks that the tendency
to separate may be entirely explained by the increased  aggrega-
tion (before noticed, § 190), which he observed in the red particles
of inflammatory blood :  these, by their cohesion, act like a sponge,
contracting and squeezing out the fibrin from  between them be-
fore it coagulates.   (Brit, and For. Med. Rev.,  Oct. 1842, p. 592.)
I do not consider this comparison a just one; for so far as I have
seen, the cohesion of the red corpuscles is not in an entire mass,
but only in  separate piles or rouleaux :  these would facilitate the
separation, not only by contractile aggregation, but also  by sink-
ing through the liquid fibrin more  quickly than separate particles
would ; just as bits of chalk fall to the bottom of water instead of
remaining long suspended, as they would do in fine powder. The
fact that the red particles do aggregate more completely and for a
longer time  in inflamed than in healthy blood, is valuable, because
it furnishes us with a microscopic test of the inflammatory condi-
tion of the blood, applicable, as Mr. W. Jones remarks, to a minute
drop of blood drawn from a prick of the finger.
   The subjoined sections of the different appearances of coagulated
blood may assist the student to understand their  nature and causes.
   206. This presents uniform coagulation with
little  contraction.   If the clot  is  moderately  1
firm, the blood is rich in fibrin and in red par-
ticles, as from persons in robust health.   If the
clot is very soft and uniform, the fibrin is defi-
cient, as in  typhoid fevers,  exhaustion from
exertion, &c.  If the clot is very soft, especially
at the bottom, and the top covered  with a soft sizy film, the coagu-

  * Alison's Outlines of Physiology, p. 89.
  f Dr. Carpenter suggests that increased  attraction of the red particles for each
other, and of the molecules of fibrin for each other, would, more  consistently
with analogy, produce  the same effect.  (Pr. of Human Physiology, p. 430,
Amer Edit.)
 
130
WILLIAMS'S  PRINCIPLES OF MEDICINE.
lation has been slow, as in scurvy and in slight inflammations oc-
curring in typhoid fevers.
                      207.  Uniform coagulation with great con-
                   traction, which  takes  place where the pro-
                   portion of fibrin much predominates over that
                   of the red particles, as  in chlorosis.   The re-
                   lative as well as the absolute quantity of the
                   fibrin is indicated by the firmness of the clot.
                   This appearance, with a buffy surface, is often
exhibited by blood drawn in inflammation  in anasmic subjects or
in advanced stages, and in phthisis.
                      208.  Blood highly buffed  and cupped, as
                   in acute rheumatism and other severe inflam-
                   mations.  The fibrin here presents in a high
                   degree  its properties of separation, coagula-
                   tion, and contraction;  having  almost  aban-
                   doned  the red  particles, which are loose at
                   the bottom of the vessel, and having risen to
the surface, where it appears as a tough, contracted, concave, and
buffy clot.
   209.  To exhibit the true properties of the blood in coagulation,
it should be drawn  by a full stream  into a deep or  globe-shaped
basin or cup, previously warmed, and kept  covered over until the
coagulation is complete.  These  precautions  retard the coagula-
tion, and favour the separation and contraction of the fibrin.  On
the other hand, if the blood merely trickles from the  vein,as when
the orifice is small or the patient faint; or when the receiving ves-
sel is shallow and cold, the  blood congeals at once, and prevents
the appearance of the buffy coat (§ 202).  This is one reason why
blood drawn at one bloodletting often exhibits a different appear-
ance in different vessels.
   210.  We have before noticed that the fibrin of the blood may
be speedily exhausted by violent muscular exertion, and  by serious
impediment to the  respiration  (§196).   These, and the fact that
it exists in larger proportion in arterial than in venous blood,seem
to point out that it is expended in the nourishment of the muscu-
lar and other textures, and  is renewed through the  agency of re-
spiration.  It  might be supposed  that  inflammation increases its
quantity by accelerating the circulation and  respiration without
adequate expenditure;  but  although this maybe a contributing
cause, particularly in acute rheumatism, it is not sufficient, for the
quantity of fibrin is not proportioned to the  frequency of the pulse
or respiration ; it is often much increased  before these  are mate-
rially affected, and  in  idiopathic fevers  it is diminished, although
the breathing and pulse are commonly accelerated. In fact, various
circumstances, to be detailed hereafter, render it probable that the
increase of fibrin during inflammation has its origin in the vessels
of the  inflamed  part.   There is little  doubt that fibrin is elabo-
 
ULTIMATE ELEMENTS OF DISEASE.
131
rated from the albumen of the serum, but whether through the
agency of the red particles, as secreting cells, as supposed by Wag-
ner, Henle, and others, or by that of nucleated corpuscles in the
blood and lining the vessels of textures, is uncertain ; but the former
opinion seems the most probable.
  211.  Fibrin, or the buffy coat of the blood, is also the material
of  which new membranes and cicatrices are formed, constituting
the coagulable lymph, which is the plasma or  basis of  the  con-
structive or reparative process.   But in its capacity for this process
fibrin exhibits some varieties.   The  plasma with which old tex-
tures are nourished, and new ones formed, is euplastic in a healthy
state, having  a capacity of life, and  may become organized in a
high degree, as in  false  membranes  resulting from acute inflam-
mation  in a healthy subject.  But in many instances this capacity
is degraded, and the nutritive material is caco-plastic, susceptible
of only  a  low degree of organization, as in the  indurations result-
ing from  low  or chronic inflammation, fibro-cartilage, cirrhosis,
grey tubercle, &c, or it  is aplastic, not organizable at  all, as in
pus, curdy matter, yellow tubercle, &c.  It is a point of great im-
portance, that the quantity of fibrin in  the blood, and the facility
with which it may  be effused, are  by no  means in proportion to
its plasticity,  or capacity  to become organized ; thus it is abundant
in the blood,  and freely effused  in the inflammations, of scrofulous
or tuberculous subjects, although the products of these inflamma-
tions and of nutrition are commonly caco-plastic or aplastic.   It is
interesting to observe that in these cases also the red particles are
defective in number.
  212.  The rudiments of organization may be seen in the  buffy
coat in the  form of nucleated globules  or  cellgerms, scattered
among  bundles of  minute fibres, crossing each other in various
ways.*   It is  probable  that the globules are  identical with the
colourless or  lymph globules  of the  blood, which are pretty good
representatives of the proportion  of fibrin in the blood.  In the
frog, the white globule in the  blood  and the cellgerm  of lymph
seem identical; but  Mr.  Gulliver observes, that in mammalia the
latter is considerably smaller in size :  it is probably younger.
  213.  The coagulation  of fibrin is promoted  by the contact and
motion  of a rough solid; thus  by stirring fresh-drawn blood with
a stick,  the fibrin adheres in  shreds to the stick.  The same pro-
perty is exhibited within the body in  the deposition of lymph (ve-
getations) on rough surfaces within  the heart  and  great vessels,
and it  is probable  that the fibrinous  concretions  called polypi,
which are found after death in  the heart, are formed on its irregu-
lar  surfaces, as its failing motions cause agitation more than pro-
pulsion of the blood.
  214.  Remedial agents. — Excess of fibrin (§ 195) is less directly
reduced by bloodletting and low diet, than is excess of the red par-

     * Gulliver's Notes to Gerber's General Anatomy, App.  p. 19. 
132           WILLIAMS'S PRINCIPLES OF MEDICINE.

tides ; yet these  are  the chief means of lowering  the quantity of
fibrin in the blood.   It would probably be found that purgatives,
and other remedies which increase much the more solid secretions,
diminish the fibin.  A similar property has been ascribed to  mer-
cury^), to alkaline salts, to iodine, and  to antimony.  1 know of
no positive  facts in support of  this notion ; but it is favoured by
some analogies, and seems well worthy of experimental investi-
gation.   The operation  of salts and alkalies in this way  was pro-
bably suggested by their property of dissolving fibrin out  of the
body.*
  215.  According to  the views of Liebig, subsisting  chiefly  on
saccharine,amylaceous, or gelatinous articles of food, must reduce
the fibrin and albumen of the  blood; and .such food is found  by
experience to be the best in inflammatory diseases, in which excess
of fibrin is a chief element.  Is the reputed efficacy of  the "cure
de raisins,"  in tuberculous disease, connected with the  absence of
protein  compounds in  the food ?    Bodily exercise  reduces  the
fibrin, and  may be advantageously employed with this  view  in
sthenic plethora;  but is  not admissible in inflammatory  diseases.
Neither can we suggest any practicable mode  of lessening the
fibrin by lowering the function  of respiration, on which its supply
seems  to depend, unless narcotics, which  impair  many organic
functions, have some action of  this  kind.   The known  utility of
opium, aconite, &c, in rheumatism and low forms of inflammation,
in which excess of fibrin is a  constant element, makes this matter
deserving of some research.
  216.  Deficiency of fibrin (§ 196) is to be remedied by assisting
those functions on which its supply depends, particularly those

   (a)  In mercurial  stomatitis, it  has been already stated (note,
p. 125), that the proportion of fibrin in the blood is increased ; but
this gives no indication of a similar effect from the protracted use of
mercury, short of ptyalism or  stomatitis.

  * My friend Mr. Blake has  made many experiments of injecting various saline
and other fluids into the veins, and he has furnished me with a summary of their
effects on the  blood, as found after death.
  The blood was found coagulated alter the injection of the following matters ; —
Liquor potassae (firmly); carbonate of potass (firmly) ; nitrate of potass (firmly ;
blood scarlet) ; nitrate of soda; nitrate of ammonia; nitrate of lime; nitrate of
baryta; chloride of calcium ; chloride of barium ; chloride of strontium;  sulphate
of magnesia; sulphate of copper; acetate of lead; arseiule of potass; nitric acid
(strongly); naicotin  (firmly); tobacco; strychnia (moderately) ;  conium; hy-
drocyanic acid ; euphorbiuui ; and water in quantity.
  The blood was not  coagulated, or imperfectly so, after injection of caustic soda,
carbonate of soda, sulphate of soda,  ammonia, nitrate of silver, sulphate of zinc,
sulphate of iron, phosphoric acid, arsenic acid, arsenious acid, oxalic acid, infu-
sion of galls,  of digitalis, alloxan.
  Some  of these results are  different from what might  have been expected ; in-
stance the decided coagulation with potass and its salts, especially nitre, and the
fluidity with nitrate of silver, sulphate uf zinc, infusion of nutoralls, which have
been commonly supposed to possess a coagulating property. 
ULTIMATE ELEMENTS OF DISEASE.
133
of digestion, respiration, and assimilation, and by avoiding its ex-
penditure in too much exercise  and other exhausting processes.
If the digestive organs will bear them, meat, eggs, bread, and other
articles of diet abounding  in  the protein compounds, should be
taken.  The digestive and  assimilative functions may be  assisted
by stimulants, bitters, quinine, and the mineral acids, which, from
their power in  stopping  passive hemorrhage, and in augmenting
the muscular  strength, seem  to  promote the formation of  fibrin
more directly than by their mere operation on the digestive organs.
To improve the function of respiration, besides attempts to remove
or diminish any disease from  which it  may suffer, the free access
of pure  cool  air to the lungs  should be secured.   The injurious
effect of exertion  is exemplified in the relapses which it often in-
duces in continued fever, in which defect of fibrin in the  blood is
a chief element.  Fatigue of every kind, and wakefulness, should
be carefully avoided, and sleep obtained by narcotics, if it do not
come naturally.  In case of deficiency of fibrin from the presence
of a febriferous or putrescent poison in  the system, it is not to be
expected that  fibrinous food, rest, or any other means,can remove
the deficiency, so  long as the poison remains in active operation.
This  poison, by its septic or  analogous influence, interferes with
the vital process by which the fibrin is formed.  But no sooner
does the influence of the  poison subside, as evidenced by improve-
ment in the symptoms, than the quantity of fibrin increases ; and
this sooner than could be explained  by any increase  of nourish-
ment taken.   (Andral and  Gavarret.)
   217.  Very little is known of the power of remedies to  correct
changes in the quality of the fibrin of the blood. The increased pro-
perties of separation (§ 204) and contraction (§ 203) manifested by
blood in inflammation, are  reduced by bloodletting and other anti-
phlogistic remedies, even more constantly than the excessive propor-
tion of fibrin is by the same means;  but they seem to be  soon re-
produced if the inflammation continues.  Thus, although  the last
cup drawn in  bloodletting may exhibit none  of the  buffed and
cupped appearance presented by the first cups, yet blood drawn a
few  hours after often shows as much as any taken before.   Know-
ing that this speedy recurrence of morbid  properties  in the blood
depends on the influence of  the local inflammation, we  see the
necessity of fully using local means, together with those calculated
to operate on  the system.
   218.  Bloodletting and  other general antiphlogistic  remedies, if
they  do not remove local inflammation, may render its products
more injurious by  lowering their plasticity, (§ 211,) and approxi-
mating them to tuberculous  and other aplastic deposits.  Thus
chronic inflammation continuing after the full application of the
antiphlogistic  treatment, almost surely  tends to produce  degene-
rated changes  of structure, over which remedial art has little power.
In connexion with this subject, therefore, we see how desirable it
is that  inflammations should be removed  before they  become
           12 
134          WILLIAMS'S PRINCIPLES OF MEDICINE.

chronic; and when there is a risk of their becoming  so, it should
be an indication to improve the condition of the blood by a tonic
and nutritive plan, at the same time that local antiphlogistic mea-
sures may be necessary for the lingering inflammation.
  219. A similar tonic  treatment is still more indicated in scrofu-
lous, chlorotic, and other  cachectic states in which the fibrin, al-
though less abundant than in inflammation, is yet copious in  pro-
portion to the scanty red  particles  (§ 211).  Hence  the  tendency
to the deposit of imperfect fibrin, even independently of inflamma-
tion ; and besides means calculated to improve the nutrient func-
tions and to raise the character of their product, it may be neces-
sary  to use  remedies likely to  keep  the fibrin dissolved, and  to
prevent its deposit in its  aplastic forms.   Alkalies and iodide  of
potassium have some claims to these properties.
                         SECTION IX.

  ALBUMEN AND OTHER  ANIMAL PRINCIPLES  DISSOLVED IN THE
                           SERUM.

  220. These form a considerable constituent of the blood, amount-
ing on an average to seventy-two per thousand in health.  It is
generally supposed that  the albumen of the serum is chiefly useful
as affording the material from which the plasma (fibrin) is elabo-
rated; but  it is by no means certain that some textures, such as
those less  highly organized, composed  of albumen  and gelatin,
may not  be formed  at once from  the  constituents  of the  serum.
The albumen is further useful in giving to the serum a consistency
favourable  for its circulation, and  for suspending and preserving
the red corpuscles, and  in blandly sheathing  the  acrimony of the
saline constituents.   The quantity of albumen  may be estimated
by the specific gravity  of the serum, which in  healthy subjects
averages at about 1030.
  221. Excess of albumen exists  in most cases of  inflammations
and fevers,  especially during their more active stages.  Its increase
is not, however, in  proportion to that  of the fibrin.  Its relative
proportion  is much increased in epidemic cholera; but this is rather
due to the removal  of the water of the blood.   Albumen  is the
principle least  affected in its  proportions by  disease.   Very poor
living, long continued, extensive  hemorrhages, and other drains
on the system, will pretty surely reduce it in  common with the
other animal principles  of the blood; but good living has less
power in raising it  above the natural standard.
  222. Deficiency of albumen  in  the  blood  is most  remarkably
met with in cases  of albuminuria, or  disease of the  kidney with
coagulable  urine; and this deficiency precedes  the  diminution  of
the red particles, which takes place in  the advanced stages of this 
ULTIMATE ELEMENTS OF DISEASE.
135
disease.  Dr. Bright found in a patient with albuminuria, the spe-
cific gravity of the serum as low as 1013.  (Bright's Report, vol.
i., p. 85.)   Dr. Babington found  the specific gravity of the serum
in a case of diabetes  as low as 1024; in another 1027, although
that of the blood was higher than usual, 1061.   In this case the
serum was  milky.  (Cycl.  of Anat. &c, Art. " Blood.") (a)   In
their later researches, MM. Andral, Gavarret, and Delafond, disco-
vered  a remarkable diminution of the albumen in dropsical sheep
affected with the rot, (a watery state of the blood, with cysticerci
in  the liver.  Sheep  in a cachectic state, with deficiency of red
particles, but without entozoa, were  not dropsical, and in these
the albumen was found undiminished.   It is therefore most pro-
bable  that  the cases of cachexia, or anaemia, attended by dropsy,
owe this concomitant to a defect of albumen  in the blood.  It is
this principle  chiefly that gives  the blood  liquor its spissitude,
which  renders it  more  fit to  pass along the vessels, and pre-
vents it from  transuding through  their walls.  This deficiency of
albumen, therefore, seems  to  be a chief constituent  of the drop-
sical diathesis.
                         SECTION X.

                             OIL.

  223. The oily or fatty matter in the blood sometimes is so much
increased as to give a milky appearance to the serum;  but  it is
not known with what pathological conditions this or  other varia-
tions in the fat of the blood may be connected.  It has  been ob-
served to occur not only in fat subjects.  Hewson  noticed it in the
blood of three plethoric  individuals.   Dr. Babington met with  an
extreme degree of it in a case of advanced diabetes.  This physi-
cian states  that  he has found milky serum of low  specific gravity,
indicating  a defect of albumen ;  and he suggests that the fat might
originate in a change in the albumen.   This would not accord with
the" views of Liebig.  The notion of Haller, that the  milkiness of
serum was caused by an admixture of chyle, does not seem exact;
the whiteness of the latter being due to an infinity of minute mole-
cules described  by Mr. Gulliver.   Under the more probable idea
that milky serum derives its increase of fatty globules from absorp-
tion from fat textures, it should be met with during any rapid di-
minution of bulk of the body.(6)
  (a) Diminution of albumen in the blood, in man, has, M. Andral
assures us (op. cit.), only been met with in  those cases in which
the blood has lost this element by the channel of the kidneys.
  (b) The  presence of fat in the serum indicates not infrequently
an organic change in the chylopoietic system, chiefly in the liver,
as scirrhus of the liver. — (Simon, Chemistry and Microscopy in
their Application to Physiology and Pathology. 
136          WILLIAMS'S PRINCIPLES  OF MEDICINE.

  224. The increase of fat in the textures is probably preceded and
accompanied by its  presence in excess in  the blood;  and the cir-
cumstances which promote obesity must operate through the com-
position of this fluid.  Of these may be mentioned fat, sweet, and
farinaceous food in  excess, without disorder of the  digestive or-
gans ; full living without exercise.  Exercise [bordering on fatigue]
lends especially to reduce the lat of the body, probably by causing
its combustion  in  respiration, whilst muscular textures are in-
creased by the same  influence.
                         SECTION XI.

                       SALINE  MATTER.

   225.  It is not known that the salts of the blood are augmented
in any diseases.   It has  been surmised, that the thirst caused by
taking much salt or saline water is due  to a febrile excitement
which the salt in the blood induces.  But this is by no means cer-
tain ;  for this thirst is not generally attended with increased heat of
skin.  There may be  thirst without fever, although fever is  often
accompanied by thirst.
   226. Diminution of saline matter in the blood has been said, by
Dr. Stevens, to take place in yellow fever and other pestilential dis-
eases, and to cause so dark and grumous a state of the blood, that
exposure to air will not, as usual, render it  florid.   This fact has
Deen more distinctly ascertained by Dr. O'Shaughnessy, with  re-
gard to malignant cholera, in which the defect of saline matter and
water seems to be the immediate cause of the obstructed circulation,
lividity, and collapse, so remarkable in that terrible disease.   Ac-
cordingly, Dr. Mackintosh found the blood extensively coagulated
in the heart and large vessels.  Hence the temporary efficacy of
injection of saline solutions into the  veins of cholera patients; it
seemed  at  once to renew circulation, respiration,  warmth, and
other  functions — life, in fact, to the patient—as if  the  saline
solution were all the  thing needed.  But this defect of serum in
the blood is only an effect of the excessive evacuations from the
stomach and bowels;  and if these go on, the good effect of saline
injections  is soon exhausted.
   227.  The presence  of a certain amount of saline matter  is
essential to the  preservation of the red particles in their natural
size and form,  and  probably, likewise,  to the  liquidity of the
fibrin.   There can be no  doubt, therefore, that, in  the extreme
cases of cholera just mentioned, the blood coagulates in the vessels
for want of saline matter, and the red  particles become dissolved
and altered.   The researches of Andral  scarcely  support the
notion that similar changes  take place in  typhus fever, as sup-
posed by Dr. Stevens.  If saline medicines are useful in common 
ULTIMATE ELEMENTS  OF DISEASE.
137
continued fevers, it  is a question whether  it is in this way, by
supplying what  is defective ;  it  may  rather be by augmenting
deficient secretions (§ 171), and tending to remove or counteract
septic influences present in the system (§ 98, 105).
                         SECTION XII.

                            WATER.

   228. It  is obvious, from what  has  been already noticed, that
 the proportion  of water  in  the blood increases as that of the ani-
 mal contents decreases.  Thus, after extensive hemorrhages, and
 in chlorosis and other cachectic states  attended with anaemia, the
 blood is more watery than usual.   The effect of this state of the
 blood is to cause a  tendency to  dropsical effusions and fluxes,
 besides the' consequences which result from a deficiency of the
 other constituents of the  blood.(a)
   229. I have before suggested a  question (§ 187), whether the
 serious functional disturbance sometimes  following the  ingestion
 of very large quantities of liquids, particularly after exertion, when
 absorption is active, may not in some  degree  arise from the too
 copious and  sudden  addition of wate  rto the blood.  Certainly,
 temporary plethora, with palpitation, feeling of oppression or  dys-
 pnoea, often results from the too free ingurgitation of liquids, and
 is not removed until perspiration, or a  free flow of urine, relieves
 the distended vesels. These symptoms are most distinctly observed
 where some permanent disease of the organs of circulation or re-
 spiration incapacitates them for the increased task. Hence the
 aggravation of the symptoms  of disease  of the heart and lungs,
 by too much drink.  The colliquative sweats in phthisis seem to
 arise from  a similar cause, and may often be relieved by a judi-
 cious reduction in the quantity  of liquid food.
  230.  Deficiency of xoater in the blood is exemplified in epi-
 demic cholera, in which the specific gravity of the serum has been
 found  as  high  as 1045  (Lecanu), which  implies a  reduction of
 nearly half the natural  proportion of water.  Some diminution
 probably takes place in other diseases,attended by profuse watery
 discharges, such as diarrhoea, diabetes, and excessive  sweating.
 In these cases, the  smallness of the pulse, and sometimes  the
 shrunk appearance of the surface from the utidistended state of
 the vessels, are  signs  of  the  diminished bulk of the circulating
fluid ;  and  thirst  pretty constantly points  out the  mode  which
nature prompts to remedy the defect.  In the same way, exposure
to heat, especially if continued,  and prolonged violent  exercise,
  (a) Loss of albumen, more than excess of water, is to be regarded
as the chief immediate cause of dropsical effusions,
             12* 
 13S          WILLIAMS'S PRINCIPLES OF MEDICINE.

 expends the water of the blood, and causes the feeling of thirst
 through which it may be restored.  Long abstinence from liquids
 has a similar effect.
   It has been already mentioned, that the extraordinary decrease
 of  the water of the blood which occurs in malignant cholera ren-
 ders the blood so thick, that it cannot circulate freely, and this
 change is the chief cause of the cessation of the pulse, lividity,
 and other signs of obstructed circulation.  No such effect is known
 to follow from any of the other causes  of deficient water.  The
 operation  of heat and continued exertion is not simple, and there-
fore not referable to this principle only.  Abstinence from liquids
for two or three days induces languor, small and easily accelerated
pulse, a somewhat pasty state of the  mouth, and scantiness and
turbidity of the urine, but little derangement of  other functions.
The digestive process, which  might be expected to suffer, in some
cases at least, shows no symptoms of disorder.
  231. We thus have means of increasing or  reducing the water
of the  blood by increasing or diminishing the liquids drunk; and
these  expedients  may  be usefully employed in the  cases  above
mentioned.   But these expedients in  their extremes  also  furnish
us  with therapeutic agents of more, extensive  power.  Drinking
large  quantities of  water may, in a salutary manner, excite the
whole vascular system and its connected secreting organs, and may
thus wash out of the blood various effete or noxious matters; and
this is  a chief good which the "water-cure"  sometimes effects.
The free use  of liquids is supposed, by Pront, to prevent the for-
mation of lithic acid, or, according to Liebig, it facilitates  its con-
version into  urea.  On the  other hand, a total abstinence from
liquids for two or three days is an effectual mode  of stopping
fluxes, and of relieving catarrhal  inflammations and  congestions.
Either plan exerts an alterative operation on  the circulation and
secretions, which, if more studied, may perhaps be turned to good
account in the treatment of many diseases.
                        SECTION XIII.

           CHANGES  IN  THE  BLOOD BY RESPIRATION.

  232. The process  by  which venous blood  is made arterial, and
rendered fit for its purpose of maintaining the life and functions
of the several parts of the body, is liable to variations; and the re-
sulting differences in the state of the blood form an important ele-
ment of disease.
  The conversion of venous into arterial  blood comprises the ab-
sorption of oxygen, the removal of some carbonic acid, a slight in-
crease of fibrin, and possibly other changes.   Each of these ele-
ments of the process is  probably concerned  in  giving to arterial 
                  ULTIMATE ELEMENTS OF DISEASE.           139

blood  its fitness for its function;  the  absorbed  oxygen, by  its
affinity for the hydrogen and  carbon  of the blood  and textures,
aiding in those processes by which these are renovated in function
as well as in structure and heat is evolved ;  the renewal of fibrin
supplying the expenditure of the plasma, particularly in the mus-
cles; and the removal of the carbonic acid being the excretion of
a noxious matter.
   233. It is doubtful  whether this change is  ever carried on in
 excess; fox by  an admirable adaptation, the activity of respiration
 is proportioned to  the rapidity of the  circulation  and the corre-
sponding need of change in the blood.  Thus  exercise, which ac-
celerates the circulation and changes of the blood, also augments
 the  breathing movements.  In  fevers also, the frequency of the
 pulse  and of respiration is increased ; but the  muscular strength
 being much impaired, it is doubtful  whether  the  rapidity of the
circulation or the real amount of the respiratory changes  is gene-
rally augmented  in  proportion.  It  has been  said, that  in acute
 rheumatism the circulation and respiration are too active  for the
 wants of the system, and that the blood reaches the veins  without
 having  wholly lost  its arterial  character.  If  this were  true, it
 might in some measure explain the great increase of fibrin in the
 blood in this disease;  but the fact is  not well established.*
   234. Defect of the change  in the blood by respiration is a com-
 mon and important element of  disease, and  constitutes  a chief
 feature  of affections  of the  respiratory apparatus.   Being  the
 essence of the special disease asphyxia  or apnoza, its minute con-
 sideration belongs to special pathology, and we shall here only de-
 scribe it in its more  general characters.
   The  amount of  mischief arising from  defective respiration
 varies greatly according to the sudden or the gradual supervention
 of the defect.   An acute attack of the organs  of respiration  may
 prove distressing, and even fatal, by an  impediment to the breath-
 ing, much smaller than that caused by chronic diseases, the gradual
 infringement of  which may be  scarcely perceived.   Thus,  too,
 persons affected with extensive emphysema of the  lungs are habi-

   *It seems to me that Professor Liebig gas given too mechanical a view of the
 change of the blood in respiration.   He appears to consider the increased arterial-
 ization of blood, during exercise and on exposure to cold, to be a necessary con-
 sequence of the greater amount of air inhaled, in one case by accelerated move-
 ments of the chest, in the other by the greater density of the cold air.   But if the
 extent of the changes  wrought by respiration  were in exact proportion to the
 quantity of oxygen received into the lungs, how easy would it be to increase them
 (and thereby animal heat also) by voluntarily augmenting the respiratory move-
 ments.  1 cannot  but think  that the proportion  of oxygen absorbed, and of car-
 bonic acid formed, depends more on the condition of the blood brought to the
 lungs ; and that the respiratory movements are regulated by this.  Thus the in-
 creased oxygenation of the blood is a consequence, not a cause, of greater changes
 previously wrought in  the blood itself.   [Vital  modifications depending on the
 varying functional activity of the nervous system  ought to go for something in
 explaining the change of the blood in respiration.] 
 140          WILLIAMS'S PRINCIPLES OF MEDICINE.

 tuated to an imperfect state of respiration, which is shown  by a
 constant lividity of the lips and cheeks :  such an appearance would
 be a sign of approaching death in  other persons.  The cause  of
 this difference is not merely the general fact that sudden changes
 produce more effect than slow changes, but it lies chiefly in the
 fact that the importance of the  respiratory function varies under
 different circumstances.  When the several parts of the body, espe-
 cially the muscular, are in a state of  full activity, more breath  is
 needed to remove from the blood the noxious  effete matter which
 always results from functional exercise.  Hence  in such a condi-
 tion (which is that of health) the  respiratory process  cannot be
 abridged without serious disorder.  This disorder is first obvious
 in the increasing feelings of oppression and suffocation which the
 want of breath causes, and which excite forced exertions to breathe.
 If these exertions still fail to duly aerate the blood, it is partly ar-
 rested in the lungs, right compartments of the heart and veins, and
 part passes in an imperfectly arterial  state  to  the left side of the
 heart and arteries.
   235.  The phenomena of asphyxia are thus compounded of—  1,
 accumulation of blood in the venous  system; 2, diminution of
 blood in the arterial system; and 3, deficiency of oxygen and ex-
 cess of carbonic acid in the blood.   These several  conditions cause
 injury to the vital functions, both by the want  of  a due supply of
 blood, and by the bad quality of that blood, which is injurious,—
 negatively for want of oxygen, the proper exciting agent,and posi-
 tively from its excess of carbonic acid and  other  excrementitious
 matters which are sedative.   The symptoms induced are also of
 two classes,— 1, those implying failure of  function, such as mus-
 cular debility, feeble action of  the  heart, coldness of the surface
 and extremities, and abolition of the senses and mental faculties ;
 and 2, those arising from congestion and the noxious influence of
 the black blood, such as palpitation, flashes in  the eyes, noises in
 the ears, delirium, muscular spasms, &c.  Each of these sets of
 symptoms may predominate in different cases, and this  causes a
 variety in the phenomena of asphyxia, which  has not been suffi-
 ciently noticed by writers on this subject.
  236. But we have to notice the other mode in which the changes
 by respiration may become defective, that occurring gradually, or
 when the functions are not active.   It is well known that hyper-
 nating animals breathe scarcely  at all, atid yet  they  live ; and
 this is obviously because their functions are reduced to an  ex-
 tremely torpid state.   So, too, animals newly born will  bear  the
 privation of air for  a much longer  period  than those which  are
 older ; and it has been supposed that in adults failure of the heart's
 action by syncope retards the  operation of asphyxiating causes.
 (Dr. Carpenter, on Asphyxia, Library  of Med., vol. 3.)
  237. Although man cannot be reduced to the torpidity of  hy-
 bernation, yet it is  certain that he may be brought to bear a
defect in the respiratory changes, which  would be fatal in a few 
ULTIMATE ELEMENTS OF DISEASE.
141
minutes under  common circumstances.   This is seen when  the
defect is congenital, as in those affected with malformations of
the heart causing cyanosis; and it is also seen where the defect
is  very  gradually induced, as  in the case of emphysema of the
lungs.
  238.  In cases of cyanosis, (the blue disease, in which, from mal-
formation of the heart, some venous blood passes into the arteries,)
we have the opportunity of observing the more essential effects of
defective arterialization  of the  blood.  Individuals thus  affected
are in a lower scale of animation.  The slower processes of nutri-
tion and secretion seem to go on  pretty well, but the  muscular
power is low; slight exertions bring on  symptoms of faintness,
palpitation, suffocation, or insensibility: the animal heat is  lower
than natural, and there is  greater suffering from the  influence of
cold.  In short, all the powers of body and mind are  slender, and
are easily disordered by any circumstances which tax their activity.
In the few that reach mature age, there is no sexual passion, which
seems to be  a happy provision against the chance of perpetuating
a malformed race — human reptiles.  The subjects of cyanosis are
said to  be very liable to hemorrhages, and when these occur spon-
taneously, or from accidental  causes, it is very difficult to stop
them.   This must be ascribed to a defect of fibrin which we have
already found to occur where the  changes of the  blood  by respi-
ration are imperfect (§ 196).  The  same defect occurs  in the foetus.
   239.  In connection with the scantiness of fibrin in the blood,
when the respiratory changes are defective, we must notice the
weakness of the muscles generally, which are probably nourished
by the fibrin.   This weakness is often observed in the subjects of
extensive disease of the lungs, especially emphysema.  In these
same subjects the deposition of fat is, on  the other hand, often ex-
cessive, which agrees very well with Liebig's idea that respiration
directly consumes the oily parts of the blood ; the respiration being
defective, the fat accumulates (§ 224).
   240.  Remedial measures. — Besides the obvious indication of
endeavouring to restore  the respiratory function where it  is  de-
fective, the view which we have taken of the mode in which  the
defect is hurtful, suggests  means by which its injurious effect may
be diminished.  Thus  circumstances which  lower the activity of
the functions often give relief.  Of  these, complete  rest of body
and mind;  warmth to the surface and extremities,  whilst air is
supplied cool and fresh  to the face and air passages ; and various
sedatives, which reduce the circulation and other functions  to a
lower standard, (or, in the language of Laennec, diminish the want
of breath,)  such as digitalis, conium,  hyoscyamus,  &c, are  the
chief.   Other medicines, such as aether, belladonna,  stramonium,
lobelia, &c, which  sometimes  relieve  dyspnoea, probably  act in
another way,  by relieving spasm or  other  impediments  to  the
respiration.
   241.  In extreme cases, bordering on asphyxia, the  enfeebled 
142
WILLIAMS'S PRINCIPLES OF MEDICINE.
circulation may require  stimulants, and  the  engorgement  of  the
venous system may indicate depletion ; in different instances each
of these conditions may most need attention, and sometimes both
must be treated in the same case.
  242. Experience  has not yet furnished us with the means of
arterializing the blood by any other process but that of respiration.
This process may in  some cases be aided  artificially, either by
mechanical means, as inflation of the lungs, electricity applied to
the muscles of respiration, the diaphragm, and abdominal muscles
alternately; and  by bronchotomy; — or by chemical means, the
supply of oxygen or nitrous oxide for respiration.   Whether  the
internal administration or the injection into the veins of saline and
other matters containing much oxygen in loose combination, such
as the chlorates,  nitrates, and some  peroxides, may be made in
any degree to supply the defect of respiration,  is uncertain, but it
deserves more extensive trials than it has received.  If these mat-
ters could furnish oxygen to the blood, they would yet leave  un-
done the other office of  respiration, the removal of carbonic acid.
Might this be accomplished by the administration of free alkalies ?
In some cases of asphyxia by carbonic acid gas, I have thought
that some benefit in the progress towards recovery was  derived
from the use of liquor potassas, with  chlorate of potash.  Perhaps
warm baths containing  these  ingredients might be of some use.
  243. The congested state of most organs which occurs when the
respiratory process is imperfect, renders  necessary remedies suited
to remove this state.  The lungs, the brain, and the liver, suffer
most.  The best  remedies  in these cases are mercurial, and other
medicines which  act freely on  the secretions  (§ 173).  Probably
these remedies act in part  by making the liver assist the lungs in
the office of decarbonizing  the blood.  The speedy relief afforded
to dyspnoea by a  bilious diarrhoea has several times seemed to me
to countenance this notion.
  244.  When from disease the respiratory changes are reduced, it
becomes an object not to increase the hydrocarbon of the blood by
the use of food abounding  in fat or containing spirit, but to make
lean meat and other fibrinous articles, with farinacea and fruit
abounding in vegetable acids, the chief sustenance.
   245.  There is little to be said on the subject of excess of changes
in  the blood by respiration, as it is not certain that such a condi-
tion ever exists as an element of disease.  It has  been supposed
that in most sthenic febrile diseases in which the function of respi-
ration is not impaired, this function  must  be more  active in  pro-
portion to the accelerated  circulation.  Acute rheumatism gives
an  example of this kind, and Dr. Christison  states  that the blood
drawn from a vein is much more florid  than usual.  If this be a
correct  observation, this hyper-arterialization  of the blood may
perhaps account  for the unusual  quantity of fibrin which it  pre-
sents in this disease, I must, however, remark that  I have found
the excess of fibrin in cases in which there  had been no remark- 
ULTIMATE ELEMENTS OF DISEASE.
143
able acceleration of the pulse or respiration.   We shall see  here-
after that the increase of fibrin is connected rather with the local
inflammation than with the fever.
  246. From the experiments of the late Mr. Broughton, it appears
that when animals are confined  in oxygen gas, they in the course
of a few hours die comatose : the respiration first ceases, whilst
the heart continues to beat  with vigour, and  the  blood, even in
the veins, is quite florid: it also presents the  arterial character of
very speedy coagulation.  It appears then, that excess of oxygen
injures first the nervous function (§ 154); but whether  it does so
by  exhausting it by previous excitement, or  by the coagulability
of the blood, or by the excessive  production  of carbonic  acid, is
not decided  by any known  experiment.  The last-named mode is
the most consistent with the related phenomena;  it can scarcely
be  doubted that an increase of oxygen in the  blood must augment
the production of carbonic  acid  ; and that this latter agent may
asphyxiate independently of the exclusion of oxygen, appears from
the experiment of  Rolando  : he found that the air-tube of one lung
of  the land tortoise may be tied  without materially injuring the
animal, but if one lung were  supplied  with carbonic acid gas
whilst the other received  air, the animal died  in a few  hours.
(Carpenter's Human Physiology, p. 396, Amer. edit.)
  247. Liebig  appears to  suppose that the  poisonous  action of
hydrocyanic acid and sulphuretted hydrogen is due to  their ren-
dering the iron of  the red particles of the blood incapable  of ab-
sorbing oxygen from the air, and  becoming thus the  medium of
its  transfer to the blood and tissues: but to this hypothesis it may
be  objected  that  the blood of  an animal poisoned with hydro-
cyanic acid exhibits the usual  changes on  exposure  to the air.
Sulphuretted hydrogen does seem permanently to  injure the com-
position of the  blood, but not the  red particles merely ;  for  it ren-
ders the blood fluid, as well as of a dirty red  colour.   It does not
seem consistent with analogy to exclude the  fibrin and albumen
from a share in the absorption of oxygen, as  well as in furnishing
the material on which that oxygen afterwards acts.
                        SECTION XIV.

            CHANGES IN THE BLOOD BY SECRETION".

   248. Having already noticed this subject under the head of
diseased secretion, (§ 158,) it will be unnecessary to dwell long on
it here.
   The most remarkable instance of change in the blood from dis-
ordered secretion  is  exhibited in  defective secretion of urine
(§ 70, 170).  The extreme effects of this element of disease were
shown in animals in which the kidneys had been extirpated,  in 
144          WILLIAMS'S PRINCIPLES OF MEDICINE.

the experiments first performed by Prevost and Dumas.   On the
third day after the operation, there  came on vomiting, diarrhoea
of a copious brown liquid ; fever with heat varying sometimes as
high as  110°, and sometimes  as low as 92°;  pulse very small and
frequent;  breathing laboured : death ensued from the fifth to the
ninth day.   After death there were found effusion of serum in the
brain, copious mucus in the bronchi, and bilious fluid and faeces in
the intestines.   The liver appeared inflamed (?) and the urinary
bladder much  contracted.   The blood was  more watery than
natural, (§ 222,) and was found to contain  urea : five ounces of
blood of a dog yielded twenty grains of urea ; and two ounces of
cat's blood, ten grains.
   249. The  symptoms induced in defective secretion of urine by
degenerative disease  of the kidneys are very similar to those just
mentioned, but more diversified, from the defect  taking place in
different degrees as to amount  and time.   Thus in acute cases of
albuminuria, or acute aggravations of old ones, there may be low
delirium and other typhoid symptoms passing  into coma (§ 129),
suffocative catarrh, obstinate vomiting, diarrhoea, or inflammatory
effusions in the serous cavities, any of which  may end in death.
In slower cases, cachexia  and dropsy may ensue, the blood and
solid structures becoming altered.  All these effects may be traced
to the urea and other  excrementitious matters being retained in
the blood ; in their greatest amount acting on the nervous system
as a narcotic poison (§ 129); in smaller, acting as an irritant, in-
ducing low inflammations  in various membranes and viscera; and
in still lower degree causing sundry  functional disorders, fluxes,
and  dropsies, impoverishing  the blood, and inducing degeneration
of certain textures (§ 211).   It has been already mentioned that
the blood in albuminuria loses its proper amount of red particles
(§ 185), and of albumen (§ 222), and the diminution of these assists
in accounting for the weakness, dropsy, and degenerations which
commonly ensue in  protracted cases.  The several  results now
enumerated  may be differently presented in differeat cases, and
the treatment should be guided according to them.(a)
   250.  The effects on the  blood of a defective  secretion  of bile
have not been so accurately determined.  The presence  of the
 bile is often obvious in the yellow colour of the serum and fibrin.
 In several cases of fatal jaundice connected with structural  disease
 of the liver, I have observed  extensive ecchymoses on the legs ; and
 I have already stated (§ 171), that in  most of the cases of purpura
 which I have seen, there has been  imperfect action of  the liver,
 and the most effectual treatment was  by medicines which this cir-
 cumstance would  suggest.  The presence of bile in the  blood,
 although sometimes causing tingling, pruritus, and  cutaneous
  (a) Under this head should come the cases of sugar in the blood
of diabetic patients. 
ULTIMATE ELEMENTS OF DISEASE.
145
eruptions, does not appear to produce local irritation and inflam-
mation, or change of the blood and general dropsy, so remarkably
as that of urea does.   Still  it appears from very prolonged cases
of jaundice, in which the dropsy is  not local merely (ascites), but
general (anasarca and  hydrothorax), that the blood at last is im-
poverished, and the whole body becomes cachectic.  Andral found
that in dropsical sheep, with hydatids in the liver, the albumen, as
well as the red particles of the blood, were diminished.
   251.  The perspiratory secretion contains lactic acid and lactates
of soda and ammonia,  which probably proceed from the  transfor-
mation or decay of the textures, particularly the muscular.  . Hence
these products abound during great  muscular exertion ; and when
perspiration  is  checked by external cold (§ 77), they may be re-
tained  in the  blood, causing rheumatism,  urinary disorders, or
various cutaneous diseases.  The very serious effects sometimes
resulting from sudden cold on the perspiring body  may be partly
owing to the  same cause, as well as to the disorder produced in
the circulation.*  Rheumatism is especially liable  to occur as  an
effect of cold, where the body is fatigued with much muscular ex-
ertion (§ 30);  and I have  frequently observed that the rheuma-
tism  chiefly affects  the limbs which have  been most exercised.
Where the skin fails to excrete, an increased task is thrown on the
kidneys, whence may result various diseases of these organs; and
if these organs fail in the task, the lactic acid accumulates  in the
blood, and, probably acting  as a ferment (§ 56), causes the forma-
tion of more, and of the kindred products, lithic acid and its com-
pounds : these, in inflammatory subjects, excite rheumatic fever ;
and in more torpid frames, various local rheumatic or  gouty af-
fections.  All  these cases are frequently remarkable for the acid
character of the cutaneous and renal excretions.t(«)

   (a)  Rheumatism, though  so frequently adduced, in proof and
as an instance of the  morbid effects  of suppressed perspiration, is
far from being the most common or most deleterious of these.  All
the diseases of the respiratory and digestive apparatus, and of the
kidneys, including, more especially albuminuria, also of the uterus
and its appendages,  are  in  no  small  number  referable to  this
cause.  Nor ought  we to look in  acute diseases  for  the  worst
effects of prolonged cold with moisture, that state of the atmosphere
most productive of impeded functions of the skin.   Those of a sub-
acute or chronic character are often derivable from this source.  Of

   * Dr. R. Willis  has recently suggested that checked perspiration may prove
hurtful by rendering the skin dry, and tnerefore  unfavourable for vital changes
supposed to take place in the cutaneous capillaries.  But if this were the only
or chief cause of mischief, it might be always removed by the warm bath, or any
other means of moistening the surface ; so too pernicious effects should always
result from a dry suite of the skin : neither of these consists with facts.
   f In a patient with acute rheumatism, 1 have found the perspiration on the
affected joints more strongly acid than on other parts.
            13 
146          WILLIAMS'S PRINCIPLES OF MEDICINE.

  252. The  remedies for rheumatism, therefore, should not be
merely antiphlogistic, but also  of a kind calculated  to eliminate
the morbid matter from the blood.  In slight cases, sudorifics may
suffice ;  but in others, the kidneys and liver should also be excited

these, the modifications  of scrofula and its degenerations and
transformations of tissue, may be cited as common examples.  The
want of success  in  most chronic diseases, in which destructive
inflammation has not yet taken place, may be ascribed  mainly to
a neglect of the appropriate means, both in  door and out, for re-
storing and preserving equable temperature  and functions of the
skin.
  In the propriety of the following remarks (Brit, and For. Med.
Rev., Oct. 1843,) "we fully coincide : — " We are much inclined to
believe, from evidence which has recently  come before us, that
too much attention cannot be given to promote  the action of the
skin in both the acute and chronic forms of this disease ;  and here
the results of practice and those of theory coincide to a remarkable
extent.   For  we  know that the skin is the  principal channel for
the elimination of lactic acid from the system, and this especially
in the rheumatic diathesis ;  if, therefore, lactic acid be the element
which it is  most desirable to  remove from the blood, a further
increase in the action of the skin would seem to  be the most obvi-
ous  mode of effecting this.  In  so far, therefore, as the hydro-
pathic system of treatment answers this end, we believe that it
will be  found  an  efficacious  method of  treating   rheumatism.
Several  cases have come to  our  knowledge, in which  great benefit.
has been derived  from  it, in the  most  obstinate chronic forms of
the disorder;  and the modification of it, which is employed by Dr.
Freeman at Cheltenham, seems  to us more desirable  than the
original plan  of Preissnitz.   The copious perspiration is induced,
not by wrapping the patient in a wet  sheet  for  five or six hours,
but  by placing him in a stove, heated  up to  160° or 180°.  There
he remains, drinking as much fluid as  he desires, until a copious
perspiration (leaving behind  three or  four  pints  of fluid in the
blanket that closely envelopes  the body, and the oilskin on which
the  patient  lies)  breaks  out; after which the  patient  takes the
cold plunge, a la  Russe, which we understand to produce the most
delightful sensations.  Such a plan would seem admirably calcu-
lated to draw off lactic acid, or any similar offending  substance,
from the blood;  and of its utility we  have had convincing  testi-
mony, particularly as regards the chronic forms of the disease, in
which the structure of the joints is undergoing alteration.   It has
the beneficial effect of not only drawing off the materies morbi,
but of preventing its re-formation, for the plan  seems to operate
most beneficially  upon  the digestive system, improving  the appe-
tite, strengthening the  powers of the  stomach, and correcting the
-secretions." 
ULTIMATE ELEMENTS OF DISEASE.
147
to assist in the process of elimination, and various combinations
of colchicum and alkalies with mercury, opium, and iodide of po-
tassium, will generally effect this purpose very satisfactorily.*
                        SECTION XV.

CHANGES OF  THE  BLOOD  FROM  THE TRANSFORMATION OF  CHYLE
                    AND OF  THE  TEXTURES.

  253. The changes of the blood from the transformation of the
chyle and of the textures, including the processes of nutrition and
reparation, have been examined too little  to supply to the  patho-
logist any distinct data.   Prout, Liebig, and other organic chemists,
have advanced interesting views on these subjects, but they are
too hypothetical to be generally applicable to medicine.  It seems
quite warrantable, however, to  connect with these changes two
remarkable states  of disease, on  the pathology of which chemistry
has thrown much light,gout and other  lit hie acid diseases (§ 176),
and diabetes.
   254.  Gout, and the commonest kind of urinary gravel, are now
generally considered to  depend on the  production in the system of
an excess of lithic acid.  This  acid, being a highly azotised com-
pound, is abundantly generated  in those who take a large propor-
tion of animal food, and  in  whom the digestive and assimilative
processes are impaired.   Hence it is produced by high living and
sedentary habits.   It is one  of  the lower forms of animal matter
into which the higher principles, fibrin, albumen, gelatin, &c.,tend
to pass in their progress towards dissolution.   Hence it is produced
in excess where there is more  azotised matter than is wanted for
the reparation of the textures, or than the vital assimilating powers
can appropriate for this purpose.  But it probably results also from
 the decay of the textures, especially during febrile or inflammatory
 irritation, during  and after which copious deposits  of the  lithates
 are seen in the urine.
   The morbid effects of an excess of lithic acid will vary consider-
 ably, according to its amount and other circumstances.  The kid-
 neys are the proper emunctories by which  it is eliminated from
 the blood, and these sometimes suffer from the irritation which
 it causes;  hence  nephralgia and nephritis  may  occur:  or  the
 water and alkali  secreted with  it in the urine may be  insufficient
 to hold it in solution, and it may be deposited in the form of sand
 or  gravel, or  calculus in the  kidneys or bladder;  and  various
 irritations and obstructions in  the urinary apparatus may be the
 result.
   * The advantages  of this due regard to all the elements of disease in the treat-
 ment of rheumatism, may be shown by the fact, that, with few exceptions, I have
 found that three or four days suffice to remove the fever and pain in the severest
 forms of acute rheumatism. 
 148          WILLIAMS'S PRINCIPLES OF MEDICINE.

   But sometimes the kidneys may fail in their power of elimina-
 tion (§ 170);  the lithic acid and its compounds  then accumulate
 in the blood, and may cause various irritations and functional de-
  ragements, (irregular gout,) until at length some circumstance
 fixes the irritation on a limb, and a fit of regular gout is the con-
 sequence.   In this fit, if perfect, inflammation  is excited, with
 more or less febrile disturbance, which subsides as  a  copious de-
 posit takes place in the urine, showing the removal of the morbid
 matter  (§ 165).   The more  acute and fixed the inflammation and
 the smarter the fever, the more  abundant is  the  deposit, and the
 more free is the patient from disease  afterwards.  On the  other
 hand, when the inflammation is low, changing its place, and with
 little  fever, it generally tarries long, and the system is not relieved.
 It is when gout thus lasts long, or frequently recurs, that  often its
 material so accumulates in the joints as to be  deposited in the form
 of a  plastery  or  calculous  matter, consisting of lithate  of soda
 (chalk stones of gout).  This chronic form of gout is connected
 with  a more or less permanent disorder of the digestive or assimi-
 lative functions, which renders its treatment more difficult or less
 successful than that of the  more acute forms of gout.  In such
 cases (chronic), lithic acid seems to be engendered in great abun-
 dance, being often thrown off" in large quantities  in the urine for
 an indefinite period, yet never leaving the body free.  Such cases
 are commonly either hereditary or those which  have been  ren-
 dered inveterate  by  intemperate habits, or neglect  of  proper
 treatment.
   255.  In saccharine diabetes, the morbid matter is of a nature
 quite  contrasted with that of gout and gravel, being sugar, which
 is wholly unazolised ; yet it is probably also produced in con-
 nexion  with the processes of assimilation and nutrition—the con-
 dition of the urine being  only a  consequence of disorder in these
 processes.  The  analyses of Ambrosiani,  Maitland,  and  others,
 have proved the existence of sugar in the blood of diabetic patients;
 and Macgregor has also established the fact of its  unusual produc-
 tion during the process of digestion.  The appearance  of sugar in
 the urine can scarcely be  considered otherwise than as a result of
 its presence in the  blood.   But whether it is formed only from
 isomeric principles in the food, such as starch and gum, or is also
 derived from a decay of the  textures by a modification of the pro-
 cess in  which  urea is  naturally evolved, or  is elaborated out of
 various principles both in the food and in the blood, is not clearly
 ascertained.   As  there  is saccharine matter naturally  in chyle, it
 might be supposed that there is, in diabetes, an  exaggeration of
 the process by which  this is formed; and  that the atrophy  and
 cachexia accompanying the disease result from the draining away
 of the nourishment of the body with  the excess of sugar, rather
 than the conversion of all this nourishment into sugar.  It is now
 well ascertained that the ordinary animal constituents of the urine
are not  only present, but are even increased considerably beyond
their natural amount. 
ULTIMATE ELEMENTS OF DISEASE.
149
  256. There is a resemblance in the indications  of  treatment in
gout and in diabetes, although in the fulfilment  of these indica-
tions the means to be employed are most opposite.  In both cases,
we must withhold those articles of diet from which the morbific
matter is most readily generated.   Thus abstinence from animal
food and stimulating condiments and  beverages, in the case of
gout — the exclusive of these very articles,  to the  avoidance of
all saccharine or farinaceous substances in the case of diabetes —
constitute a successful part of the treatment.  In both cases, it is
indicated to improve those processes of  digestion and assimilation,
from a perversion of which the morbid matter is probably gener-
ated.   But, unfortunately, we know  too  little of these processes,
and of means which  may influence them, to enable us to fulfil
this indication  with effect.   A  gouty constitution, in the absence
of the febrile  paroxysm, is often much improved by the use of
bitters and other mild tonics; and in  diabetes,  an  amendment
occasionally takes place during the exhibition of opium and some
of the stronger astringents and tonics, such as preparations of iron,
copper, &c.
  In the effect which each exerts on the economy, there is a great
difference between the morbid matter of gout and that of diabetes.
The sugar in  the latter has no tendency to accumulate  in  the
system and produce  local  effects ; but, acting as  a powerful diu-
retic, it passes  rapidly away, carrying  with  it a great quantity of
water and of the other constituents of ordinary urine  (§ 165) ;
and the  thirst, dry skin, and emaciation of  diabetes, seem to be
chiefly due to this mode of operation.   The common complication
of diabetes  with pulmonary consumption shows also, however,
that the plastic process is degraded (211).
  The lithic acid of gout and gravel, on the other hand, has a
tendency to accumulate in  the body,  and to cause  the local and
general irritations which have been already mentioned (§ 254).
Hence it becomes a  chief indication to counteract its irritating
properties, and to promote its elimination from the system.   The
medicines which are most efficacious in doing this are alkalies, or
their carbonates, or their vegetable salts, with colchicum, or iodide
of  potassium,  saline mineral  waters, and  alterative aperients.
These increase the action of the kidneys and intestinal canal, and
drain off the offending matter from the system.
  257. It is supposed by most chemists, that the urea excreted by
the kidneys is chiefly derived from the  transformation or decay of
the textures of the  body  (§ 254),  most  of their carbonaceous
matter  being  abstracted  by  the affinity of the  oxygen of  the
blood, and  carried off by  the  lungs in the form of  carbonic acid
gas (§ 232).   The  causes which increase the production of urea
are, according  to Liebig, those which  excite the activity of the
function  of respiration, which supplies the consuming oxygen,
especially active bodily exercise. Under some circumstances, how-
ever, the formation and excretion of  urea  is much augmented,
            13* 
150          WILLIAMS'S PRINCIPLES OF  MEDICINE.

without any  obvious  excitement  of  the  respiratory  function.
This is the case in the diabetes ureosus  described by Dr. Prout,
and which he considers a forerunner of saccharine diabetes. Such
spontaneous production of the matter, which seems  to be a kind
of debris  of the body, indicates organic weakness, and has been
observed to occur in young persons who have grown rapidly, and
in those weakened  by venereal excesses.  An excessive excretion
of urea (or of carbonate of ammonia, which is of kindred com-
position), sometimes takes place in typhoid fevers, and is attended
with great loss of flesh and  strength.  A great and sudden in-
crease of urea in the urine was ascertained to  have taken place,
in some patients, with  acute  rheumatism, in University College
Hospital, at the decline of the  fever and  other symptoms.   This
perhaps ought to be viewed as arising  from the removal of that
which had accumulated rather than from  an increased formation
of urea; and this  fact may be connected with that  ascertained
by Professor Chelius and Dr. Lewins, that  colchicum causes  an
augmented discharge of this and other  principles of the urine
(§ 252, 173).
  In cases of excessive formation of urea,  all circumstances which
depress or exhaust  the organic life must  be avoided, such  as great
excitement of body or mind ;  waste must be supplied by a gene-
rous diet, and the nutritive functions sustained by tonics.   Opium
and other  narcotics are found  to be  useful in reducing the urine
in the diabetes ureosus ; and it is not improbable that their opera-
tion is directly on the vital part of the process of transformation of
the textures, as  much as on the respiration.   [As in rheumatism
so in gout, the skin requires all our care.]
                       SECTION XVI.

CHANGED  PROPERTIES  OF THE BLOOD  FROM THE  PRESENCE OF
                      FOREIGN MATTERS.

  258. The blood is probably the chief seat of the morbid poisons
which excite various contagious (§ 93), epidemic (§ 88), and en-
demic diseases (§ 81).  Probably, too, it is the  hotbed in  which
some of them are propagated (§ 99);  and it is through changes in
its composition that many of the destructive  effects of these  poi-
sons are produced (§ 186, 196).  We have  already noticed some
of these changes under former heads.  It will suffice in this place
to mention a few examples in which morbid poisons have been
traced to the blood.
  Dr. Francis Home communicated measles from  one  person  to
another by inoculating with  the blood of a patient affected with
the  disease.  M. Gendrin describes the following experiment; —
A man who had been skinning a diseased animal was seized with 
ULTIMATE ELEMENTS OF DISEASE.
151
a putrid fever, attended with an eruption of sloughing pustules.
Some blood taken from this man was injected into the cellular tex-
ture of the  groin of a cat;  the animal was soon  affected with
vomiting  ofbile, dyspnoea, frequent  small and irregular pulse,
dry brown tongue, slight convulsions, and  died seven hours after
the injection.   The same pathologist produced in animals various
severe symptoms, speedily ending in death, by injecting into their
veins blood from a  person  labouring  under confluent  small-pox.
MM.  Dupuy and Leuret communicated to  a  healthy horse  the
malignant pustular disease called " charbon," by injecting into its
veins blood from a diseased animal.  Andral quotes from Duhamel
an extraordinary  case, in which blistering, pustules, malignant
fever, and death, followed  the mere contact on the lips of the dis-
eased blood of an animal.  Other instances are on record of sick-
ness, faintness, and serious illness  being caused by the odour of
 blood; and Dr. Copland tells a marvellous story of three persons
 being struck dead by the smell of the blood in the plague.
   259. There is good reason  to suppose that purulent matter, and
 the germs (§ 90) of carcinoma, and other forms of malignant dis-
ease, are spread through the system through the  medium of the
blood.   The  tendency to symmetrical arrangement which cuta-
 neous eruptions, nosodities of the joints, paralysis from lead, and
 some other  local affections exhibit,  has been adduced, by Dr. W.
 Budd and others, as an instance  of effects produced through the
 medium  of the blood—the  symmetrical distribution of this  fluid
 on the opposite halves of the body  leading  to like results in corre-
 sponding parts.
    260. In the treatment of  this element of disease, foreign  mor-
 bific matters in the blood, the two indications which present them-
 selves are — 1. To counteract the injurious operation of these  mat-
 ters ; and,  2. To expel them from  the system.   The first of these
 indications is followed, when  we give stimulants to overcome
 the depressing influence of  adynamic fevers and  other sedative
 poisons; and  when  opium  and  other narcotics are administered
 where irritation prevails.  We do not possess chemical antidotes
 which can act on the matter in the blood without injuring the blood
 itself.  The other  indication is more  generally pursued, although
 little recognised bv practitioners, — to expel the offending matter
 from the system. " The excretory  organs,  especially  the  kidneys
 and alimentary canal, are the natural emunctories through which
 foreign and offending matters are  expelled from the  blood ; and
 hence the utility of alterative aperients and diuretics (§ 173,  174),
 in the treatment of fever and other diseases connected with poison
 or injurious matter in the  blood.   Orfila found that the pernicious
 effects of small doses of arsenic in animals might be averted by
 aiving at the same time a  diuretic  medicine.  Let us bear in  mind
 how often fevers and other serious  ailments seem to be carried off
 by spontaneous diarrhoea, diuresis, or perspiration ; and, perhaps,
 sometimes by these discharges artificially  excited.   Nor should a 
152          WILLIAMS'S PRINCIPLES OF MEDICINE.

converse fact be overlooked, that persons affected with disease of
the kidney, (cacoplastic degeneration,) which impairs its excernent
function, are  peculiarly liable to contract infectious diseases, and
to suffer from their effects (§ 17, 26, 32). (a)
                      CHAPTER III.

SECONDARY OR PROXIMATE ELEMENTS OF DISEASE, CONSISTING  OF
          TWO OR MORE PRIMARY ELEMENTS (§ 304).
                         SECTION I.

                          ANiEMIA.

  261. The class of proximate elements which  have been  most
generally studied as the subjects of  general  pathology, are those
affecting the  circulation of  the blood.   They comprise  at  least
three of the primary elements which have been considered — the
blood and its constituents, and the moving and tonic fibre, (§ 110,
120,) concerned in  its distribution.   A previous acquaintance with
these elements will render very intelligible many of the kinds and
phenomena of their compounds, but it is necessary to keep in view
also the physical properties of the vessels and their contents; for
these properties, when altered, become elements of disease.  Thus
a mechanical obstruction or an enlargement of a bloodvessel con-
tributes to  the formation of disease as much as a change of vital
properties.  So it  is  impossible to  understand  the effects of too
much or too little  blood in the vessels, without  a  due considera-
tion of the  mechanical qualities of these vessels.
  We shall briefly consider the morbid conditions connected with
defect and  excess of blood  in the vessels, under the divisions of
general and partial, and as attended with an increase ox diminu-
tion of the irritability and tone of the moving fibre.  It is to be
understood that  all the proximate elements of disease now to be
considered may  occur either as distinct affections or in combination
with other maladies.
  262. Anaemia, or as it has been  more correctly termed, hypse-
mia, or oligaemia, is the name applied  to that condition  of the
system in which the predominant character is a deficiency of blood.
It is often  symptomatic of various maladies, particularly chronic
and cachectic affections; but it sometimes occurs without any

   (a) The action  set  up in the depurating organs, after the intro-
duction of  a poison or any strong irritant into the system, consti-
tute a curious and instructive study. 
              PROXIMATE ELEMENTS OF DISEASE.            153

 other known disease, and its  symptoms exemplify in  a striking
 manner the mode in which  the various functions suffer for want
 of a due supply of the vivifying fluid (§ 183, 185).
   Thus the general symptoms of  anaemia are those of weakness
 (§116); general muscular  weakness, evinced by the faintness,
 breathlessness, and fatigue caused by exercise;  weakness of the
 heart, shown by the feeble, loose, or thready pulse,rendered very
 frequent and palpitating by slight exertion, and often irregular and
 failing afterwards; feebleness of the  whole circulation (§ 123),
 manifest in the  coldness of the extremities; organic weakness,
 shown by the loss of appetite, indigestion, torpor of the bowels,
 scanty and disordered secretions (§ 172); defective nutrition (§211),
 especially of the muscular parts;  and imperfect sanguification, for
 the remaining blood becomes diseased, being poor and  watery, as
 well as scanty (§ 185, 222).
   263. There are also distinctive  physical  signs of the scantiness
 of blood in the body ; the surface  is remarkably pallid, and even
 the lips, gums, and tongue, show  none of their healthy  ruddiness.
 The complexion may vary the amount and kind of the paleness,
 dark persons often appearing very sallow, or even of a yellowish
 or greenish tint, (whence the term  chlorosis,) and those of fair
 complexion having a ghostly paleness.   If bloodvessels are seen
 at all, it is only the larger superficial veins, which are pink instead
 of blue, from the paucity and  transparency of the blood in  them.
 In the course  of the larger  veins, especially the jugulars in  the
 neck, the thin blood, running  with great rapidity in the ill-filled
 vessels, is often thrown into  sonorous vibrations, (venous mur-
 murs,) w,hich are sometimes sensible to the finger  placed lightly
 on the vein.  The same  thinness of the  blood, together with an
 abruptness in the heart's contractions (§  113), frequently causes a
 murmur with the first sound of the heart, referable  to the aortic
 orifice : as, however, this murmur varies much in different cases,
 being scarcely audible in some, whilst it is loud and harsh in others,
 it is obviously dependent in part on some irregularity or narrow-
ing at the mouth of the aorta, too trifling to give any obstruction
or sound when the blood is abundant and of due spissitude, but
readily causing vibrations and sonorous gushes when the fluid is
thin and the relations between the size of the heart and  arteries
somewhat changed.(a)
  264. The  blood,  when drawn,  is very  thin  and  watery.   It
  (a) The bellows-sound of the heart and  arteries, in anaemia of
any intensity, is, we are told by M. Andral, a distinct evidence of
the loss of red globules in the blood.  It is not met with in cases
in which the fibrin alone is diminished, as in scurvy, unless when
this disease has made such progress that the  globules finally lose
their  proper proportion.  Nor is the sound heard, when the  im-
poverishment of the blood has proceeded from a loss of the albu-
men of the serum. 
154           WILLIAMS'S PRINCIPLES OF MEDICINE.

readily coagulates, and forms a very small contracted clot (§ 207),
generally covered with a buffy coat.  This appearance is probably
due, as Andral surmises, to a predominance of the fibrin over the
red particles, for these are diminished much more than the fibrin,
being in  extreme cases nearly reduced to one-fifth of their natural
proportion (§ 185).  The albumen is also often scantier than usual;
but from the researches of Andral and Delafond on sheep, it is
probable that it is not so in all cases, but chiefly in those attended
with dropsy (§ 222).
   265. Although the symptoms of anaemia  are chiefly those  of
great weakness or depression (§ 262), there are often others of an
opposite character, indicating irritation  or  exaltation of function.
Some of these  arise indirectly from the weakness, as for example
pain, nausea, colic, and diarrhoea (§ 56, 168, &c), which maybe
traced to the weak digestion leading to  the production of sundry
irritating matters from that which has been used for nourishment.
But other more direct signs of excitement sometimes occur.  Thus
various properties of the nervous system are sometimes exalted ;
sensibility is acute (§ 126); there is intolerance of light and sound,
with flashes in the eyes, noise in the ears, a sense of rushing in the
head, and various neuralgic pains.  The excitomotory nerves are
sometimes excited (§ 140, 150), and spasms  or  convulsive affec-
tions of  different kinds may be  present, or the  organic functions
may  be  affected, and  palpitation, spasmodic asthma,  vomiting,
and such sympathetic irritations, may occur.   In a  few instances,
anosmia  has been attended with delirium, or mental excitement
bordering on it.
   266.  It thus appears  that the functions which sometimes are ex-
cited in  the midst of  general  depression and weakness, are  those
of the nervous centres, and  the generally nervous character  of
persons  in a state of great weakness (§  113) is connected with the
same fact.  No explanation of this apparent anomaly has been  to
my knowledge proposed;  but  one seems  to  suggest  itself in the
peculiar distribution of  the circulation through the nervous centres.
When the mass of the blood is reduced in  quantity, the bloodves-
sels generally contract  in proportion, their tonicity adapting  them
to the amount of their  contents  (§ 120).   But the  vessels within
the skull and spinal  canal cannot contract with  the same facility,
for not being exposed to  atmospheric pressure, and  some of them
being fixed in  bony canals, they do not shrink  as  the  blood  be-
comes reduced, and therefore they retain  more  than their proper
share of the circulating fluid.*  This disproportionate amount of
blood in the nervous centres produces  different effects, according

   * This statement is not invalidated by the recent experiments of Dr. G. Bur-
rows.  (Med. Gaz., April, 1843.)  His experiments and expositions very satis-
 factorily demonstrate the absurdity of the notions, founded  on Dr. Kellie's paper,
 that the quantity of blood in the head is always the same ; but it remains clear
 that the circulation within the head and spinal canal, especially in man, is affect-
 ed by losses of blood, differently from the circulation in other parts. 
PROXIMATE ELEMENTS OF  DISEASE.
155
to the degree in which the heart's propulsive power (§111) reaches
it.  Under the influence of palpitation (§ 112), fever, or other kind
of excitement, the brain and spinal cord  receive through their un-
contracted vessels an unusual share of the force from the heart;
an erethism of some one or other of the functions of these nervous
centres (§ 127, 153, 133) is  the consequence:  and pain, spasm,
sensorial disturbance, or  sympathetic irritations of some kind  or
another, occur.*
   267.  On the other hand, if the  heart's action is feeble (§ 116),
it may be inadequate  to propel  the  blood accumulated in the
vessels of the brain ; it  therefore stagnates, and may cause some
of the  symptoms of congestion in that  organ.   Hence headache
and giddiness, relieved by  the recumbent posture,  drowsiness,
impaired mental faculties, partial paralysis, and, in extreme  cases,
coma or  catalepsy (§ 129, 133,  141).  In  such  cases  the blood is
accumulated  more in the veins and sinuses of the  brain than in  its
arteries, and is not  moved  in  proportion to its  quantity.  This
congestion may be only temporary, and lead to no serious results ;
but  in some cases I believe there occurs an event that has not been
noticed  by pathologists—namely, a coagulation of blood  in  the
sinuses, and a consequent permanent obstruction to the passage of
the blood through the brain.   I have met  with at least three cases
 of the following description.
   A young female becomes anaemic, and  after  exhibiting various
 symptoms of feeble general circulation, with headache, drowsiness,
 and impaired sensorial functions, suddenly becomes worse:  passes
 into a state  of  stupor, with dilated pupils, sometimes varied  by
 slight manifestations of delirium, throbbing of the carotids, and
partial heat of the head, and dies comatose.  On opening the head,
a small quantity of serum is found under the arachnoid and in the
 ventricles, sometimes with a  little lymph (in one case there was
 none).  The vascularity of the membranes is remarkable, but  the
 vessels most  distended are the veins, and in the  larger of these and
in the longitudinal  sinus, there  is a firm coagulum.   In parts, es-
 pecially at the torcular Herophili, this coagulum blocks the  whole
 sinus, and exhibits a separation of fibrin, portions of  which  are
softened down into that purilaginous  matter which was long mis-
 taken for pus, but which Mr. Gulliver has shown to be a physical

   * Although the chief effect of excitement of the circulation in anaemia is thus
 directed to The nervous centres, it is by no means confined to them.   Other parts
 in the immediate vicinity of the heart become  the seat of increased arterial pulsa-
 tion  and disturbance.  Thus a painful throbbing  is often complained of in the
 throat, chest, and epigastrium, even when there  is little pulse in distant arteries,
 and  the extremities are cold.   To understand  these facts, we must bear in mind
 that when the arteries are full and  tense, they  oppose their fulness and tension to
 each contraction of the heart, which resistance reduces the strength of each pulse
 in the vicinity of the heart, although it contributes to propagate it to a distance;
 but when the arteries are empty and loose, the heart squirts into them the blood
 in an unresisted jet, the force of which is strong near the heart, but extends not
 to distant arteries. 
156
WILLIAMS'S PRINCIPLES OF MEDICINE.
 change of the fibrin which mere stagnation may effect.  These
 have been taken for cases of meningitis.  No doubt inflammation
 does supervene in them occasionally, but in two cases that have
 fallen under my notice, there was no adhesion of the  arachnoid
 nor deposit upon  it, nor any other unequivocal mark  of inflam-
 matory action; yet the fibrinous and  bloody concretions in the
 veins and sinuses were  most remarkable for  their size and firm-
 ness* (§ 213).
   It appears to me most probable that these affections originate
 in the encephalic  congestion connected with anaemia.   Fibrinous
 concretions form on the transverse  bands of the  sinuses, and in-
 crease until they considerably obstruct the passage of  the blood  :
 hence the impaired state of the  cerebral functions, amounting at
 last to coma.   Reaction (§  16) may take place, with determination
 of blood, and even inflammation, and these cause those symptoms
 of partial excitement that sometimes exhibit themselves; but nei-
 ther during life, nor on  examination after death, are the proofs of
 excitement so prominent as those of obstruction and interruption
 to the cerebral functions.  It must be remembered that in anaemia
 the fibrin of  the  blood  is not diminished in the proportion of the
 other animal contents, and  it has a greater  tendency to coagulate
 than in healthy blood (§ 207).
  26S.  In anaemia of long duration the process of nutrition often
 suffers  (§ 211), but by  no means  uniformly.  The cornea some-
 times becomes ulcerated; probably because, being a non-vascular
 texture, it  the more needs a nourishing  quality  of the plasma.
 The muscles become flabby and attenuated ; wounds and fractures
 sometimes do not readily unite ;  and in some instances spreading
 ulcers and sloughy sores form spontaneously on the surface.  Ema-
 ciation is by  no means a constant result of anaemia ; and it is not
 uncommon to see the most pallid subjects, especially females, re-
 tain a considerable amount of fat.   Dropsical effusion into the cel-
 lular texture is a common result of anasmia when either long con-
 tinued,  or  aggravated  by  additional causes  which disturb the
 circulation  (§ 222).
  269. The exciting causes of anaemia are, various circumstances
 which withdraw blood (§ 71), or interfere with its formation (§ 66) ;
 excessive bleedings, or hemorrhages ; profuse evacuations of other
 fluids which contain much of the animal parts of the blood ; scanty
 or poor food, especially that which  contains little  animal matter
 or gluten; confinement  in impure air, dark places, or  malarious
 districts; certain  chronic maladies which  deeply affect the consti-
 tution, such as tuberculous and  cancerous diseases, and granular
 degeneration of the kidneys (§ 185, 222, 249); but the common-

  * A wax model of the sinuses and membranes  in one of these cases is in the
museum at the University College. Cruveilhier gives a representation of a simi-
lar case, which, without sufficient reason, he considers as one of cerebral phlebitis.
 Andral mentions a case of cerebral hemorrhage in connexion with anaemia, which
 was probably of the same kind. 
PROXIMATE ELEMENTS OF DISEASE.
157
est cause of all is irregularity of the uterine function.   It is diffi-
cult to understand how the last operates; but that in many cases
it is a cause and not  an effect of anaemia, is plain from the well
known fact that no signs of anaemia have occurred until cold, over-
exertion,or excitement,or some circumstance,has suddenly checked
the flow of the catamenia ; it has not returned, and then the patient
begins to lose colour, and gradually to exhibit the anasmic state.
In many cases I have known this  occur in young females who
have  previously suffered from acute  rheumatism, implicating the
heart.  It would seem that  in these cases some injury is done to
the bloodmaking process;  but what, or where, must remain  ob-
scure until we  know something more about  the seat and nature of
that process.   In some of these cases of chlorosis, the appetite is
depraved (§ 131); there is  such  a complete disrelish for animal
food and other nourishing  articles, and  such a craving for  sour
things, and even for matters destitute  of nourishment, as chalk,
cinders, &c, that it might be supposed that this perverted appetite
is the cause of the anaemia  by deterring the patient from  taking
that food which is capable of making red blood ; and undoubtedly
such an appetite, when indulged,  must, contribute to this  result;
but it is not so constantly present as to be considered the only cause
of the anaemia in the examples under consideration.
  270. Anaemia, in  its extreme  degrees, may prove  fatal  sud-
denly by syncope (§ 71), brought on  by exertion or any additional
cause of exhaustion ; or  more gradually, by asthenia, or general
failure of the vital powers, often  attended with anasarca ; or by
developing  tuberculous  (§211)  or  other   cachectic diseases to
which the individual  may  be predisposed; or by  the singular
affection of the head before noticed (§ 267).(a)

  (a) Dr. Channing (New Eng. Quart. Med. and Surg. Journ.,~No.
4, and Bullet. Med. Science,^™.  1843) has  described anaemia in
its connections with the puerperal state.  Thus appearing,  it has,
within his  observation, always been fatal.   A striking symptom,
which occurred in all  the cases, was  a bright pink colour  of the
veins.  Examination  after  death showed  the  textures pale and
some  of them dry : the blood was small in  quantity, pale,  liquid,
uncoagulated ;  but no organic change of any moment was percep-
tible.  The  loss of blood in some of the fatal cases was not unusual,
and in one instance the patient lived eighteen  days after  labour
without,in this period, havingauy flooding; her food was abundant,
and well digested, and stimuli in  large quantities were well  sup-
ported.
  Some solution of the problem, which proved so puzzling to the
gentlemen  who had charge  of these cases, may be found  in the
fact stated by Andral, that pre-nancv is attended by a loss  of the
red particles equivalent to that which is met with in  the  milder
cases of anaemia.  In subjects thus predisposed it is easy to  under-
stand  how  slight additional causes, such as the loss even of a com-
           14 
158          WILLIAMS'S PRINCIPLES OF MEDICINE.

  271. Remedial measures. — Most of the measures useful  for
the treatment  of aiiEemia  have  been already described as those
suitable to restore  a deficiency of red particles and fibro-albumen
(§ 193, 216).  A nourishing diet, with as much animal food as  the
digestive powers of the patient  can  master — tonics that best re-
store the appetite,  the powers of digestion, and  sanguification —
the use of means,  if necessary, to promote the natural excretions,
(§ 172,e/ seq.) and an exposure  of the patient to the pure  air and
light of heaven, as free as the strength and sensibility will bear —
form the chief items of the treatment.
   The adaptation of this treatment to particular cases will  require
much discretion, especially in proportioning the food to the faculty
of digestion, and in selecting a tonic that shall not irritate.   Where
it does not disagree, iron, in some of its forms, is unquestionably
the best tonic ; and in many  comparative trials, I have found  the
iodide of iron (in solution with syrup) the most  speedily efficacious.
Besides its tonic action, it promotes the secretions more than other
preparations of iron ; and by its use I have seen females restored
from  extreme pallidity to  a rosy hue of health, in  less than three
weeks.   The sesquioxyde, citrate, tartrate, and ammonio-chloride,
are more tardy in  their operation ;  and  the sulphate and sesqui-
chloride are apt  to nauseate, or otherwise disagree ; but  each is
found  occasionally useful, and so are chalybeate  mineral  waters.
In  some cases, any preparation of  iron  causes headache, fever,
sickness, or  some  other  symptoms  of disorder ; and then  milder
tonics, as calumbo or other bitters, with mineral  acids, or with
iodide of potassium, are more suitable at first; and  the stronger
tonics, with iron, may be given  afterwards.  In extreme cases, as
those after excessive losses of blood, I  have found it very useful
to give sulphate of quinine at the same time as the iodide, or some
preparation  of iron.
   The success of  the treatment becomes manifest,  not only in
the return of a  healthy colour  to the  lips and skin, size  to  the
superficial vessels, and strength to  the pulse, but also by an  im-
provement  in all  the functions, breath,  strength digestion,  &c.
It  is a curious fact, that the venous murmurs (§ 263), although
diminished, are  not so in proportion to the apparent return to
health.
   272.  Besides these general measures, indicated for  all varieties
of anaemia, particular cases  require temporary measures, on the
one hand,  to prevent faintness or  excess of weakness (§ 262);
on the  other, to subdue  nervous excitement (§ 265), and coun-
teract the congestion in the  head, which  we have found to occur
(§ 267).  Diffusible stimulants, such as  carbonate of ammonia,
 valerian, aether, wine, and spirits, are often useful  as temporary

 mou  quantity of blood in parturition, added to any depressing in-
 fluence acting on  the nervous system, will readily excite alarming
 and even incurable anaemia. 
PROXIMATE ELEMENTS OF DISEASE.
159
means of obviating the extreme weakness.  Nervous symptoms
may be treated by various narcotics, such as hyoscyamus,conium,
opium,  &c.   But, inasmuch  as these  very  symptoms  seem  to
depend  on the irregular distribution of the little blood left in the
body, they will be the most effectually relieved by reducing this
irregularity, by warmth and  friction  to the  surface and extremi-
ties, rest in  the  horizontal posture, varied with such gentle exer-
cise as the patient can bear, with  pure  air, and the judicious  use
of tepid or  cold  sponging, or shower-bath (§ 124).   The symp-
toms of decided cerebral congestion  and obstruction  have gener-
ally been treated by antiphlogistic remedies,  but with unquestion-
able advantage.  I should  expect more benefit from a mild stimu-
lant plan, together with derivants, purgatives, and diuretics. Such
a plan commonly answers  best in the congestive headache, which
often troubles anaemic subjects.


                       PARTIAL ANJEMIA.

   273.  We  have the means of studying defect of blood in a part
of  the body in  more diversified degrees than defect in the whole ;
and the result we find to be an impaired state of the functions in
every degree, from that of mere weakness to that of total suspen-
sion and death.   Thus  temporary pressure on the chief artery of
a limb soon causes numbness, weakness, and reduction of tempe-
rature.    The same effects result in  a  more marked degree  from
the ligature of an artery in cases of aneurism, and are gradually
removed as the supply of blood is restored through collateral arte-
ries.   In some such cases, the supply of blood is insufficient to
maintain the vital properties of the part;  then chemical affinities
prevail, (§ 50,) decomposition ensues, and the part becomes gan-
grenous, and dies.  A similar result ensues when the arteries of a
limb become obstructed  by ossification  and coagulation, as in
senile gangrene.   This event may be produced artificially in ani-
mals in forty-eight hours, by injecting charcoal powder  into the
artery of a limb, which totally obstructs its capillaries.  (Magendie.)
It is, most probably, by obstructing the circulation, and  thus de-
priving the  parts of an element indispensable for the maintenance
of their life, that inflammation and other lesions sometimes termi-
nate in gangrene.
   Softening  and wasting of textures are also effects attributable
to continued defective  supply of blood. The former is exemplified
in softening of the brain and of the heart in connexion with ossi-
fied arteries: the latter in  the  wasting of parts subjected to con-
tinued pressure.  Hence partial anasmia is concerned in producing
many changes  of structure arising under various circumstances.
Deficient supply to secreting organs necessarily impairs the amount
and quality of their secretions (§  159). 
160
WILLIAMS'S  PRINCIPLES OF  MEDICINE.
                          SECTION II.

         HYPEREMIA [OK POLY-EMIa], EXCESS OF BLOOD.

   274.  Too much blood in the system, or in a part, is a most fre-
 quent element of disease.   It implies  an undue distention of the
 vessels  which  contain it; and a  modification of the properties of
 these, and of the heart which propels it. is almost constantly a con-
 comitant of this morbid condition.  The chief vital properties of
 the heart and vessels are irritability and tonicity;  excess (§ 114,
 121) and defect (§116, 123) of these form most important elements,
 which modify the effects of excess of blood : and thus  is suggested
 synthetically a division (long recognised as most important in prac-
 tice)  into active or  sthenic, and  passive or  asthenic  hypereemia;
 which distinction is  applicable to both the general and the partial
 excess of blood.   Another  variety of hyperaemia may be distin-
 guished by an altered or perverted action of the vessels, which is
 chiefly applicable to the  affection in a  part, and includes that sin-
gular and complex condition — inflammation.   A  view of these
 important proximate elements of disease (§ 107)  is given in  the
 following table.  It.  is not meant that the diseased conditions here
specified are  always separate, or that  they consist  merely of  the
elements here stated ; but these are their most  distinguishing parts,
and most important in regard to treatment.

                         with motion increased = Sthenic^
                                                      RESULTS.
                          — — diminished = Asthenic i TT    u„„_
                                                   I Hemorrhage.
                                                   >-
                                                  | Flux.
              fwith motion diminished = Congestion      j ^      «.
                                       °          | Dropsy, ^c.
                      increased = Determination of blood J
I  _
i
^-Local •(
       ,  —  —  partly increased,
partly diminished = Inflammation.
                         SECTION III.

     PLETHORA  [POLY.EMIA] -- GENERAL  EXCESS OF BLOOD,

  275. As general anaemia may arise from defective formation or
excessive expenditure of blood, so general plethora may proceed
either from too much blood being made, or from too  little being
expended.   In either case the blood accumulates and fills the heart
and bloodvessels beyond  the  usual degree.  But this implies a
certain activity and  health in  the  processes of digestion and assi-
milation, and also a  freedom from any considerable  local disorder. 
PROXIMATE ELEMENTS OF DISEASE.
161
A person with weak digestion rarely becomes plethoric; and one
who suffers from a local ailment is commonly warned by an aggra-
vation of this, before the fulness can become  general.
  276. The persons who become plethoric are rather those over-
flowing with health, who  have a good  appetite, and indulge it,
without sufficient regard to exercise and to  the  excernent func-
tions.  The bloodvessels becoming more and more filled, the signs
of plethora appear in the red face, distended veins, and full pulse ;
the heart labours with its load, especially on exertion ; palpitation
and short breath may ensue, with somnolency and indisposition to
exertion;  but these  may attract no further notice than to induce
the abandonment of exercise. The state of plethora, thus gradually
induced, may be extreme, without any functions materially failing,
and yet the subject is on the brink of various maladies.  It is well
if a great secreting organ is first excited under the high pressure,
and relieves the system through a free  discharge, as by mucous or
bilious diarrhoea ; by bleeding piles, &c.; or one of these secreting
organs may fail in its proper function,  (§ 170, 254,) as the  liver or
the  kidneys; and  a bilious attack, jaundice, or a fit of gout  or
gravel, is the consequence.  Any of these, by establishing a per-
ceptible ailment, disturbs the dangerous ease of the plethoric; and
by  rendering necessary a temporary discipline, saves him from the
worse results of plethora — apoplexy, structural disease of  the
heart, great vessels, kidneys, or liver.
   278. Besides  the  causes already  noticed, other circumstances
may induce  plethora.   The diminution of an habitual excretion
or loss of blood, the drying up of a long-established sore or issue,
(§ 270,) or the removal of a limb ;  all of which diminish  the  ex-
penditure  from the system, without impairing  the bloodmaking
process, often become causes of plethora, if no local  disorder  be
excited before the vessels in general reach a  plethoric tension.
   279. The  division of plethora into sthenic and asthenic arises
from different  proportions  of the strength and irritability of  the
moving fibre, which we  have noticed as ultimate elements of dis-
ease (§ 110 and 120, et seq.).  Where  the irritability and  tone of
the heart and arteries are in full amount, the  increased quantity of
blood excites these  properties to full operation.   Short of  disease,
the functions are active and energetic in proportion to the quan-
tity of blood which their organs receive ;  the heart's action and the
arterial pulse are strong and  regular: secretions are  abundant,
sensibility is keen, contractility powerful and in good tone, animal
heat is sustained, and the mental and bodily  powers generally  are
great and active.   But beyond this, plethora tends to disease:  the
heart's action is over excited ; the  pulse is frequent, as  well  as
strong and hard; the face is florid and flushed, and  the  heat is
almost feverish ; the capillaries of secreting  organs and surfaces
are variously disordered ; somtimes excited to excessive secretion,
sometimes beyond it, to a state of fulness bordering on hemorrhage
or  inflammation ;  sensibility and sensorial  powers may be over
            14* 
16.2
WILLIAMS'S PRINCIPLES OF MEDICINE.
excited by the rapid flow, or oppressed by the pressure of the blood
on the nervous centres.  If the plethoric state is moderate enough
to last for  some time  without  immediate  disaster, the nutritive
function will eventually be affected — the heart and vessels, and
more vascular textures, being the  earliest to exhibit an increased
growth, often  with  some change of properties.   Thus may ori-
ginate structural disease, from the continued excitement of sthenic
plethora.
  2S0. Sthenic plethora is that which commonly affects  the young,
the active, and those of sanguine temperament (§41).   It compre-
hends a rich state of the blood, (§ 184,) and  an active condition of
the nutrient function  (§ 195).  Its tendency is to cause general
febrile excitement, active hemorrhages, fluxes, and inflammations.
  281. In asthenic plethora, there is a want of contractility (§ 116)
and tone (§123) in the moving fibre.  The heart and other organs,
instead of being excited by the augmented quantity of  blood, are
oppressed  by its load.  The  pulse may be  full, but it is slow;
sometimes irregular or unequal.   There  is sometimes a tendency
to  faintness alternating with palpitation : physical examination
shows the  heart to be enlarged by the accumulation of its contents,
which it cannot expel. The face is purple rather than red ; the veins
are generally  distended ; sometimes the extremities are apt to  be-
come  cold.   Other functions are sluggish, and imperfectly  or
irregularly carried  on.  The bowels are torpid, the urine  high
coloured or turbid, sensibility is blunted, and the mental faculties
dull, with lethargy or somnolency.
   Asthenic plethora  affects especially those weakened  by age,
excesses, or previous disease, and those in whom  the excreting
organs act imperfectly ; which imperfect action is a cause, as well
as  a  consequence of plethora.   Asthenic plethora tends to produce
congestions and passive hemorrhages,and fluxes or dropsies; and
if continued, structural changes in some organs, as dilatation of
the heart, enlarged liver, varicose veins, &c.   Congestion of  the
brain, with apoplexy or palsy, headache, or other symptoms of
 disturbed  function, sometimes is produced; or  if there  be any
 organ, the vessels of which, from past or present causes, (§ 31, 32,)
 are weak, this organ  may be the first to suffer.
    2S2. The symptoms of asthenic plethora hitherto described  are
 chiefly those of a depressed or  oppressed  state  of the functions.
 Sometimes, however, there arise others betokening  excitement or
 reaction of an irregular kind.   The pulse becomes quickened, and
 often irregular  ; the  skin becomes hot, or  partially  perspiring;
 sickness  and vomiting may occur; the tongue becomes  much
 furred, and sometimes brown and dry ; the excretions are unusually
 offensive, and often changed in appearance; the complexion  be-
 comes dusky, the eyes suffused, the mental faculties disturbed or
 impeded in delirium or sopor.  This is a kind of congestive fever, de-
 scribed by Dr. Barlow as a result of reaction from asthenic plethora.
  It is probable that this description  has been partly drawn from 
PROXIMATE ELEMENTS OF DISEASE.
163
cases in which, besides asthenic plethora,some morbid poison (§ 2 58)
has been in operation ; but many of the  symptoms  here named
may be fairly traced to a congestive fulness of the bloodvessels,
with an impaired action of the excreting organs (§ 70, 171, &c.) ;
and consequently, the diseased condition of the blood, which we
have described to arise from imperfect excretion (248, et seq.) [as
in albuminuria].  The  process of reaction or  febrile excitement,
which  occurs in cases of asthenic plethora, is sometimes  more dis-
tinctly connected with the condition of the blood, as in the case of
gout, (§ 254,) rheumatism, (§ 251,) and various cutaneous diseases,
which become developed generally in the less inflammatory forms.
   283. Remedial measures.—The means already described as use-
ful in reducing an excess of red particles (§  192) and fibrin (§ 214),
are also applicable to the eariier  and simpler  states of plethora.
In fact, in  these states, the blood usually does exhibit this excess,
for which bloodletting and other evacuants, and abstinence, are
the chief remedies.  The  property of bloodletting  in extreme de-
grees of plethora is evinced by the extent to which it may be car-
ried without causing faintness.  Thus Dr. M. Hall found, that from
patients  with  congestive  apoplexy, from forty to  fifty ounces
might  be drawn without  producing syncope;  whilst in acute in-
flammations, the  tolerance is usually less by  about ten ounces.
The beneficial effects of bloodletting" are sometimes  immediately
manifest,  although  they  are  somewhat contrasted  in  the two
varieties of the disease.   In the sthenic kind,  the pulse becomes
softer, weaker, and less frequent; in the asthenic, it often improves
in strength and regularity, and sometimes  rises to a natural  fre-
quency.  In simple and  recent cases of both  kinds, a sufficient
bloodletting, with due avoidance  of the causes  of the  plethora, (so
far as that can be accomplished,) and the use of a little aperient
medicine, may complete the cure.
   284. But if the plethora have lasted long enough to  produce
some of its ulterior effects, (§ 282,) bloodletting may be  an  insuf-
ficient, nay, in some  instances, it  may be  an   unfit  remedy.   In
both kinds  of  plethora, medicines which increase the secretions
are generally  indicated, and the  diet must be much restricted;
but the particular mode in which  these  ends   are  to be  accom-
plished, varies greatly in  the two forms which  I have been care-
ful to distinguish.
   285. In sthenic plethora, not.  only the  blood  is in excess, but
 also the irritability and tone of the moving fibre.   Here, then, be-
 sides  removing  the excess of blood, sedative  and relaxing reme-
 dies (§115, 122) are indicated.  Antimonials, salines, digitalis, and
 hydrocyanic acid, and a cool  regimen, we have  found  to answer
 this purpose;  and these are often most  useful in the treatment of
 sthenic plethora.  The same remedies, with  mercury, colchicum,
 and some others,fulfil also another indication,  which maybe pre-
 sented, to augment excretions defective from an over excited state
 of the capillary circulation,  which borders  on  hemorrhage or 
164           WILLIAMS'S PRINCIPLES OF MEDICINE.

inflammation.   If any part should  especially suffer, local blood-
letting may be requisite to prevent such a result.
  286. In asthenic plethora of some duration, on the other hand,
although bloodletting relieves them, it does not restore lost tone to
the over distended vessels.  Tonics (§ 124), and  even stimulants
(§ 119), may be necessary at the very time that blood is drawn ;
and there may long be required such treatment as  is calculated
to restore the  impaired functions of digestion and secretion, and
to improve  the depraved  condition of the  blood  (§ 174).   In
such cases, the continued use of alterative aperients and diure-
tics, such as mild mercurials, with rhubarb, aloes, or senna, salines,
and taraxacum, nitric acid, iodide of potassium, &c,  may prepare
the way for various tonics, such as calumbo, bark, and iron.(a)  In
such cases, mineral waters, like  those  of  Cheltenham, Harrow-
gate, and  Llandridod, are often of great service ; first the saline,
which  are aperient and diuretic, and afterwards the chalybeate,
which, although  tonic,  usually contain enough  saline  matter to
keep the  secretion free.   Some  of the  latter class,  as  the  Bath
waters, sometimes excite torpid  and plethoric habits to a critical
reaction, by bringing on a regular fit of gout (§ 254).
  The diet, which should be very spare in  sthenic plethora,  must
not be loo much  reduced in that of the asthenic kind.   The food
should be simple, but  nourishing, and adapted  to the  power of
digestion.    Stimulant   drinks are  not  generally necessary; but
previous habits  must be considered, and  not suddenly reversed.
Regular out-door exercise,  as  much  as the strength will  bear
without causing excitement or exhaustion,  is a most  salutary part
of the regimen.
                         SECTION  IV.

       LOCAL HYPEREMIA.  EXCESS OF BLOOD IN A PART.

          I.  WITH MOTION DIMINISHED = CONGESTION.

  287. The true nature  and distinctive characters of  congestion
may be conveniently traced through its several causes, all of which
agree  in fulfilling the conditions here given as the definition of
congestion, excess of  blood in  the vessels of a part,  with dimi-
nished motion  of that blood (§ 274).   We  have  already found
that parts  of the vessels, and even the heart itself, become con-
gested in asthenic plethora (§ 281) ;  but this is as a part of a more

  (a) Conjointly with these remedies,  recourse should be had to
the  warm  water  and  vapour baths,  so as to aid  the  skin in
throwing off from the blood its watery without a loss of its fibrin-
ous element, and also  to  keep up a relative fulness  in the cuta-
neous vessels to the relief of internal organs. 
PROXIMATE ELEMENTS OF DISEASE.
165
general disease.   We have now to  consider the causes and phe-
nomena of congestion of blood in a part, which may occur inde-
pendently of general disease.
  As the great  source of  the motion of the blood is  the  heart,
and the  distributors of that motion are the arteries, we may anti-
cipate that a chief cause  of diminished motion is a supply from
the arteries insufficient to  propel the blood in the capillaries and
veins.  Such an insufficiency occurs when, from whatever  cause,
the capillaries and veins of a  part  are enlarged, without a corre-
sponding enlargement of the arteries leading to them.  The reason
of the diminished  motion  is thus easily found ;  but we have yet
to inquire the cause of the other element of congestion, too much
blood in  the part.
   2SS. Bloodvessels become  congested, or  unduly dilated, when
their proper elasticity and tone are overcome ; and this may happen
when an obstruction in  the veins prevents the free  escape of blood
from  them ; or it may happen  from weakness of the coats  of the
vessels themselves, which yield to the pressure of the blood trans-
mitted to them.   The chief causes  of congestion  may be classed
under these two heads : — 1.  Those of venous obstruction  ; and,
2.  Those of atony of the  vessels (capillaries and veins).  Under
these two heads we shall notice various cases of congestion,  which
will explain and practically illustrate the subject.
   2S9. (1.) Congestion from  venous obstruction. — When the
 arm  is tied for venesection, the veins are  compressed  more than
the arteries.  Hence the veins  swell, then the fingers become red,
and  after  a few minutes purple, and the whole limb is swollen
from the congestion of blood in its vessels.  In  like manner, con-
gestions are caused in internal  organs  by an obstruction  of the
veins leading  from them.   Thus congestion  of  the brain may be
produced by a tight cravat (§ 51), or by a tumour  pressing  on the
jugular veins.  Straining (§ 64), or  holding the  breath, and asth-
matic affections, which impede the flow of blood through the lungs,
cause congestions in various parts.   Disease of  the valves  of the
heart, which prevents the  blood from passing onwards through  it,
produces fulness of the veins and of the  capillaries in  both the
pulmonic and systemic  circulation.  Tubercles in  the lungs cause
congestion of these organs.   Obstruction to the transit  of blood
through the liver causes congestion in the abdomen, hemorrhoids,
&c.(«)  The characteristic of congestion beginning with the veins
is, that the veins as well as the capillaries are distended ; and this
appearance is obvious during  life in cases  of  aneurism  or other
 tumour  compressing the veins  of the neck ;  and after death in the
full arborescent appearance of the veins in the  congested part.
Certain  diseases of the  or/sans  of respiration, especially extensive
  (a) The associated congestion  with softening of the spleen  and
congestion of other organs and tissues, as in typhoid fever, has been
already adverted to in note to p. 127. 
166
WILLIAMS'S PRINCIPLES OF MEDICINE.
emphysema of the lungs, in which the efforts of expiration predo-
minate over those of inspiration, cause congestions  not merely by
opposing the return of blood through the veins into the chest, but
also by removing that  suction influence which naturally  much
promotes the  flow of blood in that direction at each inspiration.  It
has  been  pointed out  by M. Berard, (Arch. Gen. de Med., Jan.
1830,) and by Mr. A. Shaw, (Med. Gaz., July, 1842,) that the
circulation in the liver  is, in  health, much dependent on  this in-
fluence ;  and it  may be  inferred that the  diminution  of  this in-
fluence by extensive vesicular emphysema will assist in explaining
why hepatic congestion is so commonly combined with this pul-
nary lesion.
  290. (2). Congestion from atony of the vessels. — This compre-
hends a numerous class of cases.   In some the atony of the vessels
(§ 123) affects the whole system, as in case of extreme debility,
adynamic fevers, and  the sinking which  precedes death.   The
blood thus accumulates in some of the vessels, chiefly those that
are lowest in the position of the body;  which in  their weak state
yield to the accumulating blood.  This occurrence of the  conges-
tion in undermost parts (hypostatic) is the distinctive character of
that of weakened vessels.  Thus the posterior  parts of the lungs,
intestines, and integuments, are found much congested.
  291. In other cases the weakness is local, without affecting the
vessels generally, the weakening cause being applied to some ves-
sels only.   Over-distention is a common cause of congestive weak-
ness of vessels.  Thus from long continuance in  one position, the
lower vessels yield to the gravitating force (§51), of the blood, and
become congested.  This cause makes the feet swell after standing
or walking long, especially in warm weather.   A continued stoop-
ing posture, or lying with the head low, may occasion congestion
of the brain, with headache,  giddiness, confused vision, and  may
prove an exciting cause of apoplexy.  Remaining long in  a stand-
ing or sitting posture, often causes congestion in the hemorrhoidal
veins, liver, uterus,  &c.  Where the circulation is feeble,  and the
tone of the vessels weak (§ 123), these causes of congestion operate
more readily  and more permanently than where  the circulation is
vigorous; yet these congestive affections, the result of weakness,
are  often mistaken for  inflammations.  Many of the pains and
ailments of delicate females are of this nature ;  and although tem-
porarily relieved  by depletory measures, are to  be permanently
counteracted only  by  tonic  means (§ 124), which promote the
vigour and equality of the circulation.
   It must  be borne in  mind that congestion, from  mechanical
causes, when  it lasts long, may so weaken the vessels by over-
distention, as to continue after their original cause  has ceased to
operate.  Thus  congestion of the brain or lungs  induced by a
paroxysm  of dyspnoea,  or  coughing,  or by  violent  straining
(§  64), may  not  subside  with the cessation of the effort; gid-
diness, headache, pain, dyspnoea, &c, remaining  for some time
after. 
PROXIMATE ELEMENTS OF DISEASE.
167
  292. In considering the operation of cold as a cause of disease,
we found that it chiefly operates by constricting the vessels of the
surface and extremities, and thus throwing the blood  inwardly,
causing internal congestions by intropulsion (§ 77).   If this exists
long, the tone of the internal vessels will be impaired, and the con-
gestions will  not cease on the restoration of warmth to the surface.
Thus a permanent congestion in the iungs, liver, kidneys, mucous
or serous membranes, whichever happens to be predisposed, may
result;  and this congestion may variously disorder the function of
the part, or may lay the foundation for inflammation.(a)
   293.  Malaria (§ 82), and the influences which produce continued
and exanthematous fevers (§  93), seem to  have  the same effect
as external cold, but it is not so easy to explain how they operate.
The cold stage  of  these  diseases exhibits  in  a high degree the
marks of intropulsive  congestion ; and it is well known  that in
ague the congestive enlargements of the liver and spleen are among
its most remarkable phenomena.  The congestions remaining during
the febrile  stages of fevers, seem to be the chief causes of their in-
ilammatory complications.
   294.  Another cause  of congestion  is over-excitement of the
vessels.  It is well  known that after a part has been inflamed, the
vessels often  remain dilated, but without the signs of inflammation.
This is well seen in the conjunctiva, the throat, the skin, and in
certain ulcers, and might be exemplified in some  internal organs.
The liver and stomach show many signs of congestion after the
excitement of stimulant drinks (§ 5Q).  But  we  may, under the
microscope, trace the production of congestion apart from inflam-
mation.
   When a slight irritant, as a weak infusion of capsicum, is applied
to the web of a  frog, it first causes contraction  of the vessels, espe-
cially the arteries (§ 120), then quickly follows enlargement of the
arteries and  other  vessels with very rapid motion:  after  a while
the vessels gradually contract and return to their natural size.  But
if the stimulant application be repeated several times, so as to pro-
long the determination of blood  into  the part, the vessels do not
then  uniformly contract.  The arteries indeed shrink, but the capil-
laries and veins remain congested, and thus present completely the
condition given  in our definition, excess of blood  with diminished
motion (§  287).  This  dilated state  of the capillaries and veins
must be  chiefly ascribed to  their losing  tone after excitement
(§ 123), more than the arteries ;  but the process which I have been

   (a) Congestion from cold is  properly a state of imperfect reac-
tion, rather than of direct sedation, and in which  the vessels have
lost their full power of passing on the blood sent to them from the
heart.  See a former note, p. 66-71, on the modus operandi, and
the immediate and secondary  effects of cold.   Congestion we con-
sider as a  result rather than the cause of the  impaired tone of the
 vessels. 
 168          WILLIAMS'S PRINCIPLES OF MEDICINE.

 describing is accompanied by changes also within the vessels ; nu-
 merous lymph' globules are "formed and  adhere to the sides of the
 small vessels,, and contribute to impede the current, and cause con-
 gestion by obstruction.  Whenever the stimulus applied has been
 stron?, this obstruction amounts to  entire  stagnation, and many
 vessels appear much enlarged, and filled with stagnant blood, or
 rather with  an accumulation  of red particles entangled  in the
 coherent  lymph globules.  For this  reason, the vessels in which
 the blood is stagnant, are of a deeper red than others, the red par-
 ticles being arrested whilst the  liquor sanguinis  passes on.
   295.  All that has been  now described belongs to congestion, and
 there can be little  doubt that the intense and deep redness some-
 times seen in congested parts, is partly made up of vessels in which
 the blood is absolutely stagnant.  We shall find  that a similar con-
 gestion and stagnation exists also in inflammation, and may be the
 only change left by it to be found after death, where the  inflam-
 mation has not existed long enough to produce its more character-
 istic results.  It is for this reason impossible  to discern by anato-
 mical characters the difference between  recent inflammation  and
 some forms of congestion.
   296.  Besides, by its intropulsive mode of  causing  congestion,
 cold directly produces it by obstructing  the capillary and  venous
 circulation. This it does partly by its  constricting influence (§ 75),
 which acts on the veins before  it reaches the arteries, but from the
 experiments of Poisseuille it appears  that cold physically impedes
 the passage of liquids through tubes, as he supposes by  increasing
 their  adhesive  properties.  From a  few observations,  I am dis-
 posed to consider that an increased  production of lymph globules
 and their adhesion to the  vessels operate here also.
   297. Congestion occurs  in various  organs  and  surfaces when
 their proper secretionsare arrested, or  suddenly diminished (§ 167).
 It is difficult to determine  whether the congestion is the effect or
 the cause of the defective  secretion in the first instance ; and very
 probably the relation is mutual: at least  this is the most  conve-
 nient view to take of  the matter for practical  purposes.  Thus,
 means which increase the  secretion (§ 172), will often remove the
 congestion ; and those which relieve the congestion, generally re-
 store the secretion.
   29S. There are some cases of congestion which have not hitherto
 been traced to any of the causes above specified, although it is not
improbable that further investigation  may refer them to some of
these causes.   It is well ascertained that  when the blood does not
 undergo its proper changes in the lungs (§  234), its passage through
 these organs is partially impeded, and it accumulates in the lungs,
 in the right side of the heart, and in the venous  system  generally.
 Congestions thus form a. prominent  part  of the pathology of as-
phyxia.  From the observations of Dr. John Reid, it appears that
some obstruction also occurs to  the passage of the blood through
 the systemic capillaries. 
PROXIMATE ELEMENTS OF DISEASE.
169
   Again : in Mr. Blake's experiments, various saline solutions in-
jected into the veins, (salts  of soda, silver, &c.,) caused  death by
obstructing the passage  of  the blood  through the lungs, without
arresting the breath or coagulating the blood.
   It remains for future observers  to  determine whether these ob-
structions may be connected with contraction of the vessels (§ 120),
increased  spissitude or cohesion of the blood, or other simply phy-
sical cause ; or whether they depend on peculiar (vital) attractions
and repulsions  exerted  between  the vessels and its blood, which
properties  are  supposed by some physiologists to  constitute an
important element in the healthy as well as in the morbid pheno-
mena  of the capillary circulation.*


   * Whatever  influence the vital properties  of the blood may be supposed to
exert in impeding the passage of  the blood through the capillaries, I can see no
reason for admitting that they in any degree contribute to its motion.  That the
power of the heart distributed by the arteries is sufficient to carry on the circu-
lation, is apparent from several experiments, of which one by my colleague, Dr.
Sharpey, is the most complete.  A syringe, with a haemadynamometer to show
the amount of pressure used, was  adapted to the aorta of a recently dead animal,
the vena cava being divided.  Warm water was then injected, and with a  force
that raised the mercury in the hsemadynamometer  only three inches, the water
passed through the capillaries and out of the vena cava.   When the pressure was
increased, so as to raise the mercury six  inches, the flow was very free; and on
adapting another hsemadynamometer to the vein, the pressure in this was found
to rise as  high as three  inches.   The pressure  thus used  in  the arteries (six
inches of mercury) was not greater than  the natural pressure in the arteries of a
living animal; and the pressure transmitted to the veins (three inches of mercury)
was greater than  that in the veins of a livinganimal, thus showing that the force
of the heart, sustained by arterial tension, is quite adequate to  effect the circu-
lation without other aid.
  The chief arguments for and against the existence of vital properties of attrac-
tion and repulsion at sensible distances, have been well stated by Professor Allen
Thomson, in the article " circulation," in the Cyclopaedia of Anatomy, to which
I would particularly refer the student.  In addition to these I would state that in
many long and careful microscopic examinations of the circulation in the frog's
web, variously modified by different agents, I  never witnessed any movement of
the blood particles, which was not plainly referable to the action  of the heart, or
of vessels.  The  share which the arteries have in regulating the flow of blood
through the capillaries and veins,  is most evident.   VVhen the  arteries increase
in size, the flow becomes very rapid  and general;  when they diminish the  flow
is tardy, and even ceases in some  capillaries ;  and when  the arteries contract, so
as to permit no blood to pass through them, the  blood which still fills the capil-
laries and veins, becomes quite stagnant, without a sign of spontaneous move-
ment.   When motion begins again, it may always  be traced to an artery, which
first admits a file of single globules, which come few and far  between, and in
pulses ; afterwards,  as the artery enlarges,  many rush  in a continuous rapid
stream, supplying proportionate motion to the vessels beyond.
  Many of the instances of supposed vital  motions in the blood, and other organic
molecules, are referable  to mere physical causes.  Similar movements may be
seen, quite as animated in appearance, on mixing under the microscope two drops
of saline solutions of different strength or nature ; any insoluble powder in these
drops moves, as it were, spontaneously, and  the motion continues until these
drops have entirely pervaded each other.   Still more lively motions are seen on
adding any resinous tincture to water.  Similar  causes operate on blood mole-
cules, giving them motions which appear to be spontaneous.  But blood particles
             15 
170
WILLIAMS'S PRINCIPLES OF MEDICINE.
  299. We have considered atony of the small vessels (§290), as
a chief cause of congestion :  and it is so, not only by making them
yield, and  become distended by the  accumulation  of  blood, but
also  by rendering them unfit to transmit the  force  of the current
in its proper  direction.   Vessels which have lost  their tone, be-
come inelastic and  tortuous, and  by the  very stagnancy of the
blood in  them, they  oppose  an  increasing  obstacle  to its passage
through  them.  The physical  principle to which  I now refer is
not generally  understood, and  I will  illustrate it by some  expe-
riments.
  300. To one of Read's enema syringes, was adapted a tube with
two  arms: to one arm was fitted a brass tube two feet long, hav-
ing several right angles in its course ; to the other arm was tied a
portion of  rabbit's intestine, four feet long, and of calibre, (when
distended with water,) double that of the brass tube.  The intes-
tine  was placed in curves and coils, avoiding angles and crossings,
which might obliterate the canal.  The discharging end  of both
tubes was raised to  the same  height, that  of the intestine being
kept open by  a short tube of metal.  The tubes were then both
filled by successive strokes of the piston ; and when they both began
to discharge, the quantity received from each in a given number
of strokes, was ascertained.   Without giving the  details, it may
be stated that the small  metal tube discharged from two to five
times the quantity discharged by the larger but membranous tube ;
the difference being greatest when the strokes of the piston were
most forcible and  sudden, by which the intestine, although much
swelled at its  syringe end at each stroke, conveyed  comparatively
little water.   The difference was further increased by raising the
discharging ends higher ; and when both ends were raised to the
height of eight or ten  inches,  the  gut ceased to discharge, each
stroke only moving  the column  of water in it, but this subsiding
again without rising high enough to overflow.  On increasing the
force of  the stroke, the part of the  intestine nearest to the syringe,
burst.
   The experiment was repeated in various ways, of which I will
mention one, with a metal tube two feet eight inches long, and a
bore three-eighths of an inch, and a portion  of dog's intestine of

move also from another cause ; they are not only carried by the current, but they
are often changed in shape by it.  Being vesicles, they swell  or shrink by en-
dosmose andexosmose, on any change in the density of the liquid in which they
are conveyed ; and these changes affect their position and form, their aggrega-
tion and separation, in a manner which might readily give the idea of their pos-
sessing spontaneous motions.
  Although it seems unwarrantable  to admit a self-motory power in the blood
particles as aiding in the circulation, it is highly probable that changes in them,
as well as in the vessels which convey them, may impede the circulation.  The
 adhesion  of the  lymph globules to the sides of the vessels and to each other, and,
 perhaps, the cohesion of the blood-discs, are changes likely to produce this effect;
 but  it remains to be proved whether these operate in causing the obstructions of
 asphyxia, &c. 
              PROXIMATE ELEMENTS OF DISEASE.          171

the same length, but  when  distended, of double the diameter.
The metal tube yielded three  times more liquid than the intestine.
  301.  These experiments show  that flaccidity  and increased
length and size of a tube afford  impediments to  the passage of
liquid through it; and although the experiments exaggerate the dif-
erence between healthy and relaxed or congested vessels, yet they
really prove that the increased tortuosity and number of vessels in
a congested  part, the greater mass of their contents, and the atonic
flaccidity of their coats, do truly form additional obstacles to the
passage of the blood through them, although the amount of these
obstacles will  vary according  to the state of the  connected circu-
lation.
   These experiments illustrate a  principle that  is too little  con-
sidered in animal and general  physics ; the loss or  neutralization
offorce, by  misdirection.   The bloodvessels in their healthy con-
dition are so constituted as to make the most of the heart's pro-
pulsive power and  transfer it throughout their whole length; but
when  dilated, tortuous, flaccid, and  otherwise altered, they  mis-
direct and exhaust it:  (as in the experiment with the intestine,) it
is partly expended in distending  and  dilating  the  nearer portion,
whilst a sufficiency does not remain for the onward propulsion of
the blood, which therefore stagnates  and accumulates in the con-
gested vessels.  We shall have  many occasions  to revert to this
principle, which explains many anomalies of unequal circulation.
   302.  Without going so far as to say that atony of the capillaries
is in this way the chief cause  of the obstructed  circulation in as-
phyxia (§ 298),  I think that  it must be admitted as one cause,
especially operating when  the asphyxiating influence  has  been
only a short time in operation.  The free supply of air to the lungs
may soon excite the capillaries to contract, and by restoring  their
natural tone and calibre, remove this cause of obstruction.  If the
congestion remain long, the obstruction is probably increased, not
only by the more permanent  loss  of tone in  the vessels, but also
by changes  in the blood itself, which render the removal of the
congestion less easy and complete; and it is known that when as-
phyxiating causes have been  long in  operation, the congestions
which they  have produced are not dispersed by the restoration of
the respiration.

          THE SYMPTOMS AND EFFECTS OF CONGESTION.

   303.  When the arm is  tied for venesection, the parts beyond
the ligature become congested.  At first the hand feels rather
warmer  than usual, and somewhat tender, from the distention of
its vessels with warm blood, but it soon becomes numb, cold, and
weak, showing  that the want of circulation lowers its vital pro-
perties.
  Inl like manner, simple congestion generally impairs the  vital
 roperties of internal  organs, although the undue distention  of 
172          WILLIAMS'S PRINCIPLES OF MEDICINE.
their textures, by the increased  mass  of blood, may cause partial
excitement.  Natural contractility and sensibility are lowered, but
pain (§ 126), spasm (§ 114), and morbid sympathies  (§ 149), are
often excited, although in a  manner much less distinct and con-
stant than in inflammation or determination of blood.   Thus con-
gestion of the  liver is sometimes accompanied by pain or  tender-
ness ;  sometimes it is without either.  Congestion of  the stomach
sometimes causes  gastralgia, nausea, and vomiting, and  altered
appetite ; but these symptoms are often absent when the amount
of disease of the liver or heart, and the subsequent occurrence of
hematemesis, leave no doubt that the  stomach  was  congested.
The same  remark  is applicable to the  kidneys, the uterus, the
brain, and other organs.  We often see  the tonsils and uvula con-
gested and enlarged, without pain  and  soreness.  Impaired ner-
vous and muscular function  is a more constant concomitant than
pain, or any symptom of irritation.
  304.  The natural secretions of congested parts are  sometimes
at first augmented, as in congestion  of the conjunctiva and Schnei-
derian membrane from  cold ; but more  generally they are dimi-
nished, as in bronchial congestion (dry catarrh), and congestion of
the liver, kidneys,  &c.   But very commonly, congestion leads to
an  increased transudation from the whole distended capillaries,
causing effusions of the watery and saline part of the blood, more or
less  impregnated with  albumen, and  sometimes even with fibrin,
as exemplified in the fluids of fluxes and dropsies.
  The process by which this is the effect of congestion or secretion
seems to be chiefly a physical one.   The portions of the vascular
apparatus  most concerned  in supplying the secreting structure,
seem to be the middle parts of the capillaries, which are often so
turned or convoluted, as  to  receive the  most direct  force of the
current from the arteries.  But when congested, the vessels leading
to the  middle capillaries become yielding, loose, and tortuous, and
the force is much expended  in dilating  these  before it  can reach
the secreting extremities;* the secreting portions are in  the  condi-
tion of the distant  end of the intestine   in the experiment above
related (§ 300), not duly receiving the force of the current.  Thus
the more essential effect of  congestion  is to impair the natural
secretion.
  305.  But the distention of the congested capillaries sometimes
leads to a general exhalation of their more watery contents, which

  * It may seem that this is taking too mechanical a view of the process of secre-
tion ; but be it remembered that I do not ascribe  secretion wholly to mechanical
agency, but only assert what is known to be a fact, that a due force of the capil-
lary circulation is a condition favourable to this process.  In lately inspecting the
beautifully injected preparations of Mr. Dalrymple and Mr. Toynbee, I was°par-
ticularly struck with the distribution of the  capillaries of secreting surfaces, such
as mucous and synovial membranes. These capillaries run pretty straight from the
minute arteries, and end in loops and ampullae on the surface, the returning ves-
sels passing back as straightly. The physical effect of this provision is obviously
to direct the chief force on the terminal loops which supply the secreting surface. 
PROXIMATE ELEMENTS OF DISEASE.
173
mingling with  the natural  secretion, render  it watery and some-
times albuminous.  Thus congestion of the bronchi sometimes ends
with bronchorrhoea.   Congestion of the intestine causes diarrhoea;
congestion of the uterus, leucorrhoea ; congestion of the  kidneys
[as when the emulgent vein is tied or obstructed], watery and
sometimes albuminous urine ;  congestion of the lungs and pleura,
hydrothorax  ; of the heart, hydropericardium ; of the abdomen,
ascites, &c.
   306.  The element of congestion chiefly concerned in the produc-
tion of these effusions, is distention of the vessels.  They are less
commonly found, therefore, in  mere hypostatic or gravitative con-
gestions (§291), in which the distention is inconsiderable, but they
more  result from congestions from venous obstruction (§ 289), es-
pecially when these occur suddenly, whilst the vigour of the circu-
lation is not impaired.   Thus  the congestions connected with dis-
eased heart or liver, produced by acute attacks or other additional
causes of obstruction, especially in plethoric subjects, if not  soon
removed, are pretty  sure  to end with dropsy, flux,  hemorrhage,
or inflammation.  The circumstances that determine which of these
results  shall  ensue, will be considered when  we come to these
proximate elements of disease, but it may be mentioned that besides
distention of  the vessels, the condition of  the blood  considerably
influences the result: a watery state promoting the transudation
(§ 222), whilst a highly  albuminous and fibrinous (§ 195) requires
more pressure to make its watery parts pass through  the coats of
the congested vessels.                •  •
   307.  The same circumstances determine  the character  of the
effused fluid.   Where the  blood  is poor, the watery parts easily
pass from congested vessels, even without much distention, and
contain but little albumen.   But if the blood abounds in the  pro-
tein compounds, more pressure is required before much effusion
takes place ; and then, when the pressure is great, the  fluid effused
often  contains, not only albumen in large  proportion, but  self-
coagulating fibrin also (§ 211).  Thus I have seen the fluid of the
pleura and pericardium, in rapidly  fatal  obstructive mitral dis-
ease, coagulate spontaneously into a fibrinous  crassamentum, when
removed from the dead  body.   The  gelatinous masses of lymph
often found in the peritoneal sac of the abdomen and pelvis in as-
cites from contracted liver, I have no hesitation in referring to the
same origin.
   308. Fluxes arising from congestion of high tension exhibit an
unusual amount of animal matter of an albuminous  or mucous
kind, as instanced in bronchorrhoea, mucous  diarrhoea, and  leu-
corrhoea.  I have been almost induced to suppose  that the poly-
pous  concretions  and  pseudo-membranous films  occasionally
effused on mucous surfaces may result from  long continued con-
gestion, with  a highly fibrinous state of the blood (§ 195).  I have
seen these evacuated from the  air-tubes, in one case, and, in an-
other, from the intestines, from time to time,  for months, and even
           15* 
174          WILLIAMS'S PRINCIPLES OF  MEDICINE.
years, without symptoms of inflammation, but under circumstances
rendering it  probable that congestion  was  present.   Extensive
disease  of the heart existed in one case, and amenorrhcea in the
other.
  309.  I have for several years referred albuminous urine (§ 249)
to congestion of the kidney; and this view has been lately con-
firmed by some experiments by Mr. G.  Robinson.   The following
considerations led me to entertain  this  opinion : — 1.  The  urine
often becomes  albuminous during great  embarrassment of the
circulation in cases of organic disease  of the  heart, (§ 289,)  when
the kidneys are otherwise healthy.  2.  I have, in a few instances,
observed temporary albuminuria during the congestive  stage of
eruptive fevers.   3. In granular degeneration of  the kidney, the
amount of albumen in the  urine is augmented by circumstances
causing congestion  of the kidney, and is reduced  by remedies
suited to remove  this.   4. Bright's disease of the kidney, in  its
earliest  stage, presents the appearance of a highly  congested struc-
ture, and is excited by causes calculated  to produce congestion,
such as frequent irritation of the  kidneys by stimulating liquors —
congestion from exhausted tone  (§ 294); continued  exposure to
cold, especially after the kidneys  have been thus  excited—con-
gestion  from intropulsion (§ 292): scarlatina probably operates as
the two last  combined.   5. The  albumen in the  urine  abounds
most in the congestive (first) stage of Bright's disease — the ves-
sels becoming more or less obliterated in the progress  of  the  dis-
ease by a deposit of lymph (§ 307) in the  cortical substance, and
perhaps, especially in the corpora Malpighiana — which deposit
is, at the  same  time, the cause which perpetuates  some degree
of  congestion, whilst it supersedes  the  proper  secreting  struc-
ture.*
  310.  From what has just  been  stated, it maybe inferred that
congestion, if continued, may affect the nutrition and  structure of
textures.   It generally  tends to  cause an  increased deposit in
them, constituting a variety of hypertrophy.  Thus, with diseases
of the heart  which  cause congestion, there is an  increase in the

  * The secreting structure is partly diminished in another way also.  The gra-
nular deposit presses not only on the bloodvessels, but on the uriniferous tubuli
also; and wherever it totally obstructs them, their office ceases.  These tubuli
becoming distended, form the serous cysts so commonly found in granular kid-
deys, and sometimes in those which are  not granular.  But these cysts contain
serum, or a gelatinous fluid, not urine; and this fact has been urged against the
notion that they are dilated uriniferous  tubes.  The explanation, however, is not
difficult.   The secreting function of the kidney lies in nucleated cells lining the
tubuli (Bowman); growing, filling, and bursting, as these cells do, by imbibition
from adjoining vessels, this process, which is that of secretion,  must be stopped
when the cells are themselves pressed  on by an accumulation of their own secre-
tion, which cannot escape; but a serous  exhalation from the bloodvessels  still
goes on,  displacing by endosmosis the  urine, and at last distending the duct into
a cyst.  The same explanation will apply to the serous cysts of the liver. This
view explains  how retention of urine or bile may lead to the suppression of the
secreting power. 
PROXIMATE ELEMENTS OF DISEASE.
175
weight of the viscera  generally, more particularly the lungs and
liver.  (Clendinning.)   The  enlargement  of the liver  and the
spleen from long attacks of intermittent fever  (called  ague-cakes)
may probably be referred to the congestion which this disease is
known to induce (§ 293).   I have known  a similar enlargement
of these organs to ensue after long continued exposure to cold and
damp (§ 77, 292).
   311. But the hypertrophy resulting from congestion is probably
not of a uniform kind, comprising equal growth  of all  the tex-
tures ; but, arjsing from an effusion of lymph  from the most  con-
gested vessels, it is an intervascular deposit — at first mottling and
exaggerating the appearance of the natural structure, as  seen in
the nutmeg liver and in the early soft stage of granular degenera-
tion of the kidney — afterwards contracting and compressing the
natural  structure,  and  ultimately causing  its condensation and
atrophy, whilst the  new deposit itself forms a  granular or nodu-
lated texture of low vitality (§ 211).
   312. Such I believe to be the nature and origin of  cirrhosis of
the liver, and granular degeneration of the kidney.  The varieties
which these  structural  diseases present may  often  be traced to
their degree of advancement, or to the extent to which  they in-
volve the structures;  and an argument in favour of their origin in
congestion may be found in the fact that they are commonly  more
advanced and extensive in the most dependent parts of the organs;
as the lower margins  of the liver, where  congestion is most pro-
moted (§ 290).  It is highly probable, also, that these  plastic pro-
ducts of congestion  are, in some cases, more or less developed and
further modified by determination  of blood or inflammation, and
by the composition of the blood itself.
   Long  continued congestion in the lungs may cause hypertrophy
of the intervesicular and interlobular texture, and in some  cases,
partial consolidation of the vesicular structure itself.  Such changes
are frequently met with in connexion with long standing disease
of the heart, and abound most in the posterior parts of the  lungs,
and near their roots, the most  vascular parts.   In the  membranes
of the brain, and in the capsules  of the heart, liver, and spleen,
opaque thickening  is often seen  along the course  of the blood-
vessels, especially of the veins; apparently the result of the  over-
flow of nutritive matter from these vessels.

                  REMEDIES FOR CONGESTION.

   313. The most important means in the removal  of congestion
are those which contribute to the removal of  their causes.   Thus
the loosening of a ligature, or the reduction of  a tumour, compress-
ing veins; the moderating the*inordinate and inefficient action of
a diseased heart; the restoration of the secretion of the liver, (§ 172,)
will severally tend to  diminish the congestions resulting from these
different venous obstructions. 
 176          WILLIAMS'S PRINCIPLES  OF MEDICINE.

   314. So, also, in the treatment of congestion from atony or weak-
 ness of the capillaries, it is important to remove the circumstances
 which have caused  this atony.  In  many cases  it is over-dis-
 tention from gravitation (§  296) ; here change of posture  gives
 relief.  Thus, in  congestive fevers, it  is useful to change from
 time  to time the position of  the patient.  With congestion  of  the
 head, this part should be supported high.  The recumbent posture
 gives much relief to congested hemorrhoidal or uterine vessels, as
 we see it reduce the swelling of varicose limbs.
   Pressure  is sometimes a  remedy for congestion,  by supporting
 the weak vessels and promoting  their contraction.   This forms a
 chief part of the useful operation of bandages, adhesive plasters,
 and even of poultices, in various external congestions.  It probably
 might be more extensively applied to these, and  even to some in-
 ternal congestions, in the modes suggested by Dr. Arnott, by mer-
 cury, or  by the slack air-cushion.
   Friction is a modification of pressure especially suitable to some
 forms of congestion, being calculated to give the motion  that is  de-
 fective, as well  as to  support  the  weak vessels.  It-is obviously
 useful in external congestions  from cold; and sometimes, in vis-
 ceral  congestions,  as those  of the liver and abdomen generally.
 Exercise operates somewhat in the same way.
   315. Another class  of remedies for congestion  comprehends
 those which promote  the contraction of the  dilated vessels  by
 augmenting their  contractility or  tone (§  124).  In  this  way
 astringents and cold operate; as in the use of solutions of alum,
sulphates of zinc or copper,  acetates of zinc or lead, and infusion
 of decoction of oak bark, catechu, kino, nutgalls, &c, in various
congestions, particularly of  the  conjunctiva, throat, rectum, and
 vagina.  The  most obvious part of the action of bark, quinine,
and arsenic, in the  cure of ague, is in their reducing  the great vis-
ceral congestions, which form their most remarkable, and perhaps
their most important pathological  element, (a)
  (a) It seems to us, that we ought to go still farther  back in the
theory of causation, in order  to  explain both  congestion and its
cure.   Antecedent to  most functional disorders of the circulation,
not directly caused by physical obstruction, is perturbation of the
nervous system, the nervous element as we have been accustomed on
other occasions to call it, in treating of the pathology of phlegmasia?,
pyrexiae, and congestions, which, according to its kind and degree
or duration, either increases or diminishes contractile power  and
tonicity in the vessels.  The  phenomena of blushing, the con-
striction felt  in  the pulmonary circulation,  under suspense  and
anxiety, the effects of heat to a part, are familiar instances of the
subservience of the bloodvessels to» the nervous system.  It is the
primary trouble in this latter, the alternation of sedation with ex-
citement, under the influence of a combination of causes, depending
both on the states of the atmosphere and the soil, and on the habits 
PROXIMATE ELEMENTS OF DISEASE.           177
  316. The utility of astringents in  congestion is limited by the
fact, visible under the microscope, that they commonly  contract
the arteries more in proportion than the capillaries and veins,
which are  most distended.  Hence they may still further impair
the motion of the blood, and increase the congestion.   A reaction,
however, sometimes occurs, which converts the operation of the
astringent into that of a stimulant, which is another kind of remedy
for congestion.   The same remark is applicable to cold; and even
more so, inasmuch as it also causes a physical obstruction to the
flow of blood, in the manner formerly described (§ 296).
   Stimulants sometimes are remarkably effectual in removing con-
gestions.   Thus diluted spirit to a congested conjunctiva, capsicum
to a congested throat, a stimulating wash or  ointment to  a purple
sore or surface will often signally reduce the  congestion.  Other
congestions are removed by exciting the circulation  generally; a
stimulant draught, or even one of any hot liquid, relieves the pul-
monary congestion which has induced a fit  of asthma; a conges-
tive  headache  is sometimes mitigated by similar means.   Well
regulated exercise tends to disperse  congestions in various parts.
Various agents, which specifically excite particular organs or parts,
(§ 173,)  are often  useful in  removing congestions  from them.
Thus mercury is, in some cases, a remedy for  a congested liver;
some diuretics, as digitalis and cantharides for congested kidneys ;
squill, benzoin and other expectorants, for bronchial congestion.
   317. The influence of stimulants  on  congestion may  be illus-
trated by  the microscope.  A  solution  of capsicum applied to a
frog's web, congested after previous irritation, causes an  enlarge-
ment  of the arteries, and an  increased  flow of  blood to and
through  the  congested vessels.  This flow restores motion where
it was deficient, sweeps away the accumulated blood, and, in some
of the individual, commonly but erroneously represented by a
mysterious principle called miasm, that gives rise  to disorder  in
the circulation, and  finally causes congestion in  various  organs.
Bark or quinia and arsenic, but especially the former, act  mainly,
if not exclusively on the nervous system, and by giving it an equable
tone diminish, or for a while remove its susceptibility to the noxious
agents which  first disturb it.   But although the periodicity of the
disease will be removed by  these means, and farther congestion
prevented, we cannot rely on them for the cure of that actually
existing, nor for inducing a salutary change in the blood, whereby
it will be  restored to its full, original, and proper offices  of both
furnishing the nutritive elements to the tissues and of stimulating
the secretions to  their rhythmical functions. Local bloodletting,
derivation by purgatives, diuretics, diaphoretics, &c, are resorted
to for the removal of existing "congestions ; iron for imparting,  in
conjunction with suitable nutriment, the requisite qualities  to the
blood. 
178
WILLIAMS'S  PRINCIPLES OF MEDICINE.
instances, causes  the vessels  to  contract afterwards to their natu
ral size;  so that the congestion is completely removed.  In some
cases, however, the stimulus fails to clear the congested vessels ;
the enlarged arteries pour in  more blood ; but this not overcoming
the obstruction, increases the congestion, and,  as we shall after-
wards see, may convert it into inflammation.   Thus both  stimu-
lants  and astringents, although  occasionally remedies for conges-
tion, sometimes tend to increase it;  and this they are most likely to
do when the congestion is great or of long continuance, or when
its causes are still in operation.
  318. Under such circumstances congestion is better relieved by
another  class of  remedies,  depletion,  and various  evacuants.
Bloodletting, by puncture or  incision  in  the  congested parts,
enables the distended vessels to unload themselves,  and they may
recover their size; and the utility of  this expedient is  shown in
scarifications of congested conjunctiva? and tonsils.  But the blood
is more usually drawn from the vicinity of the congested  part, as
by cupping, or leeches  on the chest or side  for  congested lungs
or liver ;* to the  sacrum for congested uterus ; or by leeches to
the anus for  congested  intestines.  Or,  without actually shedding
the blood, it may be drawn  away from the congested part by de-
rivation ;  that is, by agents which  cause determination of blood
or congestion in other  parts; as  dry  cupping, mustard poultices,
and other stimulating applications  to the  surface,  and by purga-
tives and other evacuants from the interior.
  319. The operation of several of the  foregoing agents, in com-
bination  or  succession, is generally more effectual than that of
single ones in  the cure of congestions.  Thus congestion of the
liver  may resist the action  of mercury, and may even be aggra-
vated  by it (§ 294), until the vascular  distention  has  been par-
tially reduced by local  bloodletting or  derivants;  then the mer-
cury, by increasing the  secretion, reduces the remaining congestion.
Congestion of the kidneys is augmented rather than diminished
by diuretics, which then fail to increase  the secretion of urine, but
may only render it more albuminous  (§ 304).   But after some
relief has been given  by cupping to the loins,  and  hydragogue
purgatives and diaphoretics, then some diuretics,  particularly digi-
talis and cantharides [and minute doses of tartar  emetic], cause a
freer  flow of urine with  less albumen.  The  same point  might
be further exemplified ;  but it is unnecessary to multiply instances.
   320. The  cause of congestion being, in many instances, atony
of  the vessels  (§ 290), it may often  be counteracted  by circum-
stances which augment  the  tone of  the vessels, locally or gene-

  * It is remarkable how quickly congestions may be reduced by these means.
I have known a congested liver, which reached from the umbilicus to the fourth
right rib, (as traced by percussion,) reduced in twelve hours to its normal dimen-
sions by cupping and free purging.  Piorry describes a still more speedy reduc-
tion of the liver in ague, by the influence of the sulphate of quinine. 
              PROXIMATE ELEMENTS OF DISEASE.           179

rally.  Thus cold, astringent, or, occasionally, stimulant applica-
tions, by bracing  the  fibres  and invigorating the circulation in a
part (§ 124), render it less liable to congestion from  disease ; and
general tonic  measures operate in a similar way on  the whole
system.  Probably the efficacy of bark and arsenic in preventing,
as well as  in  removing internal congestions in ague, depends on
their power of augmenting the tone of the vessels of these parts
(§  315).   A similar virtue seems to be possessed, in some degree,
by iodine and its preparations, especially the iodide of potassium ;
under the use of which  the  disposition  to  local congestions is
diminished, and  those formed  are sometimes dispersed.  Mine-
ral acids and  other tonics [more particularly chalybeates] have a
like effect in cases of general weakness.  The treatment calculated
to remove the results  of the congestion will be  considered  under
the subjects, Flux, Dropsv, and Inflammation.
                         SECTION V.

       LOCAL  HYPEREMIA—EXCESS OF BLOOD IN A PART.

   II. WITH MOTION INCREASED--DETERMINATION OF BLOOD.

  321. Numerous examples of this kind of active hyperaemia are
presented in health  as well as  in disease.  Blushing, the growth
of the stag's antlers, and the uterus and breasts at the periods of
gestation and lactation,  furnish instances occurring in health.
The increased number and size of the bloodvessels,  manifest by
the vascular redness in these cases, show the increased quantity of
blood in the part; and the stronger pulsation of the arteries lead-
ing  to the part indicates the  augmented motion of that  blood
(§ 274).
  322. In disease we meet with many examples. Determination
to the head is  one familiarly known ; and  it affords  the opportu-
nity of displaying one of the characteristics of determination, in the
enlargement and  throbbing of the carotid  arteries.   I have wit-
nessed this phenomenon in a great variety of cases.   One patient
was subject to attacks of determination of blood, which caused him
so much suffering and loss of moral control, that  he cut his throat
to destroy  his life.   When recovering from  the wound, attacks
sometimes came on ; first with beating of the carotids, then flush-
ing of the face and head, suffusion of the eyes, and sensations of
distraction  in  the head.  In  the  slighter attacks,  these symp-
toms would all pass away  in  a  minute or  two.    I  have, in
several cases, observed  the  same symptoms usher   in  the pa-
roxysms of mania.
  323. Fits of epilepsy  and  convulsive  hysteria are  immediately 
180
WILLIAMS'S PRINCIPLES OF MEDICINE.
preceded by throbbing of the carotids, which shows that deter-
mination  of  blood  is the  proximate  cause of the paroxysm.
Drs. Darwin  and Parry relate  cases  in which convulsive fits
were prevented by pressure on  one of the carotids; and I have
practised this expedient with success in several instances.  Many
of  the epileptic patients whom  I  have questioned have stated
that the fit is always preceded by palpitation, which for reasons be-
fore explained (§ 266), sometimes peculiarly determines blood to
the head.   But without the patient being conscious of palpitation,
there may be determination  of blood to the  head; and in nume-
rous observations, I  have found  this to be so commonly present,
that I believe it to be the common immediate cause  of the sud-
den paroxysms of various kinds  of  disorder  which affect the ner-
vous centres.    Infantile and puerperal  convulsions are probably
to be included in this remark, although they may be  connected
with very different conditions  of the vascular system in point of
fulness.
  324. But the most common cases of determination of blood are
those caused  by the  application of stimuli.   Thus heat causes a
flow of blood to the surface ; snuff,  to the nose and eyes ; spices
in the mouth, to the salivary glands; food in the stomach, to its
secernent vessels ; purgatives, to the vessels of the intestines, and
those of glands connected with  them ;  diuretics, to those of the
kidneys,  &c, &c.  In  fact, in the operation  of  most medicines,
there is an increased flow of blood to particular organs or surfaces;
and there are few diseases unconnected with local determination of
blood.  We shall find hereafter that it occurs in inflammation as a
part of that complex process; but  Dr.  Parry was wrong in sup-
posing that inflammation consisted in this alone.
  325. Now, what is the physical cause of determination of blood ?
In some cases, increased action  of  the heart (§  112) may propel
the blood with unusual force  and quantity to the arteries in its
immediate vicinity (§ 266) ;  and  thus determination  of blood to
the lungs, the  neck, and head, is a common result of  inordinate
action of the heart.  But in many of  the examples above cited,
(§ 323, 324), local determination takes  place  without any  increase
of the heart's action.
  Is  determination of blood caused by increased action of the
arteries ?   The only  active property which we know these vessels
to possess  is  that of slow or tonic  contraction (120);  and  such
contraction of arteries leading to a part would  diminish instead
of increasing the motion and quantity of blood proceeding to the
part (294).                                            &
   326. We may answer, from direct observation as well as from
reasoning, that determination of blood is effected by  enlargement
of the arteries  : and this enlargement is the  effect of the  pressure
of  the arterial distention from behind acting on a tube  which has 
PROXIMATE ELEMENTS OF  DISEASE.
181
lost some of  its contractile power (§ 120).  The  tonicity of  the
arteries makes  them  naturally resist the  distending influence of
the mass of blood  pumped  into them by the heart; but if this
tonicity be impaired in any part, that of  other  parts  forces  the
blood in augmented quantity into it, by which it is distended, and
becomes an  enlarged channel  for the transmission of more blood
and more force (§ 323).   If the arteries are enlarged, the  capilla-
ries and veins leading from them will be also enlarged, and will
share  the  increase  of blood and motion  thus supplied to them
(§ 298, note).   We find the proof of the enlargement and disten-
tion of arteries leading to an inflamed or irritated part in their in-
creased and  harder pulse  ; the coats of the vessels being stretched
to tightness, the pulse is  no longer softened by the  usual elastic
spring.
   So, too,  in the frog's  web gently  irritated by an aromatic water,
 we see the arteries become enlarged, supplying a larger and more
 rapid flow of blood to the capillaries and veins, which all  become
 enlarged also; and  the whole vascular plexus, including  vessels
 which  before  scarcely  admitted red  particles, then become  the
channels of  a  much increased current.   This is  determination of
 blood.*

   * As these phenomena have not been dis-              Fig. 1,
 tinctly described  by observers apart from the
 further effects resulting from over-irritation,
 which leads to obstruction and inflammation,
 1 will state  shortly some results of many
 observations on the circulation of the frog's
 web, under the influence of moderate stimuli
 applied to it. These observations were made
 in the summer of 1841, and some of them
 are  mentioned in my Gulstonian Lectures,
 published in the Medical Gazette of July,
 1841.
   The  arteries may be distinguished from
 the veins in the frog's web, not only by the
 direction of their  current  and its  greater
 rapidity and transparency, but also by  a
 series of lines along  their course, marking
 the size to which they have been distended
 at some previous time.  (See A, Fig. 1.)
 These lines or channellings are most distinct,
 and are more remote from the artery at its
 angles or bifurcations.   They are to be seen
 sometimes  along the veins, but much less
 distinctly.   Now these lines are in them-
 selves  proofs of the varying distention of the
 arteries, and they also furnish the means of
 measuring this varying distention.
   When a weak infusion of capsicum is ap-
 plied  by a camel's hair pencil to the web,
 there is a momentary retardation of the cur-
 rent in the veins, and the artery distinctly shrinks in size.  But in a few seconds
 the reverse  takes place ;  the artery swells to beyond its former size, and reaches
              16
 
182
WILLIAMS'S PRINCIPLES OF MEDICINE.
   327. There appears, then, to be no difficulty in tracing local de-
 termination of blood  to its physical cause, enlargement of the
 arteries leading to the affected part.   But it is not equally easy to
 find a physiological explanation  of the cause of this enlargement.
 The terms "active dilatation" (Hunter) and "vital turgescence"
 (Kaltenbrunner)  have  been applied  to the condition in question ;
 but all that is known of animal physics is opposed to the possibility
 of there being a power of active dilatation in the arteries.
   The physiological condition seems to be a weakening or reduc-
 tion of the tone (§ 123) of the  artery; so that it becomes passively
 distended  by the vis a tergo.  In some cases, it might be supposed
 that this weakness is the result  of previous  stimulation (§ 116);
 and it has been stated above that a momentary contraction of the
 artery precedes its dilatation.  But the dilatation is out of all  pro-
 portion to the previous contraction; and, in some cases, as in
 blushing and in the growth  of parts,  there is  no sign of any pre-
vious contraction.
  Dr. Billing ingeniously conceives that, by stimulating the nerves,
 the nervous  influence is drawn  away from  the vessels; and  that
their contractility, being derived from this influence, is thus  im-
paired.  But besides other objectionable points, this view assumes
Fig. 2.
                              the outmost line of its channel ;  the flow of
                              blood through it is too  rapid to be distin-
                              guished, and all  the capillaries present a
                              scene of busy motion ; in some the particles
                              passing in numbers and  speed greater than
                              the eye  can appreciate ; in others, before
                              invisible, single files force their way in more
                              deliberate, but continuous motion ; whilst in
                              the veins the movement is again more rapid.
                              This motion soon begins to fiag, and becomes
                              remittent or oscillatory in some capillaries;
                              and it is seen that  the arteries have already
                              begun to shrink in size,  and  the channelled
                              lines which they had  reached  re-appear.
                              Sometimes, in shrinking, the artery assumes
                              for a time a more tortuous shape than before
                              (as A, in Fig. 2) ;  so that its walls cease to
                              be parallel  with the lines, which seem to
                              show thai it contracts in diameter before its
                              length is proportionally reduced.  The con-
                              traction of the artery, and consequent reduc-
                              tion  of the  quantity and movement of the
                              blood in  the vascular plexus, was promoted
                              by repeated  applications  of  coid  water
                              (§ 124),  which  in some  instances stopped
                              the motion of the blood  altogether, by con-
                              tracting the artery to so small a size, that no
                              blood panicles  entered  it.  A solution of
                              acetate of lead  also produced this effect.
                                The determination of  blood thus excited
                              produces an increased redness quite visible
to the naked eye;  but it is less intense, and  more florid than the redness of in-
flammation or congestion.
 
PROXIMATE ELEMENTS OF DISEASE.
183
that muscular irritability, even in its lowest form, tonicity, is a pro-
perty derived from the nerves—an  assumption unwarranted by
the facts and opinions most  generally received by physiologists
(§110).
   328. There can be little doubt  that the nerves — especially the
sympathetic  (§ 152) — are sometimes concerned in causing deter-
minations of blood ;  and it is not improbable that their influence
is that of reducing the contractility of particular arteries, just  as
strong moral emotions, acting through  the  nerves, paralyse the
sphincters  and  muscles  of voluntary motion  (§ 144, 154).  But
the laws of tonicity, and its relation  to the nervous influence, re-
quire further investigation.(a)
   329. We can  see something of  the final cause of determination
of blood.  " Ubi stimulus, ibi fluxus."   The flow is intended to
support the well being and function of the part.  If any influence
disturb its  well being, or excite its function, more blood is wanted :
the arteries dilate  to supply more and in greater force, and thus
the circulation through the part  is augmented.  The result is, in
moderation, to increase the redness,  warmth, sensibility, secretion,
nutrition, and other functions of  the part; in  excess, to disorder
and alter them.
   330. We have hitherto considered local determination of blood
as resulting from causes which directly affect that part of the vas-
cular system in  which the determination takes place.   In  not a
few cases,  however, the  same result arises from opposite  causes
acting on other parts of the vascular system.   Thus, as we found
external cold cause internal congestions by intropulsion (§ 292), so
too it may occasion internal determinations of blood.  By constrict-
ing the vessels of the surface and extremities, it directs the force
as well as  the quantity of  the circulating fluid on internal parts,
or those  beyond its influence.  Thus, in many persons cold weather
causes palpitation, dyspnoea, pain in the chest,  throbbing and pain
in the head,  gastralgia, colic, and  fluxes  of various kinds, whilst
the extremities are cold, the  surface  chilly, and the radial  pulse
very small, even when the heart  beats with great force.  It is ob-
vious that  in such cases this force is expended chiefly on internal
organs, which thus become the seat of determination of blood.(b)

   (a) No attempt at a satisfactory solution of the problem in this
case can be made without admission  of nervous agency,  and as a
consequence  a peculiar vital condition of the vessels through it,
different from, and something more than  mere elastic dilatation ;
as we more  readily learn  by comparing  the  phenomena accom-
panying the  throbbings of an artery in hysteric paroxysm with one
from aneurismatic dilatation.  It  is in the capillaries in which the
elastic tissue least and the nervous most abounds  that we see the
chief evidences of determination of blood.
   (b) This favourite hypothesis  of  the author, which he  so fre-
quently  introduces, to explain the effects of cold, has been com.
mented on, in note,  p. 66, et seq. 
184          WILLIAMS'S PRINCIPLES  OF MEDICINE.

  The subjects in whom cold causes internal determinations of
blood, are chiefly those  endowed with much irritability (§ 113),
but little blood (§ 261).  The same persons likewise are liable to
a flush of blood to  the face and head, with  coldness of the feet,
when they go into  a warm room.   By cooling the head, the feet
become warm; or by warming the feet, the head cools.
  331. Attacks of local  determination of blood from other causes
are often accompanied by shivering fits, pallidity, coldness of the
extremities and defective  secretions, particularly in persons of
weak circulation.  When an unusual quantity, and force of blood
is determined to one part, there must be less in other parts, whieh
therefore suffer from the  deficient supply.  This furnishes an im-
portant therapeutic indication, to be noticed hereafter.(a)
  332. As we find determination of blood to be  chiefly  produced
by an enlargement of some arteries from a reduction of their tonic
power (§ 326), so we may be led to expect that such enlargement
may affect any part of the arterial system.  We have chiefly con-
sidered it in relation to  the distribution of blood  to  parts ;  but  it
may also occur in the great arterial trunks.  Inordinate  pulsation
of the aorta, especially in the  abdomen at the cceliac axis, or at
the bifurcation into the  iliacs, (corresponding with  a little below
the epigastrium and umbilicus,) is a common symptom in nervous
subjects   Epigastric pulsation I have  found frequently before
and after hamiatemesis.  In one case, haematuria and lithic depo-
sits in the urine occurred in a woman affected with strong pulsa-
tion at the umbilicus.(6)

      SYMPTOMS AND EFFECTS OF DETERMINATION OF BLOOD.

   333. Many of the symptoms of determination  of blood, may be
learned from the preceding illustrations.   It generally exalts con-
tractility, (§  112,) sensibility, (§ 126,) and other nervous properties
(§ 149) of the part, causing spasm, pain, irritation, and sympathetic
disorder.  In its moderate degrees it  increases the natural secre-
tions  of the part (§ 162,) and thus becomes the cause of mucous,
bilious, and urinary fluxes, &c.  The nutritive function is likewise
increased, and more naturally than  from congestion, the  result
being a more simple and general hypertrophy of the  part.  The
process of absorption, although favoured when the current is acce-
lerated without distention, is often  not equal  to  the  effusion.
  (a) The explanation in the text may be met by a case in which
it is not applicable ; as when flushed face, and  throbbing  tempo-
rals and carotids  accompany accumulations in the colon, the re-
moval of which latter by spontaneous evacuation is soon followed
by the disappearance of the former.
  (b) The enlargement of the great vessels, as far at least as their
proper elastic coat is concerned, mentioned in the text,  is quite
problematical, although the throbbing and pulsatile movements are
certainly more manifest. 
PROXIMATE ELEMENTS OF DISEASE.
185
 Hence in sacs and cells  determination  of blood  may cause
 dropsy.
   A few examples will  suffice to illustrate the symptoms  and
 effects of local determination of blood.
   334. The  parts most subject to determination of blood are those
 most freely supplied with bloodvessels, (§ 30,) as the brain, the pa-
 renchyma of glands, mucous membranes, and the skin.
   335. Determination of blood to the head often takes place in some
 persons from mental excitement, violent exertion, stimulant drinks,
 or defective  excretion.   The symptoms vary considerably; but in-
 creased beating of the carotid and  temporal arteries, some flushing
 of the face and suffusion of the eyes, and an increase of the symp-
 toms on stooping, or lying with the head low are commonly per-
 ceptible in all cases.  The other symptoms are sometimes those of
 simple excitement of the nervous  centres, painful throbbing in the
 head, excessive sensibility to light and sound, flashes in the eyes,
 noises in the ears, an excited state of the mind, rapid flow of ideas,
 sometimes bordering on  delirium, wakefulness or  dreamy sleep,
 restlessness and irritability of temper.  Sometimes these symptoms
 are  replaced  by others  indicating  a  temporary oppression of ner-
 vous functions, such as giddiness, drowsiness, stupor, imperfect
 vision and hearing, with apparent specks or  mist in the eyes, im-
 paired articulation,  and power of locomotion,  occasionally with
 various convulsive affections, as in hysteria and epilepsy.
   336. It may seem difficult to  explain how such opposite  symp-
 toms, those of excitement and those of oppression, are produced by
 the  same cause—determination of blood.   But the explanation is
 readily found on referring to the true nature of determination, and
 the  different  modes  in  which it affects the circulation within  the
 head.   Moderate  excitement of the brain, as by  bodily exercise,
 mental exertion, or certain beverages, such as tea and coffee, is ac-
 companied by  increased but equal flow of blood through the brain.
 But if these  or other causes  of  excitement operate  in excess, the
 arteries supplying the  brain are still further dilated, and convey
 blood to it with more force without an equal  increase  in the  pas-
 sage of the blood through it; and this for two reasons.  1. We have
 already found that a certain proportion in the size and elasticity of
 the vessels best qualifies them to  transmit  blood freely (§ 301);
 and  that where this is wanting, increased force does not compen-
 sate  for it, but often causes new disorder.   Thus in  violent palpi-
 tation of the heart, the aorta, carotid, and subclavian  arteries are
 often dilated, and throb  strongly; but the weak pulse at the wrist
 shows that much force is expended on the larger  trunks, without
 reaching their distant branches.  This  too  is one reason why, in
determination of blood to the head, the force  is sometimes  more
expended  in the larger vessels at the base of the brain than trans-
mitted throughout its substance.  2. Another reason for unequal or
defective excitement  from determination of blood to the  head, is
the unyielding nature of the skull,  which permits no considerable
             16* 
186          WILLIAMS'S PRINCIPLES OF MEDICINE.

enlargement of any of the vessels within it, without a correspond-
ing diminution of other vessels, and a general compression  of  the
cerebral substance.  Hence distention of the arteries beyond a cer-
tain degree, will compress and obstruct the  small veins, and thus
prevent that freedom of circulation on  which functional activity
depends.  On these principles may be explained the production of
symptoms of depressed as well as excited energy of  the nervous
centres, and often a mixture of both, from the same cause, deter-
mination of blood (§ 153).(a)
   337. Determination of blood to the kidneys is caused by stimula-
ting diuretic drinks, and besides the increased  flow of urine, may
produce pain in the loins and throbbing  in  the abdominal aorta.
Excitement of the circulation, by exercise or by nervous affections,
also reaches the kidneys; exercise  carries off much fluid  by  the
skin ; but nervous excitement, where it fails to cause perspiration,
determines more to the kidneys, and this seems to be the source of
the abundant flow of limpid urine  which follows  convulsive and
other nervous affections.
   338. Determination  of blood to mucous membranes is exem-
plified in certain forms of dyspepsia, in which sudden pain, or heat,
or nausea, is felt in the stomach, accompanied by epigastric pulsa-
tion, and sometimes followed by eructation of sour or other liquid,
and sometimes by hasmatemesis.  These attacks are often induced
by excitement, general or local, from irritant ingesta.
   339. Determination of blood to the skin is often  produced, not
only by direct irritation, but from the influence of internal causes;
as in  case of blushing from mental emotion,  flushing of  the face
from acid in the stomach, and the general redness of the surface
in reaction  after cold, or at the commencement of fevers.(6)   In
  (a) In close connexion with the  topic discussed in the text are
the remarks made by M. Andral [op. cit.), on the production of the
phenomena, here attributed  to determination,  by means  of the
varying proportion of the red globules in the blood,  both when
they are in excess and when deficient.
  '• Those individuals whose blood contains an excess of globules
are  subject to some special disorders, of which hitherto no satis-
factory explanation has been  given.  They are, vertigo, indistinct
vision, singing in the ears, heat of the head, attributed to conges-
tions (determination) of blood towards the brain; but these  con-
gestions have never been proved anatomically, and the sole passage
of globules through the vessels of  the encephalon seems to me to
constitute  a circumstance adequate to explain them ;  but  singu-
larly enough, if, on the other hand, it should happen  that  the
globules traverse  in too small a number  these vessels, analogous
disorder is met  with;  so that either an excess or a defect of glo-
bules deranges in the same manner certain cerebral acts." p. 46-7.
  (b) The propriety of calling determination an excitement of the
skin, when it is the reflection of a similar and simultaneous excite- 
PROXIMATE ELEMENTS OF DISEASE.
187
various chronic skin-diseases the effect  of determination is seen
in a brightening of the  colour of the eruption, which may take
place  in a few minutes.
  340. Determinations of blood are often transient, coming on
suddenly and soon subsiding.  When they are more permanent,
they commonly lead to other disorders.   In their immediate  seat
they cause either increased secretion, with the addition of more or
less of the watery,  saline, and albuminous parts of the blood, or
hemorrhage, or they may pass into inflammation.  In other parts
of the body, there is often, at first, coldness, and defective circula-
tion and  function,  (§ 330,) but afterwards  there often succeeds a
febrile reaction, with hot skin, accelerated pulse, scanty secretions,
and other symptoms of inflammatory fever.
  341. The frequent recurrence  of determination of blood or its
long continuance in a  lower degree, affects the structure ; in-
creased nutrition, hypertrophy, being the  result.  This may be a
natural kind of hypertrophy, as in the case of muscles, which
increase in size in proportion to their exercise, which increases the
circulation of blood through them.   So the uniform  hypertrophy
of the substance  of the heart, and of other organs, after long  con-
tinued excitement of that organ, may be  referred to  the increased
determination of blood that  has been  kept  up.   In other cases
parenchymata, as those of the kidneys and  liver, exhibit altera-
tions rather than mere growth; and albuminous deposits  and
granular  degeneration result.  In these and other cases the effect
on the structure  is  commonly modified by the occasional  presence
of congestion, inflammation, and the plastic condition of the blood
itself (§ 211).
  It is unnecessary to dwell further on the phenomena and results
of determination of blood, as we shall have to advert to  them in
connexion with  its occasional results — flux and hemorrhage, and
with inflammation, of which it is a component part.(a)

ment  of another and remote organ, may be doubted ; as in redness
of the skin with irritation and injection of the mucous  membrane
of the stomach.  This certainly is not  "local hyperaemia."
  (a) The author has directed his attention somewhat exclusively
to that variety of "  determination of blood" resulting from a loss of
balance between two organs or parts, by which deficiency in the
circulation in one causes, or is supposed to cause, undue action or
determination in another.  He instances the " intropulsive"  effects
of cold in proof of his view, and points to cold feet and hot head
as example, adding  that  the remedy will be to warm the  feet
and cool  the head.   The phenomena in  these cases are  obvious,
the  cause not so clear.  The determination to  the  head may be,
often  is, the result of undue direct excitement of the  brain, which
may be followed  by  coldness of  the  feet; so that, in  fact, the
determination of blood to the head is here the cause and not the
effect of the loss of balance in the general circulation and feebler 
188         WILLIAMS'S PRINCIPLES OF MEDICINE.
           REMEDIES FOR DETERMINATION OF BLOOD.

  342.  In the treatment of all cases of determination of blood, as
of diseases in general, it is obviously proper, as  much as possible,
action in the vessels of the feet.   But we shall be told, that, for all
practical purposes, the doctrine in the text is sufficient, since, if we
restore healthy action and active circulation  to the feet, we shall
relieve the head of its fulness and over-excitement.   In some cases
this is correct; but in  others  the remedy will fail, and if continued
or increased in activity, as by the application of sinapisms, it will
aggravate the disordered and morbidly augmented circulation  or
" determination of blood to  the head."  Every now and then  it
has happened to most persons, that restlessness  and wakefulness,
with heat and throbbing of the vessels of the head, are most readily,
and, in some cases, only removed by exposing the naked feet, hot
and almost burning at the  time, to the air of the room.  We have
known  individuals who habitually had determination of blood to
the head, owing to constitutional formation and the large  use of
stimulating food and drinks,  and who could not sleep unless,  even
in cold weather, their feet  were uncovered.  These are instances
of the direct sedative and,  by sympathy, extended  operation of
cold to an organ remote from that to which the cold was applied,
— the very  reverse of intropulsive action.
  We are brought by these cases to an  inquiry into  that variety
of determination which may be regarded as the result of direct
sympathy, viz., the repetition in  one organ of a  mode of action
primarily begun in another.  Examples of this nature are found
in cerebral following gastric  excitement and determination, a state
of things adverted to in the text.  Determination to the brain ac-
companies also congestion of the liver, and, of the hemorrhoidal
vessels, pneumonia and certain  congestions of the  gastrointes-
tinal mucous membrane.   In all  these cases, and in others that
might be mentioned, there are two  coincident determinations of
blood in two remote organs,  which,  in  common, sympathize  with
one another. The relief of the one of these determinations  will be
procured by the removal of the other or the primary one, by means of
direct depletion and the diminution of vascularfulnessand activity in
the organ; and not by revulsion or derivation, as indicated in the
text for the  kinds of determination there described.  In the deter-
mination or  afflux of blood to the vessels of the foot preceding an
attack of regular gout, incident in plethoric state of the circulation
in the vena  porta, we have another example of the repetition at a
remote part  of an antecedent determination, and of its removal by
remedying the primary one.   Determination caused by leeches to
the mammas, followed by determination to  the  uterus, and men-
strual discharge, is another example in point.
  We have  not room  here to enlarge on this subject  so as to ex- 
PROXIMATE ELEMENTS  OF DISEASE.
189
to remove the exciting causes.  Thus, in  the numerous  class of
cases arising from the action  of stimuli  or irritants on the part
which is the seat of the determination, (§ 324,) the removal of
such  irritants, or the diminution of their action by soothing  or
diluent remedies, is a first indication.
   343. If we are correct in tracing local determinations of blood
chiefly to an  atonic distention  of the arteries supplying the part,
(§ 326,) we may expect measures which promote their contraction
to be efficient remedies.   This is the fact; for cold is one of the
most effectual means which we possess in subduing determinations
of blood: and this  was mentioned  as a chief remedy for the ele-
ment, defective tone (§ 124).  Astringent applications are equally
useful in some instances of local determination ; as in the applica-
tion of solutions of acetate of lead, sulphates of  zinc and copper,
nitrate of silver, and other astringent lotions to  external surfaces
(§ 326, note); but these are chiefly useful where the determination
is quite local and unconnected with generally increased circulation,
otherwise they become irritants rather than astringents (§ 317).
But besides cold and other astringents to the part which is the seat
of the determination, and  to the  arteries leading to it, derivants,
or means which draw away blood  by relaxing other parts of the
vascular system, are especially indicated by many preceding obser-
vations  (§ 330, 331, 340).   Of these  derivants, heat is  the  most
effectual, especially when combined with moisture.
   344.  Thus cold lotions or douche to the head, and the hot foot-
bath, are among the best remedies for determination to the head.
Taking copious draughts of cold water, or  more sparingly of iced
water, will often relieve epigastric pulsation and palpitation of the
heart [and every  now  and  then cause them  too].  The warm
bath, by deriving to  the surface, will diminish  the flow  of blood
to the kidneys.  I have known severe nephralgia  instantly relieved
hibit it in as full and  comprehensive a manner as its importance
requires.   The phenomena elicited by the various  movements
of the vascular system, under the heads of congestion and deter-
mination, cannot be adequately explained or understood without
large reference  to the laws of the nervous system, and a nicer
appreciation  than has  been hitherto  attempted  of  its sympa-
thetic actions, of  which we must expect to find an  evidence,
if not  a measure, in  the various  movements and  perturbations
of the  capillaries  and contiguous  smaller vessels  of an organ,
as we habitually do in the  movements of the muscular system.
Even with the additional information furnished by  M. Andral,
respecting the proportion of the red globules in cases of determina-
tions to  particular organs, we are still left in ignorance of the real
material cause of  these phenomena, since we find  them to  occur
both with an excess and  with a paucity of red globules. 
1 90         WILLIAMS'S PRINCIPLES OF MEDICINE.

by cold affusion on the loins; but the practice is too hazardous to
be recommended.(at)
  345. Various evacuant remedies may also be employed to coun-
teract determination of  blood, by determining a flow in another
direction ; and  thus purgatives, diuretics, and  diaphoretics, are
often  useful.  Of these, purgatives are by far  the  most powerful
and sure in their operation, and are of great  efficacy in  determi-
nations to the head.  Change of  posture, by elevating  the part
which is the seat of determination, may sometimes be  usefully
practised.
  346. But.  the most powerful derivant is bloodletting, general
or local.   By the microscope it may be seen how opening a blood-
vessel changes the currents of blood ; the currents of many vessels
are reversed and drawn towards the bleeding point,  whilst in
others  they  are retarded where they were before running with
great speed.   But bloodletting is unnecessary and injurious in
many  cases of determination of blood, especially  those attended
with a deficiency of blood in  the whole system ; and, as we have
seen, such cases are not rare (§ 330).   Dry cupping is a good sub-
stitute in some instances; but even this measure is more weaken-
ing than it  is  generally supposed to  be, for  much  blood being
extravasated into  the skin and cellular  texture, is really lost to
the system, as blood — its particles are  changed, and their struc-
ture destroyed.
  The cases in which bloodletting should be used are those where
determination to  an  important organ  is  combined  with some
general plethora  or local congestion, or has continued so long
as to threaten a termination  in inflammation.   A speedy blood-
drawing, as by cupping or free venesection, will  generally answer
hest.(b)
  (a) How does this practice quadrate with the author's notion of
the " intropulsive" effect of cold to the surface.   With our expla-
nation it harmonizes perfectly.
  (b) Considerable skill in diagnosis is requisite  to guide the prac-
titioner in his choice between general and local bloodletting; and
if the latter, to determine the extent to which it should be carried.
So long as the heart acts violently and with abnormal power, vene-
section should be preferred;  but after its beats are reduced, and
the presumed fulness of the bloodvessel system is diminished by
this remedy, then, if the determination  to  a  particular organ per-
sists, or appears for the first time, recourse may be  had to local
depletion.  When satisfied of the propriety of this latter, it ought
to be carried far enough to free the suffering  organ from the pres-
sure  and  irritation  of  the accumulated  blood  in it.  Depletion
short of this, by cups or leeches, only establishes or increases  the
already existing afflux  of  blood to  the part, and aggravates the
original malady.  It will  be safer, when we  can make  the selec-
tion, to draw blood locally from another  and remote organ sym- 
PROXIMATE ELEMENTS OF DISEASE.
191
  347. In the same classes of cases, certain remedies are useful
which seem to cause a general relaxation of the tonic fibres (§ 122)
of the vascular system, and an equalization of the force and  blood
which this system conveys (§ 331).   Antimony  is the chief of
these ; and it is most indicated where febrile reaction has begun.
  348. Another class of remedies suitable  for  determination  of
blood, attended with much  excitement, are sedatives,  or  those
which reduce the heart's action (§ 115), such as digitalis, hydro-
cyanic acid, and nitre.  These are chiefly useful where  the deter-
mination  occurs  in connexion with palpitation, as in the case of
the various  convulsive or other  sudden  nervous attacks which I
have proved to be so commonly excited by palpitation  (322-3).
I have  entirely cured several cases of convulsive hysteria, and
much  reduced the frequency of  the  fits in  epilepsy,  by  these
remedies,  sometimes combined with 'cold affusion on the head in
the morning, and the hot footbath at night (§ 331).  Hydrocyanic
acid probably operates chiefly on the organic excitomotory nerves,
and  by lowering  their functions  prevents the undue excitement
which they communicate to the  heart.   In this respect it surpasses
conium and hyoscyamus, which are also  sometimes useful  in
preventing  determination of blood arising  from nervous excite-
ment.
  349. We  have  found  (§ 330) that in  many instances  determina-
tion of blood to internal organs results  from weakness of the  circu-
lation, and especially a  want of tone in the whole vascular system
(§ 123) ; so that under the operation of cold  constricting the exter-
nal vessels,  or irritations exciting internal organs, the latter mono-
polise most of the blood and force of  the heart's action.  In such
cases, besides temporary means to equalize the circulation, (heat to
the extremities and surface, cold and astringents to internal organs,
gentle exercise, friction, &c.,) more permanent remedies are  to be
sought in tonics, and various particulars in diet and regimen, which
give  strength to the contractile fibre (§ 124),  and improve  the
quantity and quality of the blood (§ 271)  [and still more, give tone
to the nervous  system].
  Thus preparations of iron and bark are useful remedies in cases
of the weaker kind ; mineral acids, iodide of potassium, mild bitters,
and  the slighter metallic tonics, nitrate  of silver, sulphates of zinc
and  copper, are  serviceable  in  others which will not  bear  the
stronger tonics.   In the  use of any of these remedies it is neces-
sary to guard against their exciting effects on the  parts  which are
the seats of determination, by premising  or conjoining the tempo-
rary remedies (§  342, &c), against that condition, and by keeping
the secretions free and equally balanced.
  In all cases, country air, and exercise  suited  to the strength of

pathising  habitually with the diseased  one; by  which  we relieve
the bloodvessel system generally ; and also act by derivation from
the suffering organ. 
192
WILLIAMS'S PRINCIPLES OF MEDICINE.
the patient, and habits of posture opposed  to the peculiar deter-
mination, will  be found useful  in  removing and preventing this
morbid affection.
                        SECTION  VI.

                   RESULTS OF HYPEREMIA.

  350. Before we proceed to the third and more complex variety
of local hyperaemia, inflammation, we must  notice some remark-
able results to which the other varieties, when increased to a cer-
tain degree, tend, when  yet short of the  conditions  necessary to
constitute inflammation — I mean, hemorrhage, flux, and dropsy.
These results have been already mentioned as sometimes ensuing
from plethora, congestion, and determination of blood, and  in
describing hemorrhage, dropsy, and  flux, it will be  unnecessary
to do more than exemplify their occurrence in connexion with these
proximate elements, and to trace  the further  peculiarities which
distinguish each of these results.

                       I. HEMORRHAGE.

  351. When in any form of hyperaemia the bloodvessels are dis-
tended to a  great degree, they sometimes give way and blood is
effused.  I shall give illustrations of the more common cases of
hemorrhage proceeding from the kinds of hyperaemia, which have
been already described.
  General  plethora  (§ 275) not. unfrequently  causes hemorrhage
from the  nose (epistaxis), from the stomach (haematemesis, vomit-
ing of blood), from the rectum (hsemorrhois), and into or upon the
brain, apoplexy.
  352.  Congestion  from  venous obstruction (§ 289)  produces
hemorrhage in the cases of pulmonary apoplexy (hemorrhage into
the parenchyma of the lungs), from obstructive disease of the left
side of the heart; bronchial hemorrhage and haemoptysis (spitting
of blood) from tubercles in the lungs;  hasmatemesis  and  bleed-
ing piles from obstructions of the liver  from disease  or  violent
straining.
  353.  Congestion  from weakness  of the vessels (§  290)  often
causes hemorrhage  in  various dependent parts, in  congestive
fevers, and in various passive hemorrhages of weak subjects.  A
stooping  posture has been known  to cause cerebral  hemorrhage,
(apoplexy).  The erect posture  may bring on uterine hemorrhage
(§291).
  354. The congestion of the head from the intropulsive operation
of cold (§ 292) sometimes leads to epistaxis and apoplexy ; that
from previous  excitement of the stomach and kidneys in drunk- 
PROXIMATE ELEMENTS OF DISEASE.
193
 ards (§ 294), occasionally causes haematemesis and hematuria
 (bloody urine).  The congestion of  the  kidney in scarlatina is
 sometimes followed by haematuria.
    355. Hemorrhage, from determination  of blood (§ 322), is  ex-
 emplified in cases of epistaxis and apoplexy, preceded by increased
 beating of the carotids, flushing of the face, &c, (§ 335); hsema-
 temesis from various irritants  in  the  stomach ( 338); haematuria
 from stimulant  diuretics ( § 337); bloody dysentery from drastic
 purgatives, &c. (§ 324.)  So also we  shall find hemorrhage to be
 a common concomitant or result of inflammation.
    356. But all cases of general  or local hyperaemia now noticed
 do not result in hemorrhage : some additional element is wanting ;
 and  this additional element may be either in the bloodvessels or in
 the blood.
    357.  The bloodvessels  are sometimes obviously in a  diseased
 state.  Inelastic  and fragile, from osseous or atheromatous deposit,
 or aneurismal dilatation, the arteries of the  brain  become rup-
 tured under the influence of congestion or  determination of blood.
 Softened and lacerable from inflammation or malnutrition, blood-
 vessels give way in  various structures; and  in  this way hemor-
 rhage occurs from an inflamed stomach or colon, in tuberculated
 lungs, and in a diseased  uterus.   Sometimes actual  ulceration
 opens an artery  or vein, and  this is  not a very uncommon cause
 of hemorrhage in chronic  ulceration, or malignant disease of  the
 stomach, intestines, and uterus.   Mechanical injury may rupture
 bloodvessels in the  kidneys and nostrils: hence the haematuria
 and epistaxis which  sometimes follow violent  blows in the loins
 or on the nose.
    358. In other instances the  hemorrhagic disposition   can  be
 traced to a peculiar state of the blood, which is defective in fibrin,
 (§  196,)  but abounding in red particles, (§ 184,) as in petechial
 fevers, congestive  apoplexy, hemorrhagic small-pox, and other
 exanthemata.  But there are other cases in which the disposition
 to  hemorrhage prevails without any defect of fibrin or excess of
 red particles ; scurvy and purpura  are examples.   In the former
 [latter?] there is found to be  the very reverse of these  changes
 (§ 185, 196).*  It appears probable that an alteration in the quality
 of  the red particles  (§ 186) and fibrin  (§ 203)  is the real evil in
 these diseases.  The readiness with which textures become stained
 with  the colouring matter, the purple, brownish, or particoloured
 stains left by inflammation, and, in extreme cases, the altered ap-
 pearance of  the blood itself, seem to show  the colouring matter to
 be  diseased; and the failure of the healing process, and  the  re-
 markably loose and  bloodstained appearance of fibrinous  coagula

  *  In acute hemorrhagic purpura the fibrin is  not deficient, for I have  found  the
 blood  effused under the skin firmly coagulated.  1  have before mentioned  my
 experience that purpura is generally connected with imperfect action of the liver
(§ 171).
            17 
194
WILLIAMS'S PRINCIPLES OF MEDICINE.
which form on the spongy gums, or in wounds, seem to indicate a
want of vital plasticity in the fibrin (§ 211).   Further microscopic
observations are wanted on these subjects.(a)
  359. Another question connected with  hemorrhages relates to
the mode in which the blood is effused.  We have just seen  that
in some cases bloodvessels are distinctly ruptured (§ 357).  But in
other instances blood has been poured out in  considerable quanti-
tities from various mucous surfaces, and even from the skin, with-
out any discernible breach of vessels, or even of the surface.  This
statement has been  made,  particularly in regard  to  epistaxis,
haematemesis, and some remarkable cases of hemorrhage from the
skin, occurring successively at different parts of the  body.  Con-
sidering the size of the red particles of the blood, and the absence
of any visible pores  in the  walls of the bloodvessels, even under
the  highest magnifying powers, it does not appear possible  that
the particles can escape from the vessels without rupture either of
the  particles or of the vessels.(6)   At the same time, it  may be

   (a) M. Andral (op. cit.) points out  two different  states of the
blood as giving rise  to hemorrhages.   In the first  the  proportion
of globules  is at its highest physiological limit, or even goes some-
what beyond it; the fibrin preserving at the same time its normal
quantity.  This, as far as the blood is concerned, is the state  of a
 plethora, in which hemorrhages are of frequent occurrence, and
which is so  often relieved by them.  The second, and much  the
more common division of hemorrhages, is that in which the fibrin
is diminished in quantity and the red globules preserve nearly their
customary proportion.  Scurvy, the hemorrhages in the adynamic
 or putrid form of typhoid fever, and  in  the  petechial varietes of
 scarlatina, and even  in certain apoplectic seizures, present exam-
 ples of this kind.  M. Andral expresses his conviction, but without
 adducing cases within his  own  observation, that in hemorrhagic
 purpura when fully developed, the proportion of fibrin is less  than
 common.  The author in a note is of a contrary opinion.
   Although M. Andral does not believe in the primary occurrence
 of  hemorrhages from deficiency of red  globules; yet he has no
 doubt of their ready  and frequent recurrence  after large losses of
 this latter, because, at the same  time, the blood loses a notable pro-
 portion of its fibrin.  A practical lesson is deducible from this fact,
 viz., the impropriety of repeated bloodlettings with a view of stop-
 ping or preventing hemorrhage  ; since the remedy in this case will
 tend to produce the same morbid effects as the frequent recurrence
 of  the hemorrhage  itself, in impoverishing  the blood,  and thus
 throwing the system open to a return of the  disease.
    (b) If  the opinion, and it is the one which we  have  generally
 taught, be accredited ; viz., that  hemorrhages from mucous surfaces
 are in fact  bloody secretions, that is, blood forced through secreting
 vessels at once in place of being gradually changed into the proper
 .secreted fluids, then is there no great difficulty in  understanding 
PROXIMATE ELEMENTS OF DISEASE.
195
stated that in the frog the red particles do pass through capillaries
of caliber smaller  than  their short diameter; and in so passing
I have often seen  them rolled up in the manner of an ice wafer.
The appearances of capillary apoplexy, (cerebral  hemorrhage,)
and hemorrhagic inflammations of serous membranes, countenance
the opinion that many  minute vessels  become ruptured  at once,
probably in  connexion with an altered condition of the blood ; and
such  minute ruptures occurring in membranes would not be  dis-
cernible by  common modes of examination.

                  VARIETIES  OF  HEMORRHAGE.

   360. Besides differences  in seat, hemorrhages are distinguished
into active or sthenic, and passive ox asthenic; and the peculiarities
 of these varieties may be traced to the same elements as  the corre-
sponding  varieties of general and local hyperaemia, (§ 279,) excess
 and defect of the contractile power of the heart, (§ 110,) and of the
 tonicity of the arteries  (§  120).   Thus hemorrhages  preceded or
 accompanied by the symptoms of sthenic plethora, (§ 280,) or with
 determination of blood,  (§ 322,) are active or sthenic ;  whilst those
 occurring in  connexion with asthenic plethora, (§ 281,) or with
 mere congestion, (§ 287,) are passive or asthenic.   We may there-
 fore refer to the symptoms described under these  subjects for the
 precursory  symptoms of each kind of hemorrhage.
   361. But when the hemorrhage begins, it  may modify the pre-
 vious symptoms in various ways, besides the new local signs which
 the discharge of blood  produces.  In active hemorrhage, the  full,
 hard pulse  of sthenic plethora becomes modified by a remarkable
 jerk or thrill,  which is an important symptom where hemorrhage
 is only suspected.  I have noticed this thrill in the pulse even when

 how the  blood may escape without rupture of vessels.  Pus  is a
 secretion from inflamed surfaces, and yet its globules are larger
 than blood particles (Mutter's  Physiology, Bell's edit., p.  133).
 But if this, which is a morbid product, be objected as  not perfectly
 relevant, we  would repeat the remark of this same distinguished
 physiologist (op.  cit.,p. 437), that the  capillary bloodvessels are,
 for the most part, much more remote than the smallest branches
 of the ducts or secreting canals, and their caecal extremities even
 in the most complex glandular organs.  If, therefore, the passage,
 of whatever nature it may be, that allows  portions of blood exit
 from the capillaries into secreting cells, be  dilated, so as to admit
 at once of  the escape of  the  red particles, these can be  received
 and  passed in  by the  secreting canals without rupture of these
 latter or  disintegration of the particles themselves.   The  admission
 of this view of the manner in which  hemorrhages  take place  is
 easier, when we bear in mind the relatively greater thinness than
 common of the blood antecedent to the coming on  of hemorrhage,
 as explained  in the last note. 
 196          WILLIAMS'S PRINCIPLES OF MEDICINE.

 the loss of blood has been very trifling, and where no murmur ac-
 companies the heart sounds ; and I am therefore  inclined to think
 that it depends on an unusual abruptness of the heart's contraction
 (§ 113,) combined with irregularities in the tonicity of arteries in
 different parts, (§ 326, 332,) which cause these to react in succes-
 sive jerks at each pulse, instead of simultaneously.   In fact, this
 same thrill  sometimes is felt during a paroxysm of determination
 of blood to a part without any hemorrhage resulting.
    361. If the quantity of blood effused be  large, and especially
 if its  loss be rapid, syncope, or various degrees  of faintness and
 weakness, may ensue.  The pulse  becomes small, weak, and often
 irregular, the surface and lips pale ; either  consciousness, or the
 heart's action, may first fail, according to the posture  of  the pa-
 tient (§ 70), and the condition of anaemia (§ 262) is induced.
   362. Even after this faint state has been induced, in the course
 of a few hours the increased  action (reaction) returns; and it is
 under the influence of this that the pulse exhibits the  greatest de-
 gree of the jarring or vibratory character ; so that it may feel like
 a  loose wire twanging, or a  rough file drawn under the finger.
 With this state of the pulse, palpitation, throbbing of the  great
 arteries, and the various symptoms  of partial nervous excitement
 described under the  head  of anaemia, sometimes occur  (§ 265).
 During this reaction  the hemorrhage may be renewed.
   363.  If the hemorrhage is  inconsiderable, or if it be suddenly
 checked by styptics  before the vascular fulness or determination
 has been reduced, inflammation may ensue, with increasing strength
 and hardness of the  pulse, heat of  skin, and other symptoms of
 inflammatory fever.   On the  other  hand, hemorrhage to a consi-
 derable extent may remove the hyperaemia, and the various local
 and general symptoms of oppression, fulness, tightness, pain, and
 functional derangement which  it  had produced.   Thus we  find
 headache and  flushing  often  relieved by epistaxis; pain and op-
 pression in the chest  by hemoptysis; abdominal pain and pulsa-
 tion by haematemesis, melaena, or hemorrhoidal flux.
   364. But  the blood  effused may produce various disturbances
 and symptoms in the parts  into which it is effused.   Within the
 head it presses on the  brain ; and by interrupting the circulation
 through it, it may cause coma or paralysis (§ 273)  ; or  it may also
 break up the substance  of the brain, and cause death by syncope
 (§  116) and asphyxia combined.  In the lungs, the blood may  at
 once suffocate  by its quantity, or cause  dyspnoea and cough  until
 it is expectorated.  Here, too, it sometimes  breaks up  the texture
 of the lungs, leading to serious disorganization.  In glands it forms
 swellings, or is mixed with, and modifies their secretions, as in the
 case of haematuria.  In  other complex textures, it  produces swell-
 ing, often followed by  local inflammation ;  as instanced in the
 cutaneous swellings of purpura hsemorrhagica.
   365. Passive or asthenic hemorrhage maybe preceded by symp-
toms of asthenic plethora (§ 281) or  congestion — may be accom- 
PROXIMATE ELEMENTS OF DISEASE.
197
panied by symptoms of exhaustion if the loss is profuse, of relief
if it be moderate; and anaemia  may ensue from excessive loss;
or reaction, sthenic hemorrhage, or inflammation, if the hemor-
rhage is too suddenly checked.   The hemorrhage connected with
an altered state of the blood is generally of the  passive kind, al-
though excitement, or  determination of blood, (molimen haemor-
rhagicum,) sometimes comes on here also.
TREATMENT OF HEMORRHAGE.
  366. As hemorrhage is  commonly a result of plethora, conges-
tion, or determination of blood, the remedies for these morbid ele-
ments will be more or less needed in its treatment.  But the neces-
sity for using these remedies will much depend on the extent and
seat of the hemorrhage, and the mischief likely to result from its
continuance.   For example : a moderate epistaxis or hemorrhoidal
flux needs no treatment: it is a natural cure for  a previously ex-
isting hyperaemia.   But if these hemorrhages be profuse, whether
of the sthenic or asthenic kind, they must be restrained : if sthenic,
by artificial bleeding, which is under control, and by derivants to
other parts, to reduce the fulness which causes the  hemorrhage :
if asthenic,  by styptics, combined  with  derivants, to  save the
blood, the loss of which is injuring the system.
   367. But in some cases, hemorrhage to any amount may be in-
jurious, and should  be opposed from the first, both by remedies
for the hyperaemia, which is the cause of the hemorrhage  (§ 345,
et seq.), and  by styptics, which  peculiarly counteract this result.
Thus hemorrhage from the lungs, or into the brain or other organ,
requires prompt interference.  The  same rule may be applied to
cases of excessive hemorrhage of any kind in all cases, and of
more moderate hemorrhage in very  weak subjects; in all of which
the loss of blood is a pressing danger.
   368. In active hemorrhage, generally, bloodletting may be^used
until the hemorrhage is arrested, or the pulse reduced  ; and this
effect should  be sustained  by other evacuants,  especially purga-
 tives and diuretics.   Remedies which diminish the  power of the
 heart, such as digitalis, hydrocyanic acid, and  nitre, and  those
 which also reduce the tonicity of the arteries, especially antimo-
 nial medicines, are likewise of great use in  some  active hemor-
 rhages.  Another powerful agent in hemorrhage, connected with
 increased action or determination of blood, is cold (§ 343).   Thus
 ice, or a stream of cold water on the nose and forehead  [also to
 the nucha and scrotum] in case of epistaxis, ice swallowed in hae-
 matemesis, ice applied externally, or icy water injected, for ute-
 rine hemorrhage, is of considerable efficacy (§ 344).(a)   I do not

   (a) No fear is expressed here of the intropulsive operation of cold.
 Regarded as  a general, not a topical, sedative, no fear need be en-
 tertained.
            17* 
198
WILLIAMS'S PRINCIPLES OF MEDICINE.
 approve of the practice recommended by some, of applying ice to
 the chest for haemoptysis; I have seen pneumonia thus induced.
   The treatment of passive or asthenic hemorrhage, besides styp-
 tics to prevent excessive loss of blood, will  include  remedies for
 general plethora, (§ 286), or local congestion, (§ 313, &c.) which
 may cause the  hemorrhage.  Hence general or  local depletion,
 derivants, accompanied or followed by tonics, may be useful.
   369.  We have now to consider the means calculated to restrain
 all kinds of hemorrhage, and which is especially opposed to  the
 causes which more immediately determine this result of disorder-
 ed circulation  (§ 356).   If bloodvessels are softened, brittle, or
 actually ruptured or ulcerated, (§ 357,) a chief thing to be done is
 to diminish the quantity of blood sent to them ; and, besides by
 bloodletting, this may be effected by pressure, posture, cold and
 astringent applications, and  means  calculated  to  tranquillize the
 whole circulation.  Thus epistaxis is sometimes arrested  by pres-
 sure  on the carotids; uterine  hemorrhage by pressure  on the
 abdominal  aorta, or by elevating the pelvis ; haemoptysis by keep-
 ing the chest high; and in all cases of hemorrhage, perfect still-
 ness and a cool regimen should be observed.
   370. The  other  pathological condition which favours  hemor-
 rhage, the altered state of the blood, (§ 358,) isperhaps more directly
 influenced by the remedies called styptics.   Most of these reme-
 dies are astringents, causing contraction of the tonic fibres of ves-
 sels and other parts, but some of them  also  coagulate  the blood,
 and in both  these  ways they may tend to restrain the hemor-
 rhage.
   Of those which cause both contraction of  the vessels and coagu-
lation of the blood, the most powerful are acetate of lead,(a) alum,
sulphate of copper, chloride of zinc,  nitric  and  sulphuric acids.
Others styptics, as nitrate of silver, sulphate of zinc, sulphate  of
iron  and infusion  of nutgalls, are certainly astringent,  and are
generally supposed  to coagulate the blood;  but Mr. Blake's ex-
periments show that they have not this latter effect when  injected
into the veins of living animals (see note to §214).  It is, however,
possible that, in a concentrated form, as where  applied topically,
they may coagulate the blood in the bleeding vessels.   This seems
to be  the effect, of nitrate  of silver  when applied to leech-bites.
 The actual cautery operates in a similar way.
   In some  cases of hemorrhage, the styptic  remedies may be ap-
plied directly to the bleeding part, as in epistaxis, haematemesis,
 haemorrhoids, and uterine hemorrhage.  In  epistaxis, solutions of
alum, acetate of lead, and sulphate of zinc, are sometimes injected
into the nostrils, or  applied by sponge or lint.   In haematemesis,
sugar of lead, alum, gallic acid, oil of  turpentine  in  small doses,

   (a) With little propriety can acetate  of lead be regarded as an
astringent.   It is a sedative, both locally and generally, diminishing
the activity of the heart and arteries, reducing animal heat, &c. 
PROXIMATE  ELEMENTS OF DISEASE.
199
and the mineral  acids, given by the mouth, operate  directly on
the bleeding part.   In excessive  hemorrhoidal flux, enemata, con-
taining some of these remedies, are immediately beneficial.
   371.  In many instances, the bleeding part is beyond the  reach
of the direct application of styptic remedies ; yet some of these
administered internally show considerable  power in  restraining
the  hemorrhage.   Thus,  haemoptysis  is  assuredly  sometimes
checked by frequently  repeated doses  of sugar  of lead, (which
should be combined with a little opium or conium, to prevent its
griping the  bowels; and, according to  some practitioners, by ipe-
cacuanha, gallic acid, alum, and other astringents.  Haematuria of
the passive kind is diminished by small doses of oil of turpentine;
passive uterine hemorrhage by ergot of rye, and tincture of the
sesquichloride  of iron.   Opium  given  internally  has  been  found
effectual in some cases of  uterine hemorrhage.   It is difficult to
explain how it operates ; but it  is probably through that property
by which it. diminishes  many secretions.
   372.  In some kinds of hemorrhage, especially those  of the intes-
tinal canal, the most effectual remedies are those which increase
the proper secretions of this canal and of its  allied glands; such as
mercurial and  saline purgatives, in combination  with others of a
styptic kind, such as sulphuric and nitric acids, alum, and sulphate
 of zinc.   This  mode of treatment is often sufficient in slight hemor-
 rhage, or dispositions to hemorrhage from the lungs  and uterus,
 and in purpura haemorrhagica  ; and there can be little doubt that
 it operates on the condition of the blood, as well as by  its evacuant
 and styptic effects.
II. FLUX AND DROPSY.
  373. Another result of various kinds of hyperaemia is an effusion
of the watery part of the blood with more or less animal and sa-
line matter in solution.  This result occurring in secreting organs
or open surfaces, constitutes fluxes; in closed sacs or cellular tex-
ture, it constitutes dropsies.  There is so much that is  common in
the pathology of fluxes and dropsies, that we shall avoid repetition
by exemplifying them together in the first place ; and we can after-
wards notice their distinguishing peculiarities.
  374. General plethora sometimes ends in flux or dropsy ;  but
such a result most commonly ensues where the  bloodvessels are
temporarily distended with an  undue proportion of watery con-
tents.  Thus, if much water be slowly injected into the veins ot an
animal, the circulation and breathing become embarrassed ; and
after a time dropsical effusions take place  into the abdomen, the
chest, and  the cellular texture; or a flux  (excessive flow)  takes
place from the kidneys, intestines, or skin; or all  these  results may
occur ; and the bloodvessels are relieved of  their  distention,   lhe
same events have sometimes arisen from excessive drinking of any
liquid, but chiefly where  the kidneys and the skin,  the natural
emunctories for superfluous fluid in the body, have failed in then 
200
WILLIAMS'S PRINCIPLES OF MEDICINE.
office.   Thus, drinking largely of a cold liquid when the  body is
perspiring and fatigued, checks the cutaneous and renal secretion;
the bloodvessels become filled to tension, and may relieve them-
selves  in dropsical effusions or diarrhoea.  External cold some-
times operates in a similar way; it arrests perspiration, and causes
internal congestions (§ 292), and if, from previous over-excitement
or other defect, the kidneys are unequal to perform what the skin
fails to do, general fulness is  the result, which tends to issue  in
some dropsy or  flux.  The sudden suppression of a cutaneous
eruption, or  of the discharge from an old ulcer, has sometimes been
followed by anasarca, diarrhoea, or bronchial flux (humid asthma).
The colliquative sweats of advanced phthisis are of the nature of a
flux, by which the bloodvessels, in  their obstructed and reduced
state, relieve themselves of superfluous liquid.   These sweats may
generally be stopped by a judicious restriction in liquid food.
   375. If we seek instances of local congestion terminating in flux
and dropsical effusion,  we  easily find them in almost every variety
of congestion that has been enumerated  (§ 288, et seq.).   In fact,
these are the most common causes of partial dropsies.
   The adequacy of venous obstruction to produce  dropsy is well
illustrated by some experiments of Lower.  He tied the jugular
veins of a dog, expecting the animal to die of apoplexy; instead of
this, the face and head of the animal became much swelled with
oedema.  He then tied the ascending cava; ascites and anasarca
of the lower extremities were the result.  Disease  affords nume-
rous examples of dropsy and flux from  venous obstruction.   Aneu-
rism of the arch  of the  aorta, or other tumours, by pressing on  the
venae innominatae, or descending cava, sometimes cause oedema of
the face and upper extremities. In a case (under my care) of ma-
lignant tumour involving the roots of the lungs, there were hydro-
thorax and  flux in the bronchial tubes (bronchorrhoea).  In  ad-
vanced pregnancy and  ovarian dropsy, the legs swell from pressure
of the tumour on the iliac veins.  Many instances  are recorded in
which obliteration of a large vein was followed by dropsy of  the
part from which the vein proceeded.  The ascending  cava has
been found obliterated  in persons who  had long been affected with
ascites  and  anasarca  of  the lower  extremities.   In  the Uni-
versity College  collection  there  is  a  drawing of  such a case, in
which a supplementary circulation had  been established by an
enormous enlargement of the superficial veins of the  abdomen.
Dr.  Watson relates an instance of the  same kind.*  M. Tonnele
has made some observations which favour the opinion that chronic
hydrocephalus is caused by a  partial  obliteration  of the venous
sinuses of the head (§ 267).
   But the most common causes of venous obstruction are certain
visceral diseases, and  these  commonly produce either  dropsy or
flux.  Thus the contractile disease of the liver,  cirrhosis, is the
most frequent  cause of simple ascites;  and in  connexion  with
             * Library of Medicine, Art. " Dropsy," vol. v. 
PROXIMATE ELEMENTS OF DISEASE.
201
 various functional and structural diseases  of the liver, diarrhoea
 and gastrorrhoea (watery eructations) are apt to occur.   Structural
 disease of the heart, especially if seriously affecting the orifices or
 valves, commonly causes hydrothorax,   bronchial flux, (humid
 asthma,) and sometimes general dropsy.  Pulmonary congestion
 from causes impeding  the  respiration (§ 298), such as spasmodic
 asthma, emphysema, laryngitis, hanging, and  coma, sometimes
 results in a bronchorrhoea or hydrothorax.  In the  experiments of
 Dr. J. Reid,a serous flux into the bronchial tubes ensued after the
 division of the par vagum, which, by impairing the  respiratory
 action, induces pulmonary congestion.*
   376.  As we  found congestion to arise from weakness of the cir-
 culation and atony of  the vessels  (§ 290), so dropsical  effusions
 and fluxes may proceed from the  same causes.  Thus oedema of
 the lower extremities is a common sign of extreme weakness; as
 after severe  illness, and towards  the fatal  termination of many
 chronic diseases.  Colliquative diarrhoea and perspiration (fluxes)
 sometimes occur under similar circumstances.   The oedema and
 fluxes which arise from weakness will be more readily induced
 by postures which cause gravitative congestion in the  affected
 parts.  Thus, continued standing causes swelling of the legs, and
 leucorrhoea, in persons liable to these results of congestion.
   377.  Fluxes  and dropsical effusions sometimes occur after pre-
 vious excessive  excitement of the  vessels of  a  part.   Hence
 oedema after erysipelas, and the infiltration of serum in cavities
 and textures after excessive  excitement  of the vessels  of these
 parts, even when no inflammation  has been  induced.   The gleets
 or  fluxes which follow inflammations of the  urethra, bronchi,
 alimentary canal,  and vagina, seem to  be  connected with  the
 same condition of the vessels  that sometimes causes  congestion,
 (§ 295).   Persons who  indulge in  spirituous  liquors often suffer
 in  the morning from  waterbrash, for which they  find a glass of
 spirits the best  [temporary] remedy: in   this case, however, ob-
 struction in the liver (§  56, 371) may also co-operate.
  378. Fluxes sometimes arise from the intropulsive operation  of
 cold  (§77, 292);  thus diarrhoea  and catarrhal  affections,  too
 transient to be  considered inflammatory, are frequently thus in-
 duced ;  and diuresis (flux of urine) is a  more  healthy example
 of this effect of cold.   It is doubtful whether  this operation  of
 cold will suffice to cause dropsy; but it may increase it where
 it existed previously.
  379.  The  other variety of  local hyperaemia, determination of
 blood (§ 321), may produce  fluxes and dropsies.   The influence
 of various stimulants on secreting  organs  and surfaces illustrates
 the production  of  fluxes in this way  (§ 324).  Thus snuff in the
 nose  determines a flow of nasal mucus and of tears ; spices  in
 the mouth provoke a  discharge from  the salivary glands;  irri-
tating vapours  inhaled cause a flux in the  air-tubes;  purgative
             * Edin. Med. and Surg. Jour., vols. 49, 51. 
202          WILLIAMS'S PRINCIPLES OF MEDICINE.

medicines induce a flux from the intestines, &c.   In these cases,
the irritation is short of inflammation, which, although attended
with determination of blood and effusion, comprises further effects.
   The fluid thus secreted  in  these  several cases of flux from
determination of blood, differs from the products of inflammation ;
it commonly consists of the natural secretion of the part  diluted
with an unusual proportion of water and saline  matter from the
blood, and the excess  of saline matter sometimes gives the secre-
tion an irritating quality, as in the fluid  of coryza, bronchorrhoea,
and watery diarrhoea.
   Other  examples of flux may be referred to determination of
 blood without special  irritations;  as the leucorrhoea  which pre-
 cedes and follows the menstrual period, the  bronchorrhoea or gas-
 torrhoeain some cases excited by increased action  of the heart, and
 the sweat succeeding to flushes  of  blood to  the head or other
 parts.
   380. Dropsy is less frequently a result of simple determination
 of blood ;  because, independently of inflammation, there are a few
 causes for such determination to closed  sacs.   But probably the
 dropsy accompanying  tubercles  in  the peritoneum  and mem-
 branes of  the brain may in  some degree be induced by the me-
 chanical irritation of  the tubercles causing a flow of blood to the
 membranes.  The sudden mode of attack which tuberculous hydro-
 cephalus sometimes  exhibits  seems to countenance the  same
 opinion.   These cases exhibit the phenomena of determination of
 blood to the head, described before (§ 323,) but here this proceeds
 to effusion of serum, with its more permanent  symptoms.   Th8
 kinds of dropsy called inflammatory may be included under this
 head ; but we shall shortly see that the  determination of blood, or
 excitement of  the circulation, sometimes present in such cases, is
 consequent on an altered condition of the-blood itself.
    381. As flux and dropsy commonly arise from similar conditions
 of the vascular system, so they are sometimes found to succeed to
 one  another.  Thus  Andral mentions  a  case  in which hydro-
  thorax was removed on the occurrence  of a profuse flux from the
  air-passages.  Examples are not uncommon of the subsidence of
  ascites on the  occurrence of diarrhoea,  or of the supervention of
  ascites  when  a diarrhoea of  long  duration has been  suddenly
  checked.  Dr. Watson quotes from Dr. Farre's lectures an instance
  in which  hydrocele  was removed by  violent  purging.  It  is a
  more familiar fact that the occurrence  of dropsy is attended  by a
  marked  diminution of the urinary secretion, and  that a free flow
  of this often reduces the dropsy.  On a knowledge of the preceding
  facts may be founded the most effectual treatment of dropsy.
    382.  Enough has  been said to show that  flux and dropsy, as
  well as hemorrhage, are occasional results of hyperaemia in its dif-
  ferent varieties.  But what are the circumstances which determine
  these results ?  In the case of hemorrhage, we found the additional
   or determining cause to be in the vessels or  in the blood (§ 350). 
PROXIMATE ELEMENTS OF DISEASE.
203
So certain conditions of these  favour the  occurrence of flux  and
dropsy.  An extreme amount of  vascular distention will  pretty
certainly result either in rupture and hemorrhage, or in the exuda-
tion  of the watery parts of the  blood (§ 305, 340), and the long
continuance of congestion  or plethora, by making the exhalation
predominate over absorption, rarely fails to lead to similar conse-
quences.  But in some cases both dropsical  effusions  and fluxes
take place with a facility disproportioned to the amount of hyper-
aemia or to its duration; and  in  these cases the cause may be
traced to a generally lax, flabby state of the  tonic and contractile
fibre (§ 123), or to a poor watery state of  the blood (§ 222), or to
both these conditions together.  Persons liable to these affections
are usually of pale complexion and phlegmatic temperament (§ 40).
   The influence which relaxation of the  solids has in producing
profluvial and hydropic affections is  exhibited  in the occurrence
of these results, in parts after over-excitement (§  294), where there
is no indication of general disease of the blood.   But in cases also
 in which the blood is diseased, there is usually a relaxed state of
 the  vascular fibre ; and it is not easy to  distinguish the separate
 influence of these causes.  Thus the liability  to dropsy  and fluxes,
 after  long  fevers, defective nourishment  (§  63, 196),  or confine-
 ment  in impure air, must be attributed to the joint operation of
 both classes of causes.
   383.  The conditions of the blood  tending to watery effusions
 require further consideration.   A poor or  watery state of the blood,
 above noticed, is the most obvious of these ;  and that this is alone
 sufficient is plain, from the fact that injecting matter in quantities
 into the veins of an  animal, will cause watery effusions or dis-
 charges, whilst the injection of  blood or  serum does not  produce
 this effect.   Persons who  have  lost much blood are liable to be-
 come dropsical from the same cause ; the bulk of the lost blood is
 replaced by watery serum absorbed  from  various sources; and
 thus  the blood is in a diluted state (§ 264).  The mode in which
 a watery blood tends to produce dropsy and flux, is not merely by
 the greater proneness of thin fluids to transude through the  walls
 of  the vessels, but also by the failure and irregular distribution  of
 the force of the circulation.   It has been  already explained, under
 the head of anaemia (§ 262), that  a scantiness of blood  embarrasses
 the circulation.   The structure of the heart, its valves and vessels,
 is  adapted to certain degrees of spissitude and  quantity of the
 blood ; and  when  these  vary  much from  the  natural standard,
 when the blood, instead of being of an unctuous fluidity, is watery
 and  squashy, the hydraulic  and  moving apparatus of the heart
 and vessels is less capable of effecting  its propulsion; and this
 condition of the blood may thus not only facilitate watery effusions,
 but promote the congestions and other imperfections  in the circu-
 lation with which flux and dropsy are commonly connected.
    3S4. Several of the  circumstances which induce the thin state of
 the blood have been already stated (§ 222, 249, 3S2), and in its rela-
 tions to dropsy, we would more particularly  advert to imperfect ex- 
204          WILLIAMS'S PRINCIPLES OF MEDICINE.

cretion by the kidneys, liver, and skin, as the most common cause.
In various forms of hyperaemia, which lead  to  dropsy and flux,
(plethora, congestion, and determination  of blood,) it  will  be
generally observed that  these results  ensue  iu  proportion  as
the excreting organs fail, and that the removal of these results is
to be effected chiefly by means which restore or compensate the
defective excretion.  In many instances, exposure to cold has been
followed by dropsy; and  at first sight this might seem to operate
merely by checking perspiration, and thus  retaining in the vessels
water that should be eliminated, and which is  then effused within
the body.  But checked perspiration alone will not cause  dropsy :
there must be a failure also in the action of the kidneys before
this result will ensue.  If  these act properly, checked perspiration
may disorder the circulation, and  cause  congestions, inflamma-
tions, and even fluxes ; but I have never met with a case of dropsy
arising from exposure to cold, in which the urine was not diseased,
and, in the great majority of instances, albuminous.
   The circumstances under which exposure to cold induces dropsy,
are such as also impair the action of the kidneys.  A man in a fit
of intoxication lies for several hours of the night on the cold damp
grass; he arises much chilled, has  shivering succeeded by fever,
and general dropsy ensues : the urine  is very scanty, and on ex-
amination is found to be highly albuminous.   The  vital proper-
ties of the kidneys had been exhausted by the excitement  of the
stimulant beverage, so that when cold checks the perspiration and
throws the blood on internal organs, the kidneys cannot perform
their usual vicarious action ; their vessels become distended with
blood, and mechanically exude serum instead  of separating the
proper constituents of urine  (§ 309);  these and the  superfluous
water accumulate in the  blood, and, by their quantity and irritat-
ing quality, cause effusions of serum  containing urea in different
parts of the body, as well as various other functional disorders
before noticed (§ 170).(a)

   (a) We would repeat here what has been introduced by us else-
where on the chief cause  of albuminous disease of the kidneys.
" Warning and monition are conveyed very impressively in the
following language of Dr. Bright:  ' Where intemperance  has
laid the foundation, the mischief will generally be so deeply rooted
before the discovery is made, that even  could we remove the
exciting cause,  little could  be hoped from remedies; but, at the
same  time,  a   more impressive  warning against  the intempe-
rate use  of ardent spirits cannot be derived from any other form
of disease with which we are acquainted; since, most assuredly,
by no  other, do so many  individuals  fall victims  to this vice.'
Constitutional circumstances  are  stated by Dr. Christison to pre-
dispose to it.  These are  the  constitution of intemperance, the
scrofulous habit, and that  state of the system which succeeds to
scarlatina." — (Stokes and  Bell's Lectures  on the Practice oj
Physic, vol. ii.; p. 39.) 
PROXIMATE  ELEMENTS OF DISEASE.
205
  Another instance  of a  similar kind of general dropsy is that
supervening after scarlatina.  This has been ascribed by some to
a sub-inflammation of the cellular texture, originating in the erup-
tion ; by others to the diseased state of the skin, left by the erup-
tion, suppressing  the perspiration.  But if either of these were the
true cause, the dropsy ought to  occur most in the cases in which
the  eruption  is most abundant, which  is  by no means the  fact;
nay, I have treated several patients in whom anasarca followed a
scarlatina fever, with sore throat, without any rash at all.  But in
all  these cases the urine has been albuminous, which again shows
that the diseased action of the kidney is the most essential lesion
connected with general dropsy.  How scarlatina impairs the  func-
tion of the kidney is a question too extensive to be discussed here ;
but I will simply state my belief that it does so by causing in  these
glands a highly  congested state, which  injures  their secreting
power (§ 304), as a parallel effect is observed with regard to the
liver in bilious and  intermittent fevers.   A female under my care
for albuminuria, which was almost cured, became affected with
scarlet fever:  the urine, which had been merely hazy by heat and
nitric acid, now became highly coagulable, and continued  so until
the fever declined, when it again gradually decreased.
   The general dropsical state occurring towards the  fatal termi-
 nation of structural disease of the heart,  I have in several  cases
 found to be connected with albuminuria and slight jaundice, and
 I have been long in the habit of pointing  out these as the most
 surely fatal complications to which heart diseases naturally  tend;
 their connexion has been before noticed (§ 305, 309).
   385. The pathological  effects of secretion of serous and scanty
 urine (oliguria) have been already described (§ 249, 170), but we
 must advert  to  the mode  in which  it  induces dropsy and flux.
 Where resulting from a suddenly operating cause, such as expo-
 sure to cold, or scarlatina, a febrile state is  generally present, with
 a frequent and hard or sharp pulse, heat of skin, thirst, &c.  These
 symptoms occurring in connexion with anasarca have led to the
 use of the terms  inflammatory, febrile, acute or active dropsy ; and
 so  far as these terms only imply an excited state  of the vascular
 system, they  cannot be objected to.  But  some have  employed
 them to explain the cause of the dropsy, as if this proceeded merely
 from the excitement or  inflammatory  condition.  That such a con-
 dition is present, is obvious not only from the febrile symptoms
 just mentioned, but also from the  buffy state of the blood drawn,
 and from the dropsical  effusions and fluxes being in many cases
 combined with the symptoms and products of inflammation.  Thus
 the anasarca  is  often attended  with  great tenderness, and  some-
 times with an erysipelatous redness  : swellings of the joints fre-
 quently have the character of rheumatic  inflammation ;  effusion
 in  the abdomen  and pleura is often  accompanied by pain or ten-
 derness, and after death slight deposits of  lymph are found  in ad-
 dition to the  serum ; catarrhal  flux  from  the bronchi, and diar-
            1S 
206          WILLIAMS'S  PRINCIPLES OF MEDICINE.

rhoea, are associated with symptoms  of more irritation  (spasm,
constriction, cough, vomiting, pain, and soreness) than occur with
simple fluxes.
  Now  this inflammatory  character may be  readily explained by
referring it to the irritating quality of the excrementitious matter
which the  failing function of the  kidneys  leaves in the blood.
Under such circumstances, urea has been found in  the blood and
in various effusions, and may be fairly regarded  as the  materies
morbi which irritates various parts, and from which the system,
seeking  to  relieve itself, (§ 17,) excitement  and  sundry  effusions
or discharges ensue.  In two points this condition resembles acute
rheumatism, (§ 331,) — 1, in the number of parts which may be
simultaneously or successively affected ; 2, in the want of any con-
stancy in the seat of the  affections.  Both these points  indicate
that  the  cause  is not essentially in any part, but in the blood.
Another circumstance which approximates these affections to gout
and rheumatism, is the nature of the excrementitious matter which
accumulates in the blood.   In the latter affections there  is good
evidence that lithic and lactic acids are the chief ingredients of this
matter;  but I have so commonly found an excess of urea in the
urine of patients recovering from rheumatism, and the chief reme-
dies for gout and rheumatism so distinctly increase the elimination
of this principle (§ 257), that  we can scarcely doubt that in these
affections urea also is either produced in excess, or insufficiently
excreted.   The proximity  in composition between lithic  acid and
urea, and the probable conversion  of the former into the latter,
(Liebig,) should not be forgotten.   Both gout and rheumatism,
like  oliguria, sometimes  produces  fluxes or catarrhal affections.
Lastly, the connexion between  these affections is apparent from
the fact, that rheumatism is frequently complicated with  albumi-
nuria (as after scarlatina); and granular degeneration of the kidneys
(Bright's disease) is apt to  supervene in the most aggravated forms
of rheumatism.
  386. But besides  the  retention  of excrementitious matter  in
the blood, there is a loss of albumen from this fluid.  That this
loss, by  thinning the blood, facilitates  dropsical and profluvial
effusions, is most probable in all instances;  but this seems  to be
the especial cause of these results in the more chronic cases, and
in the most anaemic subjects, for in these  (as it has been already
stated (§ 264), the blood is thinner and more watery than in any
other disease.   Thus in advanced stages of granular degeneration
of the kidneys, and sooner in anaemic subjects, almost every con-
gestion or determination of blood ends in watery effusion.   As the
powers  of the circulation fail, the effusion is connected chiefly with
gravitative congestion (§ 291), and occurs most in  the lower ex-
tremities ;  in this respect differing from the dropsy of acute albu-
minuria, in which the swelling also affects the  face, trunk, and
upper extremities.   This form of dropsy is well entitled to the ap-
pellation — asthenic or passive, both from  being connected with 
PROXIMATE ELEMENTS OF DISEASE.
207
congestion and weakness of the circulation, and from the poor con-
dition of the blood, and depressed or cachectic state of the func-
tions dependent upon it (§ 262, 185).
  387. From  the preceding statements, it may be  inferred that
acute dropsy arises  chiefly from the retention in the blood of ex-
crementitious  matter and water, which the kidneys fail to elimi-
nate ; and that the more chronic or asthenic kinds, although often
originating in  the same way, are rather dependent on  a  poor or
watery state of the  blood, especially deficient in albumen (§ 222).
This  deficiency in many cases arises  both  from the  continued
drain by the loss of serum in  the urine, and from the imperfect
assimilation and nutrition connected with this state.  But we have
good evidence that  the more chronic and asthenic forms of dropsy
may arise from the same state of the blood, independently of disease
of  the  kidneys.   Thus Andral and Delafond found  dropsy in
anaemic sheep in  connexion with cysticerci of  the  liver,  but
only  in  those cases in which  the albumen of  the blood  was
below the  natural  standard.  So too in the human subject; the
dropsy  induced by very scanty or poor food, or close  confine-
ment in unhealthy  places, or malarious districts, and  that  super-
vening  in  extreme states of debility  or  cachexia, are probably
dependent, not merely on weak or obstructed circulation, but also
on  an impoverished condition of the blood  itself.   For the same
reason, the  various structural diseases which cause congestions,
especially those of  the heart and liver,  often do not induce dropsy
until the quality of the blood  is impaired, either by imperfect
excretion, or by inadequate nutrition.(a)

   (a) Impoverishment of the blood, regarded in the text as a cause
of dropsy, may proceed from the loss of different elements — viz., of
fibrin, or of red globules, or finally of  albumen.  It is deficiency
of this last alone that can be said to give rise to dropsy.  M. An-
dral states very explicitly, that neither from the loss of fibrin nor
of the globules, even when  carried to  an  extreme, as in cases in
which the latter have  been in  the excessively low proportion of
21  parts in  1000 of the blood, does this disease supervene.
   There is a disease, continues M. Andral (op. cit., p. 154), which,
at the same time that it augments the usual constituents of the
urine by the  addition  of a  certain quantity of albumen, lowers
more sensibly than any other the proportion of this element in the
blood.   In this disease which has  its seat  in the  kidney, a pheno-
menon  is always seen, sooner or later ;  viz., a dropsy, which at first
partial  and slight, ends by  its becoming general and considerable.
This dropsy is increased  in proportion to the escape  of a large
quantity of albumen from  the kidneys and  its diminution  in the
blood.   Here, then, we have three coincident facts ; disease of the
renal parenchyma, diminution of albumen in the blood, and dropsy.
Is it disease of  the kidneys which directly produces dropsy,in the same
manner as it is produced by an affection of the heart or liver ?  We 
208
WILLIAMS'S PRINCIPLES OF  MEDICINE.
  388.  We have thus traced  flux  and dropsy  in common, to
elements previously considered, hyperaemia in  some of its forms,
together with a diseased condition  of the blood itself (§ 222), de-
pendent on defective secretion (§ 249, 250), or defective nutrition
or assimilation  (§ 26S).  The latter  element, although not essen-
tial to the production of fluxes or local dropsies, is the chief cause
of general dropsy, and constitutes  the dropsical diathesis.   If we
endeavour further to distinguish between the pathological causes
of flux and dropsy, we find from observation that flux more com-
monly results from determination of blood or  congestion, with  a
lax state of the solids (§123,382), whilst dropsy  is rather associated
with the altered condition  of the blood just  noticed.
  389. The distinction just made between the causes of flux  and
dropsy implies  that flux is generally a more partial disease than
dropsy, many circumstances relaxing the vessels of a part without
affecting the condition of the  blood in the whole system.  This is
especially apt to occur in secreting organs and surfaces, which are
in fact the common seat of fluxes.  We have before noticed exces-
sive secretion as a primary element  of disease (§ 162), but  the
fluxes which we are  now  considering consist less in excess of the
natural secretion (although this often occurs also), than in the addi-
tion of  a  watery, saline, and  sometimes albuminous fluid derived
from the blood,  a serosity in fact (§ 305, 375). The fluids discharged
in chronic coryza, bronchorrhoea, gastrorrlicea, and  watery diar-
rhoea, are the  natural mucus of the respective  surfaces,  much
diluted with a thin serum, the saline matter of which often gives
the  secretion an irritating property.  Sometimes this serous fluid
is substituted for the proper secretion, as in the  coagulable urine of
the  early stages of granular kidney [albuminuria or  Bright's dis-
ease], and the watery urine of its more advanced stages.
  The circumstances  which  commonly induce flux in secreting
surfaces have been already noticed (§ 376, et seq.), but after a  flux
has continued for some time,  it  is apt to become habitual, appa-
rently through permanent relaxation of these affected vessels.  These
become  so weak that any circumstance disordering the circulation
may bring on an attack of the flux.  In fact the flux becomes an
cannot admit this  supposition, and  it is manifest that the kidney
exerts but an indirect  influence in the production of dropsy, and
only so far as a change in its texture causes it to abstract albumen
from the blood.  It is the diminution of this element in the serum
of the blood, that should be regarded as the true cause of dropsy.
Whatever may be  the cause of the loss of albumen, dropsy will be
the result.   Nor is there  any necessity for the production of this
effect, that the globules should be diminished  at the same  time as
the albumen.  In  Bright's disease, there is at first diminution of
albumen  alone, and  the globules only begin  to be diminished
somewhat later, and when the dropsy is already formed. 
PROXIMATE ELEMENTS OF DISEASE.
209
outlet for superfluous fluid in  the  bloodvessels, and discharges
that which ought to be evacuated  through the kidneys, skin, or
bowels.

           GENERAL TREATMENT OF FLUX AND DROPSY.

  390. As there is much that is common to fluxes and dropsies, we
may abridge our notice of the remedial measures to be opposed to
them, by first giving the treatment applicable to both, and after-
wards specifying  that indicated for each class of results.
  In so far as fluxes and dropsies depend on plethora, sthenic or
asthenic, congestion in all its varieties, or  determination of blood,
the remedies for these several morbid elements (§ 2S3, et seq., 313,
et seq., 342, et seq.) must form part of the treatment.  So, also, ac-
cording to the prevalence of these constituent conditions, fluxes or
dropsies may be more or less sthenic or active, or asthenic or pas-
sive, and more or less constitutional  or local; and the treatment
must be varied  correspondingly.    And  according to  whether
these conditions are tractable or not, fluxes and dropsies resulting
from them may be  more or less difficult  to  remove, and exhibit
many varieties as  to duration and disposition to return.  Thus,
fluxes and dropsies  which arise from congestions caused by struc-
tural disease of the  heart or liver, or by tumours compressing veins
(§ 375), although often removed, are  liable  to  return;  but those
arising from cold (§ 378), weakness (§ 376), previous excitement
(§ 377), or functional disorder, may, in many cases, be  cured per-
manently.
  391. We  have  repeatedly stated the circumstances under which
vascular congestion or fulness  in itself suffices to induce dropsy
and flux (§ 306, 383) ; and under these circumstances, the remedies
for  congestion  and plethora  are the  first to be used.   Thus, in
dropsy  or  fluxes suddenly induced  by structural  disease of the
heart and liver, often brought on by cold, over-exertion, or excite-
ment, whilst the condition of the blood has not materially suffered,
depletion, general or local, is advantageously premised before the
use of other measures.  Then follow remedies which, by increasing
the secretions, reduce the remaining congestion and the effusions
resulting from them :  combinations of mercury or antimony with
squill and digitalis are peculiarly serviceable in accomplishing this
object.  Various other means contribute to the same end, chiefly
those which act  as evacuants and derivatives.  This treatment
approaches  to  the  antiphlogistic, as we have already  found the
nature and products of congestion of  high tension, and of sthenic
plethora, approximate those of inflammation (§ 307).   But in the
more peculiar causes of flux and dropsy—those that induce these
results with slighter amounts of congestion ordisordered circulation
(§ 382)—those which constitute the dropsical and profluvial diathesis
(§ 38S),— we find conditions generally betokening weakness, and
requiring a  tonic or more supporting plan of treatment; a relaxed
            18* 
210
WILLIAMS'S PRINCIPLES OF MEDICINE.
state of the solids, and a watery condition of the blood.   But even
in the treatment of these cases, to derive from the weak or con-
gested parts, and to increase defective excretions, are objects gener-
ally to be attempted.  Further details will be better described under
separate  heads of flux and dropsy.

                    TREATMENT OF FLUXES.

   392. In all cases of flux, it is proper to derive from the affected
part, and to promote the natural excretions in other directions, by
some or  other of  the following means :  warm bathing, warm
clothing, exercise, friction, and stimulant applications to the sur-
face, diaphoretic, diuretic, and aperient medicines.   It is also neces-
sary to avoid circumstances which promote congestion or determi-
nation of blood in the affected part, such  as  dependent position,
exposure to heat, cold to other parts, too fluid  a diet,&c.  In addi-
tion to these measures, it may be requisite to use others to  coun-
teract or remove  the  irritations or obstructions  which the flux
causes in the part which it affects.  Thus demulcent and narcotic
remedies are sometimes useful in catarrh and diarrhoea, to soothe
irritation, caused by the secreted fluid ;  at other times, expectorants
and purgatives to  promote its expulsion.
   393. The further treatment of fluxes will be guided by the state
 of the vascular function, whether sthenic or asthenic.  As in case
 of hemorrhage, so with flux, it  is sometimes  attended by a hard,
 frequent pulse, heat of skin, and other signs of fever or of sthenic
 plethora : here evacuants, antimonials, sedatives, and even blood-
 letting, may be required.  In fact, the disease borders on inflam-
 mation, and needs a similar treatment.  Some cases of flux, of a
 sthenic  character, arise  from gouty  or  rheumatic matter in the
 blood: here colchicuin  and alkalies  are the proper remedies, as
 they promote the  removal of this matter  by the kidneys.  Others
 we have found to be connected  with albuminuria, (§ 380,) and are
 to be treated as dropsy from that cause.   In all these examples of
 sthenic or active flux, it is neither useful nor safe to attempt hastily
 to check the discharge by astringent remedies, lest  the determina-
 tion of blood attending it end in a worse result, hemorrhage or in-
 flammation.
    394.  The majority of fluxes  are, however, asthenic, connected
 with a weak state of the vessels, local or general: and here other
 remedies are needful.  Together with more or less of the general
 measures above  described, (§ 392,) it is here safe and proper to
 endeavour to check the profuse exhalation, by astringents, stimu-
 lants, and general tonics.   Astringent remedies are most effectual
 by direct application; and their mode  of action, by constricting the
 relaxed vessels, (§ 388,) is obvious. Thus acetate of lead, sulphate
  and acetate of zinc, sulphate of copper, nitrate of silver, alum, and
  some vegetable astringents, are effectual in leucorrhoea and diar-
  rhoea. Some of these remedies seem also to act through the medium 
PROXIMATE ELEMENTS OF DISEASE.
211
of the circulation.   Thus sugar  of  lead, sulphate of zinc, and
mineral  acids, given  internally, sometimes distinctly  diminish
bronchial flux and profuse perspiration, as we have already found
they sometimes arrest hemorrhage (§ 367).  Some fluxes  are re-
markably checked by remedies whose operation seems to be rather
stimulant than astringent.  Thus spices, essential oils, and brandy,
sometimes cure pyrosis and diarrhoea ; cantharides diminish leu-
corrhoea ; cubebsand copaiba, gonorrhoea; balsams of copaiba and
Peru occasionally check bronchorrhoea.   It is uncertain how these
remedies operate ; but it is probably  by removing congestions by
causing determination of blood, which excites contraction, and  a
new condition of the capillaries  of  the  part (§317).   They are
most successful  in  asthenic cases  originating with  inflammation.
Another remedy occasionally useful in controlling fluxes is opium :
its mode of operation is equally uncertain ; but it is probably con-
nected with its power to diminish natural secretions (§ 166).  Its
efficacy is  most obvious in diarrhoea and diuresis; and it is some-
times beneficially combined with metallic astringents in  bronchial
and gastric flux.(a)
   The state of the system  in  persons subject  to  fluxes is gene-
rally one of relaxation, and is therefore benefited  by  tonic medi-
cines.  Some of these have  also an astringent property, which
peculiarly adapts them for the treatment of asthenic fluxes.  Thus
the tincture of the sesquichloride of iron is useful in the treatment
of leucorrhoea and humoral  asthma, attended with much debility ;
infusion of cusparia in diarrhoea ; and bark or quinine, with mine-
ral acids, in various fluxes in very relaxed habits.
   For similar reasons, the diet should be as generous as  the diges-
 tive  organs will  bear ; sometimes including animal food twice
 a-day, and a moderate allowance of some sound fermented liquor.
 Excess  in liquid  food  should  be particularly avoided,  especially
 tea, and warm slops generally.   Catarrhal colds, which are acute
 fluxes, I am in the constant habit of curing simply by total absti-
 nence from liquids during two or three days;  and  although  this
 extent of dry regimen is obviously inapplicable to  chronic cases,
 yet moderation in the use of liquids, especially before or during
 exposure to cold, is an important part of the treatment in all cases.
 I have known several instances of chronic coryza and  bronchor-
 rhoea kept up, if not brought on, by immoderate indulgence  in
 tea and such liquids.  These fluids  cause  a temporary plethora,
 which immediately finds vent through the lax vessels of the weak
 part  (§ 389).   The  propriety of warm clothing, regular  exer-

    (a) Ipecacuanha is  entitled to no little confidence in  most  of
 the diseases mentioned in the text; both alone, and combined with
 blue mass, where  irritation still  persists, and with opium in the
 more evidently asthenic forms or stages.  Iodides of potassium and
 of iron are also well adapted to many fluxes. 
212          WILLIAMS'S  PRINCIPLES OF MEDICINE.

cise, and a bracing, but not too cold an atmosphere, is obvious from
the previous considerations.

                    TREATMENT OF DROPSY.

   395. In addition to the means requisite to remove the variety
of hyperaemia inducing the dropsy, (§ 391,) we have to remedy,
as far as we can, those conditions of the blood  which  we  have
found (§ 384) specially to favour  the  occurrence of dropsy.  Of
the causes of these, a failure in the secreting power of the kidneys
is the chief: its sign being an albuminous state of the urine, with
a deficiency of the  natural constituents of this excretion.  The
treatment must therefore have regard to the condition of the kid-
neys, which is the chief cause of this failure in  their action, and
to the state of the blood and other parts, which  is the  result  of
that failure.
   We have  several times pointed out (§  309) reasons for sup-
posing a highly congested  state of the kidneys to  be the first
cause of that failure in their function which induces  albuminuria
and  its consequences.  The means found  most  successful in re-
moving dropsy arising  from  renal  disease correspond well with
this  view.  Thus in  acute or inflammatory dropsy, occurring  after
scarlatina or exposure to cold (§  384), bloodletting, especially by
cupping to  the  loins, hydragogue  purgatives, and diaphoretics,
are advantageously used at first;  and subsequently some kinds of
diuretic medicines,  particularly tincture of cantharides, digitalis,
and  colchicum, sometimes promote the natural action of the kid-
neys.  Such measures, if employed at an early period, before the
disease in the  kidneys has affected the structure, are often  com-
pletely successful.   They fulfil, not only the indication of diminish-
ing the renal congestion, but that also of purifying the blood from
excrementitious  matter,  and of reducing the sundry effusions, local
irritations, and disturbances, which this matter  excites  in various
parts (§ 385).  They cure the  dropsy by exciting an artificial
flux (§ 381).
   Of the hydragogue purgatives used in  the  treatment  of acute
dropsy, I have found cream of tartar in large  doses, (3iv. to 3x.
every morning or every alternate morning,) and extract of elate-
rium, (i gr.) the most effectual.  Tartarized  antimony, alone, or
combined with opium, is the best  diaphoretic, and it often relieves
the catarrhal symptoms commonly present.  Care must  be taken
not  to cause vomiting, to which there  is often a natural tendency.
Dr.  Osborne recommends the vapour-bath, and Dr. Watson the
hot-air bath, as means of deriving [from the viscera] to the sur-
face and causing perspiration.  After cupping  to the  loins has
been repeated as often as the strength of the patient may indicate,
in obstinate cases I have seen some benefit from blisters or  other
counter-irritants to  the loins. 
PROXIMATE ELEMENTS OF DISEASE.           213
  The dropsical effusions are  often soon dispersed by the pre-
ceding measures;  but the proof of the permanent  benefit of the
treatment is to be looked for in the progressive decrease of albu-
men, and the  increase of urea and lithic acid in the urine.  It
often happens that, after the full use of depletion, cathartics, and
diaphoretics, the condition of the urine becomes stationary, and
does not advance towards a healthy standard.  Then the diuretics
before  named are sometimes  very effectual  in augmenting the
quantity of urine, without increasing the albumen in it;  and where
this is  their  first  effect, their  continuance will often produce a
gradual diminution of the albumen.  The tincture of cantharides
is more powerful than the others in exciting the action of the kid-
neys ;  and where it  increases the urine, the  dose  may be aug-
mented from nix.  to n\,xx. or 3ss. thrice a-day ; but if  the smaller
dose do not act as a diuretic, it is not safe to proceed to the larger,
nor, in fact, to persist with the  medicine ;  for if it irritates the kid-
neys without increasing their secretion, it is sure to do harm.  We
have noticed the same circumstance in the treatment of congestion
by stimulants (§ 317) ; if they fail to remove the congestion, they
aggravate the  mischief.  Digitalis and colchicum are safer diure-
tics, inasmuch as they are less irritating to the kidneys;  but they
are also less powerful.
   Mercury might  be  expected to be useful in removing congestion
or low inflammation in the kidney, and in restoring its secretion ;
 but it so speedily and severely salivates in such  cases,  without
 any equivalent benefit, that it is not generally eligible. The promp-
 titude with which the  gums are affected with  mercury may be
 ascribed  partly to the facility with which  inflammations may be
 excited in any part (§ 385) ; and, in some measure, to the failing
 action of the emunctories of the system permitting the mercury to
 accumulate  more  speedily than usual (§ 260).  But mercury is
 peculiarly efficacious in dropsy connected  with diseased  liver;
 and, in combination with squill, digitalis, and henbane, or conium,
 forms the most useful diuretic in all  recent  cases  of dropsy de-
 pendent on congestion [of the lungs,  heart, or liver] without  dis-
 ease of the kidneys.
    396. We  have  found (§  386, 387) that the  asthenic  forms of
 dropsy, and those  of the  most chronic character, are commonly
 connected with a watery, non-albuminous state of the blood,  and
 general weakness of the system.  To  obviate this condition so far
 as possible by nourishing  diet, tonics, and means to increase the
 strength, becomes here a leading indication.   In cases depending
 on malnutrition or mere debility (§ 387), this tonic and supporting
 treatment may be sufficient to effect a  cure.  In the commoner
 examples of dropsy,  rendered asthenic by the long  continuance of
 structural disease of the kidneys, liver, or other organs, the same
 strengthening and  invigorating measures  must  be more or less
 combined with means to"excite the failing excernent organs,or to
 produce  some compensating  discharge.   Thus  in dropsy from
 chronic albuminuria, or advanced degrees  of granular degenera- 
214          WILLIAMS'S PRINCIPLES  OF MEDICINE.

tion of the kidney, the occasional exhibition of hydragogue purga-
tives and diaphoretics, and  of the  diuretics  before mentioned, is
useful at the same time that bitters with  iodide of potassium, or
mineral acids, are given to keep up the general strength and powers
of nutrition.  In the  more anaemic cases, iron is often of advan-
tage ; but it  sometimes proves  injurious by impairing  the little
secreting power remaining in the kidneys, and by rendering  the
urine more albuminous.  Where it has  this effect, its use must
be abandoned.  The preparations of iron that  I have found most
serviceable in these cases are  the ammonio-citrate in combination
with iodide of potassium, and the muriated tincture.
  Asthenic dropsy arising from diseased liver  is  sometimes signally
relieved by mercurial and diuretic medicines, followed by or even
conjoined with  columbo, bark,  and other vegetable tonics.  In
two cases under my care, ascites, of great extent and  long dura-
tion, connected with granular degeneration (cirrhosis) of the liver,
was removed, and the patients  for a time  restored to  apparent
health, by a course of hydragogue doses of cream of tartar every
morning, or every other morning, with bark and nourishing diet
in the day.  Hydragogue purgatives are more directly useful in
removing ascites connected with  diseased liver, inasmuch as they
excite a discharge from the congested vessels  themselves,  and sub-
stitute abdominal flux for abdominal  dropsy (§  381).   But  they
often fail to excite a watery discharge from the intestines, and in-
stead cause much irritation, with tenesmus,  and  slimy or bloody
stools: under these circumstances they  must be discontinued ;  but
after blistering the abdomen, or applying leeches to the region of
the  liver or to the anus (§ 319), the useful operation of hydragogue
purgatives may sometimes be again obtained.   Similar  means will
often facilitate the operation of diuretics.   Dr. O'Beirne  has argued
strongly in favour of bloodletting in dropsy, under the  impression
that by  relieving the pressure  from  congested  bloodvessels, it
enables secreting organs to act.   (Dublin Journ. of Med. Sc, Nov.
1842.)   Like most other writers on dropsy, Dr. O'Beirne  does not
seem to me sufficiently to regard the mixed character of the disease.
  397.  The  tendency of dropsy connected with diseased heart,
kidneys, or liver, to recur again and again,  and  become chronic,
renders  it needful to vary as much as  possible the remedies em-
ployed,  as well  as  to  use  means to support the  strength.   It is
an  important point in the treatment of such  cases not to exhaust
the powers of any secreting  organ by too long acting on  it, and
not to expend the efficacy of any one remedy by too long  con-
tinuing  its use.  By  employing sometimes  diuretics, sometimes
purgatives, sometimes diaphoretics, and  by aiding each  of these,
by  local depletion or derivants or by stimulants, and tonics, ac-
cording to the temporary prevalence of vascular  fulness and ex-
citement, or the converse, much  may often be effected to prolong
life.  It is in the application of these rules to  the treatment of
prolonged cases, that  the skill and  resources of the rational prac- 
PROXIMATE ELEMENTS OF DISEASE.
215
titioner are most tried, and his superiority over the routinist is
best proved.  It is under these circumstances, too, advantageous
to have at command  a great variety of medicines, particularly
diuretics, and to alternate them or vary them in order to increase
or maiutain their effect.   Those that  I have found most effectual
are —combinations of mercury, squill, digitalis, and  conium (not
in  acute albuminuria); combinations of decoction  of broom, or
pyrola umbellata, with nitrate and acetate of potass; the juice or
extract of taraxacum, with the same salts or  bitartrate of potass,
or with nitric acid (particularly in hepatic disease); infusion or
tincture of digitalis, with iodide of potassium, and  bitartrate of
potass (in dropsy  after scarlatina);  the  same together with in-
creasing doses of tincture of cantharides (in asthenic cases of
albuminuria, after  cupping to the loins  and hydragogue purga-
tives) ; ammonio-tartrate and ammonio-citrate of iron in Seltzer
 water  (in  asthenic dropsy); gin  in cream  of tartar beverage
(imperial);  compound spirit of juniper, spirit of nitric aether, with
 various others (in cases of debility)   The latter stimulant diu-
 retics have disappointed me more than any of the rest.
   398. When dropsical swellings have reached a certain amount
 of tension, diuretic and other remedies produce little or no effect
 on them.   The veins and lymphatics, whose office it is to remove
 these swellings, are too much compressed to  be  capable  of ab-
sorbing.   In the case  of ascites, this pressure impedes the circu-
 lation through the kidneys and intestines, and  their secretions are
 proportionally reduced (§ 159). Excessive  hydrothorax, and even
 ascites, in a similar way embarrass the functions of the lungs and
 heart.  Anasarca, in  its extreme  degrees, sometimes impedes the
 circulation in the vessels of the lower extremities, so far, as not
 only to prevent absorption,  but even to cause the death of the
 parts: hence  gangrene of the legs is  a common  termination of
 incurable dropsy.  The gangrene is commonly  preceded  by an
 erysipelatous kind of inflammation, which often seems to originate
 in some accidental scratch, or from the irritation  of mechanical
 tension, or of the quality of the effused fluid.
    Now, in all these  cases, the great expedient is to give exit to
 a portion of the fluid, by tapping  or puncturing  the parts  which
 contain it.  Thus the abdomen is tapped for ascites  ; the chest lor
 hydrothorax; the scrotum  for hydrocele; the brain  for hydro-
 cephalus ; ovarian and other cysts, when they attain a large  size;
 and the legs are acupunctured for anasarca.   The  relief afforded
 by these  means is sometimes very remarkable, even when much
 fluid is left unremoved.  In  fact, the great utility of these opera-
 tions seems to consist in the removal of an amount of pressure and
 distention that was seriously impeding the functions of the several
 parts.  Accordingly we find, after  these operations, not only a
 Lat mitigation Sf suffering, but a restoration of  the functions of
 circulation, secretion, respiration, &c, which before were mechani-
 cally obstructed.   After paracentesis, diuretic and  other remedies 
216
WILLIAMS'S PRINCIPLES OF MEDICINE.
regain their power, and contribute to reduce the remaining effusion ;
and the secretions being free, the patient is able to bear nourishing
food and strengthening remedies,  which previously would  have
increased the excitement and oppression.
  The usual indications for the use of these surgical resources are,
an amount of dropsical effusion which seriously injures the  func-
tions of circulation, secretion, or respiration, other remedies having
failed  to  give  relief.  Under  such circumstances  the  operation
should not be delayed.  In puncturing  the legs  for anasarca, it is
proper to bear in mind the tendency to low inflammation and gan-
grene, and to avoid this, the skin and flesh should be injured as
little as possible;  numerous punctures should be made with a fine
needle, but hot too close together;  and inasmuch as there is more
tendency to (his result where the circulation is weakest and most
remote from the  heart, it is bette;- to avoid puncturing below tne
knees.
   Further details on these subjects properly belong to special pa-
thology, ar.d would be cut of place here.
                       SECTION VII.

      LOCAL HYPEREMIA.  EXCESS OF BLOOD IN A PART.

  III.  WITH MOTION PARTLY INCREASED, PARTLY DIMINISHED =
                       INFLAMMATION.
  399. The  morbid conditions connected with the quantity and
motion of the blood hitherto described, have been pretty distinctly
defined; and we have been able to refer many phenomena of dis-
ease to them.  We now come to one, the  name of which is very
familiar, and its frequency gives it so high  an importance, that it
has always attracted the first  attention of pathologists ; but  al-
though so commonly occurring, it is much more complicated in its
nature than any of the morbid elements previously Considered; in
fact, it may be said almost to comprehend them all, besides being
a still further deviation from the natural condition.
  The terms inflammation, phlegmasia, and phlogosis, have been
used, from a very remote period, to give  a figurative  expression
of the heat, redness, and burning and painful sensations  which
commonly exist in inflamed parts.  The occurrence of inflamma-
tion is so common, and its  more prominent  symptoms  so fami-
liar, that it has long been distinguished as a chief element of dis-
ease ;  in fact, it has, in a  measure, engrossed  the attention of
pathologists so entirely, that other important elements have been
almost overlooked; and this oversight has not only retarded the ad-
vancement of our  knowledge with regard to these other elements, 
PROXIMATE ELEMENTS OF DISEASE.
217
but it has rendered the subject of inflammation itself less intelligi-
ble, by excluding the consideration of some of its component parts,
and by keeping it in all its complexity and remoteness  from the
normal conditions of function and structure.  We shall  find, that
an acquaintance with the ultimate and proximate elements of dis-
ease already considered in this work is essential to  the proper un-
derstanding of the nature of inflammation ; for these form the con-
necting link between the natural properties of living textures, and
their extreme variation in the state of inflammation.   The defini-
tion given above to  distinguish inflammation from the  other va-
rieties of hyperaemia — too much blood in a part, with  motion
(of that blood)  partly increased, partly diminished — is easily
recognised in the strong pulse of arteries leading to  an inflamed
part, and in the stagnation of much blood in  the part.
   400.  The four signs which, from the time of Celsus, have been
considered characteristic of inflammation are, redness, heat, pain,
 and swelling.   These signs are sometimes produced by congestion
 (§303), and by determination of blood (§333, &c.); but in a degree
less marked, and for a time less continued, than in inflammation ;
and although there are cases and forms of inflammation in which
it is not possible to detect all these marks, they may still be said to
 constitute its most general character.   In common  with  other  va-
 rieties of local hyperaemia, inflammation owes the  sign of redness
 to the excess of blood in the part.  As in determination of blood,
 the heat and pain are in part due to the increased  motion of that
 blood.   As  with  other forms  of hyperaemia, the swelling  arises
 partly from the over-distention of the bloodvessels, and partly from
 effusions from them; but in these effusions inflammation differs from
 congestion and simple determination, departing still further than
 thes'e from the natural quantity and quality of the effused matters.

    CAUSES OF INFLAMMATION, AND THEIR MODE  OF OPERATION.

   401.   Predisposition to inflammation has been already noticed
 under the head of predisposing causes of disease (chap. l. sect. 2).
  The circumstances which render the body liable  to inflammation
 are those which  especially affect the  vascular system, whether
 these circumstances be the result of  original conformation,  as the
 sanguine temperament (§ 38); or whether  they  be  the effect of
 previous  disease  (§ 31), of  present  disease (§ 34), or of external
 or internal causes  in  actual operation, (§ 20, et  seq. oO.)  Inas-
 much as  various circumstances, external or internal tend gene-
 rally or locally to impair the healthy tone «nd balance  of the
 vascular system (§  123), whilst muscular  irnmbiluy (& 113) and
 the quantity of the blood are not. proportionately reduced (§195),
 so far  they predispose to inflammation.  Accordingly, we find pei-
 sons prone to inflammation to be those whose circulation has been
 weakened or  irregularly excited by previous d'sease  fatigue con-
 finement, impure air, or improper nourishment.   But it will  pre-
             19 
218          WILLIAMS'S PRINCIPLES OF MEDICINE.

sently appear, that predisposition to inflammation differs according
to the nature of the cause which excites inflammation ;  those most
subject  to  inflammation from causes  acting generally suffering
more than others from causes which act only locally.   Thus a de-
pressed state of the whole vascular system favours the production
of inflammation from causes acting generally (such as  cold) ;
whereas an excited state of the vascular system favours the deve-
lopment of inflammation from local irritation.
  402. The concluding part of the last paragraph  prepares us to
divide  the exciting causes of inflammation into those which act
locally on the part which inflames, and those which act more gener-
ally on other parts.   The operation of the first class is direct; that
of the second is indirect, therefore less certain, and more dependent
on predisposition.
  The local exciting causes of inflammation comprehend irritants
mechanical, chemical, and vital.   A grain of sand in  the eye, a
thorn in the true skin, and a bruise or wound in the flesh, are ex-
amples of mechanical irritants, or sources of irritation.  Chemical
irritants are those which operate on living matter by strong chemi-
cal affinity, tending to alter or decompose it; such are heat, strong
acids and alkalies, various corrosive salts, chlorine, iodine, &c.:
these act also on dead textures.  Vital irritants  are various agents
whose irritating operation is not  referable to any known chemical
property, nor do they act on dead animal textures ;  of this kind
are cantharides, mustard, capsicum, and essential oils.   In this last
class must be included various animal and vegetable irritant poi-
sons; such as that of small-pox, and the venom of some  noxious
animals and plants,  which act as local irritants, besides otherwise
affecting the system.   Various other noxious  matters, sometimes
generated in the living or recently dead body, are  also capable of
exciting inflammation when applied to an abraded surface (§ 258).
Nay, the  natural excretions of the body become most acrid irri-
tants, when  brought into contact with serous  membranes ; thus
urine, faeces, and bile, effused in serous membranes, even  in the
smallest quantities, produce intense irritation and inflammation.
   Irritation and inflammation are sometimes caused by excremen-
titious matter retained in the blood, where the functions of the ex-
cernent organs are impaired (§ 249,251, 254).  Local inflammations
are also excited by certain poisons received into the system : thus
arsenic, even when  applied  to a wound, causes inflammation  of
the stomach and intestines; mercury excites  inflammation of the
gums ; the poisons  of small-pox, scarlatina, and measles, inflame
the skin, throat, and air-passages ; that of syphilis the periosteum,
throat, skin, iris, &c.  In these cases, there can be little doubt that
 inflammation is excited by the actual presence of the peculiar irri-
 tating matter in the parts which  inflame, conveyed there in the
 blood ; and it is a leading character in the operation  of these irri-
 tants which are conveyed through the blood, that it affects several
 parts, or a considerable portion of the body at once ; and frequently 
PROXIMATE ELEMENTS OF DISEASE.
219
the two sides of the body in  a similar manner.   This is observed
in the eruptions of exanthematousand other skin diseases, in rheu-
matism, in syphilitic nodes, &c. (§ 259).
   403. The second class of  causes exciting inflammation, those
which operate indirectly, are of very common  occurrence;  and,
although comprising fewer agents, they as frequently produce dis-
eases as the more direct causes of irritation.   They comprise those
which first produce congestion, which, on the occurrence of subse-
quent reaction, is converted into inflammation.  The most common
of these causes  is cold, which, both by its  local  operation (§ 76),
and by its more general application ( § 77), may produce conges-
tions (§ 296, 292), which  may pass into inflammation.   Malaria,
and the influences which induce continued and eruptive fevers, as
they produce congestions (§ 293), so they often lay the foundation
of inflammations, which complicate the febrile affections  excited by
these causes.  Inflammations sometimes arise out of the congestions
caused by venous obstruction (§ 289) and gravitation.  Thus pneu-
monia ( with hepatization and sometimes suppuration)  frequently
occurs in  connexion with disease of the heart, impeding the circu-
lation ; in adynamic fevers, and in  the sinking which precedes
death (§  290).  The congestions from the  lungs, brain, and mu-
cous membranes, that result from the  application  of various as-
phyxiating causes (§ 298), sometimes end in inflammations, which
become a chief source of danger after the restoration of the respi-
ration (§  235, 243).
   404. Suppression of natural or  habitual  discharges, especially
the catamenia, the  sudden drying up  of ulcers, and repulsion of
cutaneous eruptions  (§ 69), are recognised as causes of inflamma-
tion (§ 67).  So far as the inflammation excited by these causes is
in, or contiguous to, the  parts previously affected, local irritation
may have a share in producing it;  but where it is in distant parts,
it  probably results  from a congestion or  local  determination of
blood, which  belongs to the second class of causes  just specified.
Very probably some of these causes of inflammation have a two-
fold operation, that just  specified (producing a local fulness), and
that of local irritation by morbid  matters introduced into the cir-
culating mass of blood.   Thus the visceral inflammations arising
on the sudden healing of a suppurating wound may be promoted
 by local congestions resulting from the  cessation of the purulent
 discharge ; but their circumscribed character, and the  uniform
 event to  which they tend, (suppuration,) seem to indicate a mor-
 bid matter in the circulating blood as the exciting cause of  these
 inflammations.  The same remark will apply to the inflammations
 of the skin, fauces, and mucous membranes in scarlatina, measles,
and srnall-pox ; the follicular enteritis of typhus,* and the visceral
   * I have observed an extraordinary development and inflammation of the iso-
 lated and  grouped follicles of the intestines in the  bodies of persons poisoned
 with arsenic.  Their enlargement in epidemic cholera, and in the severe form of
 sporadic cholera and diarrhoea, caused by putrid effluvia, is well known. Are 
220
WILLIAMS'S PRINCIPLES OF  MEDICINE.
 complications of erysipelas, and other specific febrile affections.
 In all these, besides a general tendency to internal congestions, we
 seem to trace the irritating operation of the morbid poison on par-
 ticular parts.
   405. We have  noticed  that sthenic hemorrhages (§ 363) and
 fluxes  (§ 393), if too speedily checked without sufficient reduction
 of the circulation, are apt to pass into inflammation.   So like-
 wise determination of blood, if it be long continued, may issue in
 inflammation (§ 340).  The causes which excite determination of
 blood,  when applied in a greater degree, or for a longer time, ex-
 cite inflammation.
   406. Before we proceed  to examine into the  nature of inflam-
 mation, we may properly inquire what is the mode of the opera-
 tion of its causes.  It is generally assumed that the first movement
 of inflammation, as of all pathological processes, is in the nerves;
 but this is by no means proved.   That some causes  of inflamma-
 tion (irritants) operate first on the nerves, is probable from the
 following considerations.    1.  Their action on the sensitive nerves
 is felt long  before inflammation begins ; thus the prick of a thorn
 in the skin, the smarting of caustic on a wound, the pain of the
 sting of an insect, are felt instantaneously :  there  is first  nervous
 irritation  ; inflammation follows after.   2. The irritation  is some-
 times tranferred to other parts by sympathy, of which nerves are
 the channels: thus strong  irritants in  the  nostrils may cause in-
 flammation of the conjunctiva, a carious tooth or a diseased bone
 may irritate and inflame parts which are not contiguous to it.  3.
 An injury to a  nerve is  sometimes followed by inflammation in
 parts connected  with this nerve.   Thus paralyzed limbs are liable
 to become inflamed.  Lallemand relates a case in which a ligature,
 involving the right brachial plexus, was followed by inflammation
 and suppuration in the opposite hemisphere of the  brain.
   407.  On the other hand, the following  arguments may be ad-
 duced to show that the nerves are not essentially the seat of the
 first part of the  process of inflammation.   1.  Some of the causes
 of inflammation  (the majority of those inducing internal inflam-
 mation) produce on the nerves or nervous system no known  pri-
 mary effect, which resembles that of other causes of inflammation
 (irritants):  thus inflammations excited by cold are often preceded
 by  no marked nervous disturbance ;  whereas  the strongest  im-
 pressions  of cold on this system are frequently not followed by in-
 flammation  (§ 77).   2. Inflammations often  originate in  conges-

 these glands excretory organs for the elimination of poisonous or noxious matters
from the  system? and in typhus fever, do they become inflamed and  ulcerated
by the continued operation of the  poison in the exercise of this function ?  The
favourable influence of  moderate diarrhoea in fever, the uncommon fcetor of the
 stools, the general relation between the duration of  the fever and the affection
 of these follicles, the salutary operation of mild mercurial remedies, which pro-
 mote their secretion, and other facts that might be adduced, give so much coun-
 tenance to this question, as to make it worthy of attention. 
PROXIMATE ELEMENTS OF DISEASE.
221
tions (§ 403) and in the sudden  suppression  of  hemorrhages and
other discharges (§ 405), without the occurrence of any symptoms
referable to the  nerves :  hence  inflammations thus arising may
escape  detection,  and are called latent.  3. Persons  in  whom
nervous properties are  most developed (§ 126,  152, 156), are  not
those most susceptible of inflammation ; and all varieties of ner-
vous  excitement  are sometimes manifest in the highest  degree
without any inflammation ensuing.  Even where pain and other
nervous symptoms are excessive, and are the result of mechanical
or chemical injuries, (such as crushed limbs, extensive burns, &c.,)
inflammation sometimes does not follow ; and this has led surgeons
long to distinguish between  irritation  and inflammation.  4.  In-
flammation occurs in parts, the  nerves of which are paralyzed or
have  been divided.*
  408.  Seeing, then,  that inflammation is frequently excited with-
out any obvious affection of the nerves, and is often not excited
when nervous irritation  is most intense, it may fairly be inferred
that an impression on the nerves is not  an essential part of  the
first process of inflammation.   That the nerves are concerned in
many ulterior phenomena of inflammation, and in its extension, is
fully  admitted;  and in the case  of excitement of inflammation by
irritation, the primary operation of the exciting cause on the nerves
has been already pointed out  (§ 406).  So  far as is known,  the
bloodvessels are the essential seat of the whole process of inflam-
mation, and although some of the exciting causes of inflammation
(§ 402, irritants)  act  on the nerves as well,  yet  others  (§ 403, as
cold)  operate  chiefly  and essentially only on the bloodvessels.(a)

   (a) It may be asked, whether simple cold can ever excite inflam-
mation ; and if the alternation of cold and heat be requisite, how can
these agencies operate vitally on the mere vascular tissues without
the nerves being also implicated? The chief seat of inflammation
is in the capillary tissue, that which is so intimately interwoven
with  the nervous as to render the separation  of the two difficult, if
not impossible.   The following statement of the subject  by Dr.
Carswell seems to us to be the true one.
  " If, however, we carefully examine in detail the numerous  ex-
periments which have been made  on  this subject by Thomson,
Wilson Philip, Hastings, Kaltenbrunner, Wedemayer, and trendnn,
and separate the  effects of chemical or other  agents which  are
known to modify the tissues and the blood in a manner very dif-
ferent from that of a mere stimulus, from those  produced by this

  * It is maintained  by Dr. Copland and others, that in these cases branches
of the ganglionic system distributed  on the coats of the  bloodvessels, are the
firs  subject! of excitement.  This is  a mere  hypothesis which.  g-ves no a.
in the  explanation of  the  phenomena, because nothing is definitely known as to
Ihe properties communicated by ganglionic nerves. Before the "influence o ft he
ganglionic system" can be employed as an element in pathology, its existence
mus°t be proved, and its properties defined, in physiology : this has not been done.
            19* 
222          WILLIAMS'S PRINCIPLES OF MEDICINE.

Hence we find that the causes predisposing to inflammation (§ 401),
are circumstances chiefly affecting the vascular system.  A review of
the exciting causes of inflammation (§ 402,405) will show that in
their mode of operation on the bloodvessels they may be divided
into two classes : 1, those that cause determination of blood (§ 322,
324); and 2, those that produce congestion  (§ 290, 299).   The
former class comprehends all irritants (§ 402);  the  latter class in-
cludes cold and other agents, which directly produce congestion(a)
(§ 403, 405).   We. have several times  had occasion to mention
that  determination of blood, when exceeding certain  limits, is apt
to pass into inflammation (§ 340); and  that local congestions are
liable to be converted into inflammation (§ 292, 293,  306).

          PHENOMENA  AND NATURE OF  INFLAMMATION.

   409.  Having noticed the causes  of  inflammation, and traced
their essential operation to be  on  the bloodvessels and their con-
tents, we have next  to inquire what is the character  of their ope-
ration on the vessels, and what phenomena it developes.
   That the bloodvessels are enlarged in an inflamed part is very
obvious from the  increased redness manifest  to  the naked eye.
But  in what  respect  does inflammation   differ from congestion, in
which also the vessels  are  enlarged ?  It differs not  only in the
accompanying symptoms and  in its  products, but also in the ob-
served condition of the vessels of the part.   Thus besides greater
pain and  heat in an inflamed part, and earlier and more abundant
effusions into or from  it, the more florid hue of redness, the strong beat-
ing of the arteries leading to the part, and augmented quantity of
blood flowing from its veins, clearly indicate that there is increased
motion of the blood, instead of  diminished motion,  as in conges-
tion (§  287).

latter cause,  we shall find that the results have  almost always been
similar in kind under similar circumstances, and in perfect accord-
ance with the known laws of the vital manifestations of sensibility
and contractility — properties, the sensible modifications of which,
if not the most important, are  the first  that occur in the  series of
 changes which constitute the state of inflammation.  Equally im-
 portant, because constant changes are also those which take place
 in the temperature of an inflamed part, and in  the vital and phy-
 sical conditions of the  blood,  and, as immediate consequences of
 these, in the functions of secretion, absorption, and  nutrition." —
 Illustrat. of the  Element. Forms of Disease — Inflammation.
   (a) This division is  purely arbitrary.  Some of the most marked
 and violent  forms of  congestive disease, associated  with or pre-
 ceding inflammation,  are the  product of hot seasons and climates,
 in which the reduction of temperature at any  time is too slight to
 act  as a cause of inflammation in the manner supposed in the
 text. 
PROXIMATE ELEMENTS OF DISEASE.            223
  Common observation of the pulse of arteries leading to inflamed
parts would suffice to show that there is determination of blood to
them; and some experiments performed by Dr. Alison and others
have directly proved that these arteries are enlarged.*  It was
found that the arteries leading to an inflamed limb in a horse were
considerably larger than those  of the sound limb.  John Hunter
had arrived at the same conclusion  from experiments on the ears of
a  rabbit.   Now  this enlargement  has been before traced  to di-
minished  tonicity in  the affected arteries, and this  was found to be
the chief instrument in causing determination of blood (§ 326, 327).
   That the motion of the blood is increased through an inflamed
 part, is distinctly proved  by the  observation of  Mr. Lawrence :
 venesection  being performed  at  the same time.,  and in the same
 manner, in both arms of a patient  with inflammation of the hand,
 a much greater quantity of blood flowed from the vein of the arm
 of the inflamed hand than from that of the other arm.(a)
  (a) One may reasonably doubt the assertion, that the motion of the
blood is increased through an inflamed part, and may, also, other-
wise explain the fact here adduced to prove it.   If it be supposed
that the bloodvessels, or more especially the arteries, have a power,
independent of the  heart, of quickening or retarding the circula-
tion  in particular regions  or under particular  circumstances, we
ought to  find, with a new propulsive power, pulsations more numer-
ous than those which measure the heart's action. Thus, if 80 beats
were to represent the movements  of the  latter organ, 90  or 100
should be found to indicate those of the arteries of an inflamed
part; _a proposition which carries absurdity in its very announce-
ment, and yet it is but the formula of the fact assumed in the text,
and  by some other  teachers.
   The observation  of Mr. Lawrence is no more to the point than it
we were to say, that the spouting out of blood in a full stream from
the vein of the arm, after the  latter has been tied up, is a proof
that the arteries and bloodvessels  generally of the  hand of that
side had acquired new properties, and allowed the blood to pass
with increased motion through them.   The blood was accumu-
lated in  the inflamed hand as it would be when a  ligature is tied
round the arm, and in increased quantity when the affected arm
is tied, and so soon as a vein is opened blood would be poured out
 in increased quantity.
   Assuming the premises laid  down by the author, that there is
 increased determination of blood to an inflamed part, and that  the
 arteries going to it are enlarged owing to their diminished tonicity,
 we  can  hardly reach the conclusion  that accelerated motion of  the
 blood will be'the consequence of this state of things.  It certainly
 ought not to follow either from a larger  calibre or lrom diminished
 tonicity of the arteries.
   It is to be regretted that the author did not specify the  precise
* Trans, of British Association, 1835. 
224          WILLIAMS'S PRINCIPLES OF MEDICINE.

   410.  It  is  certain, both from  the preceding facts, and from
direct  observation under the microscope, that determination  of
blood is  present in inflammation.   The vessels in the vicinity of
the inflamed  part are the channels of an increased  flow, there
being a flux of blood to  the whole inflamed  part, and through
some of  its vessels.  But if this were all, there would be no dis-
tinction between determination  of blood and  inflammation ; yet
the greater redness and  swelling and  peculiar character of  the
effusion  point out  that inflammation is not mere determination.
Microscopic research has established one great point of difference.
The observations  of  Thomson,  Hastings,  Kaltenbrunner, and
Marshall Hall, have long clearly proved that  there is  more  or
less obstruction to the passage of  the blood in the vessels most
inflamed.  Thus in the frog's web, when a part inflames from
local irritation, the blood is seen to move  more slowly  in.the
part most  iritated, and  gradually  accumulating in the vessels,
renders them larger, redder, and more  tortuous, until  the motion
ceases  altogether  in them, whilst neighbouring vessels  are still
the channel of an increased current.  A chief point then  in which
inflammation  differs from determination  of blood, is  in the  re-
tarded  or arrested flow of blood  in some of the vessels.   This
answers  to the definition  which we have given of inflammation :
too much blood in  apart, with motion (of that blood)partly in-
creased, partly diminished (§ 399).
   411. The question now naturally  arises —What is the cause  of
the obstructed or  retarded flow of blood through  an inflamed
part ?   This has ever been the chief difficulty in the pathology
of inflammation ; and  it  is especially to solve  this that various
hypotheses  have been framed.  Thus  Cullen supposed  a  spasm
of the  extreme vessels to be the cause  of obstruction, and there-
fore  the  proximate cause (§  13) of inflammation.  Dr. Wilson
Philip  ascribes the same  obstruction  to a weakness of the  capil-
laries, which he presumes to incapacitate these vessels from trans-
mitting the blood. John Hunter considered that there  is  some-
thing more  active  and  vital in  the  enlargement of inflamed ves-
sels, and he applied to it the term " active dilatation."  The  analo-
gous expression, "  vital turgescence," " turgor vitalis," '; inflam-
matory erection,"  used  by Kaltenbrunner and other  German
writers, imply a similar notion.
   The hypothesis  of Cullen is  quite inconsistent with direct ob-
stages or circumstances under which he  supposes the motion  of
the blood in an inflamed part, to be partly increased, partly di-
minished.  That there is increased quantity of blood in an inflamed
part is evident; but this does not imply increased motion.  That
there is diminished and obstructed movement is also clear, and on
the causes and effects of this obstruction depend the characteristics
of inflammation.  These are explained  subsequently in the text,
see § 419. 
PROXIMATE ELEMENTS OF DISEASE.
225
servation, the extreme vessels  being seen under the  microscope
to be  in a  state  of dilatation, not of Spasm.   This observation
corresponds  better with  the idea  of Dr. W. Philip, which  was
indeed founded upon it:  but it has been  objected by Dr. Marshall
Hall and others, that the  capillaries, by their contraction, do  not
aid in the circulation of the blood, and that their " debility" there-
fore cannot be a sufficient cause for interrupted  passage of blood
through them.  The words used by Hunter scarcely convey any
explanatory meaning.   They may be interpreted to assume  the
existence of a self-expansive power in  the vessels, which power
is supposed to act in inflammation  as well as in  natural formative
or  plastic processes in  the animal body.   But  the existence of
such a power is quite at variance with all that is known of animal
physics.   A part may be  expanded  by elasticity, or by the injec-
tion or retention of fluid in  it, but no direct  vital expansile power
has  been  ever proved  to exist.  The  apparently active  expan-
sion of  the  heart in its diastole may be ascribed  to  the natural
elasticity of the  organ and  the  increasing weight of its contents,
suddenly enlarging its size  on the cessation of its antagonizing
systole : neither its structure nor its mode of action countenance
the notion of a vital dilating power.
   412. Haller and some of his followers ascribed the  circulation
of the blood in  part  to  certain supposed properties of vital at-
traction and  repulsion, by  which the  blood is drawn into, or re-
pelled from, particular  parts, independently of  all   motion of the
living solids.  These opinions have been recently advocated with
much ability by Dr. Alison, who considers  changes in the vital
attractions and  repulsions to be the chief elements  in the process
of inflammation,  as well as  in other  pathological conditions in
which the blood and its vessels  are mainly concerned.*  This

  * See " Alison's Outlines of Pathology and Practice of Medicine," 1843, p. 122.
Several of Dr. Alison's arguments in favour of the existence of" vital attractions
and repulsions" are founded on certain physiological facts, which he considers
inexplicable in  any other view.   It belongs properly to works  on physiology to
discuss these matters ; but I must own that none of these  arguments seem to me
to be satisfactory.  The motion of the sap in the chara and other vegetables may
be well explained on the principle of exosmosis and endosmosis.   A fluid of
lower density, (water,) physically tends to penetrate and pass  into membranous
tubes, containing a liquid of greater density (sap) : that which begins a flow into
the tubes  may sustain it in a continued current through them so long as the dif-
ference in density subsists between  the water and  sap.  A  similar principle
doubtless aids in many cases the motion of fluids in the animal body, but many
motions of fluids observed in animals (as  in the air-tubes, genito-urinary pas-
sages, &c.,) have been 'traced to the  vibrations of cilia, and are no proof of the
ex^tence  of vital attractions and repulsions.
  It is said that when an artery is tied, the blood ceases to run  into the  open
part of it, and passes away by adjoining branches, which become enlarged in
proportion, whilst the tied portion becomes empty.  It has been supposed that
the blood  here spontaneously leaves the part of the artery through which there is
no passage.   I demur to the correctness of the statement, and still more to the
explanation.  Every one who has witnessed great surgical operations must have
noticed the strong pulsation above the ligature of tied arteries ; and  the occa- 
226           WILLIAMS'S PRINCIPLES OF MEDICINE.
hypothesis needs the most ample proof before it can  be  received.
It assumes the existence in the fluids as well as in the solids of the
living body, of properties as distinctive and as  peculiarly vital as
that of contractility or sensibility.   It  ascribes to these fluids and
solids powers of attraction and repulsion at sensible distances, like
the attractions and repulsions of electricity, magnetism,  or  gravi-
tation, yet distinct from all these, and sometimes opposed to them.
It attributes to the living body a new physical power, and almost
a discerning intelligence in the exercise of that power.  Now, be-
fore the  existence of such  a power can  be admitted, it must be
proved that the phenomena  of living structures are not  and can-
not be explained through any known  vital or physical  agencies.
We have already adduced and referred to arguments and  obser-
vations to show that the known  physical and vital  properties of
the living body will account for  the chief phenomena of health
and disease; and we have now to consider whether  the  same
thing may be done with regard to inflammation.   If we succeed
in explaining the nature and effects of inflammation by a reference
to ascertained properties, it will be needless  and unphilosophical
to  assume   the existence  of others,  which are  mysterious and
unknown.
   413. We  have  before stated (§  40S)  that inflammation may
originate either in determination of blood, or in  congestion, and
we now proceed to show that inflammation  essentially comprises
both these morbid elements.  The mode in which the process  of
inflammation has been chiefly studied, is  by observing under the
microscope  the effect of irritants on the frog's web.    It must be
remembered, however, that this is only  one mode  in which in-

sional occurrence of secondary hemorrhage  shows that the blood has no inherent
disposition to pass in a new direction. No doubt in time the  artery ceases to
receive blood  into its tied  portion; but this is because either a coagulum is
formed where a current cannot pass, or the tonicity of this portion effects the
contraction of the tube, the force of the circulation being diverted into the con-
tiguous enlarged branches.  Here is no proof of any self-motory and self-directing
power in the blood.  I have before stated that all my own microscopic observa-
tions have failed to detect in the blood any  spontaneous motions, independent of
contractions of the solids or of currents  caused by ciliary motion, exosmosis, and
endosmosis, and such physical causes.  The oscillatory motion said to have been
seen by Haller and Kaltenbrunner in the small bloodvessels of inflamed parts,
" even after the heart is at rest," may, perhaps, be ascribed to the tonic contrac-
tion of the arteries, which, although gradual  in itself, is often seen to act by
jerks on partially obstructed vessels.  A similar oscillatory movement is some-
times communicated to capillary vessels by the quivering contraction of adjoining
muscles.  Another observation of Haller, mentioned by Dr. Alison, that of " blood
escaping from vessels between the layers of a living membrane, and nevertheless
pursuing its course in a regular stream for a time, even against the influence of
gravity,"  may be fairly referred to the vis dtergo from the open vessel.   In the
fluids of such a nicely adjusted hydraulic apparatus as the vascular system of
animals, and even vegetables, it is surprising  how readily motions may be pro-
duced by various physical causes ; and when these motions are magnified by the
microscope, it is not wonderful that  they should  have been mistaken for vital
movements of the blood itself. 
PROXIMATE ELEMENTS OF DISEASE.
227
flammation may begin, and we shall  afterwards find that cold-
blooded animais fail to show some of the most remarkable results
of inflammation.
   The effect of weak irritants on the vessels of the frog's web has
been described before  (§ 294, 326).  We then found that irritation
may cause first determination of blood, then congestion ; these re-
sults being dependent on an  enlargement respectively of the arte-
ries and of the veins.  But if a strong irritant (as a grain  of cap-
sicum, or a minute globule of essential oil*) be applied to the web
of a  frog, all the bloodvessels  speedily  become enlarged: those
most irritated are very large  and red, and the blood in them is stag-
nant and coagulated : contiguous vessels are also very large, but less
red, and the motion of the blood  in them  is  slow, and  often  in
pulses or oscillations ; whilst in vessels  beyond, the enlargement
of the capillaries is less considerable, and the current  of  blood is
very rapid.
   Now, it is obviously the stagnation  or tardy motion of the blood
in the most  enlarged  capillaries, in the  midst of surrounding in-
creased flow, that most characterizes inflammation; and we have
still to inquire what is the cause  of the stagnation.   This cause
must be either in the vessels, or in their blood, or in  both.  The
 latter we shall find to be the true case.
   414. We have already pointed out  (§  300) that atony and flac-
 cidity of bloodvessels may  become a cause  of impediment to a
 current through them, not by preventing  these vessels from actively
 contracting on their contents, (for they have no such power,) but
 by removing that tone by which  the  vessels  maintain the calibre
 and  the tension best calculated to transmit  onwards  the force of
 the current.  Vessels  thus weak and inelastic, instead  of equably
 conveying the current, become distended, lengthened, and tortuous
 in receiving it; and  by their very mass,  as well as  by  their in-
 elasticity, they partly  break  the force of the current, and  partly
 turn it into other channels.  The  mode  in which  this results in
 inflammation will be better  understood, if we  review other local
 modifications of the circulation in comparison with it.
   In determination of blood, the  arteries are enlarged, and so are
 the capillaries in due proportion ; the circulation is therefore equally
 increased.   In  congestion,  the capillaries are enlarged, without
 any  increase of the arteries :  the motion is therefore impaired ; but
 still, being gentle, it may diffuse  itself through the  mass, which
 moves slowly.   But if to congested capillaries there be added the
 increased and abrupt  force of the current  from enlarged arteries,
 or if to determination of blood (enlarged arteries, § 326) an atonic
 congestion of the capillaries be joined, the propulsive power of the
 current  will be impaired.  As in  the experiment with the intestine
 (§ 300), the blood will pulsate or  oscillate  in  the distended vessels
 rather than  pass through them :  and the main current will  pass

   * These are preferred because they produce no chemical change in the parts. 
228
WILLIAMS'S  PRINCIPLES OF MEDICINE.
through collateral anastomosing channels, which become the seat of
simple determination or increased flow.   This is just the state of
things in the incipientstage of inflammation; and if eitherthecapilla-
ries do not speedily recover their tone,or the arteries do not contract,
the blood in parts becomes stagnant, and coagulates, and the ob-
struction is confirmed.  The arterial portions of some of the ob-
structed capillaries are still open, and exposed to the  pulsative
force from the supplying arteries, which  continues to strain  their
coats, and cause an oscillatory motion of their blood particles, but
no passage through them.  Such are the phenomena which we see
under the microscope.
  It may, then, be fairly  inferred, that one cause of the stagnation
or retardation of the blood in an inflamed part, is a weak, inelastic
state of the capillary vessels;*  such, in fact, as exists in cases of
atonic congestion ; and on referring to the causes of inflammation
(§ 404), it may be perceived that  many of them act by first pro-
ducing  congestion.  Nay, we have found (§ 294) that even irri-
tants, in some measure, operate in the same way.  " The continued
application of stimuli to a part  is sometimes followed, not by in-
flammation, but  by congestion.   This especially happens in the
liver, a chiefly venous organ ; but it occurs also in other parts.  It
might be  supposed that the stimuli act by  exhausting the contrac-
tility of the small vessels, and thus leaving them weakened and
distended by their contents.....But on the application of a strong
stimulant, such as a minute drop of essential oil, the previous arte-
rial contraction is not apparent, and the enlargement is speedy and
obvious, causing extreme rapidity of  motion and enlargement in
all the vessels.  In a few minutes, the size of the arteries begins
to diminish, and with  it the motion in the capillaries beyond them.
Many of  the capillaries still  retain  their enlarged dimensions; in
them the motion is most sluggish, and,  in  some  parts, ceases
altogether."t
  415.  But it is very certain that the obstruction, and much of
the  other features  of inflammation, are  greatly dependent  on
changes which take  place in the blood within the inflamed vessels.
J. Hunter did  not  overlook  this; and,  besides  describing the
coagulation of the blood in the most inflamed  vessels, he mentions
the  adhesion of fibrin  to their interior.   The coagulation of the
blood in  the inflamed vessels was also noticed  by Gendrin and


  * It may, perhaps, be objected that I have  supposed a similar  state of  the
arteries to be the cause of an increased flow through them, and to be the physical
cause of determination of blood.  But this is no objection.  The arteries, as com-
pared with  the capillaries, are few in number; their current is rapid ; they are
nearer to the source of power,  and are easily supplied from it; when their coats
lose some of their tone, the pressure of blood into them serves to stretch thern to
tension, and they present even less obstacle to the flow. In capillaries, on  the
other  hand, the force is  so much distributed, that it is easily disturbed, and  the
motion, naturally tardy, is readily arrested.
  f Gulstonian Lectures for 1841; Med. Gaz., July 16, 1841. 
PROXIMATE ELEMENTS OF DISEASE.
229
others;  and Dr. Marshall Hall attributed the obstruction of the
vessels in inflammation to the adhesion of blood globules to the
walls of the vessels.  It appeared to me, that microscopic observa-
tion ought to  be directed to this point more specially than had
hitherto been done; and in  1841, I made many careful examina-
tions of the early stage of inflammation in the frog's web. Some  of
the results were published in the Medical Gazette of July of that
year; and as they have been confirmed  by several other observers,
it may be proper to describe them.
  Poiseuille, in his observations with regard to the motionless layer
of serum which intervenes  between the moving  blood and the
walls of bloodvessels, had noticed that the blood particles some-
times get into  this still layer, and  either remain  fixed there,  or
move onwards more slowly than the rest of the blood.   In repeat-
ing  this observation, Mr. Toynbee and myself remarked  that it
was not the red particles, or elliptical blood discs, that thus adhered
to or slowly rolled along the sides of the vessels, but the white  or
colourless  globules, (§ 212,) called by Miiller, lymph globules.(a)
" I have never seen a solitary elliptical disc adhering to the sides
of a vessel; and whenever  one was arrested in its course, it was
from its  becoming hitched by one  or more  of the adherent round
globules.  But what appeared to me most remarkable with regard
to these  white globules, was the great  difference in their number
under different circumstances.   In young frogs, and in those much
subjected to experiment, they are always present;  but in healthy
adult frogs, placed under  the microscope  with as little handling
of the web as possible, there were few or none  to be seen.   I
have watched, for ten minutes at a time, without seeing one : the
motionless layer was  very thin, but clear, and all the blood parti-
cles in  the larger vessels seemed  to move  at the same  rate of
speed."   It is under these circumstances that the effect of irritation
or mechanical  injury was best seen.  " By pressure of the  finger
on the web, partial stagnation was produced in many of the ves-
sels ; and when this  yielded  to the returning current, the  walls
of the vessels were seen studded with the white  globules; whilst
many others of the same kind rolled over them slowly in  the di-
rection  of the current.  I  have before mentioned, (§ 294,) that a
similar result ensued after the web had  been stimulated by capsi-
cum or  an aromatic water.  Even in the rapid flow of blood fol-
lowing these applications, minute globules could be seen creeping
slowly along the transparent outline of the  larger vessels ; and  as
the arteries contracted, and the flow through the other vessels be-
came less rapid, the number of these globules increased, their motion
became slower, and many adhered to the sides of the vessels.  If
the stimulus used was rather strong or  long applied, the number
of sticking globules was so great as to  prevent the red particles
from passing; and these  becoming impacted in increased  num-

       (a) See Muller's Physiology (Amer. edit., p. 231).
           20 
230
WILLIAMS'S PRINCIPLES  OF MEDICINE.
bers, gave  to the  obstructed vessels  a uniform  and  deeper  red
colour.  When the stimulation was moderate, and equally applied
to  the web, the  stagnation usually took place  first  in  some of
those  anastomosing veins in which the current is naturally slow
and varying indirection; but when a stronger  stimulus  (as an
essential oil) was used, the stagnation speedily ensued at the point
of its application ; in fact, unless very minute quantities were em-
ployed, the stagnation was almost immediate and  extensive."*
  416. I  have varied these observations  in a  great many ways,
and have always found considerable or continued irritation  of  the
vessels in the frog's web  to be attended with the  appearance and
adhesion  of the colourless globules ; and that  when the irritant
used is at all strong, or frequently applied,  many vessels  become
totally obstructed, appear larger and redder than before by  the
accumulation of red particles in  them, (the  blood liquor having
passed on,) and exhibit to the naked eye all the appearance of in-
flammatory  injection.   The chief cause of  obstruction seems to
be comprised in  the  two circumstances — the increased production
of  the white globules, and their remarkable disposition to adhere
to the walls  of the vessels and to one another :  each of these cir-
cumstances must be noticed.
  The origin of the  white or lymph globules seen in the blood is
involved in some doubt.  They are  distinctly spheroidal bodies, of
a gelatinous consistence, and composed of granules, some of which
contain nuclei.   According to Mr. Addison,f they are invested  by

  *  Med. Gaz., July 23, 1841.   I have only recently read a paper by Mr. Addi-
son, of Great Malvern, published in the Med. Gaz. of Jan. 29th of the same year,
in which some of the same appearances had been described before I  made  the
above observations.  The following description is given by Mr. Addison : — "In
the frog's web, two days after the application of salt, in some of the larger capil-
laries or smaller veins, there are a great  number  of globules, No. 3" (lymph
globules); "and it is quite  extraordinary to observe the difference in movement
between these round speckled  globules and the oval  ones ;  the blood globules
pass in a continued stream, while in the same fluid, in the same vessel, are a great
multitude of other (lymph,  No. 3) globules, which do not move, or do  so very
sluggishly; every now and  then they move slowly, apparently urged  on by the
repeated knocks they receive from the blood  globules.   It  would appear, that
after the capillary vessels have been acted on by the salt, that the round (lymph)
globules accumulate in an unusual manner, and  the  blood globules  repeatedly
slide over and knock against them.   In some of the  vessels, there is a rapid
stream  of blood in the  centre, whilst at the circumference there are many  sta-
tionary, round, spotted globules, which do not obey the impulse which urges the
stream  of blood, but  remain,  or move  on slowly by little  starts, at uncertain
intervals, and with unequal pace."  This account corresponds very exactly with
what I  have myself observed; but I should not consider the experiment quite
conclusive with regard to inflammation, inasmuch as the chemical  action of the
salt might have been concerned in the production of the lymph globules, as  salt
seems to generate granules in the blood liquor.  In my observations, I was careful
to use no stimulus which has  any known chemical action on the blood.  The
greater prevalence of lymph globules in the motionless layer had  been noticed by
Wagner and others; and their more abundant production in an inflamed part has
been mentioned by Mr. Gulliver.
  f  Trans, of Provincial Med. and Surg. Assoc, 1843, p. 240. 
PROXIMATE ELEMENTS OF DISEASE.
231
a delicate membrane, constituting  a compound nucleated  cell,
which slowly by the action of water, more speedily by the opera-
tion of solution of potass, bursts and discharges granules and mole-
cules (nuclei  and nucleoli).  In this  respect, they differ from the
blood-discs, which are speedily burst, and are almost dissolved by
either of these fluids.  Dr. Martin Barry has endeavoured to prove
their identity with the nuclei of the red blood discs ;  but whatever
be their origin or destination, in the frog and  toad they bear no
resemblance to any part of the blood discs, differing altogether in
form, colour,  and consistence.  Mr. Gulliver has  remarked the
same dissimilarity between the white and blood particles in the
dromedary, lama, and other camelidse, and  in  birds, in which the
blood particles are elliptical.   It would seem more probable that
they are formed in the plasma, or  blastema of  the liquor sanguinis
itself; but whether they grow from  previously existing molecules
or granules, (Addison,) or  are formed quite spontaneously, cannot
now be decided.   The suddenness with which they may be pro-
duced by irritation or mechanical injury to  the web of  the  frog,
would scarcely comport with the notion of growth, or of their being
always enclosed in a cell.  The presence of these globules in great
abundance, in inflamed blood, has been noticed by  Gendrin, Gul-
liver, and others.   Mr. Addison has particularly observed them in
the buffy coat (§ 208),* together with numerous bodies  of much
smaller size (granules and  molecules).!
  417. The peculiar disposition of the white globules to adhere to
the walls of the vessels is remarkable, and might seem to be a vital
property.   But there are some circumstances which countenance
the notion that it is chiefly physical.  The reason why the red
particles are more readily carried in  the stream appears to be, that
they expose a large surface to the current;  and being covered  by
a perfectly smooth, unadhesive membrane, they are not liable to
stick to the walls.  The white globules,  on the other hand, are
more compact; and although, when in the current, are readily
carried by it, when more out of it, and  in the motionless layer, are
merely rolled by it, like pebbles by a rapid stream.   Further, they
manifest a distinctly adhesive property, which causes them to stick
to the walls of the vessels.^  In this respect, they contrast remark-

  *  Med. Gaz. Dec. 1840.              f Provincial  Trans., 1843, he. cit.
  \ The accompanying diagram exhibits the appearance of a small portion of the
capillaries of a frog's web after the application of a grain of capsicum.  The
elliptical blood discs (b) are  running in the axis of the vessel, which is much
narrowed by white globules adhering to the walls, or  only slowly rolling along
them.  These globules are speckled with nuclei or granules,  refract the light
strongly, and when rolled on by  the current, some of them become pear-shaped
from their sticking to the vessel, thus forming a kind of dragging tail, seen very
well on those marked (a) ; on altering the focus, globules may be seen adhering
to the other parts of the vessel. The shaded  portion (c) is totally obstructed
with lymph and blood particles,  so impacted together as  to form a homogeneous
red  mass.  In such a case I have often seen the particles at (d) exhibit a pulsa- 
 232          WILLIAMS'S PRINCIPLES OF MEDICINE.

 ably with the red blood discs, and the  newly formed globules of
 irritated vessels seem to have this adhesive property in the highest
 degree: they are probably without a covering.
   418.  It seems, then, to be well established, than an essential part
 of inflammation is the production of numerous white globules in
 the inflamed vessels;  and that the obstruction of these vessels is
 mainly due to the adhesive  quality  of  these globules.  The pro-
 duction of these globules must probably be  considered as an  ulti-
 mate fact in the history of inflammation and nutrition ; but it may
 be observed, that sometimes it seems to be the  direct effect of an
 irritant acting on  the  bloodvessels and  their contents (§415) •, in
 other  instances, it seems rather to  result from determination of
 blood into previously  congested capillaries (§ 414).  Any circum-
 stances causing continued determination of blood, where congestion
 is already present, will occasion the  production of the white  glo-
 bules, and,  consequently,  inflammatory obstruction  may ensue.
 The complete obstruction of some capillaries by coagulation takes
 place in all cases of severe  inflammation  of the frog's web ;  but
 there are slighter kinds of increased vascularity, in which  there is
 no total obstruction, but a continued enlargement of the capillaries
and veins, as well as of the arteries.  This might be called simple
 determination of blood; but it differs from that of a transient cha-

ting or oscillatory motion (corresponding with the action of the heart) ; and this,
 after a time, succeeds in breaking down  the obstructing  mass, which passes
away in clots, leaving the vessel (c) studded with  lymph globules like the other.
 
PROXIMATE ELEMENTS OF DISEASE.
233
racter, in the motion in the capillaries and veins being slower, and
in the vast number of white globules seen moving slowly in them
(§ 294).  Very probably this kind of process takes place in  the
lowest formsof inflammation,and in increased nutritionindependent
of inflammation.   Something of the kind is generally seen in  the
capillary circulation  of young frogs.
   419. The foregoing experiments and considerations lead to  the
conclusion, that the most essential character of inflammation con-
sists in an increased motion or determination of blood to the affected
part, with a more or less obstructed flow through the part:  the
force of  the  increased motion  being partly expended in the ar-
terial portion of the dilated capillaries (§ 414), and  partly diverted
into the collateral channels so abundantly supplied by the anasto-
mosis of vessels (§ 410).   The obstruction in the vessels of an in-
flamed part we have found reason to ascribe in part to the  increased
mass in  the  smaller vessels, and  to the diminished elasticity of
their coats; and in part, to the unusual formation of white lymph
globules, which adhere to the walls of the tubes, and to each other.
Of the exciting causes of inflammation, the direct irritants (§ 402)
seem to produce  obstruction in both these modes; those which act
indirectly (§ 403), on the other hand, in the first instance produce
congestion — to which determination of blood being subsequently
added, the inflammatory  process begins: hence the latter causes,
although very common, are not so sure of exciting inflammation as
direct irritants are.
   420. The effect of these changes, essential to  inflammation, is,
to expend much  of the circulating force conveyed  by the arteries
on their capillary terminations ; and the enlargement and tortuosity
of these capillaries, the production of globules which adhere to their
sides, and their total obstruction by the same means, seem to be so
many  progressive expedients used by nature to direct the force of
the circulation to that part of the vessels by which the process of
reparation and nutrition  is chiefly carried on.  This leads us to
consider  the further changes effected  by inflammation.(a)
  (a) Probably, as has been well remarked by Mr. Palmer,in one
of his many valuable notes on this subject (Hunter on the Blood,
Inflammation, &c. p. 314, Amer. edit.) the " effect of inflammation
is to approximate the structure of an inflamed part to that of a gland,
requiring, on the one hand, a  slow circulation, in order  that the
important offices of reparation may be carried on ; and on the other
hand, an extensive supply of the vital fluid as aliment  to this func-
tion.  It is at least remarkable, that the whole  internal arrange-
ments of glands, as well indeed as of the whole capillary  system,
seem designed to  retard the circulation, while the  most prominent
symptom of inflammation, and  that which forms the only  unequi-
vocal proof of its presence,  is the slowness  of the circulation and
the extraordinary quantity  of effusion which is poured out."
  Inflammation has  been not unaptly called by Meckel, a conges-
             20* 
2 34           WILLIAMS'S PRINCIPLES OF MEDICINE.
  421. We have already fonnd  that an  inflamed part is the seat
of determination and of congestion or obstruction.  It is this com-
bination which leads to  the changes which characterize inflam-
mation, and which, in extent and variety, exceed the changes from
any other kind of hyperaemia.  The determination of blood to and
near the obstructed vessels  is attended with the usual results of
determination (§ 333, &c.); but to a greater extent than usual, be-
cause thecause of determination is more permanent. The congestion
or stagnation hasalso its effects (§ 303, &c.); but more marked and pe-
culiar than usual, because the obstruction is more complete than in
congestion in general, and because it is modified by the influence of a
continued force of blood acting against it. All these circumstances
point out that the natural functions of the vessels must be much mo-
dified by inflammation, and this in different modes in different parts
of the inflamed site.  Thus, in the vessels which are the channels of
an increased flow, the functions  will  be more  or less exalted or
excited; whilst  in  those that are obstructed, vital properties will
be more or less impaired.   It is the  approximation of two such
opposite conditions, excitement and interruption of living actions
almost in the  same spot, that render inflammation so seriously de-
structive to structure as well as  to function.
   422. Inflammation at  first much exalts sensibility (§ 133) and
contractility (§ 111); causing tenderness, pain, and spasm.  But
the obstructed circulation may cause  a suspension of  these pro-
perties (§ 273) in  the  centre of the  mischief, whilst in the sur-
rounding parts, the seat of determination, they are  exalted.  The
sympathetic relations (§ 152, 156)  of the inflamed part are also
commonly increased.  Natural secretions are either suspended by
inflammation, or modified by the addition of various modifications
 of the serous and albuminous parts of  the blood.  This involves

 Hon with tendency to new production,— a  definition justified by
 an examination of the blood, one of the first changes in which is
 the formation of fibrin in excess, and of the solids in inflammatory
 effusions, mentioned in the  text (§ 424).
   Miiller, in common  with  Macartney (a Treatise on Inflamma-
 tion), denies that inflammation is  identical with, or necessary in
 all cases to regeneration of parts, or  that it occurs in the lower
 animals, as reptiles, &c.   He, Miiller, says, that " inflammation is
 not essentially a state of  increased action, but is compounded  of
 the phenomena of the local injury, a tendency to  decomposition
 in the part and increased vital action striving to balance the destruc-
 tive tendency;" and again "still inflammation is not a disease of
 increased vital power;  for the  phenomena of inflammation arise
  as much from the existing tendency to decomposition excited  by
  the chemical change, as from the reaction of the tissues to  oppose
  this destructive tendency."  (See Physiology, Bell's  edit., p. 55,
  66, 99.) 
PROXIMATE ELEMENTS OF DISEASE.
235
the change of nutritive secretion, which is so important and early
a part of inflammation, that it  must be noticed more fully.  We
shall recur to the other effects of  inflammation under the head of
symptoms.(a)
   423. The effusions from inflamed vessels at an early period are
much the same as  those from  tense congestion (§ 305-8) and de-
termination of  blood  (§  340,  1);  but they  commonly occur in
greater abundance, contain  more  animal matter, and, as the in-
flammation advances, they sometimes present appearances not met
with  in the products of mere congestion or determination.  Thus
the effusion at first is a  thin serum, causing swelling in complex
textures, accumulating in the dependent  parts of serous cavities,
or diluting the secretion of  the more simple  mucous membranes.
But soon fibrin  is  also  effused, part of which may concrete  into
coagulable lymph, or still remains dissolved, as in the liquor san-
guinis.  Thus an  inflamed pleura becomes coated with  a film of
lymph;  and the  clear  fluid  effused into the sac, when removed
from the body, sometimes spontaneously separates into a fibrinous
 clot and serum.   This occurring in complex textures gives a hard-
 ness  to their swelling, as in  phlegmon of cellular membrane, he-
 patization of the  lung, &c.   In mucous membranes, there may be
 thickening of the submucous  texture, and the mucous secretion
 becomes unusually viscid.
    424.  The microscope has given much additional information on
 the nature of inflammatory effusions, although it has yet left many
 points in  uncertainty.   In  the frog's web, after inflammation has
 continued some hours, there appear outside of the vessels (espe-
 cially those in  which the strongest current  encounters the  most
 complete obstruction) white globules or corpuscles, with specks in
 them, exactly like the lymph or nucleated globules within the ves-
 sels  (§ 415).  These are also  found in various inflammatory effu-
 sions, and are  called  exudation globules, or fibrinous globules.
 Mandl  supposes  them to be  merely consolidated globules of fibrin,
  and states, that the liquor sanguinis may be seen to coagulate in
 similar  globules on the glass of the microscope.   But these  have
 been described by  Gerber  as  mere albuminous granules, without
 nuclei,  and quite unlike  the true exudation corpuscle.  So, also,
 from the recent observations of Mr. Gulliver* and Mr. Addison,t it

    (a) " Inflammation, however," says Mr. Palmer (op. cit.), " is an
  act  which involves all the functions of a part.   The blood itself is
  affected."  After indicating from  Gendrin (Hist, des Inflamma-
  tions) some of the  changes in  this fluid, he adds.   « More or fewer
  of these changes invariably  attend  inflammation, which  cannot,
  therefore, be supposed to consist in a simple alteration of the circu-
  lation,  but principally of those vital affinities  subsisting  between
  the vessels and  their  contents, which are the peculiar attributes
  of life."
                *  Note to Gerber's General Anatomy, p. 31.
                |  Med. Gaz., April 15, 1842. 
*
236          WILLIAMS'S PRINCIPLES OF MEDICINE.

appears, that fibrin consolidates in extremely fine threads or fibrils
interlacing each other.  Both these observers describe the nucleated
or granulated corpuscles as occurring among these fibres, together
with more minute  granules and molecules (nuclei  and nucleoli),
which appear to be similar to  those which  compose the corpus-
cles.  Now,  all  these  bodies appear in inflammatory effusions,
although they occur in very various proportions, and present dif-
ferent modifications.   The following are the chief of these  ele-
mentary solids of inflammatory effusions.
   1. Molecules, immeasurable from minuteness, each appearing as
merely a dark speck.   (Smaller primitive molecules; Gruby.)
  2. Granules, (Gerber, Addison,) measuring  from r~  to  -^
of an inch, appearing as a light  spot, surrounded by a dark circle.
(Largerprimitive molecules, Gruby. Discs, Barry.)
  3. Fibrils, extremely fine, forming the chief solid of fibrin,  and
the buffy coat of the blood.
  4. Lymph or exudation corpuscles, measuring from ^^ to —^
of an inch, (Gulliver,) composed of granules and molecules, (nuclei
and nucleoli), and sometimes enveloped in a cell.
  Pus globules appear to be  enlarged modifications  of the  last;
and so are globules of mucus, and which, with nucleated  epithe-
lium particles, are commonly found in the effusions from mucous
membranes.  Yellow tuberculous matter has been distinctly proved
by  the researches of Gerber, Gulliver, and Addison,  to consist of
disintegrated or degenerated exudation corpuscles, or granules.
  425. Of these elementary solids, the fibrils certainly may form
from the effused liquor sanguinis out of the vessels, and even re-
moved from the body (Addison) ; but it is a question whether the
others concrete spontaneously from the liquid fibrin, or grow from
germs  (molecules or  granules), disseminated  from the vessels or
adjoining  textures.    The  close resemblance  of the  exudation
corpuscles and their contents to the white globules and granules,
so  abundantly  produced in  the blood  of the  inflamed vessels,
would seem  to  indicate  their identity ; but it is not easy to  un-
derstand how they pass through the walls of the vessels, in which
no  pores  are visible under  the  highest magnifying powers.   Mr.
Addison has, indeed, represented the white globules as first passing
into the substance of the  wall of the bloodvessel, and then beyond
it:  but  this would seem too slow  a process.  It would  appear
more  probable  either  that nuclei or  molecules, too  small to  be
discernible, do pass out in this way, and  then grow and propagate
compound granules (lymph and pus  corpuscles) ;  or that  these
corpuscles are formed by coagulation  in the  effused liquor san-
guinis as the fibres of fibrin certainly are.
  426. These solid products of inflammation, when  they cohere
and grow  into nucleated cells and fibres, are the plastic materials
of which new membranes and textures are formed : when they re-
main detached, and swell into larger globules, or split into irregu-
lar granules, or cohere imperfectly and shrink without developing
cells, they form the aplastic materials of purulent, tuberculous, and 
PROXIMATE ELEMENTS OF DISEASE.
237
kindred products, which Gerber therefore calls " degenerated exu-
dation corpuscles."*  As we shall have  to  notice these further
under the head of results of inflammation, we shall now return
to the process of  inflammation  and its  accompanying pheno-
mena.
  427.  Inflammation is always attended with  more or less effusion.
Where  the inflammation is slight, this effusion may remove it by
unloading the engorged bloodvessels ; but where the inflammation
is more intense, that is, where the obstruction is considerable and
the determination of blood strong, the effusion may go on  to a
great extent without resolving the inflammation.   It is then that
the more serious effects of inflammation result.  The effused mat-
ters press on and pervade the adjoining textures,injure their nutri-
tion, and impair  their cohesion ;  and thus takes place the soften-
ing of  textures, which  occurs chiefly in those of a complex kind,
which  retain the effused matter.  The continued obstruction in
the inflamed part leaves the veins and lymphatics free to absorb,
and the high pressure  and determination of blood tend rather to
 promote this process of absorption.   Hence, as new matters are
 effused, the old texture is compressed, disintegrated and absorbed ;
 the finer exudation corpuscles and fibres themselves are removed
 or altered, and the large pus globules alone remain : this is suppu-
 ration   Or if the original obstruction of the  inflamed vessels be
 extensive, or have been  rendered  so by the subsequent effusion,
 the supply of blood may be so  stopped in a part that it dies, ana
 the dead part may then either be only dissolved  and  absorbed at
 its circumference, and  separated from  the living  textures in form
 of a slough ; or  if more extensive, the  dead part may pass into
  decomposition  before  it can be separated,  and  thus  occur gan-
  grene and  sphacelus.   If the inflammation be of a lower kind
  the  obstruction less complete, and the effusion more  gradual  the
  nutrition of the natural texture  is only unpaired, not  arrested,
  and from the increased deposition of solid  matter, induration or
  consolidation takes place.(o)______________________________—

  ~flrtAtfcmtiot7t7^                                   aid US
  in he diagnosis of inflammation, after death, when Aecommon
  wmntoms  local and general, are  no longer present.   Diminution
  roCon iA common effect of acute inflammation, even in cases
  in which spongy organs become  more solidified by  effused fluid
  in their tissues, as in hepatization of the lungs.
    * This statement  which is founded on the recent  microscopic observations of
  CerbTr Gu 1 vS" Add.son, Watt, and others, is a remarkable  confirmation of
  Sews o, the nataw, of pus and tubercle which I have entertained for the  last
  S v vears and to which I adverted  in the following sentence, published fifteen
  twenty years, ana io                  consider tubercular matter, pus, and 
238
WILLIAMS'S PRINCIPLES OF MEDICINE.
          SYMPTOMS AND EFFECTS OP INFLAMMATION.

  428. We have described the process of inflammation in its in-
timate nature and phenomena ;  we have now to notice its more
obvious effects on function and structure, which become symptoms
of its existence.  These symptoms may be divided into local and
general; the local occurring chiefly in the part which is the seat
of inflammation ;  the general  affecting the system at large.


                      LOCAL SYMPTOMS.

  429.  We have before remarked that the local  symptoms are
commonly more prominent, and  the  first to occur, when inflam-
mation is excited  by local irritation (§ 402), and the fever which
afterwards supervenes may even disguise  the  local symptoms.
The chief local symptoms have been already mentioned in the
definition, redness,  heat, pain, and sivelling, to  which may be
added various disturbances of the function  of the  part affected.
We shall explain and illustrate these symptoms.
  430. The redness of an inflamed part  is  obviously due  to the
increased quantity of blood  in the vessels.  All these vessels are
much enlarged, so  that  they receive many more red particles
than usual;  and the finest capillaries, which  commonly are in-
visible from their admitting only the liquor sanguinis with now
and then a red particle, are now distinctly coloured from the num-
ber that pass into them.   Some observers have thought that new
vessels are formed by the blood forcing its way through  the tex-
tures.  I have never seen this in the frog's web ;  but it appears
to take place in some textures which are not naturally vascular,
such as the anterior part of the cornea, and cellular cartilage (Toyn-
bee).  But the microscope shows that besides the augmented size
of the bloodvessels  which convey blood, much of the redness of
inflammation arises  from the vessels in which  the  blood is stag-
nant.  The colour of these is much more red than that of the ves-
sels through  which a current still passes ; and this has before been
referred to  an accumulation of colouring  matter, which takes
place in  them  (§ 415, 417 note).  These vessels appear  so im-
pacted to  their outmost  limits  with colouring matter, that the
shape of the blood discs  and of the white corpuscles is no longer
discernible :  yet these are  still  present; for when  an obstructed
vessel re-opens, the  red  mass breaks  up into clots and particles,
and many white corpuscles are left sticking to its walls.   (See
note, p. 231.)   It is obvious, therefore, that the obstructed vessels
become stuffed, as it were, with red particles, the  liquor having
passed on.  In many instances, too, it may be seen that  the red-
ness of an  inflamed  partis augmented by spots and patches  of ex- 
PROXIMATE ELEMENTS OF DISEASE.
239
travasated blood, which prevail especially in some varieties of
inflammation.
   The redness of inflammation  presents great varieties according
to the  number and distribution of the capillary vessels of the
part; but its most essential seat being in the capillaries, its  most
constant character is a diffused or capilliform redness.  This  is
commonly far  more vivid and general  in the living than in the
dead body.  In the skin and mucous  membranes during life, it
is often seen as  a uniform blush of colour, varying from a deli-
cate pink  to a bright crimson.   After death  this blush has some-
times  entirely  disappeared ;  but commonly more or  less  of  it
remains ; and  on examination with a  lens, it is found  to consist
chiefly Of numerous vascular striae, network,  or points, with here
and there larger vessels and ramifications also injected.   But the
large vessels (veins) are distended much less generally than in con-
gestion (§ 280), and  the redness is therefore less arborescent and
ramiform.(a)*  To explain the reason of the disappearance of inflam-
matory redness after death, we must bear in mind that much of it
depends on determination of blood (§ 326), which is maintained by
the  action of the heart, distributed by the arteries; and that when
 this ceases in death, the tonic contraction of the arteries which sur-
 vives for a few hours, expels the blood from the vessels (§  120).
 A similar effect is sometimes produced  during life, by cardiac syn-
 cope. The redness that remains after death seems chiefly to consist of
 the vessels which have become totally obstructed and impacted with
 blood, or have been long congested and have lost their tone (§ 295).
 This  furnishes us with a  useful means of distinguishing m diffe-
 rent cases the comparative prevalence of the elements of inflamma-
 tion.   Thus in cases in which the redness  disappears after death,
 we may know that the predominant element was local determination
 of  blood (& 409) without much  obstruction or  permanent conges-
 tion.   This is observed in erythematic and diffused membranous
 inflammations, the cutaneous inflammations of eruptive fevers and
 the early stages of all inflammations  excited by  moderate local
 irritation (& 402.415).  On theother hand, if much redness remains
 after death, we may infer that obstruction or congestion of the
 vessels has  existed to a great extent.   This  happens especially in
 phlegmonous  inflammations, those of parenchymata, and others
 which have advanced  to a certain intensity, and those which have
 originated in congestion (§ 403).

   "^Tcar^uT^TdZ) describes  the varieties of  redness in
 inflammation, under the heads of ramiform, capilliform, uniform,
  nZcTfoZ and maculiform.  A11 these forms, varying in degree,
 {re he sa^s, met with combined in the mucous membranes, more
  e o'ecialy o  the digestive organs ; the capilliform and  the puncti-
  fom being the firsuhat appear, and the most characteristic of in-
  flammation. 
240          WILLIAMS'S PRINCIPLES OF MEDICINE.

  The florid hue of the redness is also during life a sign of the pre-
dominance of determination, for it shows that the blood is chiefly
arterial and not stagnant.  Where congestion prevails, or where
the blood has  been long stagnant in many vessels, the colour is
deeper ; but it is rarely so deep as in pure congestion, for the pre-
sence of white globules  tends to lighten it or give it a brownish
tinge.  In the dead body these distinctions are not equally avail-
able, for the arterial part of the blood may have been removed by
the contraction of the vessels, or darkened by stagnation ; and the
livid portions speedily become florid on exposure  to the air.*(a)
  (a)" The differential characters of inflammation and local conges-
tion  are," says Dr. Cars well, " founded on certain differences  in
the physical  characters of each, and in the circumstances under
which  they respectively occur.   Although similar forms of  red-
ness and vascularity are produced in both, it is perhaps  only in
mucous membranes that a difficulty arises in  distinguishing the
one  from  the other.    So long  as the redness and vascularity
are confined  to the capillary vessels,  or  have  their  seat  in the
villous or follicular structure, there can be no doubt as to their in-
flammatory nature.  It is only when they become more  general
and  present  the ramiform  character, that any difficulty arises.
This, however, is removed by an examination of the neighbouring
veins,  which, in mechanical congestion,  will  be found  dilated,
tortuous, and even varicose, according to the degree and duration
of the  obstacle by  which it has  been caused.   The congestion of
the  veins may likewise be  traced  to its cause.  In inflammation,
the local congestion commences in the capillaries, afterwards ex-
tends to the small veins, but never to large branches;  in mechani-
cal congestion, the  blood accumulates first in  the trunks, which
are always conspicuous, and afterwards in the branches and capil-
laries.   It is  only when mechanical congestion is combined  with
inflammation, that  the  anatomical diagnosis becomes difficult  or
impossible."
   There will still remain, however, a vascularity produced by the
depending position of parts during life or  after death, simulating
very closely that caused by inflammation.
   The redness in tissues caused by imbibition, and that owing to
transudation, are, Dr. Carswell  thinks, easily distinguished  from
the redness which is the consequence of inflammation.
   "  It  can never be confounded  with that of inflammation, when
it occurs along the  course of the larger subcutaneous veins; but it
has frequently been so in the lining membrane of the large arteries
especially, and of the veins.  Whatever may be the circumstances

  * I have often in the dead-house seen  mere congestive redness mistaken for
inflammatory, because it was florid, from the action of the air, or from the trans-
lucence of a subjacent white structure.  Frequently, too,  the claret stain of
arteries and intestines is mistaken for inflammatory redness : a common lens will
prove it to be not so, by showing that it is not vascular. 
PROXIMATE ELEMENTS OF DISEASE.
241
  The progress of inflammation modifies the redness.  The colour
becomes more florid and deeper  as the inflammation advances to
which favour the red colour of imbibition, it never bears  a  near
resemblance to that of inflammation.  It is a mere dye of a uniform,
almost scarlet,  red colour, generally limited to  the lining mem-
brane, without any other perceptible change of the coats of the
vessel ; whereas redness from  inflammation is  of  a  dull, rather
pink, tint, extending more or less to the other coats, accompanied
by a fine capillary injection of the  subjacent cellular tissue, and
marked congestion of the vasa vasorum ; the lining membrane is
softened and opaque or easily removed ; the cohesion of the other
tunics is diminished; they  are also thickened or swollen, and  in-
filtrated with serosity or  coagulable lymph."
   Permanency of redness and vascularity of inflammation is  itself
an adequately differential character to guide us in cases of doubt.
   " The redness and vascularity of mechanical congestion,  of posi-
tion or gravitation, and of  imbibition, differ, as we  have  seen,
essentially from those of inflammation, in  the mode of their pro-
duction and other local circumstances.  But they also  differ essen-
tially in other respects.  Thus, all these kinds of redness and vas-
cularity are produced and maintained by appreciable causes, which
operate external to  the  vessels, without the blood  or the vessels
themselves undergoing any change, by which the vital properties
of either are so modified as to render the  redness  or vascularity
permanent after death.   By means of ablution,  pressure, or scrap-
ing, both of these physical characters  disappear in a short  time.
In inflammation it is "far otherwise ; the  employment  of the  same
means never removing, or effecting only a slight  diminution of
either. Injections, too, which penetrate the capillaries in the former
kinds of congestion, cannot be made to reach them in that which
proceeds from inflammation.  It is necessary, however, to observe,
that this state of the capillaries, and the redness which accompanies
it, and which constitutes what I mean by the permanency of these
physical characters of inflammation, are  more or less decided by
the degree and stage of the disease.  In the highest degree or  se-
cond stage, the permanency of both is most marked; in the first
stage it is much less, the redness diminishing or disappearing en-
tirely after death, in slight inflammations of the skin of short  dura-
tion.  This difference in the permanency of the redness and vas-
cularity of inflammation in its two stages may be explained by the
facts already noticed, viz., the absence of coagulation of the  blood
in the first and its occurrence in the second stage, in which also
the  fibrin  unites  with and penetrates the capillaries, thereby re-
taining the colouring matter of the blood, and producing occlusion
of the vessels.
   " Although, however, 1  have said that redness disappears after
death in slight inflammation of the skin, some degree  of increased
vascularity remains, as  is seen by comparing  the diseased with
            21 
242
WILLIAMS'S PRINCIPLES OF MEDICINE.
its acme; it then becomes either livid  before it subsides, or paler
from the colour of the effusion.  In complex textures, the effused
lymph or pus  changes the redness to  pink, flesh colour, drab, or
yellow.
  431. The heat of inflammation  is obviously dependent on the
increased flow of blood through the part;  and it may be consider-
ed the representative of the amount of  determination of blood con-
cerned in the  inflammation.  Hence it is great in extensive  and
active inflammation, and is  generally proportioned to the florid
redness  or arterial vascularity.  It is uncertain whether  the high
temperature of an  inflamed  part is  caused  by the  augmented
changes going on in that part, or whether it arises merely  from the
greater quantity of warm blood which passes through it.  John
Hunter made some observations to determine this point, and never
found that the temperature of an inflamed part was raised above
that of the interior of the body, which it might be expected to
be if  inflammation was in itself a calorific process.  That exten-
sive inflammation raises the heat of the whole body, as well as of
its  own site, is quite certain ;  but .this may be simply by causing
general  excitement, especially of the circulation  and  respiration,
and by repressing the perspiration and  other exhalations, by which
the body is naturally cooled.  Increased heat is  a very important
and valuable symptom of inflammation, since it is more constantly
discernible than any other, and serves  to distinguish inflammation
from  congestion and nervous  irritation, which may resemble it in
other symptoms.  But to indicate inflammation the heat must be
continued, and not merely coming in flushes with simple determi-
nation of blood.  Generally the skin is dry as well as hot: but it
may be perspiring, and yet a temperature, higher than natural,
may be sustained.
   432.  The swelling of an inflamed part is caused in some degree
by the enlargement of the vessels, but  chiefly by the effusions from

a healthy part.  And, besides, it is of great importance to know
that,  even in such slight cases of inflammation, the cutis undergoes
changes which render the existence and extent of the disease very
conspicuous after the disparition of the redness, and from one to two
days after death.   The affected parts only of the  skin assume  a
purplish tint, and become infiltrated with  bloody serosity, and the
 epidermis is detached from these parts  much  sooner than from
 those which were not affected by the inflammation.  This post-
 mortem congestion,  and a more  rapid tendency to decomposition
 than in ordinary circumstances, are conditions which ought not to
 escape  the notice of  the pathologist,  when it occurs  in internal
 organs.  They are sometimes the only morbid appearances which
 are met with  in fatal cases of scarlatina, and especially in rubeola,
 and indicate the extent not only of the inflammation, but of the
 depressing influence which  it must  have exercised  on the  vital
 function of these organs." 
              PROXIMATE ELEMENTS OF DISEASE.           243

them, and will be therefore proportioned to the amount of these :
but the situation, form, and degree of the swelling will also great-
ly depend on the natural structure of the part  inflamed.   In se-
rous membranes, the vessels being comparatively few, admit of
but little enlargement; and the effusions, not being retained by com-
plexity of structure, soon overflow externally and chiefly accumu-
late in the most dependent parts of the serous sac, causing dulness
on percussion, and sometimes fluctuation in the chest and abdomen,
and  when in large  quantity  distending these cavities.  Mucous
membranes are more vascular and complex  in  structure: hence
the enlargement of vessels early causes some thickening ;  but the
swelling is chiefly due to interstitial effusion in the submucous
tissue (so manifest in coryza and  cynanche):  this effusion, when
merely serous, soon  passes off in the thin flux which  attends ca-
tarrhal inflammations, and the swelling may subside with it: when
the effusion is more solid, the swelling remains longer, is attended
with a more viscid secretion, and subsides only when this secre-
tion becomes opaque, and somewhat fat in its composition.  The
skin presents great variety in the  swelling as  well as in the  red-
ness caused by inflammation.  Sometimes the swelling is diffused
and hard, as in cutaneous erysipelas.  In urticaria the same  hard
swelling occurs in spots or patches, and the effusion in parts super-
sedes the vascular redness, causing white centres or wheals.  In
tubercular inflammations of the skin the redness and swelling are
still more circumscribed, and  the effusion seems  to be chiefly solid.
In papullse  the swelling is even more minute and confined  to a
point   In blebs and vesicles, the  effusion is  between  the  cuticle
and the true skin, and the swelling is confined  to  corresponding
patches  or  small spots.  inflammation  of cellular texture  is
attended with considerable swelling; this being diffused, cedema-
tous, and pitting on pressure, when the  effusion is serous, being
more tense when there is fibrin with the serum; and being  hard
and subscribed (as in phlegmon) when the matter effused is chiefly
fibrin.  Parenchymatous organs, in like manner, are  remarkably
swelled by inflammation.  The liver, kidneys, testicles, lymphatic
and other glands, attain a large size from  the  mere distention of
their  bloodvessels ;  and  we  have noticed a  similar result from
mere congestion (§ 293) ; but inflammation does not last long in
these structures without causing effusion, which, by various  pro-
portions of serum and lymph, may cause swelling, differing in its
firmness.   The  lungs from their   porous  structure, do not swell
materially in bulk ;'but the effusion displaces  the air in their cells,
thus increasing their  weight, and if the effusion abound in lymph,
converting  them into a more or  less solid mass,  like liver  (he-
patization).
   433. The pain of  inflammation is  caused by  that exaltation of
sensibility (§ 135) which determination of blood produces, (§ 333.)
often increased by the tension or pressure arising from the swell-
ing   The amount of pain will therefore depend much on  the na. 
244          WILLIAMS'S PRINCIPLES  OF MEDICINE.

tural sensibility of the part, the degree in which determination of
blood predominates, and the tension or pressure induced.   The
severest pain arises where these circumstances co-operate, as  in
inflammation of the pulp of a tooth, the sheath of a nerve, the
lining of a bony canal, as the auditory meatus, &c.  In most cases
pain is chiefly felt when the inflamed  partis pressed or stretched,
constituting excessive tenderness.   Thus the pain of peritonitis is
felt on pressing the abdomen, or on straining the walls by cough-
ing or  vomiting: the stitch of pleurisy is  felt on taking  a full
breath:  the pain  of external  inflammation  and rheumatism, on
motion or pressure on the limbs.  In enteritis there may be little
pain until the intestines  become spasmodically contracted in some
parts, and distended in others, by flatus and other contents ; hence
the pain may vary, whilst the  inflammition  remains the  same.
Parenchymatous organs  and mucous membranes being compara-
tively soft and yielding in texture, are  not the seat  of much pain,
when inflamed.   In the early stage, pain, with heat, may indicate
the activity of inflammation, that is, the prevalence of determina-
tion of blood.   In the more advanced stages, the pain  rather bears
relation  to the amount of tension from swelling or effusion, and is
commonly relieved  when this becomes more diffused, or ends in
suppuration.
   434. Besides pain and tenderness, sensibility, increased  by in-
flammation, sometimes exhibits other  modifications, such as feel-
ings  of  soreness, tingling, heat, itching, &c.   Peculiar sensations
are also excited in the organs of special sense when they are in-
flamed, such as noises in the ears, painful and disturbed vision, &c.
The peculiar sensibility which  excites the motions of sneezing,
coughing,  vomiting, micturition, and defecation,  is  exalted,
when respectively the Schneiderian membrane, the lining  of the
upper part of the air-tube, the  cardiac  end of the stomach, the
bladder, and  the rectum, are  inflamed.  Other sympathetic sen-
sations excited  by inflammation are peculiar  to disease,  as the
pain in the shoulder-blade, with inflammation of  the  liver, pain
in the testicle, with inflammation of the kidney; pain  of the glans
penis, in inflammation  of the  bladder; pain  of the  knee, with
inflammation of the hip.
   435. Contractile fibre  is not itself prone to inflammation; when
the parts contiguous to it are inflamed, the effect is commonly first
to increase its irritability, and subsequently to impair  it, probably
by exhaustion.   Thus the heart, when its membranes are inflamed,
acts  first with great force and  frequency, but subsequently with
feebleness and irregularity.   When the intestines, bladder, or air-
tubes are inflamed, there  is contraction followed afterwards by
more or less weakness of the muscular fibres of these  parts.
   436. Other functions are somewhat similarly affected under the
influence of inflammation.  In  inflammation of the brain and its
membranes, there is commonly at first more or less excitement of
the sensorial  functions, causing  delirium, hallucinations, and con- 
PROXIMATE ELEMENTS  OF DISEASE.
245
vulsions :  afterwards ensue stupor, and coma, and paralysis.  In
the early stage of inflammation of the spinal cord, there may be
tetanic convulsions; afterwards follows paralysis.   Often  symp-
toms of partial excitement are conjoined with others of interrup-
tion of function ; and this is not extraordinary, seeing that inflam-
mation comprises diminished as well as increased flow of blood, and
the former generally predominates as the inflammation advances and
effusion proceeds.   Inflammation of the  lungs  causes dyspnoea:
that of the stomach interferes with digestion : inflammation of the
kidneys suspends or impairs their secreting power, &c.  It is need-
less to go into further details.

          CONSTITUTIONAL SYMPTOMS OF INFLAMMATION.

   437. The irritation of  inflammation frequently extends itself to
the system at large.  The functions of the whole body are  disor-
dered.  The contractions of the heart are more frequent and forci-
ble than usual: the arterial tonicity is increased (§ 121) ; hence the
pulse is quick and hard: the skin is dry and hot: the appetite and
strength are impaired : and the natural secretions are diminished
and otherwise disordered.   This  is inflammatory fever.
   438.  Amonsr the most important general effects of inflammation
must be noticed the change in  the condition of the whole blood.
We have before noticed, that there  is an excess of fibrin and of
the colourless globules in the blood in  inflammatory diseases (§ 195);
and that the separation and contraction of this fibrin (§ 203, 4) takes
 place in an unusual decree, and  produce the peculiar bufted and
 cupped appearance of the clot so remarkable in inflamed blood
(& 2 08).   This  excess and separation of fibrin  displayed in the
buffy coat is commonly proportioned to the  extent  of the inflam-
mation and its duration in  an  active state.  This would suggest
that the change in  the blood is  altogether  produced  in the blood-
vessels in and near the inflamed part; and that the  increased de-
velopment of white globules, seen by  aid of the microscope (§ 415).
is a Icind  of demonstration of this production.  This  supposition
derives support from the fact, that blood  drawn  directly from an
inflamed  part is more buffed than that drawn from a distant part.
 The excess and separation of fibrin is more remarkable m  infiam-
mation of serous membranes than in those of mucous membranes,
ox parenchymal,  which mav perhaps be ascribed  to the  former
m Summations bring attended  with  less local ^scalar d.sention
 and overflow of the exudation globules and fibrin.   Acute rheu-
matism presents the highest degree of the buff and cupping of the
Wood? perhaps because the inflammatory irritation arising from
matter in the blood itselft (§ 251) affects a great many vessels, yet
   • I have observed this even in blood drawn by cupping, on a part inflamed by

y&^vX£™***«*in inflarama ^d'°psyadmits of a
similar interpretation (§ 385),
            21* 
246          WILLIAMS'S PRINCIPLES OF MEDICINE.

without  completely obstructing  them, so that  determination of
blood predominates over congestion ;  and although there may be
much inflammation and effusion  of the early kind (§ 423), this
does not lead to suppuration, or other of the  more destructive
changes which follow inflammation.  It has been before mentioned
(§ 245,) that  an increased activity of circulation and  respiration
might contribute to augment the fibrin of the blood in acute rheu-
matism and other inflammations not impairing the respiratory func-
tion ;  but it was then objected, that  the increase of the  fibrin is
sometimes observed in rheumatism without much  acceleration of
the pulse and breath; and, on the other hand, in fevers in which
the pulse and breath  are much  hurried, the fibrin of the blood
is even diminished (§ 196).   And it was found, by Andral  and
Gavarret, that in fevers, the  occurrence of local inflammation al-
ways caused an increase of the fibrin in the blood.(a)
   It seems pretty clear, then, that the increase  of fibrin, and its
more contractile and  separating quality, originate in  the vessels
of the inflamed part, and must be regarded as an augmentation
of the vital process of nutrition  developed by inflammation.  A
similar augmentation takes  place in  the vessels of  the uterus
during pregnancy, when the  blood drawn  generally exhibits a
buffed appearance ; and although such an appearance is not com-
monly presented by  blood  drawn  from  fast-growing  children
during health, yet in them  it is very readily induced  by inflam-
mation, and the plastic products are  unusually copious.  It has
been mentioned (§ 415), that in young frogs, even in health, many
white globules are seen in the bloodvessels adhering to or moving
slowly along  their sides; and  this appears  to be a proof of the
activity of  the same nutritive or plastic process which is exalted
to its highest degree in acute inflammation.
  439. It has been supposed,  that the inflammatory or fibrinous
state of the blood is the cause  of the  general excitement consti-
tuting the  symptomatic fever  accompanying inflammation ;  but
it may be  objected,  that this  fever frequently rises high before
the blood has begun  to  exhibit the  buffy coat,  often  subsides
when the buffy coat is most abundant, and is sometimes wholly
absent when the biood is both buffed  and cupped, as in subacute
rheumatism.   It is very  probable, however,  that the excess of
fibrin may contribute to the excitement; and it certainly materi-
ally affects the duration and  products of the inflammation.
   440. In  inquiring  into the  pathology  of  inflammatory fever,
we must bear in mind, that it sometimes precedes the distinct
development of the local inflammation, being, in  fact, a general
excitement or reaction after  the  disturbing influence  of the ex-
citing cause.  This is especially the  case where inflammations
are produced by cold, fatigue, and other causes which first induce
congestion (§ 403).  The operation of these  causes is  at first de-
(a) See note to p. 125. 
PROXIMATE ELEMENTS OF DISEASE.
247
pressing  to the whole system ; and the continuance of this marks
the cold stage of the fever, with weak pulse, coldness of the ex-
tremities and surface, general  pallor, various uneasy feelings, de-
jection of spirits, and depression of strength.   Afterwards ensues
the reaction, beginning with rigors, accelerated pulse and breath-
ing, sometimes vomiting, or other functional disturbances:  soon
the skin  becomes hot, the pulse hard, as well as frequent; uneasy
feelings in the head, back, and limbs, are experienced, with thirst,
loss of appetite, restlessness, and much weakness.  It is during or
after the establishment  of this reaction that the  local symptoms
of inflammation may become  prominent.   During the cold stage,
they may have been chiefly those of congestion of the affected
organ §  (303), impaired  function, with more or less uneasiness;
 but now pain ^§ 433), heat (§  431), and various symptoms of local
 irritation (§  434), ensue; and frequently, as  these become  deve-
 loped, the  general  disturbance  is less  complete.   In  eruptive
fevers, the general disturbance and functional disorders is greatest
 before the eruption (or  local  inflammation) appears.   In inflam-
 mations from cold or fatigue, the first disorder sometimes resem-
 bles that of continued fever,  which is changed for simple inflam-
 matory  fever as  soon  as the inflammation is pronounced.  In
 other cases, again, chiefly those which originate from local  irrita-
 tion (& 402), the inflammation is developed, and its symptoms are
 prominent,  before the  symptomatic fever is  excited.   Generally
 the  fever is in proportion  to the severity or active character of
 the  inflammation: and  if it were always so, we might conclude
 that the fever is the result of a reaction from the  disturbance of
 the  circulation produced by the inflammation ;  but we sometimes
 find inflammation of trifling  organs,  such as the tonsils, attended
 with a very smart fever; and  much greater disturbances  of the
 cireulation, such as congestions of the lungs and hver, take place
  without causing any fever.   It seems more probable then, that
  die fever accompanying inflammation arising from local irntation
   s caused by an exciting influence propagated  from the inflamed
  part o the heart and arteries through the medium of  the nerves
  The same  influence also  sustains the ^fl-^f0^/^^:
  cases before noticed in this paragraph, in which  the first  febrile
  movement seems to be the result of reaction          circulation
    441  It still remains  unexplained  why, m  fevei, the circulation
  an^me  functions are excited, whilst  o'hets ^secrettou mu,
  cular strength, and theappetttes, ate  much unpaired   V-e  canno
  entirely solve the difficulty ; but we  may point out  hat the ex
  Mtemeiit is not one of a  healthy kind, being attended with an
   'x  T  ve tonictty of the arlerie. *(§ WD, »** Vl^ThZ-li
  hardness of the pulse, and which rowans™ *e*£±  "^'ex-
  the capillaries too rapidly to permit of its pioper  cnai pC   y
  S  It is also possible that the vital powers of secretion  (§ 153) 
248           WILLIAMS'S PRINCIPLES OF MEDICINE.

one of the most prominent elements of fever in general.  Thus the
bowels are generally costive ; the urine scanty and high coloured ;
the skin dry;  the  tongue clammy, with thirst;  and ulcers  or
sores, that  may have been discharging before, now become dried
up.  So, too, on the subsidence  of the fever, all these secretions
are restored.
  442. The fever accompanying inflammation is generally high —
that is, attended  with hard pulse, hot skin, and general excitement
— in the young, the sanguine (§ 38), and plethoric (§ 279) ; those,
in short, in whom the vascular system is  naturally  active  (§ 401).
On the  other hand, it  is commonly low — that is, with  weaker,
though sharp and quick pulse, less general heat of skin, and with
tongue  more foul, and functions often rather oppressed or dis-
ordered than excited — in persons  of phlegmatic  temperament
(§ 40), and in those weak from age, disease, mal-nutrition, intem-
perance, or confinement.   The type  or  character of the fever also
varies with the seat of  the inflammation,  and the particular  tex-
tures  affected, although the variation is  less  constant  than  it is
generally represented to be.   It is commonly stated, that the fever
is high in inflammations of most serous and fibrous textures and
in phlegmonous  inflammation of cellular texture; that it is low in
inflammation of the stomach  and intestines, kidneys, large joints,
and in diffuse inflammation of the cellular texture ; and that the
fever is of an intermediate character in inflammation of  mucous
membranes and  parenchymata.   Clinical experience however
shows that there are many exceptions to these  statements; and
where the type of the fever is affected by the texture, it is chiefly
by the intensity of the inflammation and the nature of its product.
Diffused inflammations of little  intensity, often  excite very little
fever, and few local symptoms.  The reverse  is  the case  of very
acute inflammations even of moderate extent.
  443. The exciting cause, or  some  co-operating influence, often
materially affects the type of the fever. The inflammation occurring
after serious accidents or  burns is often attended  with  a low fever,
the reaction being imperfect from the continued depressing influ-
ence of the cause.  The same remark is applicable  to  the case of
inflammation from poisons, which are locally irritant,  but sedative
to the system.  Even the long operation of cold may so  depress
the vital powers—-especially that of the heart—(§  75)—that the
reaction is imperfect, and the fever is low : thus, in very inclement
seasons, inflammations are often attended by a typhoid or adynamic
form of fever (§  25).
  444.  In the lower forms of inflammation (§ 442), the fever may
be remittent or even intermittent: a state  of depression alternating
with  a state  of  excitement, ending with  perspiratiou; and when
inflammations become chronic, or are of slight character, they may
excite no fever  at all.   They generally, however, induce some
constitutional disorder, in which defective excretion (§  171) is
commonly a  predominant  element.  When it is borne in mind 
PROXIMATE ELEMENTS OF DISEASE.
249
that inflammation includes  determination of blood, it will be ob-
vious that, besides the  irritation connected with it, there may be
more  or less exhaustion of other parts of the body (§ 331): the
part inflamed  being  over-supplied with  blood, other parts are in
want. This effect is most obvious in anaemic and debilitated sub-
jects ; and to it must be  ascribed the weak  circulation, coldness,
disordered functions, and gradual emaciation of the body in gene-
ral, when a  part long suffers from low inflammation.

NATURE  AND  SYMPTOMS  OF THE  TERMINATIONS  OR  RESULTS OF
                        INFLAMMATION.
   445. The  results or events of inflammation may be comprehended
 under four  heads: Resolution,  Effusion,  (including adhesion,)
 Suppuration, (including  ulceration,) and Gangrene.  It must not
 be supposed that these often occur quite singly, or that they are
separated from each other by a very marked line ; but these terms
are conveniently attached  to those results  in which  each respec-
tively predominates.
   Resolution consists in the cessation  of the inflammation, and
 the speedy  removal  of any slight effusion.   As the essential parts
 of inflammation appear to be determination of blood, with obstruc-
 tion to its flow through some vessels; so the resolution of inflam-
 mation consists in the yielding  of the obstruction and the subsi-
 dence of the determination, the vessels contracting to their normal
 dimensions.  This may be well seen  under the microscope.  Some-
 times nothing remains of the inflammation, but more or fewer of
 the white globules adhering to the sides  of the vessels;  but more
 commonly some vessels  are still obstructed, and others congested,
 with the motion in them slower than usual, the determination ot
 blood (enlargement of the arteries) having ceased.   So, commonly,
 we find congestion  remain in a part that has been inflamed ; and
 not  unfrequently a  flux or watery effusion may result from that
 congestion  f& 375).                                       ,  .
   446  Resolution of inflammation may occur spontaneously in
 slight cases;  or in consequence of treatment;  or from the inflam-
 mation being transferred  to another part.  Some inflammations
 creep to adjoining parts, as in the case of erysipelas and some ser-
  "ginCcutaneoSs^ruptions.   Others  affect  similar texture m
 different parts of the body ; and being ^solved in one part,appear
 in another:  this  happens  in  rheumatism, which affects fibious
  exZes, and is transferred from limb to limb  or joint to joint  by
 what is  called metastasis, or translation.   This may_ be fairly
 traced to the mobility of the peculiar materies morbi (§ 40-), the
 cat se of the inflammation.  A remarkable metastasis of resoving
 mflammation is sometimes seen in  parotitis, the breast or the tes-
 ticle  Tor ovary! becoming  the seat of the new attack.
   447 The occurrence o°f resolution is marked by a subsidence of
 the chief symptoms of inflammation:  first, of the heat and pain, 
250
WILLIAMS'S PRINCIPLES OF MEDICINE.
and, more gradually, of the redness and swelling.   The heat usually
yields to perspiration.  The pain becomes gradually easier; and
in some parts, as the skin, may pass into itching before it subsides.
The redness sometimes simply fades ;  more commonly it becomes
less florid, and may pass through shades of a livid or dusky hue
before it vanishes.   The swelling soon subsides ; the effused fluids
being so speedily removed by absorption, that effusion can scarcely
be said  to have  been a result.   Still, in some instances, cogestion,
or some of its  results (§ 274, 350), or nervous irritation  (§126,
152), remains behind after the inflammation has ceased.
   448.  The resolution of any considerable inflammation is marked
by a reduction  of the fever: the pulse becoming softer and less
frequent;  the skin moist with perspiration, sometimes profuse  ;
the urine, becoming more copious, abounding in  urea, and depo-
siting, as it cools, a plentiful, lateritious, or branny sediment, con-
sisting of lithate of ammonia.   The constancy of  this last change
on the decline of inflammatory fever has  led to  the  supposition
that it is critical, and determines the removal of the disease.  The
lateritious  sediment in  the  urine is a pretty certain symptom of
the subsidence of fever, and of the amelioration at least of the  in-
flammation which excited  it; but it is uncertain how far it is the
cause  or the effect of improvement.   It  indicates an  increased
excretion of the solid constituents of the urine ;  for there is often
an excess of urea as well as of the lithates ; and comparing this
with the scanty  secretion of urine during  the febrile  excitement,
and the decay of tissues which is always taking place (§ 254),  we
can scarcely avoid the conclusion that these excrementitious mat-
ters had been accumulating in the  blood from the impaired func-
tion of the kidneys during  the fever; and that now, as the fever
subsides, and their function is restored, the accumulated matter is
thrown off.  Now, although the function  of the  kidney must be
first impaired to cause the  accumulation  of  the  excrementitious
matter  in the blood, yet this matter so retained tends to keep up
the disorder (§ 6S, 171);  and it  is by means which  promote  the
 elimination of this matter that we succeed best in reducing febrile
excitement.  So, likewise, in cases where the function of the kid-
 neys is permanently impaired by Bright's disease (congestive  de-
 generation (§ 309), inflammatory and other fevers are not readily
 brought to a termination : persons so affected are said to be " bad
 subjects," with  " broken-down constitutions ;" and they often sink
 because their excreting organs are  unequal to the  increased task
 thrown on them.   In cases in which the resolution of the inflam-
 mation is  only partial or imperfect, a daily remission or alleviation
 of the fever may take place ; and with it there is usually a deposit
 in the  urine, of a  pinker or  lighter  colour than the  usual brown
 lateritious  sediment, and containing, besides lithate of ammonia,
 purpurate of ammonia and lithate of soda. 
PROXIMATE ELEMENTS OF DISEASE.
251
                Effusion (including adhesion).
  449. Effusion we have already found to  be a result of  inflam-
mation (§ 423); but it it is not always, like resolution, a termina-
tion of this process (§  427).  An abundant effusion of liquor san-
guinis, of coagulable lymph and serum, of pus, or of inflammatory
mucus, usually lowers the inflammation — that is, reduces the de-
termination of blood,  and may diminish the obstruction, but often
does  not  remove it;  and the effused matter may cause sundry
mischievous effects, by  compressing, stuffing, or obstructing the
several structures in which it accumulates.  We may with advan-
tage pursue the history of effusions, by tracing their changes in the
chief elementary tissues.
   Serous membranes, being simple in structure, give us  the best
illustration of the history of inflammatory effusion.  In acute in-
flammation in a healthy subject, besides serum, an  exudation of
fibrin or coagulable  lymph takes place in a  few hours.  This
fibrin is  at first in a semifluid, ductile state ;  so  that the  motion
or pressure of the inflamed surfaces draws it into bands or threads,
 or spreads  it into films, as  we see it on the pleura, pericardium,
 and peritoneum.  But if we examine inflamed surfaces which are
 less  exposed to motion  or  pressure, as the  looser parts of the
 auricles of the  heart, the serous covering  of  interlobar divisions
 of the lungs, that of the less projecting parts of  the intestines,
 and of the convolutions of the brain, we find the deposit of lymph
 not uniform in a film, but in  points  forming a granular  surface ;
 which shows that either more is effused at some  points than at
 others, or that  the concretion of fibrin having begun in points,
 chiefly augments around the same points.  The granules thus de-
 posited vary in size, from that of a grain of sand to that of a millet-
 seed ; but if  the  deposit  increases,  they enlarge  into patches,
 which may run into one another, often forming  a mammillated
 coatin^ of lymph.  Even on surfaces  which are  subjected to mo-
 tion, the prevalence  of the fibrinous effusion at points is shown by
 a villous or shaggy appearance of the lymph, from this, in its duc-
 tile  state being drawn  into threads  projecting  from tne points
 where it has first concreted ; this is sometimes well seen m  tne
  pericardium.   In the  pleura, these  inequalities are  more obliter-
  ated by the rubbing motion of respiration, or by the pressure of
  liquid effusion.                          ,   „       c-  a  _ A
    450. The lymph thus effused is (like the buffy coat of inflamed
  blood) at  first transparent; afterwards it  becomes yellowish,  and
  more or less opaque,  but  in inflammation of a healthy subject
  generally retains some degree of translucency.  In this respect, it
  contrasts with the product of inflammation in unhealthy subjects,
  purulent  and tuberculous lymph,  which is more  opaque.   But
  the most important  character of healthy  ymph in its high suscep-
   ibihty of organization, which character 1 will in future designate 
 252          WILLIAMS'S PRINCIPLES OF MEDICINE.

 by the term euplastic (§ 211).  Euplastic lymph consists of fibrils
 of fibrin crossing each other in various ways, and mixed with nu-
 merous exudation corpuscles, both compound (cells with nuclei and
 granules) and simple (granules and molecules).  Now, these are
 also found in the buffy coat of inflamed blood (§ 212); and there
 can, therefore, be no doubt of their identity, and that the blood thus
 altered by the inflammatory process is their source (§ 438).  This
 leads us to anticipate  what is the fact, that the plasticity of lymph
 will depend much on the good quality of the  blood', as well as on
 the energy of the inflammation.  Healthy blood, which  abounds
 in red particles as well as in fibrin, furnishes the most plastic kind
 of lymph (§ 183); and inflammation, attended  with the most active
 determination of blood,  (so long as the integrity of the  vessels
 is preserved,)  separates this  lymph  in the greatest abundance.
 This lymph already possesses living properties, for  its materials
 arrange themselves into the basis of a texture ;  but to sustain the
 life of this texture, it must be supplied with blood, and this takes
 place in the wonderful process of the formation of  bloodvessels in
 it, which communicate with those of the adjoining parts.
   451. The precise manner in which vessels are formed in lymph
 is not distinctly ascertained.  Mr. Kiernan observed inflamed capil-
 laries become varicose, and at points project in pouches and diver-
 ticula, and stretch into loops.   If these give way, the  blood would
 be injected into  the lymph; and if something  of channels were
 previously formed by the arrangement of the fibrils, or the elon-
 gation and communication of cells, it is quite  conceivable  that  a
 current would be effected by the visiitergo through several openings,
 and that a return of the blood  would take  place by a reversal  of
 the weaker currents.  But the actual observation of the mode
 in which new vessels  are formed is yet wanting.   It  has been as-
 certained by Schrceder, Liston, and others, that the new vascular
 channels are at first much  larger than the vessels which  supply
 them;  they are afterwards contracted by the formation of a base-
 ment membrane lined with epithelium ; and the whole texture be-
 comes  more consistent and less bulky, exhibiting a filamentous and
 cellular structure, with nucleated cells scattered through it.  This
 new membrane forms  patches on, or adhesions between, the serous
 coverings of the  lungs, the heart, and intestines;  and provided
 these false membranes are loose, and of moderate  thickness, they
 may cause no disorder.
  452.  When the inflammation is of a low character, or when the
 blood is poor in red particles, and especially when these two con-
 ditions are combined, the  solid products of inflammation are less
capable of organization, and therefore may be called  cacoplastic.
 As the process of organization varies in degree,  so these products
 may attain to different degrees of structure, forming membranes
 of a denser, less pliant texture, and  less vascular than  the serous
 membranes to which they are attached, and which  they therefore
shackle.  Thus patches of a kind of fibro-cellular or fibro-cartila- 
PROXIMATE ELEMENTS OF DISEASE.
25M
ginous membrane are formed on the lungs, the heart, and the  in-
testines ; sometimes with the effect of materially impeding  the
functions of these several organs.  Where the effusion of lymph is
scanty and  slow, its  granular mode  of  deposit is more obvious
than  in the  more acute disease ;  for being less ductile, it is less
readily spread or stretched by the motion of the parts (§ 449). This
is well seen in chronic inflammations of the peritoneum and arach-
noid, in which  the deposit  is almost entirely in  granules or flat-
tened patches, commonly called tubercles.  These are generally of
a buff or skin colour, of  firm consistence, and sometimes exhibit
slight traces of  bloodvessels in them ;* but sometimes their colour
is more yellow  and opaque, their  texture uniform and tough, and
 they are totally destitute  of vascularity.   These constitute the for-
 mations described under the names cirrhosis and  crude yellow
 tubercle, and are the lowest of the organized products.   Being, in
 organization and  consistency,  dissimilar  to  the  membranes on
 which they are formed, they prove a source of irritation and  con-
 striction; and being liable to ulterior changes, (shrinking and  con-
 traction in the  case of cirrhosis;  further degeneration and soften-
 ing in the case  of yellow tubercle,) they may bring further mischief
 in contiguous parts.                                    .  a
    453. In some cases, again, more or less of the product of inflam-
 mation is  aplastic, or totally incapable of organization  and is
 thrown off with the liquid in  separate large globules filled  with
 granules and molecules, constituting pus ; or in detached flakes, or
 curds, consisting of aggregations of irregular °Paq«« C(?.rPu^
 and  molecules held together by a few fragments of fibrils:  such
  effusions are exemplified  in the sero-purulent liquid and crndy
  matter of low  pleurisy, pericarditis, and peritonitis.   It is obviou*
  Sat Inch HfeleL prodiicls  must act prejudicialy on ^containing
  structures ; and the fact might be anticipated that they are little
  susceptible of absorption.                      „r inflammation
    454 I  have mentioned (§  452  a low form of nflammation,
  and an unhealthy  condition of the blood, as causing  the  caco-
  Xstic character of  the  products  of  inflammation.  It may be
  added Sat the long continuance  of  any inflammation,  and  s
  olefin subjects in  whose blood fibrin  aboun^  wh  ejie



  o^n^nt-^ c^ncet iS  Ha  —n

    • Mr. J. Dalrymple  has observed, that live^sc.laiity of lymph may be =

   earlier, in ™^^™^^^^^^^ «^
real texture.
           22 
2 54
WILLIAMS'S PRINCIPLES OF MEDICINE.
continues, its product either is thrown beyond the reach of vascu-
lar communication, or displaces that already effused, and  thus the
outer layer will be in a degenerating condition.   Added to this, the
pressure of the liquid effusion may impede the construction and in-
jection of the new membrane, which therefore is degraded into one
ofthecacoplasticor aplastic mattersabovedescribed. Again in scrofu-
lous or cachecticsubjects, the blood, although scanty in red particles,
abounds in fibrin, and this is readily effused in inflammation ; but
is of low vitality, and   susceptible of  little or  no organization.*
There is yet another circumstance tending  to lower the plasticity
of  lymph, although, from the  observation of Mr. Dalrymple, it
sometimes accelerates its organizationt—that  is, the admixture
of the colouring matter of the blood with  it.   Laennec supposed
that contraction of the chest had its origin in hemorrhagic pleurisy
only.  This is not correct;  but I have many times remarked after
death, that  lymph on  the pleura and pericardium, in cachectic
subjects, is much  stained  with  blood ; and where patients with
similar  symptoms have recovered from inflammation, they have
been affected with structural disease.   So far as we yet know, the
colouring matter does not  form a  material for organization ; and,
further, it is very probable that in  such cases the colouring matter
is itself diseased (§ 186).
   455.  The more  complex  structure and  secreting properties  of
mucous membranes considerably modify the form  and  appearance
of the products of their inflammation.  But, according  to Gerber,
Henle, and  Gruby, they microscopically consist  of exudation cor-
puscles, granules, and molecules, together with more or less amor-
phous and glutinous mucus, the natural secretion, and scales of epi-
thelium.  I must add, however,  that, in the early stage,  serum is
present, manifest by the  saline taste and  coagulability by heat;
and at  an advanced stage, the mucus contains fatty matter.
   Irritation of mucous  membranes merely causes a flux  (§ 379);
that is, the  natural mucous secretion  more copious, watery, and
saline than usual, and containing fewer globules.   But if the irri-
tation be continued, and inflammation follows, the secretion is at
first diminished by the effusion of serum and exudation corpuscles
into  the interstices of the mucous and  submucous texture, which
causes more or less thickening or swelling.  Soon, however, the effu-
sion overflows to the surface in the form of a more or less viscid, sa-
line-tasted liquid, containing more globules and epithelium  scales ;J

   * When a coagulum of fibrin is retained  long in a vessel without becoming
organized, it loses its structure, and softens into an opaque semifluid matter,
which long was mistaken for pus ; but Mr. Gulliver has shown that  it consists
of  much smaller particles, mere irregular granules.  In this state it bears  the
closest general and microscopical resemblance to mature and softened tuberculous
matter.  It appears to me, that certain softened tuberculous appearances, met with
in the lymph of serous membranes and parenchymata, are similar in their nature.
   t Medico-Chirurg. Trans., 1840, p. 212.
   X Gruby; Morphology of the Pathological Fluids.  Translated by Dr. Good-
fellow.  (Microscopical Journal, Nos. 19-23.) 
PROXIMATE ELEMENTS OF DISEASE.
255
andas the inflammation becomesmoreintense, the globules predomi-
nate, and the mucus becomes more scanty, but is still very viscid.
On the first  decline of the inflammation, the mucous and saline
matter diminish, and the globules  compose the  chief mass of the
secretion, and give it  the yellowish or greenish opacity seen in
u concocted" sputa; and this opaque matter  is  afterwards gradu-
ally replaced by the natural mucous  secretion.  In some cases,
especially in young subjects  and others in whom the inflammation
penetrates to the  submucous cellular  texture, fibrinous matter is
thrown out, forming films or shreds of lymph ; but this very rarely
becomes organized on mucous membranes, because their secreting
apparatus and its product  lie between the lymph effused  and the
vascular structure.  Hence the exudation corpuscles of inflamma-
tory mucus  are degenerating or aplastic, and constitute the opacity
of viscid, mucous, muco-purulent, purulent, and shreddy fibrinous
matters exuded by inflamed mucous membrane.  If inflammation
persists in a mucous membrane, the globules continue to abound
in the effusion, commonly  rendering it opaque and purulent; and
the natural  mucous secretion being  impaired, the product is  more
diffluent.   But inflammation rarely continues  long over a  great
extent  of surface ; it is confined to  patches,  which  yield their
opaque effusion whilst other parts may be secreting natural mucus.
Hence the compound appearance  of the secretions in chronic in-
flammations of mucous membranes (bronchitis, mucous  enteritis,
and cystitis).
   Sometimes  interstitial effusion,  which takes  place at the  com-
mencement of inflammation of mucous membrane, is not entirely
removed by the subsequent discharge.   In such cases there may re-
main a permanent thickening of the mucous and submucous tex-
ture, which is the cause of the indurations and strictures which in-
flammation sometimes leaves in the intestines and urethra ; and to
 a less degree in the air-passages.   This, however, it must be ob-
 served, is the result of inflammation rather of the submucous cellu-
 lar texture  than of the mucous membrane  itself.
   456. Inflammation of the skin presents great varieties as to the
 amount and kind of its products.   The full consideration of these
 would lead us into the pathology  of skin diseases, a subject replete
 with interest  and practical  importance, although  sadly neglected
 amidst the  artificial distinctions of writers  on cutaneous diseases;
 but the subject is too wide to be discussed here.
    Some of the  effusions  in  and  from the skin  have been glanced
 at under the  head of the symptoms of inflammation (§ 432).  It
 may now be added, that these effusions may consist of clear serum,
 with few exudation corpuscles and molecules, as  in the liquid of
 blisters and blebs, and eczema, which dry  into thin scabs; or of
 milky serum  more abounding in the corpuscles, which dry into
 thicker scabs, as in herpes, rupia  simplex, &c.; or of liquor san-
 guinis and purulent serum, with more numerous corpuscles,  which
 form very thick, yellow, or brown scabs, as in rupia prominens,
 impetigo, and ecthyma ; or the effusions may be chiefly solid, and 
256          WILLIAMS'S PRINCIPLES OF MEDICINE.

into the substance of the dermis, as  in tubercular inflammations
and incipient pustules.  In all cases of inflammation of the skin,
there is an  increased production of epidermis, which is sometimes
thrown off in scales with the scabs ; or in a peeling of the cuticle ;
or thickens, and forms a hard covering, liable  to clefts and sore
ulcerations, as in psoriasis, inveterate eczema, &c.
  457. Inflammatory effusion into the  cellular  texture consists of
serum, with more or less of the exudation corpuscles and  fibrin.
In diffuse erysipelas or cellulitis, the fibrin is  deficient, and the
corpuscles either are in moderate numbers, or else are degenera-
tive  (purulent).   In  phlegmonous inflammation there  is  more
fibrin,  which circumscribes  the  effusion,  and  causes  a  harder
swelling ;  and the pressure of this with a continuance of  inflam-
mation may lead to  suppuration or sloughing.
  458. Effusions from  inflammation of parenchymatous  organs
resemble those from  inflammation  of cellular  texture; but the
parenchymata in general being very vascular, as well as yielding,
the  solid effusion may be very copious, without  causing the pres-
sure  or tension that leads to suppuration  and gangrene.  The
lymph effused exhibits, in  regard to plasticity,  the same varieties
which  we  have described  in  the products  of serous membranes
(§ 450, et  seq.).  But  inasmuch  as  lymph effused in the  paren-
chyma of  an organ would greatly interfere with its  function, we
rarely find  it to become organized, except in .limited portions,
which  thus remain solid and dense.  More usually the  matter de-
posited is  gradually removed  by absorption or  secretion after the
inflammation declines ;  or if the inflammation continues, the exu-
dation  globules and  lymph are converted into, or replaced  by pus
or tuberculous matter—that is, degenerated corpuscles.
  459. Effusion so closely attends  the process of inflammation,
that the symptoms of effusion have been comprehended in those
of inflammation.  Swelling, pressure, obstruction, irritation, con-
solidation, displacement, and various functional, as well as struc-
tural disorders, may arise  from the presence  of effused matter.
Hence the  occurrence  of effusion may aggravate  some  of the
symptoms of inflammation, whilst others may be more or less re-
lieved by it.  Where a  copious effusion takes place, the  pain, heat,
redness, and fever, are  commonly reduced; for the vascular and
nervous excitement  and determination  of blood are lessened ; but
the local Or visceral  disorder  may be increased.  The  pulse may
be as frequent, but it is less hard and full; the fever less constant,
but it may continue in  a lower degree, or  assume a remittent or
hectic form.  The relief by effusion is greatest in slight inflamma-
tions, or where  the  effused matter  can be thrown off from the
body, as in  the  case  of mucous  membranes;  but there may be
much irritation and exhaustion of strength in the process of throw-
ing it off (as in cough and expectoration, diarrhoea, purulent mic-
turition, &c.); and  these  will be more  harassing where, as we
have found  is  sometimes the  case, the effusion  does not remove
the inflammation. 
PROXIMATE ELEMENTS OF DISEASE.
257
                 Suppuration and Ulceration.

  460.  The formation of pus among the products of inflamma-
tion  has been  several  times  noticed (§ 424, 453, 455, 457, 45S).
Pus  is an opaque, greenish, or yellowish-white liquid, of creamy
consistence, little  odour, specific gravity varying  from 1030  to
1040.   It is chemically composed of water, albumen or fibrin of
the globules (pyine), albumen in solution, fat, osmazome, and the
same saline matters  as  those  in the blood.  According to Gerber,
mature  pus contains more fat  and less albumen than that recently
formed.
  Microscopically, pus consists  of  serum, and globules  of pretty
regular size  and"  form.  These  globules are  obviously  a modifi-
cation of the exudation corpuscles; each consists of a fluid, with
granules and molecules contained within a thin cell, which some-
times has granules also on its surface.   The  granules render the
appearance of  the investing cyst or cell obscure ; but its existence
is clear from the action of distilled  water, which causes the cell to
dilate (by endosmosis) to double  its former size;* and what is
curious, the continued granules  swell  also,  which shows their ve-
sicular  nature.   Pus globules are larger than the general size of
exudation corpuscles (§ 424), and  exceed in size the blood  discs
(Gulliver).  According to Mr.  Addison, they measure  from ^
t0 _J_  0f an inch.   Besides in size, they differ frOm other exuda-
tion5c°orpuscles in  being more distinctly vesicular, and containing
a fluid, as well as granules :  their more readily swelling, bursting,
and shedding their contents under  the influence of water, or solu-
tion of potass  (Addison), may be referred to  the same difference.
This probably imitates the process by which  the exudation cor-
puscle is converted into a pus globule.   From a peculiar constitu-
tion either of the corpuscles or of the adjoining fluias, the disposi-
tion to  endosmosis is increased, and the corpuscles, and even their
contained nuclei, swell into vesicles, instead of remaining in the
gelatinous condition which characterizes the corpuscles within the
bloodvessels (§ 416), and in coagulable lymph (§424).t  (a)

"T^TltTwould seem, from the observations of Autenrieth, Brug-
man and Vogel, that the fluid secreted directly from a suppurating
surface is at first a clear fluid, which afterwards becomes thick and
opaque, by the formation of globules. - (Midler's Physiology-
Bell's edit. p. 447.)

  * Gulliver; Notes  to Gerber, PI. 259, 60.  Gerber describes pus globules as
flatted disc's, consisting of seven granules, without arnnvesUng eel', and  formed
hv a nartition of  the  exudation corpuscle into these granules,  mis sldle™eni
 synaotPconfirmed by Gruby or Addison, whose descriptions more cordonwth
those of Mr. Gulliver, and  with observat.ons which my friend Mr. Dalrympie

h3?  pTL^Voduced in birds or in cold-blooded animals; the reason of tht.
            22* 
258         WILLLVMS'S PRINCIPLES OF MEDICINE.

  461. Another  distinguishing character of the pus globules is
their want of cohesion ; and  in  proportion as they predominate,
they impair  the  consistence  of fibrin or mucus with which they
may be combined.  Pus effused into cellular and complex textures
also impairs their cohesion, and leads to the destruction of their
substance ; hence suppuration consists in  not only the  formation
of pus, but also  its substitution for more or less  of the inflamed
texture :  for this reason suppuration, more than effusion, may be
called a termination of inflammation, for the inflamed vessels are
in great part destroyed.
   462. The circumstances which  determine suppuration as a result
of inflammation, are  chiefly three : — 1. A certain intensity (ob-
struction and determination in the  vessels,  (§419) and duration of
the inflammation ; 2. The access of air to the part; 3.  A peculiar
condition of the  blood.
   1. Intensity and continuance of inflammation pretty surely lead
to suppuration in common inflammation of the true skin, cellular
textures,  glands, and most parenchymatous  organs. -  Lymph is
effused first, and it is pretty  certain that the exudation  corpuscles,
at least, of this lymph, are changed into pus globules by the con-
tinued operation of  the  distended vessels.   In circumscribed ex-
ternal inflammations, pressure, which reduces the distention, some-
times prevents suppuration ; and  in serous membranes, intensity
and continuance of inflammation do not lead to suppuration, be-
cause the distended vessels are fewer and smaller, and in less close
contact with the exudation  corpuscles.   In  mucous membranes,
duration, rather than mere intensity of inflammation,  causes  the
more abundant  formation of pus ; but the disposition of  mucous
membranes to secrete pus rather than lymph may depend on the
disintegrating effect  of the remaining mucous secretion.
   2. The access of air to a  wound or to a serous membrane  dis-
 tinctly promotes the formation of pus, probably by a chemical influ-
 ence, which disposes the exudation corpuscle to swell into a vesicle;
 but it is uncertain how much this influence may be  due to a che-
 mical change, and how much to the increased irritation which the
 contact of air may cause on the living parts.  Certainly a limited
 access of air promotes the decomposition of pus, and leads to serious
 consequences from its putrefactive changes.
    3. The condition  of the blood which promotes the suppurative
 termination of inflammation is not well understood.  It is generally
 connected with a cachectic, ill-nourished   state of the system, as
 exemplified in  persons affected  with impetigo and other suppura-
 ting diseases of the  surface, in whom slight scratches or punctures
 readily  fester, and whose wounds do not heal by the first intention

 is not understood,  as the exudation corpuscles do not materially differ from those
 of .mammalia. A  careful investigation of the products of inflammation in birds,
 as well  as in animals, would probably throw much  light on the true nature of
 pus and lymph.  . 
PROXIMATE ELEMENTS OF DISEASE.
259
(simple plastic adhesion).  It has been said that, in such cases, pus
globules may be found in the blood.  It is quite certain, however,
that the presence of pus in the body, when that is not duly limited
or thrown off, causes a tendency to the production of  more ; and
the most plausible notion with regard to this is, that  it operates
somewhat in the manner of a  leaven, like  other  morbid poisons
(§ 98).  For a similar reason, suppuration, when begun in a part,
usually proceeds until pus is substituted for the inflamed textures
and former products of the inflammation; and until by the process
spreading, the pus finds exit on some surface.
   463. The process of suppuration strongly illustrates the opposite
character of the elements of inflammation before alluded to (§ 421).
The obstruction to the  passage of the blood through many vessels
 of an  inflamed part, and the increase of this obstruction by the pres-
 sure of matter effused  by those vessels that are the seat  of deter-
 mination, reduce the vitality of the obstructed parts to so low a de-
 gree, that they  are  unable to  withstand the chemical solvent power
 of the effused fluids * exalted as it is by high temperature.  The
 textures are therefore gradually dissolved,! and are absorbed away,
 whilst the exudation globules in form of pus occupy their  place,
 and continue to be effused by the vessels which  are still the seat
 of determination of blood.   This assumes that absorption is  still
 active in an inflamed part; and the assumption is warranted  by
 the fact, that the absorbing vessels, veins and lacteals, remain per-
 fectly free : and the very occurrence of increased pulsation and flow
 in communicating and contiguous vessels (§ 413), will promote the
 exosmosis of fluid matter by the absorbent vessel. That the pus
  globules should remain unabsorhed will not appear extraordinary,
  when their large size is taken into account (§460), and that they
  are not dissolved by their proper fluid.   Thus  the combination of
  apparently opposite results, which has been considered so inexpli-
  cable, — excited and lowered  action, increased  secretion and in-
  creased absorption, — admits of an explanation in exact accordance
  with all the phenomena.
    464 The amount and extent of the process of suppuration varies
  in different cases.   In some cellular and parenchymatous textures
  it sometimes occurs as purulent infiltration, not circumscribed by
  lymph, but leaving the texture  much softened, and partially re-
  moved   This diffused kind  of suppuration is  to be referred either
  to the porous  nature of the organ (as with the lungs) not admitting
   an effusion of lvmph  sufficient to limit the  suppuration, or to  a
   purulent diathesis or  disposition in the blood (§ 462).   In  most

     *  That the liquid  of pus can chemically dissolve dead animal  matter was
   proved by J. Hunter, who found that pieces of raw meat were dissolved .nab-
   Eses or even in pus kept warm out of the  body. The experiments of Sir C
   Winuingham showP that other  animal fluids have a like property.  Dr. Prout

   "tTL'Slhat the removal of textures in suppuration is owing to their death,
   originated with Dr. Billing. (See his■« Principles of  Med.cme.  ) 
260          WILLIAMS'S PRINCIPLES OF MEDICINE.

cases, the process of suppuration is limited around by solid effusion,
which may be either the remains of the earlier product of the in-
flammation, or it may be thrown out expressly for the purpose of
defending the adjoining structure from the  operation  of  the pus
which is obviously a noxious matter.   A collection of pus thus
circumscribed is called an abscess; and when mature, it represents
the perfection of suppuration.   The bloodvessels of the inflamed
part are destroyed like other textures ; but their supplying trunks
are obstructed by lymph ;  whilst the adjoining capillaries, which
remain pervious, become dilated and varicose on the walls of the
abscess, which are lined with  a coating  of organized  lymph, the
vessels in which continue to secrete pus; whence this lining is
called the pyogenic membrane.  As the pus increases, the abscess
becomes enlarged, generally towards some cutaneous  or  mucous
surface where it points; the skin or membrane ulcerates, and the
pus is discharged.  The direction which  the abscess takes seems
to be  that in which there is least resistance :  the parts  here
are more  stretched than others ; and from being stretched their
vessels  are more  obstructed,  so  that they cannot maintain  the
vitality, nor throw out the same  amount  of protecting  lymph,
which limits the  abscess in other directions.   Fibrous and other
hard textures resist the progress of abscesses and the escape of
pus.  Serous membranes, by their ready plastic process,  first ad-
here together, and then often give passage to the contents of an
abscess through them, without any pus escaping into their sac.
Thus  abscesses of the liver and kidney make their way across the
peritoneum into the intestines, through the walls of the abdomen,
and even through the diaphragm, pleura, and  lungs.   Where pus
from an abscess does  make  its way into a serous sac, it causes
severe irritation, and fatal inflammation.
  465. After an abscess has opened, it may continue to discharge
pus, pure or diluted with serum or sanies; but in healthy subjects,
a process of healing takes place by an increased effusion of lymph,
and growth of new vessels in it  in  the form of  granulations,
throughout the interior of the  abscess.   Pus is  still formed by the
superficial layer of exudation corpuscles degenerating or swelling ;
and a free vent must be given to this pus until the growth of the
granulations and the contraction of the walls shall have obliterated
the cavity of the abscess, and left no more room for the pus to ac-
cumulate.(a)
  466. Ulcers sometimes  arise from abscesses: an abscess that
has discharged its contents  is, in fact, an ulcer.  But  more com-
monly, ulcers originate from limited inflammations of the  skin  or
mucous membranes, in which the natural cohesion of  the  skin is
  (a) For a description of the manner in which granulations are
formed at the surface of a suppurating wound, and  the transfor-
mation of granulating cells into the fibres of cellular tissue, see
Miiller's Physiology — Bell's edit., p. 135-6. 
PROXIMATE ELEMENTS OF DISEASE.
261
so much impaired, that it is broken up at one  or more spots, and
either carried away in the pus discharged, or absorbed.  There is
then left a solution  of continuity or  excavation, the  bottom and
edges of which continue to discharge pus, or a serous fluid mixed
with exudation corpuscles, and sometimes blood particles.  Ulcers
may tend to spread by the same process ; or to heal, by the effu-
sion of fibrin on their walls and the extension  of vessels into  this
lymph in the form of granulations, which are the materials of the
new texture.  Ulcers,  besides, present a great  diversity of cha-
racter in the nature of their secretion, and  the condition of their
walls, as well as in the symptoms which they produce:  these cir-
cumstances constitute the varieties of ulcers described in surgical
works.
   The cause of ulceration is commonly local, the inflammation in-
terfering with the normal nutrition of a part.  It is often preceded
by induration from the amount of solid deposit; and the ulceration
commences in the centre of the induration, because the nutrient
influence of the vessels is most reduced  by the pressure at that
spot.  But a very poor condition of the  blood is often much con-
cerned in determining this result, and seems to be sometimes suffi-
cient to cause ulceration without any distinct previous induration,
 or even inflammation: the parts that suffer being  either those
 which have become congested by posture (as in cachectic ulcer-
 ations of  the  legs), or those  most remote from the nourishing
 influence of the blood ; such as the non  vascular textures, the cor-
 nea, cellular parts of cartilages, &c.   In  cases of extreme  anaemia
 a 26S), where  the fibrin and albumen of the blood are very defec-
 tive (§ 197), ulcers of this description arise, and are to be coun-
 teracted by measures the very opposite  to antiphlogistic.   A
 similar result was found, by Magendie,  to ensue in animals fed on
 su^ar, starch, and other non-azotized articles ot food.
    467  Softening  of textures may arise  from  the  same  change
 which, in a greater degree, and more circumscribed form causes
 ulceration.  It  has already been noticed as an effect of  inflamma-
 tion 'S 427) • and it may now be added, that the condition of the
 blood which disposes to  ulceration sometimes leads to the more
 diffused operation of the same change in the'softemng of textures.
 Thus softening of the brain, liver, muscle  and mucous membrane
  sometimes results from amemia, or imperfect supply of  blood in

  ^Te^Yt^mav be  gathered  from the  previous description, that
  suppuration is  a work  of destruction, and therefore is, m  some
  Sure, to be contrasted with effusion of lymph, which is intend-
  ed to be a process of construction  or reparation   Pus is totally
  anlastic itself;  it is formed at the expense of the plastic product of
  te    ss    and the liquid of pus seems  to act as a sol ventor septic
  on textures when their vitality is reduced.  Although, therefore,
  suppuration is often useful  in terminating inflammation, and in
  r mo v ng superfluous products and parts injured by it or its causes, 
262          WILLIAMS'S PRINCIPLES OF MEDICINE.

yet suppuration must be viewed as a depressing and exhausting
process, and its product as having a noxious character : the symp-
toms which  accompany it will be found to correspond  with  this
view.
  469. The occurrence of suppuration is marked by a diminution
of the heat, pain, and other signs of irritation and increased action
in the part.  The pain often becomes throbbing, as if the external
pressure on some of the larger vessels had yielded, and  these be-
come expanded at each pulse.  The swelling becomes softer ;  and
if within the reach of touch, is felt to be first more yielding under
the finger, and afterwards to present the fluctuation of fluid matter.
The  redness  present in inflammation  is also  diminished, being
wholly superseded by the pale yellow of purulent effusion in  the
central parts of the suppurating mass, being mottled by it in others,
and retaining its deep character only in  those parts of the circum-
ference  where the suppuration has not  reached.  In external in-
flammations, the redness of the skin becomes deeper before sup-
puration ;  but when this process  reaches  the skin, a pale spot is
seen, which by its fluctuating feel  indicates the approach of the
abscess  to the surface.
  The great reason of the alleviation of the symptoms of inflam-
mation, on the occurrence  of suppuration, is the diminution of
tension and hard swelling, which  chiefly cause the pain and  irri-
tation (§ 433); and where suppuration takes place amidst unyield-
ing parts, as under  a fascia  or within  a  bone, the  tension is in-
creased  rather than lessened, and the symptoms of  pain and  irri-
tation may be  more severe than ever.   The powerful influence of
hydraulic pressure in causing  the injection of a liquid into a com-
pact texture, and the swelling of the pus globules by endosmosis
after their first formation, will assist in explaining the effusion of
pus under a dense periosteum or theca,  and the extreme pain  and
irritation which it produces.   The free secretion of pus  from  mu-
cous membranes relieves inflammation, and  removes the sub-
mucous deposit (§ 455).
  470. The influence of suppuration on the system is manifest in
the lowering  of  the  inflammatory fever; the pulse  losing its
strength, but retaining its frequency ; the  heat subsiding, or alter-
nating with chills and sweats; the general redness being succeeded
by paleness, or a hectic flush ; the urine depositing a pale or pink-
ish sediment;  and the general excitement giving place to weak-
ness and exhaustion.  The amount of the change will greatly de-
pend on the extent of the suppuration, and the  importance of the
organ affected ;  but  another  chief circumstance  determining the
effect of suppuration, and proving the noxious influence of pus on
the system, is the difference between those suppurations that are
diffused without a circumscribing  barrier of lymph, and those that
are thus limited, are thrown off at once  from the body.
   In some cases of inflammation of the cellular texture, skin, and
of serous membranes, pus is formed with little or no previous  exu-
dation of  lymph, and produces in the system the  most formidable 
PROXIMATE ELEMENTS OF DISEASE.
263
effects.  The pulse becomes very frequent and weak ; the tongue
brown and dry, or coated with  an  offensive fur, and tremulous ;
sweats break out profusely ; the urine is scanty, high-coloured,
and offensive, sometimes surpressed ; diarrhoea sometimes occurs ;
hiccup comes on;  the  mind is much depressed, or excited by oc-
casional delirium ; the patient's manner and motions are agitated
and restless; the breathing becomes hurried  and  sighing ; and
death ensues in from  one to  four days from the commencement
of these symptoms.   Similar results ensue in  suppurative in-
flammation of veins; and they have been known to follow where
an external abscess  has suddenly subsided without opening, and
in cases in which the discharge from  a large suppurating wound
has suddenly ceased.  On opening  the body after death, in a few
such  cases,, nothing peculiar  has been found, except a  general
fluidity of the blood, and the gravitative congestions and stains
which that fluidity induces (§  196).   In most instances, however,
there are found in some of the viscera, particularly the lungs and
liver, purulent deposits, as they are  called;  collections of pus,
generally confined to lobules or portions of lobes of these viscera,
with more or less inflammatory injection and deposition of lymph
around the collections.   In these  cases, there can be little doubt
 that pus in some way is conveyed  in the circulation; and being
 arrested in the lungs and  liver, leads to  the  formation of more
 (^ 462),— whether  by the production of suppurative phlebitis, as
 supposed  by Cruveilhier, Dance, and others, is  doubtful, — and
 that the pus in the blood is the cause of the formidable symptoms
 and results above noticed.  From the experiments of M. D'Arcet,*
 it is probable that the poisonous influence of purulent matter arises
 from chemical changes  induced by air in its serosity (§ 460);  but
 that obstruction  to  the circulation in  the lungs and liver, and con-
 sequent circumscribed inflammations  of these organs, result from
 cohesion and consolidation of the globules of pus  contained in the
 blood.
   Some difficulty presents itself as to the possibility of the globules
 of pus being absorbed, their large size apparently excluding them
 from passing through  the  coats of the vessels (§ 463);  and  it is
 more probable, that, in the cases under consideration, pus is gene-
 rated within as well as without the  bloodvessels, just as we have
 found  (§ 416) the exudation corpuscles to be, of which, in fact, the
 pus  globule  appears to  be  a modification (§ 460).  In fact, Mr.
 Gulliver distinctly  describes  pus globules, with  all their peculi-
 arities of size and constitution  (§ 460), as present in the blood of
 persons affected with severe  inflammation and suppuration ;  and
 ifthese observations are exact, (as from  the known accuracy  of
 their author there is everv reason to believe they are,) the varied
 symptoms occurring in different cases of suppuration may be fairly

   ♦ "Recherchessurles Absces Multiples," &c.; and Brit, and For. Med. Rev.,
 Jan. 1843." 
 264          WILLIAMS'S PRINCIPLES OF MEDICINE.

 referred to the different amount to which the pus globules are pro-
 duced within  the  vessels, and, perhaps, to putrefactive  changes
 which they subsequently undergo.(a)
   471. The preceding observations prepare  us for the fact that,
 besides the extreme effects above noticed, extensive local  suppu-
 rations cause various symptoms of  depression  or  low irritation.
 Of this kind are the rigors often experienced at the commencement
 or increase of suppuration.  Dr. Billing plausibly ascribes this to
 the system sympathizing at the death of the part which is  under
 destruction by the suppurating  process; but the rigor not being
 always present suggests rather that the presence of a certain amount
 of pus in  the blood might be its cause.
   Again,  when suppuration  continues long, even if it be  dis-
 charged outwardly, as in extensive wounds, or  ulcerations of the
 skin or mucous membranes, there is great wasting of strength and
 flesh, with a  partial  febrile  irritation of a  peculiar kind,  called
 hectic fever.   This is remittent in its symptoms, the exacerbations
 recurring  once or twice daily, beginning with chills  and depres-
 sion, and followed by frequent pulse, partial heats, especially of
 the cheeks, hands, and feet, and ending in a profuse perspiration.
 As this proceeds, the body more or less rapidly  wastes, and colli-
 quative diarrhoea, vomiting, and aphtha? of the mouth, often hasten
 the fatal result.  The febrile  part of hectic is most observed in the
 young and irritable ; but the  depressing and exhausting effect of
 extensive  suppuration is seen in all cases, in progressive emaciation
 and cachexia.
  472. The matter  of abscesses is laudible or healthy in  pro-
 portion as it is thick  and opaque, but uniformly liquid and  free
from smell; for although, even in this state, it is fit only to be ex-
 pelled from the body and  is  prone  to decomposition, yet the for-
 mation of such pus is pretty sure to be attended with a protection
 of lymph, and it is  far less  noxious than ill-conditioned sanious
 matter, the fetor of which indicates that decomposition has already
begun.

  (a) We  must pause before  giving our assent to the accuracy of
 M. Gulliver's observations stated in the  text, or rather to the in-
ferences that may be drawn from them, as similar pus-like globules
have  been found by Kiernan and  Gueterbock in  the  blood of
 healthy persons.  Andral  (op. cit.) details cases, the blood of the
 subjects of which exhibited after death pus globules in abundance.
 Blood mixed with fresh pus he did not find to be at all changed.
 Pus, on the other hand, long  exposed to the air  or putrefied, acted
 on the blood as ammonia would do, by destroying both globules
and fibrin.  See § 470,  in which D'Arcet's experiments are re-
ferred to. 
PROXIMATE ELEMENTS OF DISEASE.
265
                           Gangrene.

  473.  Gangrene, like the more complete forms of suppuration,'
may be well called a termination of inflammation, for the inflam-
mation ends in the death  of  the part.   In  suppuration, the dying
textures are  softened and displaced by pus as fast as they die ; in
gangrene, the textures die more extensively than pus is formed,
and they run into decomposition without being removed.  In some
cases, especially in limited gangrene, the dead portion is dissolved
away at its  circumference by the  inflammatory exudation from
the living parts, and it is thus separated or sloughed from them ;
but if the dead portion be extensive, and the power  of  the living
parts low, the separating  process will not be accomplished before
decomposition ensues, which produces the changes called gangrene
and sphacelus.
  474. The circumstances which cause inflammation to terminate
in  gangrene are those which completely.suspend the circulation
in the part (§ 273), and those  which greatly injure  the  composi-
tion of the blood  or directly destroy vital properties.   The circu-
lation in a part may be destroyed  by long-continued pressure, by.
severe contusion, laceration, or other  mechanical injury, by ex-
treme  heat or cold, by strong chemical agents, by the  excessive
pressure of the solid matter effused in the early stageof inflammation,
(as in carbuncle,) and even by an extreme amount of congestion.*
The. occurrence of gangrene is favoured by extreme weakness of
the heart, the great moving power of the circulation ; and the fail-
ure is most  manifest in parts most-remote  from the heart, as in
various structural diseases of this organ in  low fevers, and states
of extreme exhaustion.   It is favoured  by ossification  or partial
obstructions of the  supplying arteries, which, although  adequate
to maintain the ordinary nutrition  of the part, cannot dilate to sup-
ply the  demand increased by any injury or irritation of the  part.
The agents  which cause gangrene  by a directly destructive opera-
tion on  the  vital  properties of the solids and fluidsof the body, are
various strong poisons, such  as arsenic, sulphuretted  hydrogen,
the poison   of the rattlesnake  and other  venomous animals, the
poison  of the plague, malignant scarlatina, small-pox, and  erysi-
pelas,hospital gangrene,  glanders, &c.
  475. An  external  part becoming gangrenous loses  all feeling
and other vital  properties; its colour becomes livid, or leaden,
greenish, or almost black, the  cuticle rises in blisters on it, and be-
gins to exhale an offensive odour.  The rapidity of this change
will depend  much on the  moisture and warmth  derived from the
adjoining living parts; in dry gangrene, the dead portion becom-
ing horny and black instead of putrefying.   For the converse

  * Two  cases of gangrene of the lung which have occurred in my practice
seemed referable to this cause.
           23 
266          WILLIAMS'S PRINCIPLES OF  MEDICINE.

reason, in internal parts the progress of  decomposition is more
rapid.  The putrid matter affects the living body (like many ani-
mal poisons) as a local irritant, and a general sedative or repress-
ing influence ;  and  the symptoms will vary much  as one or the
other of these two operations predominates.
  In persons of robust constitution, active  vascular system  (§ 112,
120), and good  blood (§ 195), a dead part arouses active inflamma-
tion and  effusion of lymph in the surrounding living parts, which
may protect the system more or less completely from the infection
of the dead matter.   In such cases, although gangrene be present,
the predominant symptoms  may be those  of inflammation and in-
flammatory fever.  But living parts, with  all their activity, cannot
long withstand  the pernicious influence  of dead matter;  so that if
this matter be not soon thrown off in the form of a slough (§ 473),
or liquefied in the inflammatory exudations poured out, the  system
becomes  infected, and suffers from  its poisoning and  prostrating
operation.  This will happen more surely and early, where the
dead part is in the interior of the body, of great extent, surrounded
by vascular texture,  and with its decomposition promoted  by the
warmth and moisture.   In  subjects of  weak  constitution, feeble
vascular  system, and blood  defective in  plastic matter (§ 196), the
irritation of dead matter may fail to excite a protective (adhesive
or plastic) inflammation, and the putrid or typhoid symptoms then
show themselves earlier, and  prove more speedily fatal.  These
symptoms  are  increasing feebleness and frequency of the  pulse,
reduction of the fever, collapse and extreme pallidity of the coun-
tenance,  cold sweats,  brown, dry, or clammy foul tongue, low
delirium, or restlessness  and agitation  of manner, hiccup, fetid,
diarrhoea, urine very  offensive or suppressed, coma or syncope, and
death.  In external parts, or those which communicate with the
surface, the putrid odour of the gangrenous part becomes a  dis-
tinguishing physical  sign ; in gangrene  of the lungs it is commu-
nicated to the expectoration and breath  ; in other cases, the whole
body exhales a fetid  odour.
   The supervention  of  gangrene sometimes terminates the pain
and other severe  symptoms of the preceding  inflammation, and
thus induces a false calm; but they are often replaced by distress-
ing symptoms of nervous irritation, which subside  only with the
collapse  ofdeath.
   476. In concluding this account of the results or terminations of
inflammation, I must repeat what was said at the beginning (§ 445),
that they rarely occur quite separately  one from  another, and in
many instances they are all combined in  different portions of an
inflamed organ or texture.  Thus  resolution is always attended
 with some amount of effusion : lymph often has the colour, opacity,
and much of the microscopic character  of pus; suppuration is
almost always preceded and generally accompanied by the effusion
of some  lymph; and often abscesses are  attended with gangrene
and sloughing of parts; and these  combinations are further illus- 
PROXIMATE ELEMENTS OF DISEASE.
267
trated by the terms, purulent lymph, flaky pus, sloughing ulcer,
gangrenous abscess, &c, which pathologists are obliged to employ
to describe what they meet with.
                VARIETIES OF INFLAMMATION.

  Inflammation may vary in consequence of the predominance or
defect of some of its elements or results, or from its combination
with some of the other elements of disease previously considered.
Or inflammation may derive a peculiar character from the nature
of its exciting cause, which is exemplified in what are called spe-
cific inflammations.   The  following varieties demand a  brief
notice: — sthenic  and asthenic; acute, subacute,  and  chronic;
congestive ; phlegmonous;  erysipelatous ; pellicular or diphthe-
ritic ; hemorrhagic ; and scrofulous.   Of the  specific inflamma-
tions, the gouty and  rheumatic, syphilitic and gonorrheal, will
be merely alluded to.
  477. The varieties of inflammation termed sthenic and asthenic
correspond with the parallel varieties of plethora (§ 279), hemor-
rhage (§ 360), and flux (§ 393), and are  referable  to a difference
in the strength and irritability of the  heart and arteries (§ 110,
 120, &c).   Thus sthenic inflammation is  marked by a strong hard
 pulse, high fever  (§ 442), very fibrinous blood (§ 208, 438), a full
 and active development  of the chief symptoms of inflammation
 (§ 429), and a tendency generally  to  the  more plastic products
 (§  450).    Patients affected  with  sthenic inflammation require
 and bear a greater amount of antiphlogistic  treatment; and in
 them, if used in  time, it is commonly most successful, for sthenic
 inflammation occurs in  those of the most robust  constitution, in
 whom the effects  of disease are most readily shaken off.
   Asthenic inflammation  occurs  in  persons  the  tone and  real
 strength of whose vascular system is low (§ 116, 123), and their
 blood" (generally speaking) poor (§ 207).   The pulse is  not always
 affected ; when it is affected, it is in frequency more than in strength
 or firmness; the fever, if there be any, is of a slight, remittent, or
 low character (§ 442, &c).   The products are either scanty, or  of
 a cacoplastic or aplastic character (§ 451); or  the effusion may be
 chiefly watery,  the inflammation  differing little  from flux and
 dropsy.
    478. The terms acute, subacute, and chronic, applied to inflam-
 mation, properly relate to its duration ; but they are often used in
 the sense which  I  have given to sthenic and asthenic.   Acute in-
 flammation may be,and commonly is, sthenic; but it is by no means
 always so : its  distinctive character  is, that  it tends to a speedy
 termination of some kind  or other.  It  may end  in  resolution,
 effusion, suppuration, or gangrene, in a period varying from a few
 days to three weeks.  An  inflammation  lasting above the  latter
 period is subacute, and  if protracted beyond six weeks is properly
 called  chronic.   Very commonly,  inflammation is acute because 
 268          WILLIAMS'S PRINCIPLES OF MEDICINE.

 it is severe or sthenic, its intensity leading to a speedy result: but
 asthenic inflammation is often also short in its duration; whilst
 chronic inflammation sometimes presents a good deal of the sthenic
 character (§ 477).  Acute inflammation, when at all extensive, is
 attended  with  considerable  fever  and constitutional  disorder.
 With subacute  inflammation the fever  is  less, and may even be
 absent.  In chronic inflammation  there is rarely fever; when pre-
 sent, it is of a remittent or hectic kind (§ 444, 471).
   The products of acute  inflammation are commonly so copious
 as to be obvious in their character, being coagulable lymph, pus,
 inflammatory mucus, &c.   In subacute inflammation they are often
 intermediate, such  as  purulent lymph, curdy matter, and tubercle
 in some  of its forms.   As with asthenic inflammation, the more
 they are in quantity the less likely are they to become organized.
   479. Chronic  inflammation may originate  in the  acute or sub-
 acute  forms, the vascular obstruction  and excitement  persisting
 in the  part, even after  some  of  the  results (§ 445, formerly called
 terminations) of inflammation have been produced.   Its general
 character is asthenic ; but there  may be considerable determina-
 tion of blood  and  local excitement.  Its effect in disturbing the
 functions, both of the part which is its seat, and of other parts, is
 much less prominent than that of acute inflammation ; but its dura-
 tion causes a more serious  and  lasting alteration  of  structure.
 The matter effused by serous membranes in chronic  inflammation
 is always either cacoplastic or aplastic ;  hence, dense and contrac-
 tile  adhesions, or  patches of fibro-cellular or  semi-cartilaginous
 matter, cirrhosis, grey  miliary tubercle, curdy and  yellow  tuber-
 culous matter, may be numbered among the  common  products
 of chronic  inflammation.  Mucous membranes discharge muco-
 purulent matter, and the  more  complex membranes of this class
 become thickened and may ulcerate.  Sub-mucous textures become
 the seat of deposit,  which, in becoming organized, often contracts,
forming strictures in  mucous passages.   These strictures,  by ob-
structing the passages, may lead  to dilatations above  them.   In
 glands and other complex textures chronic inflammation  causes
consolidation and induration, which often afterwards contracts and
causes obliteration of the connected texture, as in the changes in
the lungs, liver,  and kidney, inaptly described under the  name cir-
rhosis.*  Sometimes the  indurated  parts, from the  pressure  on
their vessels, become  softened (§ 463), as in the softening  of the
brain, or undergo a process of  iiregular suppuration and ulcera-

  * Mr. Gulliver describes the consolidation of chronic pneumonia as character-
ized by "dark exudation corpuscles," as pale exudation corpuscles are the chief
objects in red or acute hepatization.  It appears, however, that these corpuscles
 are not dark from colour, but merely from opacity, as pus and tubercle are ; and
they bear a further resemblance to this last product in their irregularity, in shape,
 size, and composition, being of various shapes, and consisting of molecules, ge-
 nerally without a nucleus,  and often without envelope. — Notes to Dr. Boyd's
 ' Vital Statistics/'  Edin. Med. and Sur. Jour., July, 1843. 
PROXIMATE ELEMENTS  OF DISEASE.
269
tion, as in the excavation of the lungs after chronic inflammation.
As we noticed of congestion (§ 311), so it may be added of chronic
inflammation, that the hypertrophy or excessive deposit of nutritive
material  is irregular, more in  some textures than in others, gene-
rally  abounding  most in the  interstitial  cellular  or filamentous
tissue, which, by its hypertrophy, presses on the vessels and other
textures, and  often causes their atrophy and partial obliteration.
Chronic inflammation in the cartilages ends in caries and ossifica-
tion : in  the bones also  it causes caries or exostosis, just as in the
skin and other compound textures it leads to induration as well
as ulceration.   The production of these apparently opposite results
by  the same process, inflammation, is not paradoxical, when  we
bear in mind the compound character of this process [its different
seats], and the variations arising from different proportions of its
elements and products.  Chronic inflammation exhibits these oppo-
site results the more strikingly, because its effects are accumulated
by its long duration ; the hypertrophy arising from one of its ele-
ments (determination of blood) increases  in the  immediate neigh-
bourhood of atrophy and ulceration, the results of another of its
elements (vascular obstruction).
   4S0. Congestive inflammation is  that in which the accumulation
and retardation of the blood in the vessels of the affected part pre-
dominate over the determination of blood.  Hence it is commonly
asthenic in  its character  (§  477), and generally  originates  from
causes producing  congestion  in  the first, instance  (§ 403), the
 reaction which converts this into inflammation, being imperfect or
 partial.   Its symptoms are less prominent  than those of more active
 inflammation," and partake more of the character of those of con-
 gestion.  Thus there may be little  pain, heat, fever,  and other
 signs of irritation or increased action  ; but the redness (where visi-
 ble)  is more marked and deeper than usual, and if the organ be
 very vascular, (as the liver, lungs, and kidneys,) the swelling may
 be considerable.   Congestive inflammation is usually subacute or
 chronic, not tending to speedy results; but a  kind of flux or dropsy
 may occur early, as  from  congestion (§  375).  So, too, the  solid
 or nutritive effusion is generally cacoplastic, like that  of conges-
 tion  (h 311)'  hence the consolidations or indurations arising from
 it are often of a dense indolent kind, tending to contract  or to de-
 generate still  further into aplastic matter (tubercle).   I he inflaim
 mation  of the lung supervening on disease of the heart, on bron-
 chitis, and asphyxia, is generally congestive ; and so is mflamma.
 tion of the liver from any cause.                 ,
    481  Phlegmonous inflammation is exemplified  in the phlegmon,
 furuncle, or "boil of the integuments.  Its chief character consists
 in its beiti" abruptly circumscribed by an effusion of so id lymph,
 which brings  the inflammation to a  termination, either by suppu-
 ration or by slow subsidence, as  in the case of blind boils.  A
 hiffhlv fibrinous condition of the blood (§ 195) contributes to render
 inflammation phlegmonous;  but this form of inflammation is that
             23* 
270          WILLIAMS'S PRINCIPLES OF MEDICINE.
commonly exhibited by cellular and parenchymatous textures.
The type of phlegmonous inflammation is usually sthenic (§ 477);
and even where it advances to suppuration or sloughing, it defends
the body against the noxious influence of the pus and dead matter.
Hence the fever is more inflammatory (§ 442), and the local pain,
irritation, and heat, are considerable.
  482. Erythematic or erysipelatous inflammation  is contrasted
with phlegmonous, in its  tendency  to spread, not  being attended
with the  effusion of much lymph.   In its severe forms, it is accom
panied by much redness,  pain or  smarting heat, and swelling;
the effusion is chiefly serous, and often raises the cuticle in blisters.
In its worst kinds, it terminates in diffused suppuration, sloughing,
or gangrene.  The fever is also of  a  lower type  (§ 443) than  in
phlegmonous inflammation ; being attended by great weakness,
disorder of the secretions, foulness or  dryness of the  tongue, with
delirium, and confusion or dulness  of the senses, and in the worst
cases, the fever is typhoid, with stupor,  muttering delirium, dry
brown tongue, sordes on the teeth and lips, slight convulsive start-
ings of the limbs, (subsultus tendinuin,) fetid or suppressed secre-
tions, and sinking.
  These  adynamic or typhoid  symptoms show  the presence  of
something more than a form of inflammation, and that something
must  be considered to be a poison.  It is probable that this poison
sometimes originates in infection  (§ 93);  for persons in the same
room, or who have had much communication with a patient with
erysipelas, have been more frequently attacked than others; but
it is also pretty certain that bad ventilation, and a  crowded un-
cleansed state of surgical patients, are capable at any time of ren-
dering common inflammation erysipelatous ; and this effect is much
promoted by unknown  epidemic  conditions of  the atmosphere
(§ 89).   The most probable hypothesis which we can form of this
matter is, that under certain circumstances the products of inflam-
mation become  (as we know they sometimes do, §  470), poisonous;
and capable of acting (as many animal poisons do as local irritants
and general sedatives or depriments ; that they  then  modify the
character of the inflammation, and depress the whole  vital powers,
(as we have found pus  and gangrenous matter  do, § 471,475);
and that their effects, and the general and  local  reaction  against
them  (§ 17), lead to the various degrees and forms which we find
erysipelatous inflammation  and  its accompanying fever present.
The  same morbid matter, being transferred by any of the  three
modes of infection (§ 94)  to other persons, may induce erysipelas
in previously existing inflammation, or if strong enough, may de-
velope it anew in the body.  The  fact  that patients  often sicken
with fever (rigors, vomiting, headache, quick pulse, delirium, &c.,)
before the erysipelatous inflammation appears, is  a sufficient proof
that the  poison acts on the constitution as well as  on a part; and
the fact  that weakly persons, and those  with previous structural
disease,  (especially of the kidneys,) chiefly suffer from the  worst 
PROXIMATE ELEMENTS OF DISEASE.           271
effects of erysipelas, shows the essentially depressing operation of
the poison.
  Some asthenic inflammations of mucous and serous membranes
and internal organs exhibit many of the constitutional effects of the
worst forms of erysipelas ; they sometimes prevail when it is epi-
demic, and may be traced to the same infection.   This may be said
especially of puerperal metritis and peritonitis, erysipelatous, ton-
sillitis and laryngitis, and suppurative phlebitis.
  483. Pellicular or diphtheritic inflammation of mucous mem-
branes has some  affinity to the  erysipelatous, being diffused and
spreading, generally asthenic, and accompanied with  a low kind
of  fever.   It  is  attended  with  more  soreness than pain,  little
swelling, and  a deep redness, which is early obscured by the cha-
racteristic film of greyish or dirty white albuminous matter, which
is exuded  on the inflamed surface.  Patches of this kind often
occur on  the tonsils in sore  throat, and  have been commonly
mistaken for sloughs.  In certain epidemics, often connected with
scarlatina, a diphtheritic  inflammation  affects  the whole throat,
and sometimes extends to  the trachea and air-tubes, the mouth,
the gullet,  and more or less of the  alimentary  canal.   The films
of  lymph thus effused are  often fetid,  apparently from incipient
decomposition, which  is promoted by  their  exposure to air and
moisture in the throat and air passages.   As in  the case of dif-
fused suppuration and gangrene, this result of  inflammation thus
tending to putrefy is at once a sign of the low condition of the vital
powers, and a cause of their further depression.
   The exudation of lymph instead of  mere mucus or  purulent
mucus  as usual, I am disposed to refer  to  the inflammation
affecting  the  submucous  cellular  tissue, and being at  the same
time  diffused  like erysipelatous inflammation.  Deep-seated in-
flammation of a  more sthenic character  is circumscribed by the
effusion causing  a thickening  of the membrane, as in laryngitis ;
but the matter effused by diphtheritis, although fibrinous, is thin
enough to transude through the mucous membrane on the sur-
face of which it  concretes. The  thinness of the mucous mem-
 brane of the air-passages in children facilitates the transudation in
 their deep-seated inflammations : hence, at  an  early age, all such
 inflammations may cause  an  effusion of fibrinous matter, as we
 find  exemplified in  croup.  So, too, the extreme tenuity of the
 mucous lining of the smaller divisions of the air-tubes makes the
 exudation of fibrinous matter a  common result  in pneumonia and
 some kinds of capillary bronchitis.  This  is exemplified in the
 ramiform  moulds of the bronchial tubes sometimes expectorated.
 Similar skin-like exudations are sometimes passed from the intes-
 tines after the irritation of calomel or other strong purgative, and
 in some cases without any such irritation.  I have at present three
 patients under my care, who  from time  to time pass from the
 bowels  a  quantity of shreds like white  kid leather, without any
 symptoms of active inflammation : congestion seems to be a chief
 cause in these cases (§ 308). 
272
WILLIAMS'S PRINCIPLES OF MEDICINE.
  In the mouth and throat, various asthenic inflammations seem
to be capable of causing a fibrinous exudation, as that from mer-
curial action, and that in the aphthous mouth and throat of adults,
which  occurs towards the  fatal termination  of various  chronic
diseases.   The  aphthce  of children are different, being vesicular
elevations of the epithelium, with or without a fibrinous film un-
derneath.
  484. Hemorrhagic inflammation is entitled to be considered as
a distinct variety.  In most inflammations, there  are slight extra-
vasations of blood ;  but sometimes there is  so  much  colouring
matter in the inflamed  texture  and in the products effused, that
it may be difficult at  first to say from the appearance whether the
disease is a hemorrhage or an inflammation.  These  inflamma-
tions I have found to be asthenic ;  often the subjects were scorbu-
tic, or affected with  purpura;  and, as  I  have stated with regard
to the  latter  disease  (§ 358), there has been distinct evidence of
imperfect action of the liver and  kidneys.  Thus  I have met with
hemorrhagic pleurisy and pericarditis in conjunction with cirrhosis
of the liver and Bright's disease of the kidney.  An altered con-
dition of the colouring matter (§  186) is perhaps  more concerned
in causing this result than a deficiency  of the fibrin, to which  it is
commonly ascribed.
  485. Scrofulous inflammation is decidedly asthenic, and exhi-
bits many deviations from the common form of inflammation.  It
may be well exemplified in the lymphatic glands, one of its most
common seats, and within the  reach of direct observation.  These
glands, in common inflammation,  become very painful and  hot,
as well as swollen, and  the  inflammation tends soon  either to
resolution or to  suppuration.   In scrofulous inflammation,  on
the other hand, lymphatic glands swell to a great size; and often
the deep redness extends to  the surface, but with little pain or
heat;  and the  swelling  remains for a very long period without
either  resolution or suppuration, and little influenced by antiphlo-
gistic  remedies.  Sometimes  it  seems  to suppurate, so that the
swelling becomes  distinctly fluctuating,  very red, and  ready to
open ; but afterwards the skin becomes wrinkled, and the swelling
subsides.  When  it  does burst, or is  opened, the pus is serous
and curdy, or  mixed with matter of  a soft  cheesy consistence,
(soft tuberculous matter); and the abscess thus  opened leaves a
deep  ulcer  with a narrow orifice (fistula), which is indisposed
to heal.  The kind of inflammation of which this is one example,
occurs in persons of what is  called the scrofulous diathesis or
constitution.
  The scrofulous diathesis is  merely a  term employed to desig-
nate  a state of the  body in which scrofulous inflammation  and
malnutrition are apt to occur.  It has been generally stated  that
this diathesis has certain outward marks, by which its existence
may be recognised independently of the actual occurrence of dis-
ease.  Thus a relaxed state of the  muscles, a soft transparent skin,
a fair  or pale complexion, with partial patches of a peculiar pink 
PROXIMATE ELEMENTS OF DISEASE.
273
or purplish redness; a pearly whiteness of the eye  and teeth;
tumid  upper  lip; fair  or  reddish  hair; large  and weak joints ;
precocity of intellect, and  some other signs, have been described
as characteristic of the scrofulous  diathesis.  But such marks are
met  with without any manifestation of scrofulous  disease; and
still more frequently, scrofulous disease is induced in persons quite
destitute of these characters.
   More  constant  concomitants of  the scrofulous  disposition
(although  they  sometimes occur  without scrofula) are, various
signs of weak  circulation  and imperfect nutrition, such as  cold
extremities;  weak,  but easily accelerated pulse; small  develop-
ment of muscles ; uncertain digestion and irregular excretion ; slow
or defective  healing of wounds.   The  circumstances which most
favour the production of the scrofulous  diathesis are also causes
of a weakening kind, especially when these  are long continued,
such as poor  or insufficient nourishment, especially in childhood
or youth;  cold  and damp situations, or defective clothing;  long
confinement  in  close, ill-ventilated habitations ; long continued
illness, especially from eruptive or typhoid fevers ; and prolonged
and  aggravated  disorders of the digestive  organs.   Scrofula is
also, in  a marked  degree, an hereditary affection (§ 36); and
mere feebleness of  constitution  in  parents,  whether  original or
from disease, or from excesses, or from age, often developes a dis-
position to scrofula in children.
   In persons of the diathesis now noticed, inflammation frequently
runs a course, and leads to results different from those of inflam-
mation in a healthy subject.  Commonly the inflammation is more
asthenic (§ 477); often it is more subacute or chronic (§ 479) than
usual; but in all cases, its solid products are not euplastic, (§ 450),
as in healthy persons ; and may be  either cacoplastic (§  452)  or
aplastic (§ 453), according to the prevalence of the scrofulous con-
stitution, the texture affected, and the quantity of the inflamma-
tory product thrown out.  Where the scrofulous diathesis is most
developed__where the texture inflamed is an internal  one, not
freely discharging externally — and where the  product of inflam-
mation is most copious, — there the deposit will be most aplastic,
consisting of scrofulous pus or yellow tubercle, devoid of regular
structure, and wholly insusceptible of organization ;  and beingnot
fit for absorption, it  operates as a foreign body,irritating, obstruct-
ing  and compressing the  adjoining parts, in various ways detri-
mental to their functions and structure.   Thus arise tuberculous
or scrofulous deposits and  abscesses in lymphatic glands, in bones,
cartilages, and in the connected cellular textures, tuberculous in-
filtrations in the lungs, and deposits in serous cavities.  Where the
scrofulous  diathesis is less  pronounced, and the  inflammatory effu-
sion less copious and more gradual, the result may  be  a cacoplas-
tic product, susceptible of only a low organization: asgrey,mihary,
and tough  yellow tubercle  ; cirrhosis, atheroma of  arteries, fibro-
cartilage,  and other degraded living solids.   These  have been
already noticed  (§ 453,454), and will again come under considera- 
274          WILLIAMS'S PRINCIPLES OF MEDICINE.

tion as products of altered nutrition.   The aplastic tendency of in-
flammation in scrofulous subjects is  sometimes manifest in other
ways in different,  textures.   Synovial membranes of joints are
softened into a brownish pulp (Brodie); articular  cartilages and
the cornea ulcerate, from absorption predominating over effusion
(§ 466); the integuments of the face and other parts inflame  in
small cutaneous tumours or tubercles, which ulcerate, and the
ulcers are phagedenic, spreading and destroying the nose or adja-
cent parts, as in lupus,
   It seems, then, that the most constant peculiarity of scrofulous
inflammation is, that it degrades or arrests nutrition, by supplying
a material in a condition little or not at  all susceptible of organi-
zation.   This leads us  to inquire what is the condition of the blood
in scrofula ; and we are answered by the interesting result obtained
by Andral and Gavarret before mentioned (§ 454), that there is  an
excess of fibrin (§ 195), but a deficiency of red particles (§  185).
The fibrin is, however, defective in vitality ;  and this seems  to
favour the hypothesis that the red particles are concerned  in pre-
paring this plasma (§210); when they are deficient, it is ill prepared.
   486.  Gouty and  rheumatic inflammations  have already been
noticed in relation to their specific cause, a  morbid matter  in the
blood or in the textures (§ 251, 254); and  some of the peculiar
characters of the inflammation were then adverted to (§ 385).  It
is highly probable that the peculiarities of many other inflamma-
tions, especially of the  skin, may be referred to a similar cause, a
particular matter, in the  blood irritating the parts  through which
it circulates  (§ 402).
  487. The poisons of gonorrhoea and syphilis excite  inflamma-
tions still more peculiar in their phenomena and course.   Gonor-
rheal inflammation chiefly affects the genito-urinary passages and
the conjunctiva.   It is  generally acute, and results in the secretion
of an opaque sulphur-coloured pus, which is capable of propagating
the disease.   Sometimes it affects the testicle  also with acute  in-
flammation, and the joints with more chronic,  constituting  gonor-
rhoeal rheumatism.
   Syphilitic inflammation exhibits  great   varieties  in site and
effects.  Locally, the syphilitic poison may excite on any  thin-
skinned surface a papula, or small tubercle, which,  ulcerating,
forms  a chancre.   As  the matter is absorbed  from this, it causes
inflammation with great pain and swelling of the neighbouring
lymphatic glands (bubo), which  may suppurate.   These are pri-
mary inflammations, and of  an acute character.   When absorbed
into the system, it may excite secondary inflammations ; sore throat,
generally asthenic, and tending to ulcerate ; and a great variety of
inflammations of the skin, which vary greatly in their type  as well
as in their character, according  to  the vigour, &c, of the subject.
They often leave a  peculiar  lurid or copper-coloured stain in  the
upper layer  of the epidermis, which obviously arises from an  ex-
travasation of some colouring matter of the blood, and probably  im-
plies a change in  it.  The periosteum and bones are also  often 
PROXIMATE ELEMENTS OF DISEASE.
275
attacked  with  syphilitic inflammation ;  and  painful  nodes, exos-
toses, suppuration, and caries, may result.   The iris is sometimes
attacked  with  acute  inflammation  and  effusion of lymph, which
may endanger sight if not reduced.
                 TREATMENT  OF INFLAMMATION.

  488. We have found inflammation to be an essentially complicated
process, composed of several  constant elements, to which are fre-
quently added others, which further increase  the complexity of
the disease.   A proper  knowledge  of these elements, and  of  the
means which best remove or counteract  them, separately and  in
combination, forms the best guide to the rational treatment  of in-
flammation, and supplies  a safe clue through  the confused  and
paradoxical assemblage of agents which experience has proved to
be antiphlogistic remedies.  As we  have  not time  to  discuss in
detail the elements and results of inflammation  with regard to
treatment, it will be very useful to enumerate these elements and
results, with  references to  the text, which  more fully  explains
them,  and  then to represent  in  a  tabular  view  the  remedies
that  may be  opposed to  these  elements  and   results, various
combinations  of  which  remedies  constitute  the  antiphlogistic
treatment.
               489. Constituents of Inflammation.
                Congestion, (§ 403, 407,)
From operation
      of
exciting cause.
Essential   ele-
  ments of in-
  flammation
   (Local).
Constitutional
  effects of
 inflammation
(not essential).
f Nervous and vascular irritation ($ 402, 408).
f Determination of blood towards the affected part (§ 409,419).
  Obstruction of the vessels most affected ($ 410, 419) ; by atonic
    enlargement of  the capillaries (§ 414) ; by production and
    adhesion of white corpuscles in the vessels (§ 415).
  Distention of arteries and capillaries before the obstruction
    (§ 4-20), causing increased effusion (§ 423) of serum, lymph,
    pus. &c. (§ 427").
  Emptiness of veins  beyond the obstruction (§ 427), causing
    increased absorption (§ 467), hence softening, &c.
"\ Impeded  or arrested  circulation at the obstruction  (§ 118),
    causing a reduction or abolition of vital properties (§ 273),
    hence the death of the part, and its  removal by ulceration
    (§ 466) and  suppuration (§  127), or its decomposition by
    gangrene (§ 473).
  Increased circulation of blood around the obstruction (§410),
    causing exaltation of vital  properties (§ 421, 333) ; hence
    spasm"* I13)' Pain (§ 135)' sympathetic irritations (§ 149),
    increased secretion (§ 159), &c.
 f Extension of the excitement to the heart and arteries (§ 440),
    causing inflammatory fever.          ,,.,./•    .u
  Change in the whole blood, by increase of fibrin from the in-
    flamed part (§ 438), and by diminution of  the excretions by
J   the inflammatory fever (§ 441).
  Exhaustion ensuing after the excessive excitement (110) or the
    effusions of inflammation (,§ 459, 470).
  Depression, sometimes with partial irritation, from the presence
 L  of pus, or gangrenous matter in the blood  (§ 470, 4/5). 
276           WILLIAMS'S PRINCIPLES OF  MEDICINE.
490.  TABULAR VIEW OF THE CHIEF ELEMENTS OF INFLAMMATORY
                  DISEASE, AND THEIR  REMEDIES.
 CONSTITUENTS OF INFLAMMATION.       ANTIPHLOGISTIC REMEDIES.
 ,  „                          S Astringents; stimulants;evacuants ""j - c
 1. Congestion......|   $ 315, et seq.)......I .||
 n T  •. *•    t                 (.Narcotics;  counteHrritants  (137,  l-~"g
 2. Irritation of nerves   -  -  -  \   155-,  _........    rg |
 „           ,     .            <j Sedatives; derivatives; evacuants   g^g
 3.    _    of vessels  -  -  -  J   (§ 342, e« wy.)......J £ -S
 ,  r»     ■   •      ,           S Cold and other sedatives; derivaO
 4. Determination to the part   -  j  tiveS; evacuants   -   -  -  -
 5. Obstruction in the  part : -  -
     —  by atonic enlargement    Remedies for congestion (see above)
         ,    ,,  .     °       ,  C Remedies not known ; attenuants?
 6.   —  by adhesion  of corpuscles <  rs. n\n\
S Counter-pressure; bloodletting; de-
 7. Distention of vessels -  -  ■   ^  rivation (§ 319)
 „ r^a,  ■                       \ Evacuants; derivatives; operations;
 8. Effusions......<     ,  f  ,'  fo 7        r
                               (  sorbefacients .'   -  -  -  -  -
                               C Direct remedies not known ;  stimu-
 9. Increased absorption -  -  -   <  lants;  diminishing  atmospheric
                               (  pressure on the part?  -  -  -
10. Impeded  circulation in the part  Moist, heat and other stimulants -
, , T      ....        ,    ( Remedies for  determination  (see
11. Increased circulation around -  <   ,  ,  .
                               (  above)  --------   j
,n-■&           /..,  ,            C General bloodletting and other eva- ">
12. Excitement of the heart  -  -   5       . .   , .-,  ?,. nM
                               (_  cuants; sedatives (§ .115)  -  -
                               C General bloodletting and other eva-
13.   —   of the arteries generally -?  cuants ; relaxants (antimony, &c.
a
s
14. Change of the blood :
§ 122) ;  salines ]
eS
  a  >

^r£  -
  - ._
 -  S;
         ,   .         c ~,  .      $ Bloodletting and  other  evacuants
         by increase of fibrin     <   ,rn,A^  &        i   j;  .
          3                    I   (§214);  mercury; low diet -
15.   —  by diminution of the ex- S Evacuants; alteratives (§172, et
            cretions  -  -  -   -   c   seq.).........J
16. Exhaustion.....-    Stimulants and tonics (§ 119,  124).
17. Depression from poison  -  -    Stimulants; antiseptics; evacuants (§ 260.)
io e< i-j    j   .„  e ■  a     .•    S Attenuants 1 alteratives ] sorbefacients 1 sti-
18. Solid products of inflammation  <      ,  ,             j <••.•/  \
        1                       (   mulants, pressure, and fnction.(a)

  491. My limits will not enable me to do more than  offer some
brief comments on the principles of the treatment, and to exem-
plify the above table by the results of experience.

  (a)  This table ought to be  regarded  as suggestive, rather  than
guiding.   The ' elements,' as they are  termed, are  not separable,
in this manner, except by an abstraction ;  nor, since  they are not
directly cognizable, can they  be  treated separately by different and
distinct remedies.  Even  in some  which are more easily detected,
the treatment is not by  any means as simple  as that indicated in
the text.   More  is gained  by an observation of  the  different tex-
tures,  which may be  the seat of inflammation, than of the succes-
sive phenomena  (elements, of inflammation), viewed isolatedly and
without relation to textural modifications. 
            PROXIMATE ELEMENTS OF DISEASE..           277

  1. Congestion. The efficacy of topical astringents and stimulants
in  the congestion preceding inflammation, is  illustrated in the
effect of a strong solution of nitrate of silver or sulphate of zinc  in
curing conjunctival ophthalmia, and of the  same agents, or pow-
dered alum (Velpeau), or capsicum gargles, in curing an incipient
sore throat.  But as with  regard to congestion (§ 317), so still
more in the congestive stage of inflammation, if it be  extensive,
long  established, or  already  complicated  with determination  of
blood, stimulants and astringents do no good, and may aggravate
the inflammation ; and it is especially under these circumstances
that evacuants, derivatives, and even  bloodletting, may be requi-
site.  The utility of these has been mentioned  under the head  of
congestion (§  318);  but they  may be more necessary in the con-
gestive state of inflammation, inasmuch as it tends to further and
worse results.   A strong purgative and diaphoretic, if given early
enough, may suffice to remove an incipient inflammation; but if
this inflammation be extensive, especially when  the  subject  is
plethoric, the  proper remedy, even  at this stage, is bloodletting,
local or  general, according  to  the situation and extent of the in-
flammation.
   492. — 2 and 3. Irritation of nerves and vessels. The irritation
of the nerves, which  we have found to constitute a part of the com-
mencement of some inflammations  (§ 402), is  so closely followed
by irritation of the vessels that  their remedies are much the same.
The efficacy of a large dose of opium in incipient inflammation
exemplifies the utility of narcotics in subduing  nervous irritation,
and these remedies are the more indicated where pain, and other
signs of excited  nervous  function  (§ 151)  predominate.  On the
other hand, where heat  and  redness rather prevail,  the vessels
are more excited, and the  more appropriate remedies  are seda-
tives, such as cold and  saturnine lotions to the part, and various
evacuants and derivatives, which  draw the   blood away  from
the excited vessels.   Counter-irritants or  revulsives  of the  most
speedy operation, such as heat, dry and  moist, mustard poultices,
and other stimulating applications near the affected part, seem to
act both on the nerves  and  vessels, and are  powerful means
of subduing the irritation which leads to inflammation.  In these
applications the effect on nervous irritation is proportioned to the
sensation which they produce, and  where  pain  or other sign  of
nervous excitement predominates,a heat almost scaldingor burning,
or stimulating agents which cause severe smarting, are  most effec-
tual.  On the other  hand, where the vessels are excited, as evinced
by heat and redness (if visible),counter-irritants or revulsives which
act extensively rather than intensely are of more avail;  such as a
o-eneral or partial hot bath, or large" poultice, or fomentation, made
more stimulant by various additions.  On the same principle, pur-
gatives and other evacuants continue to  be indicated.   Emollient
and demulcent remedies, where they can  be directly applied, often
soothe an inflamed  surface, both by promoting the natural secre-
            24 
*..
273           WILLIAMS'S PRINCIPLES OF MEDICINE.

tion, by removing  irritating  matter  which may have caused the
inflammation, and  by reducing the  acrimony of the morbid dis-
charge, which is often acrid  (§ 455). (a)
  493.—4. Determination to the part. This, with the following
element, obstruction in  the part, is  only the further result of irri-
tation of the vessels;  but it is here named  as a constituent of
established inflammation.  It is to be opposed by  the same reme-
dies as  those  just  mentioned for vascular irritation, and formerly
noticed as suitable for simple  determination of blood (§ 342, et seq.),
but as part of a disease which is more enduring  and serious, the
determination attending inflammation requires a fuller than usual
application of these remedies.   Of the sedatives applicable to this
element, none is so effectual as cold, which we  have found more
than any other agent to promote the  contraction of arteries (§ 120).
It is thus  that ice  and cold  lotions  are very salutary in reducing
active inflammation where they can be  properly applied, as in ex-
ternal  inflammations: in some  internal inflammations the  cold
may be made to reach the interior,  as  by a bladder of ice to the
head in meningitis, and  by swallowing slowly small pieces of ice
in gastritis.  Cold  will do harm instead of good in inflammation,
either when it does not reach the enlarged arteries through which
the determination takes place (§ 326), or when it is not sustained
long enough to prevent the effects of reaction (§ 79), by which the
arteries again become enlarged and determination  is renewed.
For these reasons, external cold applications are injurious in  most
interna] inflammations,  and if not  steadily regulated, they may
prove so in other cases likewise.
  Warmth and other derivants applied to parts more or less remote
from the vessels which are the channels of determination are very
serviceable aids in the treatment of  this element:  thus, partial or
general warm baths, hot poultices, &c,  operate.  Diaphoretics
which equalize the circulation without stimulating, such as anti-
mony, are also beneficial, by relaxing the cutaneous vessels gene-
rally, and thus deriving to the whole surface.  So we  have found
(§ 345) purgatives and diuretics to  operate as derivatives as well
as evacuants ; and bloodletting was then stated  to  be the  most
effectual of all (§ 346).   Change of  posture, by elevating the part
inflamed, should also  be mentioned  among the means which coun-
teract determination of blood.
  (a) The coincidence of these two states, of congestion and irri-
tation, constituting some of the worst forms of disease, may be ad-
duced in confirmation of the remark in the last note (to § 490); —
that  we cannot often separate the  " elements of inflammation" in
practice, but must proceed at once with treatment to remove both
congestion and irritation, and to prevent their return by curing the
irritation,not bysedatives alone,but by tonics,and especially quinia.
We have enlarged on this topic in another place (Stokes and Bell's
Lectures, vol.  ii., Lect. xcviii.-cii.). 
PROXIMATE ELEMENTS OF DISEASE.           279
  These different measures, which may suffice in simple determi-
nation, may be insufficient for that attending inflammation, chiefly
because they cannot easily be sustained for a length of time.  To
produce a more  permanent derivation or revulsion, as well as to
act as counter-irritants, various agents are used to excite artificial
inflammations, which counteract inflammatory disease by deriving
and irritating in another direction.  To this class belong blisters,
mustard poultices, applications of tartar emetic, croton oil, strong
ammonia, mineral acids, some  essential oils, heat above 120° Fah-
renheit, &c, varying in the amount of inflammation which they
excite according to the manner and duration  of their application.
 As these  fulfil several indications in inflammation they will again
 come under our notice.
    494.—5 and e. Obstruction in the part by atonic enlargement
 of the capillaries and by adhesion of the while corpuscles.   These
 two are classed together, because they both contribute to produce
 the  partial  obstruction  which is characteristic of inflammation.
 The atonic enlargement of the capillaries may be thought to be
 included in the congestion before noticed ; but it stands here as a
 part of established inflammation, and therein different from mere
 congestion (§ 287).  The remedies to be opposed to it are, how-
 ever, the same  as those mentioned under that head ;  but here they
 generally occupy a subordinate place, unless they fulfil other indi-
 cations.   There are, however, a few cases in which the treatment
 for congestion, even  by stimulants, proves effectual in curing in-
 flammation.  Catarrhal inflammations of mucous membranes are
  sometimes  removed by a highly stimulant treatment with wine,
  spirits, or ammonia.  It is probable that the  circulation is  so much
  accelerated as  to excite the dilated vessels to contract,(a) and the
  obstruction is thus swept away.   This treatment generally causes
  sweating and a deposit in the urine ; but these seem to be as much
  the effects  as the causes of the improvement, for sweating by other
  means is not so effectual.  But this mode  of treatment is hazardous,
  for it acts by increasing the flow of blood, and if this fail to remove
  the obstruction, it will surely aggravate  the inflammation.
     But the  most constant and important part of the obstruction ot
  inflammation is due to the  unusual  formation and adhesion ot he
  white corpuscles  in the  inflamed vessels; andin^smuch as it is

     (a) An in^a^o7dTsreiiding force, as by the blood in  accele-
  rated circulation, is not exactly the means that would seem best
  adapted to relief or  remove  the existing distention of vessel-,
  whose  contractility at the  best is very sight and barely ap-
  preciable under particular  circumstances, after  the  application of
  fhe strongest stimuli; irritants in fact, and, of course  very-different
  from the blood.   If contraction be a term applicable to a dimi-
   nution of the calibre of an artery, it is only seen to occur, as far
   as the blood is concerned, by the diminished or arrested impulse of
    the fluid. 
230             PROXIMATE ELEMENTS OF DISEASE.

this especially that establishes inflammation and is the cause of its
most  serious results, it would be most desirable to find some reme-
dial influence  to counteract it.  Unfortunately, however, we  are
not acquainted with any direct means of preventing the formation
and cohesion of these globules, or of dissolving them when formed.
As these globules  appear to  be formed in the blood-liquor, we
should look for the desired remedies among the medicines which
affect the blood;  and it might be surmised that alkaline and other
salts may possess this virtue.  The efficacy of carbonate of potash
as an antiphlogistic  remedy has been much vaunted by Sarconi
and other Italian writers;  but this is not confirmed  by general
experience.   In fact, it appears,  from the experiments of Mr.
Blake (§ 214), that, salts of potass injected into the veins promote
the coagulation and stagnation of the  blood instead of preventing
them.   Whether antimony or mercury possesses any such quality
is not. known ;  the subject deserves careful  experimental investi-
gation ; for  if a medicine could be found capable of  fulfilling this
intention, it would be the most efficacious of all antiphlogistic re-
medies.  It cannot be doubted that bloodletting and other eva-
cuants which reduce the mass of blood also diminish the white
corpuscles as well as the fibrin (§ 214) ; but they do  so at a great
expenditure of the  red particles,  and  therefore  of  vital power
(§ 183).
  495. — 7. Distention of vessels.  This is another  of the  more
characteristic constituents of inflammation, and has been explained
to be  the result of determination of blood into congested and  ob-
structed  vessels.   In congestion,  we  formerly  found distention
sometimes to occur (§ 306);  but there it is chiefly in the veins ;
here it is in  the small arteries, and all those parts of the capillaries
that are on  the arterial side of the obstruction.   This may account
for the greater degree of distention, and the larger amount of effu-
sion and other changes that result from it.  We see, too, that the
most effectual means of relieving it will  be by lessening either the
determination of blood or the obstruction.   The  measures for  re-
ducing the determination must be now of the stronger kind, such
as bloodletting and free derivation or  evacuation ;  because the
arteries  which  are the seat of determination are closed at most of
their capillary ends, and must be  drawn  upon either  directly or
through means which reduce the  pressure in the arteries gene-
rally.   Where, therefore, there is any considerable determination
of blood, the distention which it  causes will not be relieved with-
out drawing blood either from the enlarged vessels themselves, or
from other parts, in sufficient quantity to reduce the general  arte-
rial pressure.
  Other slighter means  give some relief to the distention of  the
vessels in inflammation.  External pressure, carefully equalized,
can sometimes do this, as in the  effect of  well-applied  bandages
and strapping on wounds.   Fluid  pressure, as proposed by  Dr.
Arnott, by means of quicksilver, or the slack air-cushion  under a 
PROXIMATE ELEMENTS OF  DISEASE.
281
bandage, might be still  more useful in various external inflamma-
tions, because its equality insures its proper  application.  It is
very probable that a part of the efficacy of poultices depends on
the soft and uniform pressure which they produce on the inflamed
vessels.  But certainly poultices, fomentations, and  other means
of applying moist heat, relieve distention in part also by relaxing
the solid fibres, and by promoting the exudation of the  watery
parts of the blood.
   496.— s.  The effusions from the  vessels are the result of their
continued distention.  They may therefore be  prevented  or less-
ened by means which  reduce this distention;  but in severe cases
of inflammation, effusion is the natural mode in which the vessels
are  relieved of their  load:  and we have just mentioned that-
poultices and fomentations give  relief by promoting  this result.
If the effusion is outwardly, as from  a mucous membrane, it may
not  be necessary  to check it, except so far  as  it may interfere
with the functions  of  the  part;  but if it be too thick, alkaline
medicines sometimes succeed in attenuating it, and thus promote
its discharge ;  whilst acids and various astringent remedies check
it when it is too  profuse ;  but here blisters and various evacuants
should be combined with  these  last, otherwise the inflammation
may be increased.   This corresponds with what  has been said of
the  treatment of sthenic  fluxes (§ 393).   When  the effusion is in
cellular texture, a serous  cavity, or parenchyma,  it may more
seriously interfere with the functions of the part; and it  may be
 more important to prevent, or restrain, or remove the effusion.
 Thus, in the submucous  cellular  texture  of the  glottis, or  in the
 serous  membranes of the brain,  a little effusion may prove fatal;
 and in  the lungs or pleura, effusions are injurious in proportion to
 their extent.   Besides  the measures directed against determination
 and vascular distention, it  is doubtful that we possess means  of
 restraining effusion.   It is pretty certain that some other antiphlo-
 gistic remedies, especially mercury and antimony, do diminish the
 effusions of inflammation, and promote their re-absorption ; but it
 is not clear that they do so in any more direct way than by reduc-
 ing the local and general excitement, or  by their  evacuant effect.
 The expressions, " sorbefacient" and " exciting  the absorbents,
 hypothetically ascribe  to remedies the property of increasing ab-
 sorption ; but nothing in physiology points out any direct mode
 in which absorption can  be artificially increased.   A free  action
 of the excreting organs promotes absorption,  by reducing the dis-
 tention of the vascular system.   Absorption is also promoted by a
 circulation that is free, Without excitement or distention ;* and the

   *  In my Gulstonian Lectures, (Med. Gaz., July, 1841 ) I adverted to the effect
 of a rapid  current in promoting absorption.  Mr. G Robinson has lately .illus-
 trated ths effect by some experiments (Med. Gaz  May, 1843)   Another influ,
 ence which probably contributes, is the different density of the fluid w.thm and
 witho^  the vessels*:  that  within is more dense and sahne, and by  the law of
 endosmosis! tends to attract the thinner fluid from without.  Th.s explains  the
               24* 
282          WILLIAMS'S PRINCIPLES  OF MEDICINE.

return of the vessels to a healthy state is generally attended with
more or less absorption of  the  effusions.  It is probable that blis-
ters and other counter-irritant applications near the inflamed  part
promote absorption, not merely as evacuants or derivants, but also
by causing a rapid flow  of blood through  the  adjoining vessels,
which facilitates  the  endosmosis and removal  of effused fluids.
Hot fomentations  and stimulant frictions seem  to operate in the
same way.
   In various cases it is necessary to give vent to the accumulated
effusion by surgical  operation, as by  incisions or acupunctures in
erysipelas, opening abscesses, paracentesis in empyema, &c.   This
is chiefly necessary where  the effused matter is purulent and little
•susceptible of absorption, as well as  noxious to the system ; but
sometimes the  mere quantity or situation of the effusion, by en-
dangering life, renders the  resource of an  operation necessary, as
in acute laryngitis and some cases of  pleurisy.
  497. — 9.  Increased absorption is  manifest in the processes of
softening, ulceration, and  suppuration.  I have endeavoured to
explain how, in the midst  of distended and effusing vessels, ab-
sorption is increased.  The veins and lymphatics are free, and by
the motion communicated  to them from the current of the neigh-
bouring  and anastomosing branches, they are ready  to convey
away all  the fluids that can pass through their coats (Gulstonian
Lectures, 1841).   In fact,  this  is doubtless a provision for the re-
moval of superfluous matter, old and new ; but the process be-
comes injurious and destructive when  it predominates over effusion,
and extensively invades the living textures.  But we have found
reason to suppose that textures do not fall a prey to the softening
or ulcerative process, unless their vitality is lowered and their nu-
trition impaired by a defective supply  or quality of blood (§ 466, 7) ;
and that inflammation does  produce  these  effects very differently
in different  cases.  Sometimes local stimulants  and general tonics
check softening and ulceration by improving the vitality and nou-
 rishment of the obstructed part; but they may have the opposite
 effect if the circulation in  the affected part is too much obstructed
 to admit of increase.  Hence we  find, in phagedenic ulcerations,
 stimulants sometimes check and sometimes aggravate the disease.
 The increased absorption whieh forms a part of ulceration might
 be arrested  by diminishing  atmospheric  pressure  on the part, as
 by applying a cupping-glass over a phagedenic  ulcer; but such an
 expedient is rarely practicable.
   498.— 10. Impeded circulation in the part has been just ad-
 verted to as contributing, with increased absorption, to  the pro-
 cesses of softening and ulceration ; but its greatest effect is mani-
 fest in gangrene, or the complete death of  the part.   In suppura-
 tion, also, the  part dies, but it  is removed by absorption, and re-
 greater readiness with which the thinner effusions are absorbed.   Can  we  in-
 crease absorption by rendering the blood more saline than usual ?  The thirst
 after taking salt food would 6eem referable to this cause. 
PROXIMATE ELEMENTS OF DISEASE.
283
placed by pus, which makes its way to the exterior.  Of the few
agents that may be directed to restore or improve obstructed cir-
culation, heat is the chief  one to be named.   Heat enlarges ves-
sels, especially arteries (§ 120), and facilitates the passage of blood
through them ;  and  although, for this  very reason,  hurtful  in
sthenic inflammation and  in parts where determination prevails,
it is really very beneficial in the stages and forms of inflammation
in which  obstruction predominates and endangers the  vitality of
the  part.   Hence  the utility of hot fomentations of poultices  in
low forms or advanced stages of external inflammation.  In slight
cases, frequent applications  of heat and moisture may entirely re-
move the obstruction, restore the  circulation, and thus the life of
the  part,  although  the  inflammation may have  already caused
much effusion.   In other cases, heat does not remove the obstruc-
tion, and  therefore  does not maintain the life of the part; but  by
increasing the determination around it, it promotes its removal
by suppuration, and  it hastens and matures this process, which is
the best by which  a part, the circulation of which is obstructed,
can be removed.  In a similar way, too, heat favours the effusion
of  lymph, which circumscribes  the suppuration  and prevents it
from spreading or infecting the system.  Lastly, in a similar way,
heat and other stimulating applications promote the  process of
separation or sloughing of a gangrenous part (§  475), the whole
circulation and  life of which have ceased.  These latter effects of
heat may often be  promoted  by medicines and food calculated to
maintain  the vigour of the  general circulation.
   499.— 11. The increased circulation around the obstructed part
is often  that constituent of inflammation which  causes the most
 prominent, symptoms, the  greatest  heat, pain, tenderness, and
other marks of excited function being commonly  dependent on it.
 We  have already noticed  determination as an element of inflam-
 mation in its  early stage, and  refer to that clause  (4) for  an
 account of the remedies with which it is to be combated. We now
 advert to determination  to the  neighbouring vessels as a part of
the extending irritation of inflammation, which often sympatheti-
cally excites the whole system into fever.   The treatment, there-
 fore, partakes of  the character  of  that suited for inflammation
 with fever.

             Treatment of Inflammation with Fever.

   500. The fever excited  by inflammation consists chiefly of  the
 items mentioned in the table ; but it will  be more convenient to
 notice them  here together.  They are —(12)  Excitement of the
 heart and (13) of the arteries ;  (14) change  in  the blood by in-
 crease of fibrin and (15) by diminution of the excretions.
   The addition of  fever to inflammation very materially modifies
 the treatment.   The disease then  to be treated is not  merely  the
 inflamed  part  and a  few other  parts in sympathetic  relation 
2S4
WILLIAMS'S PRINCIPLES OF MEDICINE.
with it, but the whole vascular system, its blood and the secretions
and functions which it supports.  In  like  manner, the treatment
must now  become general instead  of  local; not because  the
local inflammation has lost its importance, but because it has now
become a part of a general disease, which sustains it with such an
energy that local remedies now become trivial, or even injurious.
Thus, when inflammation is backed  by febrile excitement of the
heart and  arteries,  the stimulant and  astringent antiphlogistic
remedies (§ 491) irritate  the distended vessels  instead of making
them contract.  What can local bloodletting do when there is  an
excited force from behind impelling the blood to the inflamed part
more rapidly than  the  oozing by local bleeding can  relieve it ?
Derivants  also have little power when  the tension of the whole
vascular system is so much raised.   Counter-irritants must even
prove injurious, by adding another  cause of excitement  to  the
system.  So, too, narcotics  can have no control over fever once
established, and may prove hurtful by exciting the nervous centres,
and still further impairing the secretions (§ 166).  Under these
circumstances, a more general  remedy is wanted, which shall re-
duce the action of the heart and arteries, and diminish  the inflam-
matory character  of the blood.  The  first  and  most powerful
remedy of this kind is general bloodletting; next come the stronger
evacuants, antimony and mercury ; and lowest  in power are what
are  called  refrigerants  and direct sedatives.  We shall briefly
notice these antiphlogistic remedies.
   501. Bloodletting, if carried far  enough, is sure to  reduce  [at
least temporarily],  the  action  of the heart; for, as formerly ex-
plained, it may produce syncope (§ 70).   A remarkable fact, first
pointed out by Dr. Marshall Hall, is, that in inflammatory disease
a much larger amount of blood may  be drawn without producing
syncope than can be taken in health or in other diseases.(a)  The
following is Dr. M. Hall's table of the results of his investigation
of the tolerance of bloodletting in different diseases.  The numbers
represent the mean  quantity of blood which flows before incipient
syncope in the sitting or erect posture : —
    I. Augmented Tolerance :
       Congestion of the brain.....^ xl—1.
       Inflammation of serous membranes   ...    1
       Inflammation of synovial membranes     -   -    >^xxx—xl.
       Inflammation of fibrous membranes                )
       Inflammation of the parenchyma of organs (brain, lung, ? ?
         liver, mamma, &c.)....." 5^ XXX'
       Inflammation of skin and mucous membranes (eryaipeO ?
         las, bronchitis, dysentery)   ....    50 XVI-

  (a) This fact, like the tolerance of enormous doses of opium  and
alcoholic stimulants in certain diseases, seems to our mind to have
been too early received to allow of our  attributing it to Dr. Hall.
He is probably the first in this case, as in the theory of the reflex
action of excito-motor nerves, to formally enunciate the already
familiar facts into a system. 
PROXIMATE ELEMENTS OF DISEASE.
285
   II. Healthy Tolerance :
       This depends on the age, sex, strength, &c, and on the J
         degree of thickness of the parietes of the heart;  and > § xv-
         is about........)
   III. Diminished Tolerance :
       Fevers and eruptive fevers.....§ xii—5 x'v'
       Delirium tremens and puerperal delirium  -         § x—xii.
       Laceration or concussion of the brain              }
       Accidents before the establishment of inflammation   > § viii—x
       Intestinal irritation......)
       Dyspepsia, chlorosis......% viii.
       Cholera........§ vj.
  The explanation of the  increased tolerance of bloodletting in in-
flammation is, I apprehend, to be found in the increased excita-
bility of  the heart and  tonicity of the  arteries, which maintain a
sufficient force and tension to preserve the circulation, especially
through  the  brain (§ 266), even when much blood is  lost.   In
asthenic  or  atonic diseases, on  the other hand, the arteries being
lax, and  ill fitted to  transmit the blood, a smaller loss  is felt, and
syncope  may result.   The variations between inflammations occu-
pying different seats  must be referred to  the arterial tone  being
less augmented  in some than in others, and are therefore indica-
tions of  the more or  less sthenic (§ 477) character of the inflam-
mation.  The quantity of blood in  the whole system will affect
the  heart's action and  arterial tension  in a similar way ; and  no
doubt the more stimulating quality of the blood  may contribute to
the same results.
   502. The object of bloodletting in inflammation is not merely to
produce  syncope, or  a  temporary impression on the pulse but a
permanent reduction  of the excitement of the heart and arteries;
and this is to be effected in different modes of bloodletting under
different circumstances.  Where the inflammation is quite recent,
and the  fever has not  existed long, a  moderate amount of blood
rapidly taken from  a large orifice, or from two arms at once, or
even from the jugular vein, will often be sufficient to reduce  the
fever and inflammation.   The circulation is thus reduced, perhaps
to syncope; and, relieved of the pressure and  determination of
blood, the inflamed vessels soon recover their normal state, if  not
spontaneously, at least with the aid of some of the subsidiary anti-
phlogistic  measures.  The benefit resulting from this mode of
 bloodletting in recent  cases is sometimes very striking, and  the
cure is effected at a comparatively small expense of blood.
   503. But the case is different when an  acute inflammation and
fever have lasted  for two or three days.  There is then not merely
excitement, but sundry changes in the inflamed part and in  the
 blood, which keep up the excitement; the inflammation has become
 established in the part, and the fever  in the system ; and no brief
 impression on the circulation, however sudden and complete,  can
 remove  them.  If in this state a patient be speedily bled to fainting,
 reaction will soon come on, and renew the fever with increased
intensity.   Here, therefore, it is necessary to bleed more slowly 
286          WILLIAMS'S PRINCIPLES OF MEDICINE.

and to draw more blood ; and instead of promoting the occurrence
of syncope by the erect or sitting posture, it is proper to keep  the
patient in an easy recumbent or reclining position, and to watch for
the good effect of the bleeding in the softening of the pulse, or  the
relief of the pain or other distressing symptom.  The actual occur-
rence of syncope is rather to be avoided, and may be pre vented by
untying the  arm as soon as the lips lose their colour, or the patient
complains of feeling sick or  faint.  Thus  practised, bloodletting
causes a more permanent reduction of the  active elements  of  in-
flammation  and  fever, diminishes the exciting and  too fibrinous
condition of the blood, and although it cannot  repair the changes
already produced in  the inflamed  part, it prevents their increase,
and puts them  into a condition favourable for  the curative efforts
of nature and the further operation of other antiphlogistic remedies.
In the more severe and confirmed cases of  inflammation it is often
requisite to  repeat the bloodletting again and again ;  the indication
for this being the return of incompressibility of the pulse, heat of
skin,  and a new aggravation of the symptoms.  In all such cases,
the advantage of the gradual over the sudden mode of bloodletting
is apparent, for where  the reducing influence  of this measure is
longest sustained, it is least necessary to resort to it again.
   Another case in  which it is expedient to draw blood  largely
rather than  suddenly is  where inflammation is combined with  ple-
thora.  On  the other hand, in anaemic subjects, the  blood should
be economized as much as possible ;  the early depression from the
loss of blood should  be promoted by a posture favouring the oc-
currence of syncope, and might  be sustained  by the influence of
 antimony and other remedies.(a)

   (a) The author has not presented the question —to what extent
 does  bloodletting exert a controlling power in inflammatory fever ?
 By some its influence has been restricted to modifying the disease
 by an abatement of its intensity, without curtailing its duration ;
 whilst there are not wanting others who deny  its curative efficacy
 entirely.
   M. Andral has some useful remarks on this point, in his work
 so often quoted  in these notes.  We  find, he tells us (p. 122),  that
 however copious and frequent the bloodlettings  during  the  first
 stage, or that of increment, of inflammation, the quantity of fibrin
 is still increased beyond its normal proportion ;  although after each
 abstraction  of blood there is an evident diminution of red globules.
 It would seem, then, he  tells us, that when once  the blood has
 begun to produce an excess of fibrin, a certain duration and  suc-
 cessive periods are required to be gone through before this tendency
 is  exhausted;  no matter how copious are the  bloodlettings, to
 which recourse has been had on the occasion.  But M. Andral
 disclaims the inference, that might be drawn from this fact, against
 the utility of venesection at all  in the phlegmasiae.  Experience
 has satisfied him, in common, we may add, with every observing
 practitioner, that although these diseases are not removed at  once 
PROXIMATE ELEMENTS OF DISEASE.
287
  504. After the general excitement has been lowered or removed
by general bloodletting, the local  inflammation  often has  to  be
treated by topical bloodletting, which now is not only more effica-
cious in reducing the determination and distention of the inflamed
part, but contributes to keep down the general excitement.  In fact,
local bloodletting, as by cupping or numerous leeches, may be made
so extensive as to be tantamount to general bloodletting; and the
cases in which it has most of this effect are those  in which slow
bleeding answers best.  In either extreme  of age, and  in the fee-
 ble,  local  bleeding only is admissible.   Local bloodletting  is
 chiefly suitable  for  inflammations which  are superficial and ex-
 tended, as those of the pleura or peritoneum [and in gastritis, ente-
 ritis, laryngitis,  tonsillitis, angina,  &c.; in  fine, in  phlegmasia  of
 membranes generally].  It  is of much less  avail in pneumonia,
 cerebritis, and other inflammations of deep-seated or  parenchyma-
 tous organs.
   505.  Of other evacuants  none are equal to purgatives, which
 are a great  aid to  bloodletting, and should  be used  in most cases
 of severe inflammation, uncomplicated with  gastro-enteric irritation.
 They operate on so large a surface that they affect the system, and
 their effect may be pushed to the extent of producing syncope ;  but
 such an extreme  result is  attended with  much exhaustion, and
 their continued use  may cause intestina. inflammation.  The chief
 benefit, arising from purgatives may be obtained from a few effi-
 cient doses  at the  commencement of the treatment.   This aids  the
 depressing  effect of bloodletting, removes feculent matter, which is
 often a  source of irritation, and clears the  intestinal canal for the
 operation of other medicines.  The stronger and less heating pur-
 gatives are to be preferred, such as calomel, jalap, salts and senna,
 combined with tartar-emetic or colchicum.    A combination  of
 several, which operate  most on different parts of the canal, answers
 best.
by this means, yet it does abridge  their duration, and contribute
towards a favourable result.  He even admits, that if a large quan-
tity of blood be abstracted at once in a case of inflammation, when
there is  yet little else  than  congestion of  the  solid  and but a
slight elevation  of the  medium numeral  of fibrin, we may pre-
vent  the progress of  the disease ;  and, in certain  cases, even
strangle  it at once.  But  if the disease  have  made some pro-
gress,3 we cannot count upon this result:  it will be no longer in the
power of art to prevent a completely developed pneumonia, for
example, from lasting seven or eight days  at least, although we
shall be  able to  prevent its extending beyond fifteen days.   We
cannot  make a  well-established acute articular rheumatism, to
take another instance, terminate before eight, twelve, and oftener
fifteen or twenty days ; but we shall find, by the  use of the lancet,
that the disease  will more frequently  be arrested at this latter
period than if the remedy had not been resorted to at all. 
2SS           WILLIAMS'S PRINCIPLES OF MEDICINE.

  506. Of internal remedies against inflammation with fever, that
which most resembles bloodletting  in its effects is tartarized anti-
mony.  It is far less sure in its operation, and  its influence is not
proportioned to the quantity ;  yet, under its use, especially if pre-
ceded by bloodletting, the pulse becomes less  hard and  frequent,
the heat of skin is moderated, and  sometimes  perspiration ensues,
whilst the local symptoms are generally more or less  improved.
Sometimes it causes vomiting, more rarely purging, but its best
antiphlogistic operation occurs where these  effects do not ensue to
interfere with a  continuance  of the medicine ; and I  have fre-
quently found its  utility most  marked when it  did not  cause even
nausea or profuse diaphoresis.  Tartarized antimony, and the milder
preparation. James's powder,  have been very long used in  this
country as febrifuge medicines; and  Dr. Marryatt, who practised
at Bristol in the last century, used the  former in large  doses for
inflammation.  The practice was since  carried to a greater extent
by  Rasori, and other Italian physicians, who gave from 10 to  120
grains in tWenty-four  hours.(a)  Laennec  adopted the use of the
remedy in more  moderate quantities, giving from  one to four
grains in some agreeable  vehicle  every second or third hour for
six doses;  then intermitting or continuing  it, according to circum-
stances.  In  pneumonia  and rheumatism, he  considered  it  the
chief remedy.  Most  practitioners in this  country now  consider
tartar emetic a valuable  aid in subduing inflammation, chiefly to
be  used after bloodletting ; or in slighter inflammations, where
bloodletting is inexpedient.  I rarely find it useful to raise the dose
beyond two grains every three hours ; and  in most cases one grain,
half a grain, or even less, will suffice.  The first doses sometimes
causes vomiting ; but this generally subsides  when the  doses are
repeated, and may be prevented by giving the medicine in a mild
neutral saline draught, with from five to ten minims of the diluted
 hydrocyanic acid in it.   Antimony acts most  satisfactorily in in-
flammations of vascular  parenchyma  and complex membranes ;
such as the lungs, the testicles, the mammae, the air-passages, the
cellular membrane and skin, and the joints.  It is less effectual in
inflammations of serous membranes, and would be  unsafe in in-
flammatory affections of the intestinal canal.  It is most beneficial
in  the early stages of inflammation, especially when attended with
fever; and seems to have little effect on  the  products  of inflam-
 mation.
   How antimony operates in  reducing fever and inflammation  is
quite uncertain.   Rasori  considered  it to be a direct  sedative or
contra-stimulant, diminishing the excitability of the vascular sys-
tem, and thus neutralizing the inflammation.   He supposed  that
the tolerance, or  power of the body to  bear large doses of the re-
 medy, depends on  the presence of inflammation in the system ;

   (a) Through Rasori and his countrymen only has  the practice
 become common, even among English physicians. 
PROXIMATE ELEMENTS OF DISEASE.
2S9
but, as Laennec has observed, this is not correct; for patients that
are quite convalescent have continued to take 12 or 18 grains daily
without nausea, or even loss of appetite.  Laennec first considered
that the medicines act as a  revulsive, by irritating the  stomach;
but this view being made, by the Broussaians, a ground of oppo-
sition to the use of the remedy, Laennec latterly  represented it to
act as a sorbefacient.   It seems to me, that  the  most  reasonable
view  to take of its operation is, that it chiefly acts by diminishing
the tonicity of the vascular system (§ 122).   Small doses certainly
relax the  pulse and skin, and, where there  is no fever, produce
perspiration without stimulating.  They also seem to increase the
biliary and intestinal secretion.  In inflammation and fever, larger
doses are required to produce the same result; and as soon as the
excessive arterial tension is  relaxed, the chief part of the fever is
removed  (§ 441).  By thus  reducing the  increased tonicity of the
arteries, the circulation is equalized and quieted, and the determi-
nation to  and distention of the inflamed part are diminished; and
the vessels generally are placed in the condition for their natural
offices of secretion, which their extreme tension  had before inter-
rupted.   This  view is, however, at  present, no  more than hypo-
thetical, and might with advantage be tested  by experiments  on
the lower animals.(a)
   507.  Another great remedy in inflammation is mercury, alone
or combined with opium.   The combination of calomel and opium
 was  first  employed by Dr. Hamilton of Lynn Regis; and the rules
which he proposed for  its  use have hardly  been improved on.
 After a sufficient venesection and a full  purge,  he gave from one
to five grains  of  calomel with from one-fourth to one grain of
opium every six, eight, or twelve  hours.  When much fever was
 present with dryness of skin, he added tartar emetic and camphor.
 If no relief ensued in twenty-four hours, venesection was repeated.
 Most practitioners admit the  power of this  remedy, although
 some ascribe its efficacy to the mercury, others to the opium ; and
 the proportions  of each have been variously altered.   The bene-
 ficial effects of this remedy generally, but not entirely, depend on
 the mercury affecting the system, as manifested in adults by the
 fetor of the'breath, and the tenderness and swelling of the gums ;
 and  in children, by spinach-like  evacuations  from the  bowels.
 Improvement is, however, often manifest before these results take
 place.  In iritis, the  influence of mercury  is  quite visible in re-
 moving effused lymph; and it  thus  obviously in some way pro-
 motes absorption, as well as prevents effusion.   The same  « sor-

   (a) The view in the text  is quite  too  limited. Antecedent to
 the impression and effects generally of tartar emetic on  the blood-
 vessels, is its influence on the nervous system, through  the depres-
 sion  and relaxation of which it  acts in a  similar manner on the
 muscular, and thus favours the reduction of dislocations, hernia, &c.
            25 
290          WILLIAMS'S PK1NC1PLES OF MEDICINE.

befacient" operation is seen in the effect of mercury in removing
the callous margin of indolent  syphilitic ulcers, and in promoting
the spread of phagedenic ulcers.  Dr. Farre thinks that mercury
destroys red particles of the blood, and causes in the system a dis-
position to erythematic inflammation, which is incompatible with
phlegmonous or plastic ; but this is opposed by the fact that lymph
is thrown out, and granulations form and healthy ulcers heal dur-
ing mercurial action.   It will be useful  to  give briefly a view of
the operation of  mercury and opium ; for although we cannot be
confident as to  its entire accuracy, yet it is founded on what is
best known of the effects of these medicines, and may therefore be
a guide in their administration.
  The opium is useful in preventing  the calomel from purging,
and especially in subduing the nervous irritation attending inflam-
mation, and which we have found to be one cause of that sympa-
thetic excitement which, when complete, constitutes fever (§ 440).
This salutary effect of opium alone  is  sometimes seen when the
vascular excitement has been subdued by a large bloodletting, and
in cases in which nervous irritation forms a chief element of the
disease:  here  a full  dose of opium will  subdue the  remains of
the inflammation better than any other  antiphlogistic  remedy;  it
seems to paralyze those sympathies which are concerned in renew-
ing or maintaining the excitement of inflammatory fever.  So, too,
in combination with  mercury, the opium  exercises this narcotic
influence ; whilst the  mercury prevents its astringent effect on the
secreting organs  (§ 66, 173).  The mercury acts further: it aug-
ments  the biliary  and intestinal secretions; sometimes inducing
copious mucous and bilious evacuations ; and from its effect in iritis,
it may be presumed to facilitate the  solution and  removal  of ef-
fused lymph.  How it has this effect is quite uncertain  ; probably
it is by changing the condition of the blood, by a diminution of the
fibrin and white corpuscles, the increase  of which is  much con-
cerned in contributing to  the  changes of inflammation.  So we
find  mercury chiefly  useful where the blood is very much buffed,
and  there is tendency to copious fibrinous effusions, as in inflam-
mations of  serous membranes  and  croup.  Calomel and opium
have little influence over high inflammatory fever ; and  the system
thus excited generally resists the mercurial action.  This remedy
has no further sedative effects than those which proceed from its
action on the intestinal  canal; and unless to produce  this action,
it is not well adapted for the earliest stage and most active forms
of inflammation.   In these circumstances, bloodletting  is more re-
quired with mercury than with antimony; and if fever returns during
the action of mercury, bloodletting or active purging may be ne-
cessary to reduce it.  In fact, the operation of calomel  and opium
is less antiphlogistic,  and more  alterative, than that of bloodletting
or antimony: it is inferior to them in the power of reducing inflam-
matory fever and active inflammation; but it is superior to them 
PROXIMATE ELEMENTS OF DISEASE.
291
in arresting and  removing the more plastic products of inflam-
mation.(a)
  508. As considerable  aids  in  the treatment of inflammatory
fever, although quite inefficient alone, must be mentioned various
saline medicines, such as nitrate of potass, and the alkalies com-
bined with vegetable acids.  Diluted solutions of these allay thirst,
and seem to cool the fever; hence they have obtained the  title of
refrigerants.   It is uncertain how far they may operate in  dimin-
ishing  the cohesion and excess of fibrin in  the blood (§ 438); but
we can distinctly trace their good effect in augmenting the secre-
tions, particularly that of the kidneys (§ 256).  They are all more
or  less diuretic;  and  most of them also supply an alkaline base,
which, by uniting to the  lithic and lactic acids formed in the blood,
facilitate the separation of these matters by the kidneys.   Colchi-
cum and digitalis are sometimes reckoned among  antiphlogistic
remedies; but in common inflammation, they are of very inferior
power.  In the absence of high fever, colchicum somewhat resem-
bles mercury in its special action on the secretion of the liver, and
it augments the elimination by the kidneys  (§ 257); and  digitalis
acts as a diuretic, as well as  a sedative on the irritability of the
heart;  but during severe inflammation, these effects are  scarcely
produced by doses which it would be prudent to administer.
   509. The utility of counter-irritants as  a remedy for  several
elements  of local inflammation has been already noticed  (§ 493,
496) ;  but their operation is positively injurious in sthenic  inflam-
mation during the prevalence  of fever.  They then add to  the ex-
citement  of the  system: and  in proportion to the  inflammation
which they excite, they  prove a new source of the  inflammatory
changes in the blood (§ 438).  But after the fever has subsided
under the influence of remedies, or is exhausted by time,  the ad-
vantage  of counter-irritants  returns.  Blisters and  suppurating
counter-irritants, which cause  copious discharge, are the most use-
ful ; tending to  draw away the remains of inflammation, and to
promote the removal of  effused matters left by it.  These  become
chief remedies  as  inflammation inclines to a chronic state, or
where it has left such structural changes  as cannot be speedily
removed.
   510. It is not necessary to dwell on  the last three items of
treatment in the table  (16.  Exhaustion; 17.  Depression  from
poison;  IS. Solid effusions).   The  exhaustion ensuing  after
long sustained excitement of inflammation and  fever often  ren-

   (a)  He who is familiar with the effects of mercury, calomel for
instance, in common disordered digestion with some febrile irrita-
tion, and in gastritis, cholera,  and dysentery, can hardly deny its
soothing and sedative operation, fully as manifest as, and in  some
of these cases more procurable than, from opium.   Its constitu-
tional effects, short of ptyalism, are often  sedative and enfeebling
in the extreme. 
292           WILLIAMS'S PRINCIPLES OF MEDICINE.

ders stimulants and tonics, as well as a generous diet, necessary
in the after treatment; but the greatest circumspection  is neces-
sary to be sure that these  measures shall be proportioned to the
wants of the case, and not pushe'd so early or so far as to rekindle
the inflammation afresh, or to produce other disorder in the weak-
ened organization.  Similar aids are required, but are less success-
ful in supporting the system  against  the pernicious  influence of
purulent or  gangrenous matter resulting from the inflammation.
Even in cases of suppuration, the occurrence  of  the premonitory
rigors, the diminished strength of pulse and heat of skin, point out
the time for changing the reducing plan for one more supporting;
but the degree to which the change is made must depend on the
symptoms and efficiency with which nature is attempting the pro-
cess  of limiting the destroyed  part.  It is probable that, in all
cases, some purulent  or  some  gangrenous matter finds  its  way
into the circulation ; therefore, in addition to stimulants and tonics,
antiseptics  (such as chlorinated liquids, nitromuriatic acid, and
creosote) are sometimes with advantage given  internally to coun-
teract the septic influence ; and the secretions are kept free  to
promote  the elimination  of the morbid matter (§ 260).  For  a
similar reason, foul, suppurating, and gangrenous sores are dressed
frequently, and their discharge  corrected and promoted by  anti-
septic and alterative applications.
   511. The removal of many  of the  products of inflammation
(serum, liquor sanguinis,  and the healthier kind of fibrin  and exu-
dation corpuscles (§ 424), is effected by the natural process of ab-
sorption, aided by various remedies before  mentioned, particularly
blisters  and other counter-irritants, mercury, iodide of potassium,
colchicum, and other diuretics.  Products of external inflammation
are sometimes more speedily dispersed under the influence of what
are called discutients, which are generally  slight stimulant appli-
cations, such as a warm spirit lotion, or solution of hydrochlorate
of ammonia, common salt, or iodide of potassium ; and  in  more
chronic cases, by friction with  liniments  containing  mercury,
iodine, ammonia,  and spirit.   These  operate in various  ways
already explained, by promoting the current of blood through the
part,  and thus facilitating absorption; by  diminishing the atonic
congestion left by inflammation ;  by promoting secretion or exha-
lation ; by pressure, &c.
   512. The antiphlogistic regimen consists in the exclusion of all
causes of excitement  in the food which the patient takes, and in
the circumstances to which he  is exposed; such  as  light, noise,
temperature, exertion, mental excitement, &c.  The diet in active
inflammation should  be  of the most sparing kind, consisting of
mere diluents, tea, barley-water or thin gruel, whey, toast-water,
soda-water, and the like :  all stimulants, and articles abounding in
the protein  compounds (§ 215), or in oil  (§ 59), being carefully
avoided.   When fever is  present, the  total loss  of appetite is  a
sufficient guide to the necessary abstinence ; and the stomach often 
PROXIMATE ELEMENTS OF DISEASE.
293
will  not retain or digest  much  nourishment, especially of a solid
kind;  but this is not the case in all cases of inflammation where
the restraint is equally necessary.

          TREATMENT OF VARIETIES OP INFLAMMATION.

  513. The sthenic (§477) form of inflammation requires the whole
array of antiphlogistic remedies to be directed with energy against
it.  The prevalence  of  determination of blood, active vascular
excitement, and the over-fibrinous condition  of the  blood, de-
mands the free use of bloodletting, purgatives, and antimony, at
the onset; and the full operation of mercury if the disease continue.
In  asthenic inflammation, on  the other  hand, bloodletting is ill
borne, and often  can only be practised locally; and the chief
treatment is with antimony or mercury, and blisters, which, in the
absence of high fever, may be  employed at a much earlier period
than usual.
  514. Acute inflammation (§ 478) demands a very prompt use of
the suitable antiphlogistic remedies; but the choice made of them,
and the extent  to which they  are  to be pushed, will depend on
whether the inflammation be sthenic or not.  Sub-acute inflamma-
tion is generally of the  asthenic form ; and  being less severe, as
well as slower in its progress and  effects, it does not require such
active treatment.  It must not,  however, be neglected ;  for its  ob-
scurity sometimes renders it dangerous: and in  an insidious man-
ner, it sometimes seriously injures function and structure.  Its long
continuance, or liability  to  recurrence, renders it necessary to con-
tinue a moderate antiphlogistic treatment for several weeks. When
lasting so long, it tends to become  more  asthenic, when  the more
lowering antiphlogistic remedies are no  longer  serviceable;  and
sometimes it is proper even to  call in  the aid of tonics, and  im-
proved diet, whilst the local inflammation is treated with counter-
irritants.  Mercury with opium is generally one  of the most useful
remedies in subacute inflammation.
  515.  Chronic inflammation  recedes still  further from  the in-
flammatory type, and borders more on  congestion or  disease of
nutrition.   The absence of fever generally supersedes the need of
the stronger antiphlogistic remedies — those for local inflammation
being sufficient; general bloodletting is needful only when plethora
also Ts present: and even local bloodletting should not be too freely
employed; for it weakens the  system, which is generally already
too feeble  in chronic inflammation.  Counter-irritants  are more
constantly useful; and their application should be varied according
to the seat and extent of the inflammation.  In inflammations of
serous membranes, a succession  of blisters  answers best.   For
chronic inflammations of parenchymatous organs, and ulcerations
of mucous membranes, counter-irritants, which excite pustules, or
setons, are  of more  avail.  Mercury is  often useful, and so  are
other  alterative medicines, especially salines and the  iodide of
            25* 
294
WILLIAMS'S PRINCIPLES OF MEDICINE.
potassium.  Mercury is more suitable to the more  sthenic forms,
attended with effusion of lymph, leading to tough thickening and
induration of textures.  Iodide of potassium is better adapted for
chronic inflammation of an asthenic character, with reduced blood
and strength, with tendency to ulceration, suppuration, or aplastic
deposits.   It is often requisite to  keep up the general strength by
the  mildest tonics, such as  sarsaparilla and mild  bitters, and to
allow a mildly nourishing, but not stimulating diet.  Careful atten-
tion to the state of the excretions is particularly necessary.  Courses
of mineral waters, and change of air by gentle travelling, are often
serviceable in chronic inflammations.
   516.  In congestive inflammation (§ 480), the treatment for con-
gestion should  be combined with that of  subacute inflammation.
If the subject be plethoric, general bloodletting would be proper;
otherwise  local  bleeding and various derivants  or revulsives,
among which cupping  and dry cupping  are  the  most effectual.
Rubefacient applications to an extensive surface, as large mustard
poultices, and strong ammoniacal or mineral acid liniments, are of
considerable efficacy ; and their use can  be renewed and varied
daily for a long time.  Mercury and antimony are both highly
useful in the  more active stage of congestive inflammations : the
former especially for inflammations of the abdomen, the latter for
those of the  lungs.  In the absence of much  irritation, iodide  of
potassium, mineral acids, and even quinine, sometimes help to dis-
perse the congestive part of inflammation.   So, too, in  secreting
organs, as  the liver, kidneys, and mucous membranes, various
stimulants which excite the secretion act  in a similar way.  For
further particulars, see the treatment of congestion (§ 313, et seq.).
  517. The treatment of phlegmonous inflammation* is generally
that for the sthenic form. Erysipelatous inflammation being gene-
rally asthenic, is not benefited by active antiphlogistic measures ;
and in some cases it is necessary to adopt quite an opposite treat-
ment, by ammonia, wine, bark, &c.:  this is where the influence of
the specific poison (§482) predominates.   In other cases, the reac-
tion against this influence is very vigorous, and  requires modera-
tion.   Generally warm fomentations to the affected  parts, a saline,
with small doses of tartar emetic, and keeping the secretions free,
answer best  at first, and  are, in a few days, to be  gradually re-
placed for ammonia or wine, and  bark or quinine, with improving
nourishment.   A more  decided counter-agent against the poison
(as against other animal poisons) is a desideratum; but cleanliness,
and careful regulation of temperature and ventilation, are the best
preventives.   Punctures and  incisions, which relieve the inflamed
part by the discharge of blood and morbid matter — and by nitrate

  * This term is used here in the sense in which Cullen employed it, as opposed
to erythematic or erysipelatous.  I mention this, because boils or furuncular in-
flammations are sometimes of an asthenic character; and with them not unfre-
qnently the constitution requires suppoit. 
PROXIMATE ELEMENTS OF DISEASE.
295
of silver, which, by exciting adhesive inflammation, arrests the
progress of the erysipelas — and mercurial ointment, which is sup-
posed to modify its character, — are the chief kinds of local treat-
ment that have been found useful.
  516.  Pellicular or diphtheritic inflammation is  usually of an
asthenic character, little benefited by bloodletting, but chiefly to
be counteracted by mercury, which is the suitable remedy for all
inflammations effusing lymph ; and by local  astringents, or even
caustics, which, by powerfully exciting the vessels, change their
action.   Thus nitrate of silver, in substance and in solution, hydro-
chloric  and diluted nitric acids, (one part to three or four parts of
honey applied  with a brush,) and  finely powdered alum, have
been used with  advantage  in diphtheritic sore  throat.  In  the
croupy inflammations of children, the most effectual remedies are,
calomel freely used, antimony, and certain expectorant or attenuant
medicines, which promote the more liquid secretions of the inflamed
membrane.   The aphthous  inflammation of children is  readily
subdued by a solution of borax, or a weak solution of sulphate of
zinc, using at the same time magnesia and mild mercurial aperients
to correct the secretions of the alimentary canal.
   517.  Hemorrhagic inflammations (§484) are often of the con-
gestive kind ; and the hemorrhage arises from the excessive dis-
tention of vessels, as in the hsematemesis that sometimes precedes
gastritis, the bloody discharges of dysentery, and  the haematuria
which occasionally ushers in inflammation of the pelvis and tubes
of the  kidney  (pyelitis).   The hemorrhagic tendency  exhibited
in purpura, and sometimes combined with inflammation in lichen
lividus, and ecchymosed erysipelas, I have often found connected
with congestion and torpid action of the liver (§ 171), and accord-
ingly benefited by  mercurial and  saline  aperients, followed by
nitric or nitro-muriatic acid.
   51S.  Scrofulous inflammation (§ 485)  being generally asthenic,
is little benefited by  bloodletting  or  other  active antiphlogistic
measures.  Its disposition to produce early cacoplastic and aplastic
effusions makes it important that it  should be subdued, if possible,
at an early stage, in situations where  the formation of curdy pus
or  tuberculous matter would be injurious.   In scrofulous inflam-
mation of the lymphatic glands, warmth and moisture, and discu-
tient applications,  (solutions of  muriate  of  ammonia, iodide of
potassium, warm vinegar,) are often useful in dispersing the_swell-
in <*  before it comes to suppuration.   In internal inflammations in
scrofulous subjects,  (as of the lungs, glands,  and joints,) local de-
pletion is generally advisable, followed by free counter-irritation,
especially such  as  may cause an external discharge of pus.   Dr.
O'Beirne and others recommend  a  free mercurial course for scro-
fulous  inflammation;  but  this I consider admissible only in the
earliest stage  of  the disease, and in its more active forms;  for I
have found (what I believe is the experience  of most practitioners)
that  mercurialization  greatly injures the  consitution of scrofulous 
296           WILLIAMS'S PRINCIPLES OF MEDICINE.

subjects, degrades the products of inflammation, and  promotes
softening and ulceration in textures where deposit has already
taken place.   It seems to me, that  it is rather asthenic  or chronic
inflammation  (§ 479), in subjects  that are not scrofulous, that  is
benefited by mercury, and  not that especially occurring  in the
scrofulous diathesis.   Preparations of iodine, especially the iodide
of potassium, do  sometimes appear to  countervail low scrofulous
inflammation ;  and their commonly salutary operation on the con-
stitution renders them eligible medicines in scrofulous subjects.
  But the source of the peculiarities of scrofulous inflammation, and
therefore the chief object for peculiar treatment, is the scrofulous
diathesis or constitution; and as this seems to consist in a degraded
condition of the plasma, or nutritive material of the blood (§ 211),
often connected with a deficiency of red particles (§ 185), an in-
vigorating and nourishing treatment and  regimen are  especially
indicated (§  21S, 219), and may  sometimes be employed even
when low  inflammation is present, this  being  counteracted by
counter-irritation  or  other local antiphlogistic measures.  Hence
the best remedies in scrofula are tonics, nourishing diet, and other
means calculated to  improve  the  nutritive function  and general
health.  Of medicinal agents, the  iodides of potassium and iron,
other preparations of iron, bitters with  alkalies, bark or quinine,
and mineral acids, have been found the  best aids.   But still higher
in efficacy  are pure  and mild air, especially near  the  sea or on
mountains;  warm clothing; regular exercise ;  warm sea-bathing,
or cold when borne (§ 79), followed by friction ;  a good propor-
tion of wholesome animal food, with due regard to the state of the
excretions.(a)  These  measures are of great efficacy in the scro-
fulous diathesis, and  are often  useful even after inflammation has
produced disease ; for they do much to prevent  its increase, and
assist nature in removing  or  rendering inert the cacoplastic or
aplastic matter.
  519. The peculiarity in the treatment of rheumatic and gouty
inflammation consists chiefly in the use  of means calculated to eli-
minate  the  morbid matter, which  is its cause (§ 251-254), from
the system.  The remedies which  best promote this object have
been  already mentioned (§ 252, 254).   But it  must be remem-
bered, that the inflammation and fever excited  may be so high
and  sthenic, as to require  active  antiphlogistic  measures before
colchicum or mercury can be made  to act; and this is particularly
the case in  acute rheumatism, in which  inflammation is excited in
many parts  at once ;  and probably as a consequence (§ 438), the
blood becomes surcharged with fibrin.   Here general bloodletting
is necessary, not to remove the cause of the inflammation, but the
  (a) We have found, in some cases, that a cure of scrofula is
brought about  by simplifying the diet, and substituting for much
animal food and  gravies, milk with good bread  and well  boiled
vegetables. 
STRUCTURAL DISEASES.
297
inflammation  itself.   If  after bloodletting the  rheumatic cause
abound still in the blood, which is commonly the case, it is proper
then to give  colchicum  with alkalies, or iodide of potassium, or
nitre in large  quantities much diluted (Gendrin), and to continue
such remedy for  some time, until the morbid  matter shall have
been sufficiently eliminated.  In  asthenic cases, the use of bark,
quinine, or other  tonics, may be serviceable in improving the tone
of the vessels after the irritation and exhaustion which the disease
and its treatment have produced (§ 174).
   520.  The infectious character of gonorrhoea and syphilis proves
the specific nature of their cause ; but it is only of the latter that
we can speak of  a specific remedy.  How mercury cures syphilis
is quite uncertain.  It is not by any property directly destructive
of  the virus ; for the disease cannot be prevented from appearing
by mercurial action ;  and when present, it is  not always cured by
it.  It is more probable  that mercury acts as an alterative, by re-
moving the callous indurations of syphilitic  sores and swellings,
and by increasing the secretions, and thus gradually eliminating
the syphilitic virus from the system.  It is now well known that
other  remedies,  which  promote  absorption  and  secretion, also
promote the cure of syphilis, especially the iodide of potassium.(a)
Gonorrhoeal inflammation  generally tends to a spontaneous cure
in a few weeks' time ; but  this  may be accelerated by mild anti-
phlogistic  and demulcent  measures  at first,  and astringent injec-
tions and terebinthinate remedies subsequently.
                       CHAPTER IV.
 STRUCTURAL DISEASES  OR DISEASES OF NUTRITION—ULTIMATE
                  AND PROXIMATE ELEMENTS.

                         SECTION I.
                  NATURE AND CLASSIFICATION.

  521. Although we have  had frequent occasion  to advert to
the changes in  the process of  textural nutrition effected by in-
flammation, congestion, &c, and although nutrition  might be in-
cluded under the head secretion (§ 178), a primary element, yet it
has seemed better to defer the notice of diseases of nutrition  until
now ; both because the previous consideration of disorders ot the
blood and its vessels gives the best introduction to them, and be-

"VflYThe admission of this faciis; opposed to the assertion at the
beginning of this paragraph, viz., that mercury is a specific remedy
Antimony and arsenic have  respectively cured  obstinate cases of
syphilis; and we  know now that  in all its stages it is successfully
treated by  common  alterative  remedies, either of a reducing  or
tonic order, according to the  state of the  general system, and tne
decree of local  irritation.  With all these  facts before us, it is not
sound philosophy to call mercury a specific for syphilis. 
298
WILLIAMS'S PRINCIPLES OF MEDICINE.
cause we cannot strictly distinguish structural disease into ultimate
and proximate elements.  By analogy,  indeed, we might infer
that ultimate  structural disease  is that which affects elementary
structures  singly, such as muscular fibre, nervous matter, cellular
texture, &c.;  but  we find structural disease rarely to be thus con-
fined to one anatomical element, but  rather to affect structures as
they exist in more or less complexity.
   It will not  be consistent with the plan  of this work to give the
details of structural  disease, which belong rather  to the  depart-
ment of morbid anatomy.  It will be sufficient for our purpose
to notice the  chief forms of diseases of structure by tracing them
through the alterations in the function of  nutrition  which produce
them.  This  method will enable  us  to  class these diseases in a
natural arrangement, and under each head to state  briefly what is
known with regard to their nature and  origin, and the remedies
which influence them.(a)
   As in  the case  of functional  diseases,  so  of structural  lesions,
which are modifications of the function of textural nutrition, they
may  be  comprehended  under the three  heads, increased, dimi-
nished, and perverted nutrition.
               ELEMENTS OF STRUCTURAL DISEASE.
f Increased = hypertrophy
  Diminished = atrophy
f;
NUTRITION
Induration.
Softening.
Transformation.
       C F  I  t'  S Cicatrices.
           "     (_ False membranes.
^ Perverted.....<^
                  ("Cirrhosis.
         „   ,  ..  J Fibro-cartilage.
Deposits^  Cacoplastic^ Grey tuheJ^
                  ^Atheroma, &c.
 ALTEHEIJ
MECHANISM
 f Contraction
 j Dilatation
J Obstruction
 ] Compression
 | Displacement
 l_ Rupture, &c.
k. Aplastic
LGrowths-^
        I
f   Non-
  malignant
^_ Malignant
"Yellow tubercle.
' Calcareous matter,
      &c.

 Cysts.
 Tumours.
 Hydatids, &c.

"Carcinoma.
1 Encephaloma.
 Melanosis, &c.(6)
  (a) " If we take a general view of the different aberrations from
the natural state to  which organized bodies are liable, we shall
find that they are all referable to two classes ;  viz., vicious confor-
mations and alteration of structure.  The latter class seldom make
their appearance until after birth ; whereas the former generally
occur  in  the mother's womb, before the individual  is perfectly
formed." — Andral, Patholog. Anat. p. 71, vol. i., Amer. edit.
  (b) The reader, who has not at hand Andral's admirable Trea- 
STRUCTURAL DISEASES.
299
  522.  It is not possible to enter fully into the minute or micro"
scopic nature of these different  modifications of structure, for ob"
servation has not yet supplied sufficient facts for  such  a detail; a
general view derived from the more obvious characters of struc-
tural diseases will suffice  for our  present purpose.   It must be
remembered that the division  here given, simple as  it is, is too
precise to be rigidly applicable  to many cases.  Lesions of nutri-
tion often graduate into each  other, and are very commonly com-
bined; hypertrophy of some textures frequently co-existing with
atrophy of  others, perverted nutrition being often combined with
excessive or defective, and several of these different changes often
occurring in succession  in  consequence of the operation of the same
 cause.  We have  already  found this to be the  result of inflamma-
 tion (§ 479) ; and  inasmuch as that  process exaggerates the changes
 of nutrition, it has furnished us with  many examples of the pro-
tise on Pathological Anatomy, may like to compare the tabular
exhibitions, in this work, of the various morbid alterations of nutri-
tion with that given in the text.   But as it is hardly worth while
to separate the several sections of his division,  we shall introduce
them  in their original connexion,  viz.:
     Section I.
Lesions of Circulation.
     Section II.
Lesions of Nutrition.
Increase of quantity of blood.
Diminution of quantity of blood
'Alterations of the ar-
 rangement of the ele-
 mentary particles.
Malformations.
— of their number.
—of their consistence.
I"
    Section III.
Lesions of Secretion.
     Section IV.
Lesions of the Blood.

     Section V.
Lesions of Innervation.
  . of their nature.

Alteration in the i
 quantity of the
 secretions.
 Increase.

 Diminution.

i Softening.
I Induration.
[ Transformation.
I Hypertrophy.

i Atrophy.
\ Ulceration.
Increased quantity.   < p1(]
Effusion.
                v Diminished quantity.
                ^ Development in an-j j„ substance-
J — in their situa* I  unusual situation.  '
 i  tion.          f Translation  to  an  fIn elements
 I               J  unusual situation. J
                ( The natural secretions  modified in
  _ in their quali- >   jtg comp0sition.
 L ties.          ^ A new secretion.

 r Alterations in the Physical proper- ~\ prjmit,ve-
 \  ties of the Blood.              \
 ") — of its Chemical properties.     V Consecutive.  •
 ( — of its Physiological properties.  )

 c Primitive.
 £ Consecutive. 
 300          WILLIAMS'S PRINCIPLES OF MEDICINE.

 duction of  structural lesions.   What we now have to notice, are
 those changes, which take place independently of distinct inflamma-
 tion, and which are mere modifications of that process of nutrition
 or reparation which is continually going on in the textures of the
 living body.*
   523. As  in inflammation* so probably in the ordinary process of
 nutrition, the material of which the organized solids are formed is
 the fibrin of the blood.   This, by the formation of nucleated cell-
 germs, and fibres, constitutes  the basis of textures, which are after-
 wards further modified  by growth and multiplication, and by the
 deposition of homogeneous or hyaline matter in their interstices.
 Some structures are chiefly formed of the nucleated  cells pressed
 together and  consolidated in  rows and layers, as in the epidermis
 and the epithelium of mucous membranes.  In other textures, the
 cells  elongate into fibres, as in cellular texture, and its modifica-
 tions, serous  membranes,  fibrous and tendinous structures.  In
 other textures, as cartilage  and bone, the chief material is an amor-
 phous solid deposit in an  organized fibrous or  cellular structure
 already formed. In  the first  formation and growth  of  textures,
 the production and multiplication of cell-germs from the plasma of
 the blood  is  necessary ;  and  it  is interesting to observe that in
 young animals, in pregnant females, and in the subjects of inflam-
 mation, the colourless corpuscles  in the blood (§ 212), which pro-
 bably are cell-germs, are much more numerous than usual (§418).
 But in the ordinary textural nutrition of adult animals there is less
 need  of the formation of new cell-germs ; those  already existing
 in the texture maintain the process by drawing nourishment from
 the blood-liquor, which furnishes the materials of all the solid tex-
 tures ; the formation of  new  cell-germs thus normally diminishes
 as age advances, and when then increased it  is usually the result
 of disease.  Nutrition  in all its stages is essentially a vital process :
 the formation of cytoblasts or  cell-germs, their growth into  cells,
 their  power of separation or secretion of certain matters from  the
 blood-liquor, their power of reproduction, all are properties peculiar
 to living matter, and are  to be regarded  as ultimate  facts or ele-
 ments in  physiology.   When their laws  shall  have been  more
 fully  studied, we may hope to trace to these  elements, varied in
 proportion and kind, corresponding elements in pathology, which
 will explain much that is at present obscure in the origin"and na-
 ture of structural diseases.  But we must now be content with a
 more  superficial notice of these lesions.
  524. As nutrition depends on the blood  for its  material, and on
 the supply of arterial  blood for the activity of the process, so it
 may be anticipated that changes of nutrition commonly arise'from

  * For the best summary of our present knowledge on the subject of nutrition,
 see Dr. Carpenter's " Human Physiology."  [Also  Miiller's Physiology, Bell's
 edit.,  section  on Nutrition and Growth, and chapter on the  Formation and De-
velopment of the Animal Tissues, and Regeneration of Tissues.] 
STRUCTURAL DISEASES.
301
differences in the quantity and quality of the  blood, and  from
variations in  its arterial character.(a)   Hence diseases of nutrition
are usually connected with diseases  of the  circulation  and of
the blood (§  279), a  moderately active circulation  and a  rich
blood favouring nutrition;  a  poor blood (§ 260) and either too
active  or too feeble a circulation, impeding it;  and a  diseased
quality or proportion  in  the elements of the  blood (§186,211)
rendering it depraved.   These causes operate on the whole frame ;
but they commonly affect some textures more readily than others,
because the process of nutrition is naturally more active, and there-
fore is more speedily influenced in some than in others.  Thus fat
and cellular textures are increased or diminished sooner than mus-
cle, muscle sooner than tendon or bone, &c.; and for similar rea-
sons degenerations and  other  changes  of structure affect  some
parts more  than  others  (§ 311).  But structural  diseases are
more commonly partial, from  causes existing in the part; and no
causes are more common  than  those which affect the circulation
of the part, so that  partial anoemia, congestion, determination of
blood, and inflammation, are the most frequent causes of partial
structural disease.  We have made a similar remark of  diseased
secretion (§ 159)  and other elements  of disease.  If the nervous
influence affects  nutrition, it is probably through its operation on
the circulation of the part.   Thus a paralyzed limb wastes  because,
not being exercised, it is not so freely supplied with blood.   The
muscles  of the limb of a frog, the nerves of which are divided, lose
their irritability and waste also ;  but Dr. John Reid has shown
that by  exercising these  muscles by electricity, which promotes
the circulation, both their irritability and nutrition are maintained.

   (a) " The proximate elements of the tissues exist in part ready
formed in the blood.   The albumen which enters into the compo-
sition of the brain and glands, and of many other structures  in a
more or  less  modified  state, is  contained in the  blood; the fibrin
of the muscles and muscular structures  is the coagulable matter
dissolved in the lymph and blood ; the fatty matter, which contains
no  azote, exists in the free state in  the chyle;  the azotised and
phosphuretted fatty matter of the brain  and nerves exists in the
blood combined with the fibrin, albumen andcruorin. The iron of
the hair, pigmentum nigrum, and crystalline lens, is also contained
in the blood  : the silica and manganese in the hair, and the fluor
calcium  of the bones and of the teeth have not hitherto been de-
tected in the  blood, probably from their existing in too small pro-
portion.   The matters here enumerated are in part attracted from
the blood in the state in which they afterwards exist in the organs ;
while  in other instances their  ultimate  elements  are newly  com-
bined, so as to form new proximate principles." — Midler's Phy-
siology, ut ante, p. 472.
           26 
302          WILLIAMS'S PRINCIPLES OF  MEDICINE.
                         SECTION II.

             INCREASED NUTRITION. --HYPERTROPHY.(a)

  525. Hypertrophy, as a disease, is always partial; for although
the whole body in cases of obesity acquires an enormous bulk, this
is from the extraordinary growth of the adipous tissue, a part only
of the frame.(6)  When the nutrition of textures generally has
reached the acme of full health, there is no more increase, and the
  (a) As it is very desirable that the student should be able to attach
definite meanings to the terms used to express morbid alterations
of texture, we introduce here an explanation of those  of hyper-
trophy and atrophy, in  the words of  Andral (Pathol. Anat.), at
the  risk of our being taxed by the more advanced  reader with
obtruding common places :
  " The number of the constituent molecules of any solid, may be
either increased or diminished.  An increase of the number seems
to indicate an exuberance of the nutritive powers of the part, as
is expressed by the term hypertrophy, used to designate this par-
ticular alteration.   On  the other hand, the  diminution  in  the
number of these molecules appears to  proceed from a deficiency of
the  nutritive powers; hence the term  atrophy has been adopted
to express the condition of  the solid, which receives less nourish-
ment than  natural, in which, when  the nutrition is totally sus-
pended, becomes at last  completely obliterated."
  " The term hypertrophy should be  applied exclusively to those
cases in which  the tissue whose volume is  increased retains its
natural structure  and organization; and not to  those  lesions in
which  the increase of volume is owing to other causes than  the
mere increase of number of the molecules of the tissue."
  This restriction of meaning to be attached to hypertrophy is over-
looked by the author in  the text, as in § 527, when he introduces
under  this head various  organic alterations of the epidermis other
than mere increase.
  (b) The remark, that  hypertrophy is  always partial, is  in  the
main correct, but it would be wrong to regard it as always a local
disease, and never an evidence and part of a general  one.   Hy-
pertrophy of the spleen,  for instance, is often part and effect of a
lesion  of the circulation and innervation conjoined, and  hyper-
trophy of the brain conjointly with that of the lymphatic glands,
and portions of the osseous  system ought to  be regarded as  not
merely local affections, or separate modifications of nutrition, but
as evidences  of scrofulous  disease of assimilation, secretion,  and
nutrition, in fine, general or constitutional disease.   Now and then
a case under the title of  general hypertrophy is met with, as in  that
recorded by Dr. Gross from a French journal (Elements of Patho-
logical Anatomy, vol. i., p. 112). 
STRUCTURAL DISEASES.                 3Q3
superfluous nutriment accumulates  in  the bloodvessels, causing
plethora (§ 276).   Hypertrophy  may affect individual  textures
or whole organs composed of many textures :  in the former case,
it  may be called simple hypertrophy (an ultimate element of struc-
tural disease);  and  in  the latter, complex hypertrophy (a proxi-
mate element).  Let us mention a few examples of each.
   526.  Muscles become enlarged by full exercise alternated with
sufficient repose, and a healthy condition  of the blood.  This in-
creased development in the voluntary muscles generally cannot be
called disease ;  but  I  have seen it occur in the sterno-cleido-mas-
toid muscle, long the seat of convulsive motion, and by giving too
 great power to  the  muscle, it seemed to perpetuate the distortion.
 The best cure for this would have been  Dieffenbach's operation of
 dividing the muscle, as in the case of squinting, in which certain
 muscles gain too much power and probably bulk.  But muscular
 hypertrophy is  chiefly morbid when it affects involuntary muscles.
 Thus, in the heart, it results from continued excitement in sthenic
 subjects;  and  from the violence with which the enlarged heart
 moves and propels  the blood, it produces various bad effects.  The
 muscular fibres of the bladder become hypertrophied in case of
 enlarged prostate, or other cause of difficult micturition : those of
 the stomach  are so from stricture of the pylorus;  those of the
 bronchi are in chronic bronchitis, and dyspnoea  is the result.
    527.  Hypertrophy of the interstitial cellular textures of the lungs,
 liver, &c, occurs after long-continued  congestion from disease of
 the heart, &c. (§ 311.)  In the cellular  texture of the lower extre-
 mities it  appears to be a chief constituent of elephantiasis.   Hy-
 pertrophy of the epidermis occurs  in  callosities of the skin, and
 corns  from continued irritation  or pressure, which  causes deter-
  mination of blood to the part.   Another form of hypertrophy of
  the cuticle is that  arising from chronic inflammation in  psoriasis,
  chronic eczema, and impetigo.  The cuticle is here retained, and
  from its stiffness it often cracks into  chaps or rhagades.  In the
  more temporary or more superficial cutaneous flushes, congestions
  or inflammations of erythema, scarlatina, lepra, and  pityriasis, the
  superfluous epidermis is thrown off in a peeling of the skin, or m
  detached scales.   But ichthyosis presents the most  extraordinary
  instance of hypertrophy of the epidermis, its scales accumulating
  in a solid state, so as to form scales, or coarse  bristle-like projec-
  tions.   These affections of  the epidermis have their parallels in
  diseases of mucous membranes; but the secretions of these mem-
  branes being fluid, the nucleated cells, which on  the skin would
  form  solid scales, here are thrown off in the mucus, which presents
   an increased number of epithelium scales as well as  the exudation
   corpuscles and a viscid amorphous fluid (§ 455).   Such disordered
   secretion of the  mucous membranes not untrequently  co-exists
   with  cutaneous diseases; thus, bronchial  congestion with viscid
   secretion occurs in persons affected with psoriasis and lepra
     528  Complex  or hypertrophy of organs of a healthy kind may 
304
WILLIAMS'S PRINCIPLES OF MEDICINE.
result from a more copious flow of blood to them, contingent on
their increased use.  Thus, the uterus becomes hypertrophied in
pregnancy ;  the breasts during lactation; one kidney becomes en-
larged when its fellow is incapacitated by disease.  The brain is
more developed in proportion to the active exercise of the mind ;
and when this is  carried  too  far, if inflammation, congestion, or
some other vascular disorder, do not occur, the brain may become
hypertrophied, and by its bulk being  too great for its bony case,
it compresses the  vessels, becomes  indurated, and, as  an obvious
consequence, its functions are more and more  impaired.   Thus,
in young subjects who  have  been remarkable for  precocity and
activity of intellect, the brain  has been over nourished, and fatuity
and coma have been the result.   Mucous and cutaneous follicles
sometimes acquire an extraordinary development after continued
excitement, or without any such obvious cause.   Bursa? become
enlarged in  situations exposed to much pressure or friction, as on
the shoulders of porters, the knees of housemaids, the  elbows of
miners, and  the ankles of tailors.
  The hypertrophy of the liver and  spleen  in protracted  ague,
may perhaps be referred to the frequent repetition and long con-
tinuance of the enormous congestions which this disease induces
in these organs.   I have known a similar enlargement, ensue after
prolonged exposure to cold and wet.   But in some cases no such
external cause can be traced; and the hypertrophy must be re-
ferred to a peculiar condition  of the  circulation  of  the affected
organs, or to an unusual activity in their nutrient molecules.  To
this obscure category may be  appended the case of enlargement of
the ihyroid gland in bronchocele.(«)
  529.  The treatment of hypertrophy must depend on the patho-
logical  cause which induces it.  In most cases, this cause is some
variety of hypersemia, and the treatment suitable for the  variety
is  to be employed (see  Congestion, Determination of Blood, and
Inflammation). But some remedies seem especially calculated to
counteract the hypertrophy which these  elements  induce ;  such
are iodine and its preparations, mercury,  alkalies, and, in the
more  sthenic cases  sedatives and evacuants, together with low
diet.  The same remedies are occasionally useful  also  in  hyper-
trophy less distinctly connected with hyperaemia, as  bronchocele.
In all cases it is proper to attempt, as much as possible, to remove
or counteract the  exciting causes of hypertrophy,  as by tranquil-
lizing the circulation in hypertrophy of the heart;  by soothing irri-
tations of the stomach, bladder, &c, in obstructive  diseases of these
viscera : removal  from  malarious districts in case of visceral en-
largements, &c.

  (a) Although we  cannot well  conceive of hypertrophy which
is  not preceded by hyperemia, yet we sometimes see this latter
replaced by anaemia, the excessive growth still continuing, but be-
coming exsanguineous. 
STRUCTURAL DISEASES.
305
                         SECTION III.

              DIMINISHED NUTRITION — ATROPHY.

   530.  Atrophy, unlike hypertrophy (§ 525), may be  a general
disease,(a) that is, all parts of the body may waste so  much as to
impair their functions.  General atrophy, marasmus, or emacia-
tion, consists in a removal of a considerable amount of the textures
by decay and absorption without a sufficient reparation by nutri-
tion (§ 523).   Hence the causes of atrophy may be divided into the
circumstances which promote decay, and those which prevent re-
paratory nutrition.   Among the former  may be counted excessive
and prolonged exertion, want of sleep, extreme anxiety of mind, or
continued suffering; under any of these, a person is familiarly said to
be " worn to  a shadow," without any more distinct disease taking
place.   But on examining the urine in such cases, it will often be
found to contain an excess of urea, resulting from the decay of tex-
tures.   This  secretion is also  sometimes alkaline, and unusually
prone to decomposition, and the intestinal and cutaneous excre-
tions sometimes exhibit an  uncommon  fetor, arising from  the
tendency to putrescence.  A fever of a low or hectic kind may be
excited as a secondary result of these  changes, and this fever is
mistaken for the cause of the wasting.  In cases of marasmus from
excessive secretions  or drains from the body, there is often also
proof of accelerated  decay : thus, diabetes mellitus reduces  the
body,  not  only  by perverting and draining  off its nourishment
(§  255), but also by promoting the  decay of textures which is
manifest in the increased amount of nrea excreted.
   The circumstances which impair or prevent reparatory nutrition
are several, and may occur in any or all the steps of the nutritive
process, from the reception of food into the system to its appropria-
tion and assimilation to the living textures.  As examples in this se-
ries maybe mentioned—1. Defective quantity or innutntious quality
of food • 2. Disorder of some part or  parts of the digestive appa-
ratus, such as extreme dyspepsia, diarrhoea, &c, which prevent the
formation of chyle;  3.  Diseased mesenteric glands or tumours ob-
structing the thoracic duct, intercepting the supply of chyle to the
blood ; 4.  Perversion of the  assimilating  process by  which chyle
is converted  into blood (§ 253), as in diabetes mellitus and chylo-
sus; 5. Defect in the  formation  of  fibrin (§ 196)  and albumen
(k 221) of the blood, the materials of nutrition, so that, instead ot
becoming the plastic material for repairing the texture, they have
a tendency either to  pass into decomposition, as  in malignant
    (b) See note, ante, to § 525.
26* 
306
WILLIAMS'S PRINCIPLES OF  MEDICINE.
fevers* (§ 257), or to concrete in a cacoplastic or aplastic form, as
in tuberculous diseases ;  6. Excessive  discharges of various  ani-
mal fluids, of blood, pus, serum, milk, semen, mucus, &c, or morbid
growths, which monopolize the nourishment of the body, such as
tumours of various kinds, particularly cancer ; 7. Parasitical crea-
tures, such as hydatids, worms, &c.
  531. A consideration of the above list of causes of emaciation
will show how uncertain it is as a symptom if it be taken alone;
but when traced to its cause, it is a very important index of the
amount to which that cause operates on  the  living body.  Ema-
ciation will rarely continue  or advance  to an extreme degree with-
out  structural  changes rendering the cause  permanent; hence,
extreme  marasmus  is  generally  connected  with  tuberculous
disease, carcinoma, (especially of the stomach,) or some serious or-
ganic disease.  The chief exception to this is diabetes, the intracta-
ble persistence  of which  is involved in much obscurity.
  532. Partial atrophy, the  reverse of partial hypertrophy, com-
monly arises from  defective supply of  blood  to the part.  Some-
times the defective supply is from the disuse of the part: thus the
eye wastes in confirmed  blindness;  muscles and whole limbs be-
come atrophied from disuse in paralysis and anchylosis; the testicle
and the mamma waste with age, &c.   Frequently partial atrophy
in an  organ succeeds  the  changes induced  by inflammation or
other structural disease ; the matter effused swells some parts, com-
presses others of the texture, and, by preventing a due supply of
blood, causes a subsequent atrophy.   This is especially the case
when the products of  inflammation or congestion are cacoplastic,
as in cirrhosis of the liver and granular disease of the  kidney, in
the consolidation of the lung caused by pleuropneumonia, &c.: the
deposits here produced tend to contract and compress the vascular
structure, and thus deprive  the organ of its nourishment; it accord-
ingly shrinks in size, or, in the case  of  the lungs, the texture may
become thin and  emphysematous.   In  chronic pneumonia  and
phthisis, also, many bloodvessels in  the lung  become  obliterated,
and the texture may either waste or further degenerate, according
to its condition.  Atrophy of the heart and brain have sometimes
been found connected with  ossification  and partial obstruction of
the arteries supplying them.  The dwindling  of limbs  in children,
and the lameness in old persons from shrinking  of the  neck of the
thigh-bone, appear to depend on similar impediments in the ves-
sels supplying the  parts.
  533. The treatment of general atrophy (§ 530), must be directed
to remove or obviate the cause where that is practicable, to supply
proper and adequate nourishment, and  to promote the healthy ac-
tion of the digestive, assimilatory, and circulatory functions.  The

  *  My friend, Dr. Hodgkin, considers a suspension of textural nutrition to be a
chief cause  of the phenomena of fever, and has  very ingeniously applied this
notion to explain many of the symptoms. — Lectures on Morbid Anatomy of Se-
rous and Mucous Membranes, vol. ii.,p. 490. 
STRUCTURAL DISEASES.
307
means of fulfilling these indications, where attainable, would re-
quire too lengthened a detail to be introduced here : it must suffice
to mention the chief remedies  and measures to be opposed to the
several pathological causes of atrophy.
   Atrophy, from excessive or  prolonged exertion, is  to be treated
by a sufficient amount of rest and nourishment; that  from anxiety
of mind,  suffering, or  sleeplessness, by various  medicinal nar-
cotics, and change of air and scene, as well as by measures calcu-
lated to  soothe  under  the particular circumstances.  The effect
which opiates and other narcotics sometimes  have in diminishing
the urea excreted in such cases, points out that these remedies tend
to control  decay, and they may sometimes  be aided by mineral
acids and various tonics.  The same remedies are useful in diabetes
mellitus,  the marasmus of which  is however to be still further
checked by withdrawing all articles of food that can be converted
into sugar — that is, all farinaceous, amylaceous, saccharine, and
gelatinous matters (§ 256).  I have generally found  the excessive
discharge and the emaciation of diabetes to be effectually controlled
by the full application of this rule, but never by its partial observ-
ance, as recommended  by Dr. Prout.
   The counteraction of the circumstances which impair or prevent
reparatory nutrition (§  530) comprise the treatment of the several
diseases and causes of disease before enumerated under the seven
head's, which it  is not necessary to recapitulate.   In most of these
the  use of food  as  nourishing as the stomach can  digest, and  of
tonics, medicinal and hygienic, as bracing as the body can bear,
with due attention to the  regularity of the excretions, afford the
best change of  resisting  or  retarding the emaciation ; and their
utility will much depend on the judgment  with which they are
applied.(a)                           „     , ,  .       ...
   534. As partial atrophy often arises from  defective circulation
in a part   it may sometimes be counteracted by measures calculated
to promote the  passage of blood  through that part    Thus mus-
cles wasted by  disuse are  sometimes increased and strengthened
by blisters, stimulant frictions, electricity, and exercise   Atrophy
 following  inflammation or congestion  may sometimes be advanta-
 geously opposed by the remedies  for the  results of these condi-
 tions, especially iodine in combination with  tonics  as iodide of
 po as'sium and iarza, iodide of iron, &c.  In  this and most other
 cases of  structural disease,  although treatment can  do little to

   (a) Prolonged general irritation kept up by latent lesion  of  an
 orian, as  "cliroiiie gastritis or enteritis, slow inflammation of the
 mesenteric gland, &?., will cause  atrophy  with-t  any not.Ue
 disorder of the  functions, except in  slight daily febn e exacsrba
 tion bardlv attended to by the individual himself.   In such a case
  h  Uel me^it    one of extreme difficulty.   The  hyperemia must
 be removed by evacuants, while at the same time nourishing food
 and mild  tonics are administered. 
308
WILLIAMS'S PRINCIPLES OF MEDICINE.
remove partial atrophy already induced, yet  it may sometimes
retard its increase by restoring a more healthy circulation through-
out the body.

                   PERVERTED NUTRITION.

  535.  Under  this head  are comprehended all those changes of
textural nutrition that go  beyond mere degrees of plus and minus
in the  natural molecules of the textures;  they either  alter  the
quality of the texture, or form new textures, growths, or deposits,
in connexion with the  normal  texture.    These changes  often
comprise partial hypertrophy and atrophy  as well; and in so far
as they do so, the observations already made with regard to those
elementary changes may be extended to these, but with new addi-
tions.
                        SECTION IV.

                 INDURATION  AND SOFTENING.

  536. We  have  mentioned both induration and  softening to
occur as  the  results of inflammation ; softening being commonly
connected with the increased secretion and absorption occurring
in acute  inflammation  (§  427) ;  and  induration being  rather
a sequel  of  the  more chronic  kind, which causes a continued
overflow  of  the  solid nutritive matter  (§ 479).   Both  these
changes sometimes take  place  independently of complete  inflam-
mation ;  but  they probably, in most cases, depend on some of its
elements.
  537. Induration is constituted by an increased deposit of solid
matter in  a structure, or by compression  of that structure, or by
both.(a)   In  some cases  of insanity, the inner table of the skull
acquires  the hardness of ivory.  In newly-born children, the skin
acquires an unusual hardness and rigidity, rendering them  "skin-
bound."   Glands and other  soft compound structures sometimes
become hard  without inflammation.  Probably, in all these cases,
there  is prolonged determination of blood to the parts,  which
causes an exaggeration of the nutritive function ;  but the matter
exuded is more hyaline (§ 523), or simply granular (§ 452, 3), than
consisting of  highly organized  cell-germs or fibres; hence the re-
sult  is not simple hypertrophy or increased growth, but a more
condensed and more uniform texture. A somewhat similar change
is produced  in  the lung  by compression, by liquid effusion, or a
solid tumour, especially when the lung itself is also inflamed, as

  (a) Induration may also be  caused by a  removal or deficient
secretion of some of the anatomical elements of an organ, as of the
cellular tissue of bones, or in an alteration  of  the fluids, as in in-
duration of the spleen. 
STRUCTURAL DISEASES.
309
in pleuro-pneumonia, in which the pressure  restrains the full de-
velopment of the exudation corpuscles.  The  induration of car-
tilage, &c. by osseous deposit is more properly transformation than
simple induration.  So induration of the liver, kidneys, and other
organs, generally comprise granular deposits, and other changes of
structure.
   538. Softening arises from different causes in different  textures.
In some instances the cause, being  peculiar to the structure, may
be  called specific.  Thus in the bones it proceeds from defective
deposition of  phosphate of lime, the earthy matter  which gives
solidity to these structures.  The softening of the  stomach found
after death is caused by the solvent action of the gastric juice, (a)
The softening  of various textures, especially muscles, in fevers
and other cachectic states, is connected with a defect of  fibrin in
the blood (§ 196): the same cause which removes this fibrin, and
prevents its formation (§ 216), apparently dissolving  or loosening
the fibrinous parts of solid textures.  In other instances, softening
is a variety of  atrophy, arising from a defective supply of blood;
so that the texture of a part decays, and is absorbed away faster
than it is repaired.  Thus softening of the brain and heart is some-
times found connected with ossification and partial obstruction of
the arteries supplying these parts.  Softening of the affected mus-
cles sometimes accompanies  paralysis, especially that from lead.
In a few instances, partial softening, like  atrophy, follows inflam-
mation, and is  to be ascribed to the obstruction of vessels which
that affection  has produced.   Thus softening of  portions of  the
brain occasionally follows meningitis ;  softening of the heart  suc-
ceeds to pericarditis ; softening of the stomach and intestines occurs
after some kinds of gastro-enteritis ;  softening of the  articular car-
tilages sometimes succeeds to  their inflammation.
   In all cases of partial softening, although the chief cause is local,
yet a non-fibrinous or  aplastic condition of the blood materially
assists in  promoting this result;  and  it is a  serious  question
whether the continuance of antiphlogistic measures and abstinence
does not  occasionally promote this consequence of the changes of
inflammation.   Some of the most distinct cases of softening of the
heart and brain that I have met with, have been those in which
the patients have been long kept in a reduced state for fear of re-
turn of inflammation of the heart and head.
   539. Induration and softening being opposites of each other,
although  sometimes preceded by similar  causes, require in some
decree parallel modes of treatment, but in an opposite way.   In-
  (a) Softening of the mucous membrane of the digestive canal, in
some part or another, is of common  occurrence, coming on both
primarily and associated with some fevers.  It merits a more dis-
tinct notice than can be given to it here.  Softening of the mucous
membrane of the stomach in infants, for example, is  a question of
no small moment in pathology and therapeutics. 
310          WILLIAMS'S PRINCIPLES OF MEDICINE.

duration, consisting of condensed hypertrophy, and often arising
from  prolonged  determination, may be counteracted  by partial
antiphlogistic measures, especially those tending to remove ob-
structions and deposits  (§ 511, 515).   Thus mercury and iodine,
externally and internally used, and alkaline saline medicines, are
supposed to have some power in discussing hard swellings ; and
setons, issues, or suppurating  counter-irritants, which draw away
blood and nutriment from  the  indurated  part, may be found in
some  cases  useful.   But extreme antiphlogistic or reducing mea-
sures  are  not indicated  (§ 218),  inasmuch as induration itself im-
plies a degraded kind of the nutritive material (§537), and does not
result from acute or sthenic inflammation.(a)
   540. Incases  of softening that are not specific (§ 538), the indi-
cations of treatment are, to restore a more fibrinous or plastic state
of the blood generally, and to improve the circulation in the atro-
phied part.   In  fevers and cachectic states, where the softening is
general, the first is  the chief indication, and some of the means of
fulfilling it have  been already noticed (§ 216).  Besides nourishing
food,  and agents which improve the  digestion and  circulation,
tonics and stimulants are often useful.   How far the operation of
mineral acids, bark, and other tonics, depends on their astringent
or bracing influence on the  animal fibre, we cannot undertake to
determine ;  but after fevers and in cachectic states, they do appear
to improve  the  substance  and  firmness of the solids in a way
more direct  than by merely exciting the circulation and amelio-
rating the condition of the digestive organs.  So, too, the opera-
tion of stimulants,  both local and general, probably goes beyond
that  of accelerating the circulation, and  determining blood to
parts where it   is ill supplied: it probably  also increases the pro-
duction of fibrin and cell-germs  from  the  albumen of the blood,
just as we see this to result from the* application of stimulants be-
fore they cause  inflammation (§  294, 415).   The relief sometimes
afforded  to  the  symptoms of softening  of the brain and heart,
after all inflammation has ceased, by mild stimulants, tonics, and a
moderately  nourishing diet, is too little known to those who have
always the dread of inflammation before, their eyes, and who yet
forget that a chief evil of inflammation  is the injury it inflicts on
function and structure, which injury often lasts when the inflam-
mation is gone or is of trivial  amount. The  beneficial effect of
nourishing diet and stimulant applications to soft, flabby ulcers, is
another illustration in favour of  this kind of treatment in cases of
internal  disease, where the general weakness, apyrexia, pallidity,
and muscular emaciation, much preponderate over the symptoms
of local irritation.
  (a) As often resulting from prolonged irritation and hyperaemia,
induration will sometimes, in its first stage at least, require an eva-
cuant treatment, part of which will consist  in topical bleeding.
This last often singularly favours the operation of other remedies,
discutients, as they are sometimes called, viz., mercury, iodine, &c. 
STRUCTURAL DISEASES.
311
  541. The treatment of the specific example of softening found
in the bones  is not well understood.  The circumstances  which
promote or impede the deposition of phosphate of lime in the bones
are not clearly known ;  but measures of a tonic  kind, with  appro-
priate nourishing diet, have been found distinctly useful in  rickets
in children.   The mollities ossium of adults is a  still more obscure
and intractable affection.  The formation of callus at the ends of
fractured bone, and the  completion of the ossific process in it, are
promoted by generous diet and tonics.
          SECTION V.

TRANSFORMATION OF TEXTURES.
  542. When one elementary texture, as muscle, is replaced by
another, as fibro-cellular, it is said to  be transformed.   The term
degeneration is also generally applicable to this change; for the
new texture substituted for the old  is most commonly lower in
vital  properties.  The chief exceptions are in  the  case  of  skin
being transformed into mucous membrane, when by anchylosis of
a joint, an  external surface is brought, almost to the condition of
an  internal; and the converse  case of transformation of  mucous
membrane into skin, as in long prolapsed uterus.  In these instances,
the changes appear to arise from the  physical condition in which
the membrane  is placed: the exudation corpuscles remaining soft
and moist, and becoming epithelium scales and mucous globules
in one case, and drying into epidermis in the other.
   543. Muscle is sometimes transformed into fibrous or fibro-cel-
lular texture, in some cases after inflammation of contiguous parts.
This has been noticed in the  heart after pericarditis  and endocar-
ditis, in the intercostal muscles after chronic pleurisy, and  in some
of the muscles of the limbs after prolonged  rheumatism.  Loss of
substance in muscles from wounds or ulcers is generally replaced
by a similar fibro-cellular texture, and never by new muscle.
   Muscle has rarely been found degenerated into a fatty matter,
the proper muscular fibre being replaced by  a greasy homogeneous
structure.  This  has been observed  under circumstances similar
to those  attending fibrous degeneration.  Something of the same
kind takes place sometimes in the muscles of persons long affected
with sea-scurvy.  Natural fat sometimes  infringes on  muscles,
particularly the heart; but that is by the hypertrophy of the iat-
cells pressing on  and causing atrophy of the muscular fibres, and
not by transformation.  The same abnormal growth of fat is not
uncommonly met with in the  pelvis and  cahces of the  kidneys.
The fibrous transformation of muscle seems to be simply the result
of  a degradation of the nutritive process, fibrous  texture  being
obviously less endowed  with vitality than  muscle.  According to 
312
WILLIAMS'S PRINCIPLES OF MEDICINE.
Mr. Gulliver, the opaque patches  in arteries called atheromatous
consist of a fatty deposit.  The fatty degeneration of textures is
involved in  more obscurity; but it may receive  some illustration
from  the spontaneous conversion  into  adipocire which this an
other animal substances undergo in the course of time, when kept
moist, yet prevented from rapid decomposition.   The considerable
proportion of oil globules found in some exudation corpuscles by
Gulliver, Gruby, and  others, would also seem to point out  that
fatty matter may result from a modification of the nutritive secre-
tion.  Nay, according to the examination of Dr. Davy, exudation
corpuscles (in the lungs at least) chiefly  consist of margarine and
olein.*  But this does not accord  with  the account of fibrinous
exudations  generally  given by  chemists.   The whole  subject
requires a fuller examination.
  Fatty degeneration of the  liver admits of easier interpretation ;
for, according to Mr. Bowman, the natural secernent structure of
this  gland  contains a  considerable proportion  of fatty particles;
and  the  excessive  increase  of these, with  atrophy of the other
structures, may  constitute the fatty transformation.t   It  has been
surmised that this fat  is that of the bile in the process of its  forma-
tion  in the secreting cells;  and that its increase in phthisis is due
to the additional task thrown on the  liver  to excrete  the  hydro-
carbon, which the lungs cannot  remove.  If this were true, fatty
degeneration of  the liver should occur more constantly in phthisis,
and  in other diseases of the lungs, than it does.   It is  met with
chiefly in females, in whom emaciation has proceeded with rapidity;
and I should rather ascribe it to the arrest of the fatty matter from
the blood, which is taken up from the textures in their rapid decay,
and of which  the  liver appears to be the appropriate excreting
organ.  It is also possible that the fatty matter which is formed in
tubercle during its process of softening may be conveyed into the
circulation, and contribute to  the greasy degeneration of the liver.
  544. The most common transformation is that of cartilage into
bone.  This commonly takes place as a result of age, and may be
said  to be rather a petrifaction than an ossification ; for the proper
structure of bone is wanting.  The deposition of osseous  matter,
however, seems  to follow the same rule as in true bone,  in which
it increases with age.   So, too, morbid ossifications result from in-
flammation or continued determination  of blood, as instanced in
the ossification of the  cartilages of  the air-tubes in chronic laryn-
gitis and bronchitis, of the cartilages of the  ribs  in  chronic pleu-
risy,  and of the  inter-vertebral cartilages after injuries  of the
spine.  Thus inflammation, or rather the determination of blood
which accompanies it, hastens the  process of ossification to which
cartilages tend in the  lapse of years.

  + Mr. Gulliver's Notes to Dr. Boyd's " Vital Statistics," p. 53.
  | In the most authentic accounts of cases  of spontaneous combustion of the
human body, there are some particulars which  seem to imply that there must
have been a fatty transmutation of textures. 
STRUCTURAL DISEASES.
313
  A similar tendency to ossification (or rather petrifaction, for there
is still less of the true  bony structure than in the  last case) is ob-
served in cartilage, fibro-cartilage, and fibro-cellular texture, acci-
dentally produced by inflammation (§ 452), transformation (§ 542),
or morbid growths.   Thus, osseous  concretions or laminae are
formed on serous or fibrous membranes, in cellular texture, and in
the accidental cartilages found in joints.  This appears also to be
the mode in which ossification of arteries and the valves and mem-
branes of the heart takes  place : an  opaque fibro-cellular deposit
first occurs, and phosphate of lime afterwards concretes in plates
or granules in it.  The plastery and  calcareous transformation of
tubercle  is obviously allied to the  same  process, and by proving
that it takes place in aplastic and comparatively dead matter, seems
to prove  that osseous deposit  is a chemical rather  than a vital
change.   The similar changes sometimes exhibited  in  the carti-
laginous bodies loose in veins (phebolites) and in the cavities of
joints, equally show that the transformation is spontaneous.(a)
   545. Our  knowledge of  the  nature and symptoms of  trans-
formations is not sufficiently definite  to suggest any observations
with  regard  to their  treatment.   The general fact  that they are
examples of degeneration or degradation  of vital properties, would
indicate the propriety of employing  measures for supporting the
vital powers  generally; but inasmuch as local inflammation or
determination of blood sometimes seems to hasten these changes
by supplying the material, topical measures against these elements
may sometimes be useful.
          SECTION VI.

DEPOSITS IN OR  UPON TEXTURES.
  546.  I apply  the term deposits to matters which  result from
an  overflow of the  nutritive material  beyond  what  is  neces-
sary to  nourish  the textures themselves.   The structural lesions
hitherto considered are  alterations  of the  textures themselves;
deposits are new matters  added to the textures.   The basis of all
deposits is the fibrinous matter of the blood ; and in the products
of inflammation (§ 450-3) we have described its  varieties in rela-
tion to its plasticity or capability of organization.  The same divi-
sion is  applicable  to  deposits, which take place  independent^ of
inflammation, as results of an overflow of  the material  of the re-
paratory nutrition, and  thus we  have euplastic, cacoplastic, and
aplastic-deposits from perverted  nutrition.   The history already
given of these as they result from inflammation will supersede the

  (a) The reader may consult with  advantage  the  chapter (xiv.)
on Transformation, in Dr. Gross's Pathological Anatomy.
           27 
314
WILLIAMS'S PRINCIPLES  OF MEDICINE.
necessity of much  detail now, and it will suffice to  advert to the
circumstances in which they arise independently of inflammation.

                Euplastic Deposits — Cicatrices.

  547.  When a living part is cut or wounded, the breach may be
repaired by three modes:—1. By the growth of the adjoining
parts, or walls, of the  wound ;  2, by the medium of coagulable
lymph, which becomes organized and forms a cicatrix, or bond  of
union; and  3, by granulations and lymph together.   The latter
mode  being necessarily attended with  inflammation, is excluded
from notice here ; but the other two, as Dr. Macartney has shown,
may occur independently of obvious  inflammation, and are more
perfect  without  it.   To these, however, a certain amount of de-
termination of blood, which supplies the plastic material, is neces-
sary ; and premising  this addition, I  will quote the  clear descrip-
tion which Dr. Carpenter [following Macartney] has  given  of
these reparative processes (Principles of Human Physiology, 184 3,
p. 440, et seq.).
  " The surgeon has, until recently, regarded the processes of gra-
nulation  and suppuration, which  are  attended with  much local
inflammation and with a considerable amount of constitutional
disturbance when the  surface is large, as the only means by which
an  open wound can be filled up.   Occasional instances, however,
have not, been wanting in which large  open wounds have closed
up  under the dry clot of blood by which they were at first covered
over, without any suppuration or other symptom of inflammation ;
and in these  it  has  been found that the new surface much more
nearly resembles the ordinary one than does the cicatrix which
follows granulation.   To  Dr. Macartney,  however,  is  due the
merit of explainiflg the rationale of this action, which is precisely
analogous to that  which is concerned in the  ordinary processes
of  growth, and to  that reproduction of whole parts which takes
place in the  lower animals without  inflammation.*   It  is termed
by  him the modelling  process ;  and  lie remarks, as  characteristic
of it, that when it goes on perfectly and without inflammation, the
patients are so completely free from uneasy sensations  as only  to
be  aware of the extent  of  the  injury by their own examination.
In  this process the  surfaces of the wound do not unite by vascular
connexion even when  they lie in contact, nor is the space  between
  * The following observation illustrates this point: — "I made a small pin-hole
in a frog's web ; the capillaries that were divided yielded no blood, and became
obstructed ; but the circulation continued, although sluggishly, in those adjoining,
which were distant from the puncture the length of six or eight blood-disks.
The next day, these vessels were  no nearer;  but the circulation in them was
more active, and the hole was partly filled up ; and on the third day, it was com-
pletely so, yet no moving blood could be seen nearer to it.  On the fifth d.iy,  the
distribution of visible vessels was not altered, but the matter with which the hole
was filled had contracted and become opaque, so that the adjoining vessels were
drawn nearer together, and the opacity prevented my seeing whether any passed
through the cicatrix." — Gulstonian Lectures, Med. Gaz., July 30,1841, p. 721. 
STRUCTURAL DISEASES.
315
them filled up with coagulable lymph; but they are smooth and
red, moistened with a fluid, and presenting the appearance of one
of the natural mucous membranes.   " It might be anticipated that
as this mode of  reparation bears so strong a resemblance to the
natural formation and development of parts, it is the slowest mode ;
but this is of little  account when compared with its great advan-
tages in  being  unattended with pain, inflammation, and constitu-
tional sympathy,  and leaving behind  it the best  description of
cicatrix."  In the case of large burns on the trunk of children, the
difference between the two modes of reparation  will frequently be
that of life  and death, for it often happens that the patient sinks
under the great  constitutional disturbance  occasioned  by a  large
suppurating  surface, although  he  has survived the immediate
shock of the  injury.
   548.  "The most effectual means  of  promoting this kind of re-
parative process, and of preventing the interference of inflamma-
tion, vary according to the nature  of  the  injury.   The exclusion
of air from the surface, and the regulation of the temperature, ap-
pear the two points of chief importance.   By Dr. Macartney, the
constant application of moisture is also insisted on.*   He states that
the immediate effects of injuries, especially of such as act severely
on the sentient  extremities of the  nerves, are  best abated by the
action of ' steam at  a high but comfortable temperature, the in-
fluence of which is gently stimulant, and at the same  time ox
tremely soothing.*  After the pain and sense of injury have passed
 away,"the steam, at a lower temperature, may be continued;' and, ac-
 cording to Dr. M., no local application can compete with this, when
 the inflammation is of an active character.  For subsequently re-
 straining this, however, so as to promote the simple reparative  pro-
 cess, water-dressing will, he considers, answer sufficiently well, its
 principal object being the constant production of a moderate degree
 of cold, which diminishes, whilst it does not extinguish, sensibility
 and vascular irritation, and allows the reparative process to be car-
 ried on as in the inferior tribes of animals.   The reduction of the
 heat in an extreme  degree, as by the application  of ice or  iced
 water  is not here called for, and  would  be positively injurious;
 since it not only renders the existence of inflammation m the part
 impossible  but" being a direct sedative to all vital actions, suspends
 also the process of reparation.  The efficacy of water-dressing in
 iniuries of the severest character, and  in those which are likely to
 be attended  with violent inflammation, (especially  wounds  of the
 lar-e joints,) has now been established beyond all question  and
 its employment  is continually becoming more  general.  Other
 plans have been proposed, however, which seem in particular cases
 to be equally effectual.   To Dr. Greenhow, of Newcastle, for in-

    * Treatise on Inflammation, p.  100-3, Amer. edit.
    | Promoting determination of blood without inflammation. -C. .1. B. \,. 
316
WILLIAMS'S  PRINCIPLES OF MEDICINE.
stance, it was accidentally suggested, a few years  since,* to cover
the surface of recent burns with liquefied resinous ointment  (con-
solidating as it cools);  and he states that in this manner suppura-
tion may be prevented, even where large sloughs are formed, the
hollow being gradually filled up with new tissue, which is so like
that which has been destroyed, that no change in the surface mani-
fests itself, and none of that contraction which ordinarily occurs,
even  under the best management, subsequently takes place.   A
plan has moreover been proposed for preventing suppuration and
promoting reparation by the modelling process, which consists  in
the application of warm dry air to the wounded surface.   The ex-
periments made on this have not been entirely satisfactory; but they
seem  to show that, although the process of healing is much slower
under treatment of this kind, it is attended with much less constitu-
tional disturbance than is unavoidable under the ordinary method."
[Macartney, ut supra,  p. 116.]
   549. The other mode of reparation is that long denominated by
surgeons union by  the first intention,  in which  the  sides of a
wound  heal by the organization  of coagulable lymph, or  more
rarely of a clot of blood, which, when complete, forms a cicatrix.
" This mode of union is ordinarily considered by British surgeons
to be  the result of an adhesive inflammation.  In so regarding it,
they conceive that they are following out the views of Hunter;
but he expressly states that wounds may heal without any pain or
constitutional disturbance, the re-union proceeding ' as  if nothing
had happened;' so that he in effect admits that reparation of this
kind  may take place without inflammation.  It is well known that
if a slight wound which is thus healing be provoked to an increased
degree of inflammation, its  progress is  interrupted, and all the
means which the surgeon employs to promote  union are such as
tend to prevent the  accession of this state.   The doctrine that the
effusion of lymph for the reparation of the tissues is not to be re-
garded as necessarily a  result of the inflammatory process is not so
novel as  its opponents have regarded it, since it has been main-
tained by many eminent observers, even  from the earliest times.
It is supported by the fact that coagulable lymph may be thrown
out by a natural and healthy action, as  in the formation of the
decidua uteri, and  that the surface of a wound is covered with
lymph too soon after the receipt of  an injury for inflammation to
have  set in.t  The only case in which the occurrence of inflamma-

  * Med. Gaz., Oct. 13, 1838.
  f Although I admit that inflammation in  its pronounced form is not essential
to this reparatory process, yet I  cannot allow that this  statement is altogether
correct. If inflammation is essentially what we have defined it (§410), an increase
of blood in a part, with the motion of that blood partly increased and partly dimin-
ished, it may commence  a few minutes after a wound has been made.  When a
frog's  web is cut or pricked, the vessels adjoining the wound are  immediately
obstructed by coagulated blood ; but in a few seconds, those adjoining them be-
come enlarged, and receive an increased current, and it is this determination of 
STRUCTURAL DISEASES.
317
tion can be regarded as salutary, is that in  which there is a defi-
ciency of fibrin in the blood causing a deficient organizabllity of
the lymph" (or rather a deficiency of lymph itself).  " It has been
seen (§ 438)  that  the amount of fibrin is rapidly increased  by in-
flammation ; and the surgeon well knows that a wound with  pale
flabby edges,  in a depressed state of the system, will not heal un-
til some  degree of inflammation has commenced.
   550. " When the liquor sanguinis, known as  coagulable lymph,
is effused between the two edges  of a wound, or upon the surface
of a membrane lining a  closed sac, the following appears to be
the history of its organization.  The new matter which is poured
out in a  fluid  state undergoes a coagulation resembling that of the
blood ; the serum, being set free  by the concretion of the fibrin, is
absorbed ; and the fibrinous coagulum speedily attains an almost
membranous  density.   If examined with a microscope at the com-
mencement of the process of organization, it is seen to contain a
large number of the exudation corpuscles (§ 424) ; these originat-
ing, probably, either  in  the lymph globules that have circulated
in the blood, or in the nuclei of the red corpuscles.  In a short
time these corpuscles present the appearance of regular  cells dis-
posed in layers, and adhering together by an  intermediate unor-
ganized  substance, bearing,  in fact, a strong resemblance to  the
cells  of  tesselated epithelium.  Some hours later,* the mass ex-
hibits an  evidently fibrous  character ;  and this is due  (?) to the
adhesion of the cells to each other  in  lines, their form being pro-
longed in the  same direction.  Between these cellular fibres a con-
siderable amount  of the cytoblastema or hyaline substance (§ 523)
yet  remains,  and  they may be readily separated  or torn in any
direction.  A vascular rete next makes its appearance, and forms
connexions with the vessels of the subjacent surface ; the first ap-
pearance of this network  is in  the form of transparent arborescent
streaks, which push out  extensions on all sides;  these encounter
one  another, and form a complete series of capillary reticulations,
the  distribution of which very nearly resembles that  which has
been seen  in  the  villi of  the intestines.  Before the vascular rete
appears, pale-coloured cytoblasts  are produced, which, after the
completion of the rete, pass over  into the nearest capillary veins,
being pushed   on  by the blood which is brought from the nearest
arteries (§ 451); and in this manner the circulation is established.
This process  appears  to  be conformable  in all essential particu-
lars  with that  which has  been  observed in the development of the
toes of the larva  of the waternewt and similar growths.   The
character, whether arterial or venous, which each  tube is to as-

blood  towards vessels which  are obstructed which causes an increased trans-
udation of the plasma of  the  blood (§ 419).  If this do  not amount to inflam-
mation, it  differs from it only in degree.            .
  * In this description, Dr. Carpenter seems to-have chiefly followed tne account
of Gerber; but  Messrs. Addison and Gulliver have  shown that the formation
of fibres takes place at first, and constitutes the chief part of the coagulation of
the fibrin.
           27* 
318          WILLIAMS'S PRINCIPLES OF MEDICINE.
sume, depends upon its proximity with some vessel of the  subja-
cent membrane, with which  it becomes continuous;  but its first
formation is not due, as some have supposed, to the  simple pro-
longation of these vessels into the fibrinous mass, since the latter
is able of itself to originate a capillary plexus."
  551.  Under some circumstances the fibrin of  coagulable  blood
has been found  to become vascular, and more  or less organized.
Thus, clots of blood in the bloodvessels have been injected, and
those  effused  in the brain in  apoplexy have been found pervaded
with vessels (Cruveilhier) ;  but  the  colouring matter does not ap-
pear to assist in the  process:  in fact, blood  coagulated   in  or
upon  a  wound  generally comes off in  a  scab as soon  as the
wound  is healed.  In  other  instances, the  presence of colouring
matter seems to retard or degrade  rather than  assist the  plastic
process (§ 454).
  552. The remedial measures by which the euplastic process is
promoted in cases  of injury are treated of in surgical  works.
Their object  is to  promote such an amount of determination of
blood (whether this be called inflammation  or not), and  such a
plastic condition of the blood, as shall contribute to the effusion
of a sufficient amount of healthy organizable lymph.  Where  in-
flammation rises too  high,  it  causes too  much  effusion  of the
plasma, which degenerates into  aplastic pus globules, and it de-
stroys the  adjoining textures :  here it must be  repressed by anti-
phlogistic measures.   If the inflammation is too low (§ 477), or
the determination of blood is wanting, then  the  plasma will  be
defective in  quantity or organizability, and the wound will not
heal, or  will  heal imperfectly.   Here  stimulant applications may
be  useful.    Where  the  blood is too abundant in fibrin, the
plasma thrown out will be  too copious to admit of organization,
and will consequently become  purulent, and  therefore aplastic.
Here, bloodletting or  evacuants, and low diet for a time, may be
 serviceable.  Where  the  blood  is deficient in  fibrin, the wound
 will be flabby and the discharge ichorous  or sanious, from want
 of  the proper plasma: here, nourishing diet, tonics, and  even
 stimulants, general  and local, may be  useful.   Where the wound
 exhibits congestion  more  than  determination  of blood, and  the
 plasma  is  organized  into  loose spongy or fungous  masses pro-
jecting from the wound, astringent  and stimulant applications  are
 beneficial.


                Cacoplastic and Aplastic Deposits.

   553. Under various circumstances which have been alluded to
 in  the preceding remarks, wounds or ulcers may be  impaired by
 lymph which is cacoplastic ox defective in organizability;  and the
 cicatrix resulting from  such  imperfect reparation is  lower in  the
 scale of vitality than  the  texture in which it is produced.   Thus,
 in the  skin, a tough, hard, fibro-cellular structure, constitutes  the 
STRUCTURAL DISEASES.
319
cicatrix;  the seams formed on the healing of  scrofulous sores
sometimes exhibit this character; the blood  not supplying a good
plastic material.   Or sometimes the cause of the degraded organiza-
tion seems to be in the nature of the wound, or in modification of
the vessels of the part, or of their exudation, as in the scars which
result from  burns and  scalds, and from some poisoned  wounds.
In these cases, the cicatrix is dense and thick, and tends further to
contraction,  which causes a puckering  of the parts, and sometimes
great distortion of the integuments.  Similar deposits  have been
noticed to result from chronic and scrofulous inflammation  of in-
ternal parts (§479, 485), and from congestion (§ 311), and to consti-
tute  the material of dense fibro-cellular and fibro-cartilaginous for-
 mations on and under serous and in cellular membranes ;  the indu-
 rated  interstitial structure  which  characterizes cirrhosis,*  and
 granular  degeneration  of  the liver and  kidneys, and  old  cica-
 trices and consolidations  very commonly  met with in the lungs.
 The opaque, tough thickening of the valves  of the  heart, often
 attended  with  corrugation,  contraction,  and   rupture,  and  the
 similar change  in the  coats of arteries, appear to belong to the
 same class of deposits.
   554. The structure of these deposits deserves  to be more fully
 investigated.   They  appear to possess some  organization, being
 composed of irregular  cells and fibres, with more or less granular
 or  amorphous solid matter  to  complete  their substance (§  424).
 They, however, exhibit various  degrees  of organization,  some
 being vascular, and some  not;  but they  are all inferior to the
 structure with  which  they are connected, and to  the euplastic
 deposits  above described.   Although rarely  occurring  in  great
 abundance  in  an  organ or structure, except from some hyper-
 emia of that part, yet, in  a small  extent, cacoplastic  deposits are
 to  be met with in most subjects at all advanced in life,  and  more
  particularly those who have long  suffered from ill health.   The
  opaque  thickening  of the membranes investing the  liver, spleen,
  lungs, heart, and brain, often arborescent  from  its accompanying
  the°course  of the bloodvessels —the coarser and  less regular granu-
  lar  appearance exhibited in parts of the liver  and kidneys, espe-
  cially at their  most depending portions, the  granules commonly
  adhering to the capsule of the viscus  when it is  torn off— the par-
  tial consolidations of the lungs, particularly near their apex — the
  opaque patches in the lining membrane of the heart and arteries, —
  are all specimens of the result of cacoplastic deposits which age or
  disease  has produced ; and the more the nutrient  function  has
   been degraded in  the individual, the more abundant will  be the
     * The term cirrhosis (from  an obsolete Greek  word, *w»c, yellow,) was first
   applied by Laennec to the granular degeneration of the liver, because the deposit
  is commonly yellow from being stained with bile.   The  term is  obviously inap-
   plicable to contractile deposits in the lungs and other parts ; to which, neverthe-
   less, the name has been applied.  The epithets, granular or contractile deposit
   are respectively more suitable to the forms in which this cacoplastic  product
   manifests itself. 
320
WILLIAMS'S  PRINCIPLES OF MEDICINE.
 specimens of this cacoplastic deposit.  But  generally this  deposit
 takes place  more  abundantly in one particular organ, in conse-
 quence of disease predisposing it to suffer (§  31,2).  Thus, if a
 person, from habits of intemperance or other  cause, has  injured
 the function  or  structure of the  liver or  kidneys, in the  lapse of
 time, as the nutritive function  begins to fail from  age or debility,
 the injured organ is the first  to suffer, and becomes  the subject of
 cirrhosis or granular  degeneration ; and this may destroy life  by
 arresting excretion, &c. (§ 170, 311) before other organs are much
 affected.
   555. But  there  is another  more  general  form of cacoplastic
 deposit,  which  takes place, when textural nutrition is  degraded
 still further than in the preceding examples;  this is in semi-trans-
parent, miliary, grey, and tough yellow forms of tubercle.  In-
 stead of  (with Laennec)  classing tubercle under the vague term of
 " accidental  productions," or (with Carswell) as a "secretion sui
 generis," I have for many years referred  tubercle to a  degraded
 condition of the nutritive material from  which old textures are
 renewed, and newones formed ; and have held, that it differs from
 fibrin or coagulable lymph, not in kind, but in  degree, of vitality
 and capacity of organization.*    These views have received almost
 demonstrative confirmation in  the microscopic  researches  of Mr.
 Gulliver  and others, which have detected in tubercle the materials
 of lymph, but in a  degenerated and confused state, the cells being
 few, irregular, shrivelled, with imperfect nuclei, and incapable  of
 further development ;  no fibres  being perceptible, and the main
 substance  being composed of granular  or  amorphous  matter.t

  *  A somewhat similar opinion, but less definitely expressed, has been enter-
 tained by Dr. Alison, and formerly by M. Andral ;  but these pathologists seem
 originally to have regarded tubercle chiefly as the product of a modified inflam-
 mation.
  f  " Corpuscles more or less globular or oval are seen in tubercles ; but the
granular matter preponderates as the  tubercular  mass increases.  Cells may be
recognized  in the miliary tubercles ; but as they increase in size, the well-marked
and complete cells disappear.  Tubercles appear to differ essentially from th«
plastic exudations, inasmuch as the cells of the latter not only grow into a higher
organization, but increase in number towards the centre ; in other words, plastic
 matter has an inherent  power of multiplying and evolving organic germs.  But
tubercle has no such power; for it would appear that its primitive cells can only
retrograde and degenerate." {Gulliver's Appendix to Gerber's  General Anatomy,
p. 87.) — " If a tubercle, or even the tissue of the lung near it, be slightly com-
pressed between two slips of glass with a drop of water, it will crumble down
and break to pieces, the fluid being at the same time quite white or milky. This
white appearance is attributable to a great number of minute objects, the assem-
blage of which  constitutes the substance of the  tubercle.   They consist for the
most part of molecules, granules, and  granulated corpuscles, of various sizes, of
aggregated  granules without  any tunic, and of collapsed tunics without any
granules.   These objects  are mingled  with a great many shapeless flakes and
filaments, which are no doubt fragments of the membrane of the air-cells, and of
the  minute bloodvessels, which, when involved in a tubercle, become so extremely
brittle, that they must necessarily form a considerable proportion of the objects
occupying the field of the microscope.  The granulated corpuscles of a tubercle
are sometimes very large, ( -L, or—~ of an inch); and the molecules and granules. 
STRUCTURAL  DISEASES.                 321
Every gradation  may be found  between euplastic and  aplastic
deposits; the cells and fibres which are the  representatives of or-
ganization diminishing in number and completeness, and the  ma-
terial becoming m'ore granular or amorphous, in proportion as the
deposit is degraded, until, in opaque, crude, or yellow tubercle,  it
is altogether aplastic, consisting of a mere aggregation of granules,
with mere traces of the remains of cells.
   I consider that the more solid forms of  tubercle are entitled to
a place among cacoplastic  deposits; because, although destitute
of vascularity, they seem to possess a kind  of structure, like  that
of the lower kinds of fibro-cartilage and granular deposit.   Their
affinity with granular degeneration is shown  by their commonly
occurring  in  the  same subjects,  and  by  their frequently  ex-
hibiting  the  same tendency  to  contraction.    In a  very large
majority of cases of chronic granular degeneration of the kidneys
or liver, there are found more or less traces of tubercle in the lung,
its chief seat; and in very few instances of  chronic phthisis have
I failed to find some degree of  granular disease in  the  liver or
kidney.  In acute phthisis and acute granular disease,  local causes
accelerate the degenerative change to a destructive extent in  one
organ, before there is time for others to  become affected.
   556. Let us now trace the history of cacoplastic deposits in  a
few examples.  The  dense false  membranes on  the  surface  of
serous membranes may be often seen   surrounded by a  radiated
wrinkling or puckering of  the adjoining parts, indicating that the
new deposit has shrunk in  size.   A similar contraction is  noticed
in the deposits on and under the lining membrane of the heart
and its valves, and causes a serious disturbance of their  mecha-
nism.  The  contraction  of the chest in  some  cases  of  pleurisy
is, in part, dependent on the same property of cacoplastic deposits.
This general tendency of certain false membranes to contract  was,
I believe, first distinctly pointed  out  by Dr.  Hodgkin ;  and the
fact has been applied by Dr. Carswell to explain the contraction
of the liver in cirrhosis, which  he considers to depend on a deposit
in the intravascular cellular texture prolonged from the capsule of
Gibson.  I do not consider that the contractile deposit in cirrhosis
is exclusively confined to any texture.   False membranes, which

which are very conspicuous, may frequently be seen on the point of escaping from
tnem      . . . The semi-transparent forms of tubercle and tubercular infiltra-
tions owe their peculiarity to a great  relative amount of granulated vesicles {cells,
Gulliver); whereas the opaque white forms of tubercle are attributab e to great
numbers of isolated  granules." - Mr. Addison's " Experimental and tracheal
Researches, &c. ,-" Trans. Provincial Med. and Surg. Association, 1843, p. 'Mi. 8.
  These quotations supply microscopic evidence in favour of views regarding the
nature of tubercle, which I have long held and taught, and to which I was led
bv an attentive examination of the common characters and changes  ot lymph,
nus  and tubercle  A brief notice of these views may be found in the four edi-
tions of my little work on the « Pathology and  Diagnosis  of Diseases of the
Chest •" in my » Lectures on Diseases of the Chest," published in the " Medical
Gazette" of 1837, 8; and in the » Library of Practical Medicine," vol. hi. 1840.
All these works were  published long before any of the above microscopical ex-
aminations were made. 
 322        WILLIAMS'S PRINCIPLES OF  MEDICINE.

exhibit the same contractile property, are sometimes found on the
free surface of serous membranes, and especially along (he course
of the vessels (veins as well as  arteries) ; and on the liver and
lung, depressions from atrophy of the substancte of the organ are
sometimes seen under these deposits.  There can be little doubt
that these deposits are merely exuded from the vessels  in certain
pathological states, (congestion, chronic inflammation, and malnu-
trition,) and form a  dense structure of low vitality, which, by its
subsequent contraction, tends to constrict and compress the subja-
cent parts, and more or less to interfere with the passage of blood
through them, and consequently with their secretion and nutrition.
The same tendency is shown in the higher  (less aplastic) forms of
tuberculous disease.   Miliary or  granular tubercles in the  lungs,
when  in  considerable numbers, and not soon softening, cause a
contraction  of the lung, chiefly at the upper part, and a  corre-
sponding collapse in  the upper part of the chest.   I have met with
many cases, in which a sinking in of the infraclavian region took
place before any symptoms of softening or excavation had oc-
curred ; indeed, it is a very common sign of tubercles which long
remain stationary.   The  still  greater amount of collapse, in the
advanced stages of tuberculous lesions, although partly dependent
on other causes, is  also in some  degree  connected with the con-
traction of cacoplastic deposits in the lungs and  pleura.  In the
peritoneum, agglutinated tubercles often cause considerable con-
traction ;  and I have seen the omentum thus puckered up into a
knotty mass.
   It would be an  interesting point to  compare  the  microscopic
 structure  of cacoplastic deposits before and after their contraction.
 It is most probable that it is by the partial absorption of the gra-
nular or amorphous portion of the deposit, and by the  closer ap-
 proximation of the cells or more organized constituent, that the
 condensation takes place.   Hence, it may be, that the structure so
 contracted is less liable to the  further degeneration to  which caco-
plastic deposits commonly tend.   Certain it is, that of different por-
tions of cacoplastic deposit in the lungs and elsewhere, those that
 are  contracted remain unchanged,  whilst others pass into the
 aplastic state of opaque and softened tubercle.   This contractile
 process seems, therefore, to raise  the deposit to a  higher standard,
 in  which, although  below them, it is  tolerated by the adjoining
 textures.   But this  very  change may seriously  injure them, by
 contracting and  compressing  their vessels, and  interfering  with
 their nutrition and  other functions.  This  is the chief mode in
 which the granular diseases of the liver and kidneys gradually in-
 fringe on  the circulation and secretion of these organs, and thus
 may eventually prove fatal  (§ 249, 375).   The contraction which
 takes place near the summits  and roots of the lungs, in the more
 limited and therefore chronic forms of pulmonary tuberculous dis-
 ease, often lay the foundation of emphysema of the  lungs and
 habitual asthma.  I  have notes of  a large number of cases illus- 
STRUCTURAL DISEASES.
323
trative of this fact; but such details belong to special pathology,
and are reserved  for another work.
  557. Having adverted to the less degraded or degenerating form
of cacoplastic deposits, we have now to  notice those of a  lower
character, which tend to become aplastic.   These include the com-
moner forms of tubercle.  In the granular, miliary, grey, or drab-
coloured tubercles of serous membranes and parenchymata, we find
a dense  homogeneous solid, closely resembling some of the other
cacoplastic deposits which have just been described.  Their resem-
blance, and even identity, may often be well  traced in chronic or
subacute arachnitis, peritonitis, and  pleuritis, in which portions of
the affected membrane are covered  with  diffused patches of semi-
opaque deposit, which no one would  hesitate  to call  false mem-
brane ; whilst in other parts the same deposit, occurring in separate
granules, exhibits all the characters  of granular or miliary tubercle.
But  how comes  it (may be asked)  to assume the granular form?
 In answer to this question, I may refer  to  the observations made
on  the products of inflammation (§449), where it was pointed out,
 that  the effusion of lymph  on  an inflamed membrane  is  at first
 granular, and would'continue  to be so, if it were  not drawn or
 spread into threads or films by the  friction or pressure of the sur-
 faces where it is poured out; and several examples were cited, in
 which, from the absence of such friction or pressure, the granular
 appearance is preserved even in  acute inflammation.   In  chronic
 inflammation, in which the matter effused is from  the first less
 ductile and more consistent, the granular condition more generally
 remains ; and  it is generally admitted, that the product  of chronic
 inflammation of the peritoneum and arachnoid is always more or
 less granular.
   But tubercles do not always result from inflammation.   In many
 cases, they are found disseminated in so many textures, after few
 or no'symptoms of inflammation, that it is impossible to regard
 them otherwise  than as the result of modified textural nutrition.
 The cell-germs by which the material of textures is renewed, are
 imperfect  at  particular  points; the granular or hyaline matter
 abounds and concretes without fibres or vessels being developed ;
 at this point a hard granulation  appears.  Where  a granule has
 once been formed, it becomes a nucleus for the concretion ot more :
 a new habit or mode of  nourishment is  established  at the spot ;
 or, to speak less figuratively, cacoplastic matter (it present m the
 blood) concretes around it by a process similar  to that by which
 fat attracts fat, or  bone, osseous  matter; perhaps the process  is
 not  wholly unlike that of crystallization.   But however it happens,
 the  result is, that the granular tubercle grows, and may attain the
 size of a millet-seed, hemp-seed, or even a small cherrystone; or
 being subjected to pressure, may somewhat spread or flatten into
  various shapes.                        . ,       . ... .      .,  „
   55S  But tubercles rarely grow much without exhibiting another
 change in their  appearance.  They lose  their semi-transparency, 
324
WILLIAMS'S PRINCIPLES OF MEDICINE.
and become of an opaque or dead, pale, yellow hue, like the colour
of raw potato or parsnip.   This is the  transformation  to crude
yellow tubercle first  described  by Laennec.  This change is the
result of a further degradation of the deposit.   The few cells which
are to be detected in grey tubercle become indistinct, and the mass
is merely granular, and therefore  quite  aplastic.  Generally the
change begins in the centre of the  mass, apparently because, being
devoid of vessels, the centre is further  removed from  the vivifying
influence of the  blood.   Yet congestion  or inflammation in the
neighbourhood seems to accelerate this change, just as they hasten
the conversion of lymph into pus,  the plastic into the  aplastic, by
the increased  warmth and afflux of fluids promoting  the  degene-
rative change — the loss  of vitality — to which tuberculous de-
posits tend.
   559. But tubercle is frequently deposited at first in this yellow,
opaque state,  this circumstance being  a mark  of  the still more
degraded condition of the nutritive function ; and the more exten-
sive forms of  tuberculous disease commonly abound in this aplastic
matter.  Thus in rapid  phthisis,  whether resulting from acute
inflammation  or  from the  prevalence  of scrofulous (cacoplastic)
diathesis, yellow tubercle commonly forms a  large portion of the
deposit; and  it is in these cases that its resemblance to, and  con-
nexion with, coagulable lymph may be best seen.*   Yellow tuber-
cle is rarely so hard or  so tough as the  grey or semi4ransparent
kind;  and in  the cases of rapid deposit just mentioned, it  is often
much softer and  more friable.   Now, this is the commencement of
a change to which  the lowest forms  of tubercle tend — that of
maturation and softening into a cheesy  substance.   The conver-
sion of the grey into opaque tubercle, and the further softening of
this, seem  to be the converse of the contractile  process to which
the higher class of cacoplastic deposits tend : in that, (the contrac-
tile process,) the  deposit becomes  more dense  and organized: in
this (opaque change and softening), the deposit becomes less dense,
and loses the  little trace of  structure which  it  had :  it degenerates
into an  amorphous, granular  mass;  and being lifeless, it is no
longer nourished ; but  its  granules  lose their  cohesion, and be-
come disintegrated by the chemical action of the adjoining fluids.t
Mr.  Gulliver  has also  observed  an  appearance of fat globules

  * The affinity between lymph  and tubercle was recognized by older writers ;
but after it had been kept out of view by the too exclusive opinions of Bayle and
Laennec, it was again fully pointed out by Dr. Alison.   (Trans, of Medico-Chi-
rurg. Soc. of Edin. vols. i. and iii.) .
  ■f Dr. Elliotson, 1 think,  first suggested that the softening of tubercles is due
to a spontaneous chemical change. I also consider the change to be chemical ;
but to arise from the action of fluids from  adjoining parts.  So long as tubercles
are kept free from superfluous moisture, they manifest little disposition to change;
but an afflux of fluids around them hastens their maturation and softening.   This
effect may be rudely illustrated by the action  of water or serum on coagulated
albumen.  When nearly dry, it is tough and semi-transparent; but when well
moistened, it becomes opaque, soft, and friable.  The softening of clots of fibrin
by warmth and moisture gives another illustration of the same change. 
STRUCTURAL DISEASES.
325
in softened tubercle.  The formation of these in old pus (§ 460), in
atheroma of arteries, and in gangrene of the lungs, seems to show
that fat is sometimes a debris of animal matter, as in the conver-
sion of flesh into adipocire (§ 543).  The lenticular corpuscles con-
centrically striated, supposed by Gruby to  be characteristic of soft-
ened tubercle, Mr.  Gulliver has found, in  various textures, uncon-
nected with tubercle or any other disease.   The detection, by Dr.
Davy, of oleine and margarine in  opaque exudation corpuscles
(§ 543), shows a tendency to the production of fat in all degene-
rated plasma.
   560.  But in these different  changes in tuberculous matter, as
well as in the original deposition of this matter, the adjacent living
parts have a  considerable share.  A  miliary tubercle from its first
formation may become a cause of irritation and obstruction to the
contiguous textures.  The amount of this irritation and obstruction
will depend on the natural or present vascularity and excitability
of the part, its function, and the situation and size of the tubercu-
lous deposit.   Thus, in vascular textures, especially parenchymata,
there is more tendency to  mischief and  change  than  in serous
membranes.   Where the irritation  is very slight, it may merely
cause so much determination of blood  as to promote the growth
of the grey tubercle.  Where it is more, it may cause the conver-
sion of grey into yellow tubercle, its further increase in  this form,
and its  softening.   If the irritation  be  still  greater, inflammation
is excited  around the tubercle ; and the  products of this inflam-
mation  (pus, lymph, mucus, serum, &c), may also hasten the soft-
ening of the tubercle, their mixture  together, and  their evacuation
by ulceration into adjoining open surfaces.  Or, the product of in-
flammation being  more  solid and  plastic, consolidations, or false
membranes, are formed around the  tubercle, and its irritating in-
fluence may  be thus reduced.   And  although we have  just men-
tioned that the opacity, maturation, and softening of tubercle, de-
pend essentially on a further degeneration and loss  of  structure,
yet these changes are much promoted by the afflux of blood to
the neighbouring parts.
   561.  In the absence of any of the circumstances just mentioned,
which tend to promote the increase or further change of tubercle,
we  find that it may remain harmless for  months, and  even  for
years;  but then it often  exhibits the transformations which may
be considered spontaneous.   The change  of the  less cacoplastic
deposits by contraction has  been already  noticed (§ 556).   In the
lungs, the consolidations may remain long without any contraction,
but  they become  deeply blackened by an  accumulation of the
peculiar black matter of'the lung.   Yellow and softened tubercle,
if not evacuated in  time, become replaced  by a plastery, or putty-
like  matter, composed chiefly of phosphate of lime, and often con-
taining  solid concretions, consisting entirely of that earthy matter.
This petrifactive change  reminds us of what takes place in the
cacoplastic deposits in the coats of arteries  and  on serous mem-
           2S 
326           WILLIAMS'S PRINCIPLES OF MEDICINE.

branes (§ 544, 553), constituting what is erroneously called ossifi-
cation.  The calcareous conversion of tubercle can be explained
only on the  supposition that the animal  matter is absorbed, and
the earthy matter is deposited  in  its  place.   This is exactly like
what takes place in true petrifaction of organized bodies, the silica
or calcareous substance being substituted molecule for molecule:
so that, when all is converted into  stone, the shape of the  organ-
ized body is  retained.  But we  further learn  from  this  that  the
animal matter of tubercle may be  absorbed.   This occasional  ab-
sorption of tuberculous matter is further proved by its accumula-
tion in the bronchial and mesenteric glands, which sometimes con-
tain it when  the lungs and  the intestines contain little more than
traces of it, such  as  cicatrices, with  some cretaceous matter in
them.  In the bronchial glands, too, the tubercle very commonly
exhibits the petrifactive change, and the concretions so commonly
found in these glands  may generally be ascribed to this cause.
   562. The circumstances which degrade the material of nutrition,
and lead to the deposition of cacoplastic  and aplastic matter, may
be either local or general.  Of the local causes, congestion and  the
lowest and more chronic forms of  inflammation have been men-
tioned as capable  of determining cacoplastic deposits; but even
in these cases it is probable that  the  general cause also more or
less operates — that is, a degraded state of the plasma of the blood.
Congestions and chronic inflammations certainly cause cacoplastic
effusions; but then, such congestions and chronic inflammations
do not easily occur in healthy subjects ;  and  the want of  health
may imply that  the plasma of the blood is  bad  in addition to
the  local  cause.  But  practically, it is of great  importance to
keep in view the local as well as the general cause, for the  former
is often more tractable than  the other, and it is  by guarding against
it that slighter degrees of the general cause (diseased plasma) may
be prevented from doing mischief.  But the general cause, when
present in great degree, leads to cacoplastic and aplastic deposits,
as modifications  of  ordinary  textural  nutrition,  independently
 of inflammation or even congestion.   This  general cause thus
 prevailing constitutes the chief element of the scrofulous diathesis
 or tuberculous cachexia, and we have before mentioned that a de-
 fect  of the red  particles and an excess of fibrin in the blood con-
 stitute its most remarkable  feature (§ 1S5, 211).  In this condition
 of the blood there is  an increased disposition to deposit, and often
 an  abundance of the fibrinous or nutritive  material, but an im-
 perfect vitality  or organizability  of this material, so that when
 deposited, instead of being assimilated  to the textures, it forms
 the degenerated structures  or mere granular  or amorphous depo-
 sits, which we have  been describing.  But with this condition of
 the blood, these  deposits must be greatly promoted by all varie-
 ties of hyperaemia, and  prevail most in  organs which receive the
 largest amount of blood.   Hence, the peculiarly pernicious effect
 of inflammation of internal organs, especially the lungs, in scrofu- 
STRUCTURAL DISEASES.
327
lous subjects.   Even  acute inflammation may be unequal to raise
the nutritive material to  a  plastic  standard  at which it may be
organized or absorbed, or to mature it to the process of complete
suppuration by which it may be speedily excreted ;  but the matter
thrown out is  cacoplastic, or curdy lymph, or  a caseous kind of
pus, inorganizable, inert, irremovable  by absorption, and  perma-
nently obstructing or compressing  the structures  in which  it ac-
cumulates, until  it gradually excites an  irregular destructive sup-
 puration or  ulceration,  forming vomicae, or imperfect abscesses
 pervading the structures, and without walls capable of healing,
 whilst the body wastes with hectic fever, night-sweats, and colli-
 quative diarrhoea.   So likewise  fevers, by causing congestions in
 organs, lead to the production of  a crop of these deposits, from
 which tuberculous disease takes its origin.
    563.  The lungs and bronchial canals are by far the most com-
 mon seat of tubercles;  when  found elsewhere,  tubercles  com-
 monly abound more, and  are more  advanced in  these parts.(a)
 The situation of the prevalence of tuberculous disease varies also
 with the age  of the subject.  Thus, M. Papavoine found yellow
 tubercle in children  to occur especially in the cervical and mesen-
 teric glands; next  in  the spleen, pleura, liver, and small intes-
 tines ;  less  frequently, in  the  large  intestines and peritoneum ;
 and more rarely in other parts.   In 350 consumptive cases ex-
  amined by M.  Louis, tubercles were  found  in  the small intes-
  tines in one-third of the whole ; in the mesenteric glands, in one-
  fourth ; in  the large intestines, in  a ninth; in the  cervical glands,
  in a tenth ; in the  lumbar glands, in a twelfth; in the spleen, in
  a fourteenth  of all the cases; and in other parts, in smaller pro-
  portions, (b)
     The greater liability of the lungs to tuberculous deposits, has
  been  lately ascribed by Dr. Campbell and others  to the finer size
  of their capillary vessels, which  causes them to act as  filters to
  the blood, arresting the tuberculous  matter which is supposed to
  become solid in the blood itself.   But this view is untenable for
   several reasons.   1. If the fine  size of capillaries were the chiet

   ~ (a) His owrTsubsequent experience  and the observations of
   others, confirm the statement made by M. Louis in 1S25, viz , that,
   after the age of fifteen, tuberculous matter never presents itself in
   any tissue or organ unless  it exists, also, in the  lungs.   To this
   general law he has met with  but one, and refers  to another ex-

   ^(^Dr. Engel, of Vienna, found  the  proportional frequency ol
    the occurrence of  tubercle in the lungs to that of  tubercle in the
    cerebral meninges, the pleura, liver, and spleen, to be as IS to1,
    o that of tnbercle'in the brain and kidney as 18 to 2; and ha of
    tubercle in  the peritoneum and intestines  as 18 to 3   The fre-
    quency of tubercle of the lungs is to that  of all  other diseases of
    these organs as 2  to  3. 
328           WILLIAMS'S PRINCIPLES OF MEDICINE.

cause of the deposit, it should take  place abundantly in muscle,
the capillaries of which are  even finer than  those of the  lungs.
2.  If the cause of the first deposit were a solid matter obstructing
a vessel, the appearance  of  vascular  distention and obstruction
would be obvious in  the earliest formation of tubercles, and the
deposit would exhibit somewhat of  a  capilliform shape, which is
not the case.  3. The deposit  has been distinctly traced by Messrs.
Gulliver and Addison to be extravascular, sometimes on the sur-
face of the air-cells, and  sometimes in or under the membrane
composing them.   I think it  highly  probable  that tuberculous
matter may form within the bloodvessels themselves ; and I have
repeatedly found  something presenting all the  external characters
of yellow tubercle in the bloodvessels of tuberculous lungs.  In
fact, wherever fibrin  may coagulate, there  its  degraded  form,
tubercle, may occur ; and  I cannot but refer to the case of opaque
softening of clots of fibrin  in coagula in the heart and great blood-
vessels  as bearing on this point.  Formerly, this softened fibrin
was  mistaken for pus:  Mr. Gulliver pointed out  this error  by
showing that it had no pus globules.  But its aspect and micro-
scopic composition difler in no essential particular  from those  of
soft tubercle, and  the  views which  I  have given would identify
them in nature.   This leads me to  infer that  the fibrin of blood
stagnant within vessels, or extravasated from them, in tuberculous
subjects, may sometimes change  into  aplastic tubercle.   But the
reasons before stated  make it obvious that the early forms of tuber-
cle are extravascular deposits, resulting from modifications of the
ordinary nutritive secretion.
  I believe that several  circumstances contribute to render the
lungs especially liable to tuberculous deposit.   1. Their great vas-
cularity and the large quantity of blood that passes through them.
2.  Their being a chief seat of the formation of fibrin, that princi-
ple being more abundant in arterial than in venous blood (§ 194).
3.  The softness and yielding  nature of their texture, which per-
mits effusion  to take place more readily than denser  textures do.
4.  Their exposure to external causes of disease, whether by cold
and irritations directly entering by the air-tubes, or by circumstances
operating through the medium of the circulation.  In hot climates
cacoplastic diseases affect  the liver  and  other  abdominal viscera
more than the lungs; the same persons there suffering from liver
disease and dysentery, who, in a cold  climate, would fall victims
to phthisis.(ff)

  (a) These observations confirm the statement of Dr. G. H. Bar-
low, propounded by  him as a  law, viz., "that any organ is most
liable to become the  seat of tuberculous deposit when its vascular
and functional activity bears the greatest ratio  to the  other organs
of the body."  In support of this law, he refers to the greater fre-
quency of tubercles in the brains of young children, or when that
organ is relatively largest; also in thechylopoietic viscera of older 
STRUCTURAL DISEASES.
329
  564. As we have found (§ 562) that  the cacoplastic condition
of the blood of tuberculous or scrofulous subjects comprises a dimi-
nution of the red particles and a preponderance  of fibrin, so we
can state that the causes which develope this condition, and there-
fore induce tuberculous disease, are such as intelligibly induce one
or both of these changes.  Insufficient food, want of pure dry air,
of warmth, and of light, long-continued mental depression, aggra-
vated and prolonged disease of the digestive organs, insufficient
excretion (§ 249), and the injurious influence of fevers and other
serious diseases-, are acknowledged causes of tuberculous disease,
and may be considered to operate in both ways.   Excessive eva-
cuations of blood,or of the more animalized secretions, and severe
courses of mercury, also predispose to phthisis, and may perhaps
 act chiefly by reducing the red particles of the blood.  The cessa-
 tion  of growth, the  termination of pregnancy, the stoppage  of
 habitual discharges, especially purulent, and the amputation of a
 limb, all of which circumstances are known to favour the develop-
 ment of tubercle, may be  supposed to operate chiefly by increasing
 the proportion of fibrin in the blood, when there is not a sufficiency
 of red particles, and of vital power, which is represented by them,
  (§ 183) to  give to this fibrin a due amount of vitality.
   565. The treatment of cacoplastic and aplastic deposits, and of
  the conditions which lead to them, involves a vast number of  de-
  tails, according to their kind, situation, extent, and other circum-
  stances in which they occur.   It is not consistent with  the limits
  of this work to enter into these details ; but it is hoped that  a ra-
  tional view of the principles on which these deposits are to be pre-
  vented and treated may  be  deduced from  the foregoing account.
  This view will comprehend those measures which  have the best
  sanction of experience.
    The elements of disease chiefly to be kept in view in  the treat-
  ment  are: —1.  The disordered condition of the blood, and its
  causes; 2, the disordered distribution of the blood, and  its causes:
  and 3, the presence of the  deposit, and its effects and changes.
  The second element comprehends the varieties of local hyperaemia,
  which we have found to be so much concerned in producing the
  higher kind of cacoplastic deposit (fc 553), and  in promoting tne
  formation and changes of those of a lower character (§ 560).  Hence>
  the remedies against inflammation, determination of  blood, ana
  congestion, are frequently more or less needed  in  the  prevention
  and treatment of cacoplastic and  aplastic  deposits.   But, ex-

  children Tand inthelm^gTof youths atTperiod when these organs
  are attaining their complete  development.  Arguments are found,
  Dr  Barlow thinks, in favour of this view, in the  partial suspen-
  sion of tuberculous disease  in the lungs during pregnancy ; and
  in the absence of tubercles from portions of the lung which have
  been compressed in cases of pneumothorax,  following phmisis.
   (Guy's Hosp. Reports, April, 1S41.)
                28* 
330          WILLIAMS'S PRINCIPLES OF MEDICINE.

cept as preventives, the utility of  this class of remedies isgenerally
limited  to  those of a  topical kind, such  as local  bloodletting,
counter-irritants, revulsives, derivants, and alteratives (§ 174).
  566. The more constant and important element to be considered,
in the treatment of cacoplastic and  aplastic  diseases, is the first
named — the diseased condition  of the blood ; and this more  de-
mands attention, the more general and the more degraded are the
deposits.  The first point to be attempted is the removal or coun-
teraction of the several causes before enumerated (§  564), as con-
tributing to induce the diseased condition of  the  blood.   Thus a
sufficient supply of food  of a  nutritive  quality — free  access of
pure dry air and light, while the warmth of the body, particularly
of the surface and extremities, is carefully secured  —• the removal
or counteraction (so far as is possible) of diseases impairing diges-
tion and excretion, and of depressing mental or bodily  influences, —
are among the first  objects to  be  aimed  at in treating cacoplastic
diseases.  Where excessive losses of blood or  other evacuations
have contributed to lower the  plastic process  of nutrition, a  gene-
rous animal diet, and tonics, especially those  containing iron, are
especially indicated.  Where  the altered condition  of the  blood
can be traced to an excess of ill-developed  fibrin accumulating
after the cessation  of growth, the termination  of pregnancy, the
amputation of a limb, or the sudden stoppage of an habitual  puru-
lent or other discharge — means to eliminate the superfluous mat-
ter from the blood, either by increasing  the natural  secretions, or
by establishing an artificial drain by blisters, setons, issues, suppu-
rating counter-irritants, &c, are distinctly indicated ;  whilst  tonic
and invigorating measures may be also useful  to raise the plasticity
of the blood to a higher standard.
  The foregoing measures may be  considered  rather as  preven-
tive than curative; but in so far as they  may  succeed in arresting
the growth of deposits already formed, and in improving the  nutri-
tive function  in general, they will favour the  limitation of the de-
posits, and their gradual absorption  or quiescence in contraction
(§ 557) or calcareous transformation (§ 561).
  567. The third object to be regarded in the treatment  is the de-
posit that is already formed.   In  this case, as in  most  others of
diseased structure, medicine can do  but little.   Unlike the euplas-
tic products of inflammation, and, in some instances,  unlike a sim-
ply overgrown  texture or organ, the changes  of absorption scarce-
ly reach unorganized  matter; and  it is doubtful whether any
remedy that we can use will materially promote its  removal,  un-
less, perhaps, by the simultaneous destruction of the texture which
contains the deposit.  Mercury has seemed  to  me to hasten  the
softening and evacuation of pulmonary tubercles;  but this is by a
work of destruction, and its influence on the blood  has been al-
ready mentioned to be injurious.  Drs. Graves, Stokes, and others,
have, however, recommended mercury in the earliest stage of tu-
berculous disease.   My own experience would lead  me to  avoid
the specific influence of mercury in  all cases of mere  tubercle; but 
STRUCTURAL DISEASES.
331
I have given it with advantage in cases of subacute and chronic
inflammation simulating tuberculous disease, and even  where tu-
bercle probably existed in  a limited extent.  Whether mercury is
of any use in granular disease of the liver and  kidney, is also  a
subject of doubt.  Alkalies and their carbonates, and  iodide ot
potassium, have better claims to  notice, although  their power to
dissolve cacoplastic and aplastic deposits is very  uncertain    The
 occasional subsidence of external scrofulous tumours under their
 use is the best argument in their favour -and they have this advan-
 tage, that when judiciously administered, they do not injure the
 blood or  the constitution.  They act best, and  are longer  borne
 when combined with fluid extract of sarsapanlla  and  tincture  of
 hop, or^me other narcotic;  and I have found this combination
 more useful than any other in the early stages of tuberculous dis-
 use  where there is no fever, active inflammation, or tendency to
 hemo rhage.  Whether the  iodine and  alkali  ever directly pro-
 nioTe he solution or absorption of tuberculous matter,   am still in
 Z bt • but the si<ms of the presence of limited tubercles have, in
 m^ii"
 regained colour flesh, and strength.  Other combinauons^me,
 particularly with iron,  have been  recommended in «roMous
 disease   The iodide of iron, and other preparations of this metal,
  I have  found  very beneficial  in  cases  of anamna  or general
   veakessvthout much  fever or local inflammation ;  but  I have
  Ten no reason to suppose that they promote the --val of tiib -
  cles already formed.  The same may be ^^^.^^^Tectic
  which  are, however,  sometimes very useful  m reducina hectic
  fpvpr whpn it assumes an intermittent form.
    ,««nnrinl "the ulterior degeneration  of cacoplastic deposits





   rsss:?.:." r,'..i ir.»«»«««.«- •«-




   esteemed remedy  in scrofula, in any way contn



                            ■,       ,„f, fanv constituent in cacoplastic
     . The discovery of a considerable amount of a CM,.const'         I-  ^
   a„d aplastic deposits « 559, 479) WXli««  "°li°" <*<>™ '° 
332          WILLIAMS'S PRINCIPLES OF  MEDICINE.

already formed,) because they are more peculiar, I again repeat,
that these are less efficacious, and more doubtful in their operation,
than those  adverted to — but not  detailed — to fulfil the first two
indications (to improve the condition of the blood, and to equalize
its distribution);  the judicious application of these constitute the
most important points in the prevention and  treatment of caco-
plastic and aplastic deposits.

                      MORBID GROWTHS.

  569. Under the term morbid growths, may be arranged certain
structures developed in the animal body in addition to the natural
textures.  They differ from hypertrophy and  euplastic  deposits
in the peculiarity of  their structure; and from cacoplastic and
aplastic deposits, in their possessing a higher degree of organiza-
tion.   In other words, they differ from hypertrophy and euplastic
formations in their kind of vitality;  and from  degenerations and
cacoplastic deposits, in their degree of vitality.  They are, in fact,
new structures: and although some of them in general characters,
and  most of them in elementary composition, resemble some of
the natural textures of the body; and although all derive  their
nourishment from the blood; yet, in their origin and growth, they
are more essentially distinct from the natural structures than are
any of the results of diseased nutrition hitherto considered.  For
these reasons, they have been called new and parasitical growths;
and the term parasitical is the more applicable to them, because
their existence and mode of growth cannot generally be traced to
variations in the local circulation, which we  have found to  be
chiefly concerned in producing and influencing the modifications
of nutrition hitherto noticed.
  Morbid growths have been divided into analogous, those whose
structure resembles some  natural  texture, (including  false mem-
branes, &c.);  and non-analogous, or heterologous, those which
have no parallel in the healthy state of the animal economy.  But
this division is inconvenient, because it is applied to the other pro-
ducts of diseased nutrition previously  arranged  under  another
division: and it is often  inapplicable, inasmuch as many morbid
growths are essentially compound, comprising some forms  that re-
semble natural textures, others that do not; yet all these are con-
stituted of similar elementary molecules: this  remark especially
applies to carcinoma.
  The division which I  have adopted  into non-malignant and
malignant is more useful in a practical point of view, although it
may not be easy  to make it precisely applicable to all cases. 
STRUCTURAL DISEASES.
333
                       SECTION VII.

                  NON-MALIGNANT  GROWTHS.

  570. I would  apply the term  non-malignant to those growths
which occur in a part of the body, without tending to infect other
parts; and which  arise among, but do not invade, the  natural
structures ; and if they prove injurious, it is by their bulk or posi-
tion, or  by the extent to which they abstract the  nourishment of
the body.
  571. The most simple form of new growth is the serous cyst,
which is a shut sac, "containing serum, and formed  of condensed
cellular substance resembling serous membranes, which are formed
gradually around a clot of blood, or any foreign substance in the
system ;  and are frequently developed spontaneously in various
parts of the  body.   They are frequently attached to the natural
serous membranes,  but sometimes quite  separate  from these;
sometimes solitary, sometimes set tosether in clusters; and their
size and shape  are  very  various.  They must be  distinguished
from enlargements of natural cavities, such as the  calices of the
kidneys, or Graafian vesicles in  the ovaries.  They are often un-
connected  with  disease of  the  adjacent  textures;  but in some
cases, these  textures  are  found either  wasted by absorption
(atrophy  from pressure, § 532),  or  disorganized  by  inflammation
around them. There is no evidence of their being generally con-
nected,  in  their commencement, with inflammatory action ;  and
when they are small, their existence is often  not denoted by  any
symptoms whatever."*
  Besides  the instances above  excepted  from  this  class of new
growths may be mentioned several others, which are rather instances
of hypertrophy.dilatation,or unusual developmentof a natural struc-
ture, and therefore belong to a former division (§ 52S).   The en-
larged bursas, in parts subjected to  pressure : the dilated mucous
follicles, in the cervix uteri;  the  cutaneous follicles distended with
fatty or  other matter (epidermis scales), constituting the subcuta-
neous adipoma and  melliceris ;  the salivary ducts obstructed and
filled with concretion, in the  tumour called  ranula;  are of this
kind, and do not belong to the  present division.  I would, with
Dr. Hodgkin, extend the same remark to  the small serous cysts
frequently found in  the kidneys and  liver, which I have before
described  as portions of secretory ducts obstructed and distended
with serum (p.  174, note).  It may be fairly questioned whether
other serous cysts are not  also due to enormous  enlargement of
the primitive or  compound cells of which textures are partly com-
posed   My friend, Dr. Hodgkin, has most plausibly advocated an
♦ Alison's " Outlines of Pathology," p. 231. 
334
WILLIAMS'S  PRINCIPLES OF MEDICINE.
opinion ofthis kind, and has applied it also to explain the production
of more solid and complex  growths, by the formation, multiplica-
tion, and compression of a series of cells.*
  572. Cysts, like tli3 serous cysts above described, are sometimes
found filled with different contents, and then constitute the simplest
kind of encysted tumours, which may form probably in any part
of the body that has the cellular structure, and have received names
descriptive of their contents : — " hygroma, when they contain  a
nearly serous or sero-purulentt (?) fluid, and form encysted dropsy
if they be of very large size ; haematoma, when  their contents are
bloody ; steatoma, when they approach more nearly to the  ap-
pearance and consistence of fat; and atheroma, or cold or chronic
abscess, when they contain purulent (?) matter of more or less con-
sistence, without having been preceded by distinct marks of inflam-
mation.  Sometimes  substances distinct from  any found in  the
healthy body, or substances which in the natural state exist only in
individual parts of the system (e. g., cholesterin), are found in  the
interior of these encysted tumours.   Those tumours of this kind
which are of considerable size are often formed of a congeries of
such cysts, and their contents in the same  tumour are often very
various, as is seen remarkably in the most common case of enlarge-
ment of the ovary, which appears to consist in gradual distension
and alteration of the fluid contents of the Graafian vesicles.  Fur-
ther, not only  the contents, but the coats or envelopes of these cysts,
are subject to a great variety  of changes, becoming in some cases
fibrous or cartilaginous, or  having  bony" (calcareous) " matter
deposited irregularly through  them."J
   573. Dr.  Hodgkin considers that the complex cystiform tumour,
as it occurs in the ovary, exhibits a  type of the origin of morbid
 growths in general, not excepting those of a malignant kind.  From
the  internal walls of one original  or parent  cyst, there spring a
 number of other cysts, varying in their contents, and as they grow,
 they fill the original cyst, and project beyond it, other cysts being
 produced within them ;  and thus a growth  takes  place, subject to
 modifications from the nature of the  texture which is its seat, as
 well as from the contents of the  cysts.  In solid structures, asdense
 cellular membrane, the cysts are so compressed as to present the
 appearance of fibres radiating  from a centre,  and they lose all
 their liquid contents.  The adjoining textures, as well as the walls
 of the cells, may also inflame and  cohere, so as  to obliterate the
 cystiform structure of the tumour.   Professor Alison adverts to the
 connexion  between encysted and solid, or sarcomatous tumour in
 the commencement of the following passage : —
   " In many cases, though not in  all, we can  clearly distinguish


   * Med. Chir. Trans., vol., xv. part 2.
   ■j- More probably, the fluid is turbid, from epithelium scales or  degenerated
  exudation corpuscles.
   ^ Alison's " Outlines of Pathology," p. 233. 
STRUCTURAL DISEASES.                 335
from these encysted tumours (where the organized secreting sub-
stance  is external to the chief bulk of the morbid growth), tumours,
the organization of which is so far different, that their substance
is penetrated throughout by a  vascular cellular or  fibrous struc-
ture, in which  they are nourished, and by which they are often
divided  into lobules.   These  are generally called sarcomatous
tumours; and  the simplest example is the common vascular sar-
coma, which consists merely  of condensed  cellular substance,"
(well supplied  with bloodvessels,) " and may be found in any cel-
lular texture, but is  often seen  in the mammae and testes.  But,
according  to the different  situations  they  may occupy, and the
different textures of which they may consist, (sometimes, probably,
from their original formation,  and  sometimes  in consequence of
 their gradual transformation,) tumours of the  same general struc-
 ture have  received different names, adipous sarcoma, or ceroma,
 when of fatty or waxy consistence ; polypus, when projecting from,
 and often  closely resembling the structure of, mucous membrane ;
 neuroma, when seated on a nerve, or when growing on its sheath,
 and splitting up and  separating its fibrils;  chondroma ox fibro-
 cartilaginous  tumour, when  traversed  by numerous bauds or
 strias  of the consistence  of cartilage; and osteosarcoma, when
 containing much bony deposition.  In many  instances, the differ-
 ence in these morbid textures may be  ascribed to their partaking
  more or less of the nature of the sound texture in which they are
  developed; but in some, no similarity of the diseased structure to
  the surrounding healthv parts  can be observed.  In some cases, as
  e. g., in the coats of the"stomach and intestines, it may be observed
  that the formation of such  morbid growths is preceded by simple
  thickening  and hardening  of  the sound cellular texture, a parrot
  which only afterwards assumes the strictly morbid appearance.  *
    574. The pathological cause of morbid growths is involved in
  much obscurity. We cannot at present go beyond the supposition
  that they arise from altered vital properties in some of  the mole-
  cules of the textures in which they are developed ;  so that  instead
  of being assimilated to these textures, and conforming to the laws
  of their&growth and decay, these molecules grow of themselves; m
  modes more or less peculiar, and more or less independently of the
  mnuences of  the adjoining living part,  Where these modes^
  less peculiar and more dependent on  the nutrition  o  tl e .idjacent
  structures, the growths are  less abnormal  vary less  ho n the e
  structures  and more resemble either hypertrophy § f ^) °i e^
  plastic deposits (§ 547), and they do mischief,ra thei by then size
  or situation than"from their intrinsic  nature.   V her  the mode of
  growth is more peculiar and more independent of that ot  the tex-
  Uires in which tliey arise, the resulting tumours are, mo re abnor-
  mal  in their nature  and  mode of development; they approach m
  character to malignant disease, acting injuriously, not only by their
  biitk and position" but also by abstracting the nourishment of  the
  body, and by tending to supersede the natural structure,
                            * Alison, loc. cit. 
336          WILLIAMS'S PRINCIPLES OF MEDICINE.

  575. At the outer limits  of the non-malignant growths may be
classed those peculiar  bodies,  called hydatids or acephalocysts.
These are more peculiar in structure and contents than any other
morbid growth, and they are quite detached from the structures
in which they occur.  They may  therefore be inferred to possess a
vitality quite independent of  that of these structures.   Their vita-
lity is low, but indisputable, and is exhibited  (1) in their power of
self-nutrition, as manifest in the growth and the peculiar structure
of their walls, which are much more elastic than any normal ani-
mal texture ; (2) in their power of secretion, shown by the pecu-
liarity of their contents, which are limpid and colourless, whatever
be  the nature of the  matter in  the  serous cyst which separates
them  from the living textures; (3) in  their power of reproduction
by gemmation, the young being developed between the  layers of
the parent cyst, and thrown off either internally or externally ac-
cording to the species.  Professor Owen* describes the hydatid to
be " an organized  being, consisting  of a  globular bag, which is
composed of condensed albuminous matter, of a laminated texture,
and containing a  limpid colourless fluid, with a little albuminous,
and a greater proportion  of gelatinous  substance."  He  adds,
"As the best observers agree in stating that the acephalocyst is im-
passive under the application of stimuli  of  any kind, and mani-
fests no  contractile power, either partial or general, save such as
evidently results from elasticity—in short, neither feels nor moves
— it cannot, as the animal kingdom is at present characterized, be
referred to  that division of organic nature.  It would then be a
question, how far its chemical composition forbids us  to  rank the
acephalocyst among vegetables.   In this  kingdom, it would ob-
viously take place next those simple and  minute vesicles which
in the aggregate constitute  the  green  matter of Priestley (Proto-
coccus viridis, Agardh) ; or those equally  simple but different co-
loured psychodiariae, which give rise to the red snow  of the arctic
regions (protococcus kermesianus).   These ' first-born of Flora'
consist, in fact, of a simple  transparent  cyst, and propagate  their
kind  by  gemmules developed from the external surface of their
parent."
  The researches of Schleiden, Schwann, and their followers, have
thrown some light on the possible origin of hydatids,  by  showing
that the primitive cells of animal, as  well as of vegetable, struc-
ture, are often not unlike hydatids, in their anatomical  composi-
tion, growth, and mode of reproduction; for  the hydatid appears
to be a nucleated cell, from the interior of which are developed nu-
clei and nucleoli, the germs of young cells.  But if it be presumed,
in accordance with this fact, that hydatids are really offsets of
living structure, capable of living detached from the solids of the
body, it still remains a mystery how this divided or detached life
is acquired  by certain  molecules on  rare occasions, and  contrary
* " Cyclopaedia of Anatomy," &c, article Entozoa. 
STRUCTURAL DISEASES.
337
to the usual law.  We might perhaps imagine some analogy be-
tween hydatids and the polype tribe of animals, which may be in-
definitely propagated by division; and it might be conjectured that
the conditions of the body in which hydatids are most commonly
found, might reduce the plasma of certain parts to the standard of
this mode of life ; but these subjects are too speculative to be dwelt
on here.
  576. The situations in which hydatids have been most commonly
found, are  the  liver, the  lungs, the spleen, the  kidneys, and  the
ovaries.   M. Andral  records  an instance in  which  he  found
hydatids in  the blood within the pulmonary veins;  there was also
a large cyst full of hydatids  in  the  liver.   The  condition  of  the
system in which they have been most frequently found to occur, is
one  of cachexia and mal-nutrition.  They are usually  contained
in a serous or protective cyst (§571) formed by the texture around
them ; and  the symptoms which they occasion are  merely those
caused by their bulk and position, compressing, displacing, and
irritating  organs, and causing atrophy and  inflammation of their
textures.   In the  cyst which contains them, there  is commonly
found more or less opaque laminated matter, which appears to be
the debris of collapsed hydatids; indeed, some of those retaining
the globular form often exhibit the commencement of this  decay,
in an opacity and wrinkling of  their walls, and a changed  colour
of their contents.
   577. The echinococcus is a variety of hydatid, differing from the
preceding chiefly in its having a yellowish and tougher outer tunic,
and in its containingdistinct animalcules within it  (vermiculus echi-
nococci).   It has been found in the liver, spleen, and mesentery,
and rarely  in  the urine.  The cysticercus  is  found  in muscular
structure, and in one instance was seen in the aqueous humour of
the eye.  It has a distinct structure, consisting of  a cystiform body,
and a head provided with suckers and hooklike  processes  for at-
tachment.   The distoma* hepaticum, or liver-fluke, is rarely found
in the human subject.  It is  the supposed cause of the rot in sheep,
and was found by Andral and Delafond in those  animals in which
dropsy was present, and there was a defect of albumen in the blood
(§ 222).   The rot is a  disease which chiefly attacks sheep fed in
wet clayey  pastures.
   The subject of intestinal  worms  belongs  properly to special
pathology.
   578. Little can  be said on the medical treatment of morbid
growths.   To those of the kinds most approaching to the natural
textures may be extended the observations applied to hypertrophy
(% 529)  and euplastic  deposits  (§ 552).   So far as they originate
from, or are augmented  by  local determination  of blood, or any
other kind of hyperemia, the remedies for these  morbid elements
may retard  the increase of the growths.  But  as we  have found

     * In § 222, the word cysticercus was inadvertently used for distoma.
            29 
338          WILLIAMS'S PRINCIPLES OF MEDICINE.
that the chief peculiarity and cause of these growths is an altera-
tion of the vital properties of  the primitive molecules of textures,
little is to  expected from measures which act only on the quantity
of the nutritive material.   In  fact, we have seen that, in many in-
stances, morbid  growths seem to originate in connexion with  a
depressed  rather than with an exalted condition of the vascular
functions; and in those last noticed, which  bear more  distinctly
the character  of parasites, the general or constitutional powers
are weakened in proportion as  these are developed.  Hence, the
general treatment indicated in such cases is of the supporting and
tonic kind, with  due  attention to the regulation of the digestion
and of the secretions.   But this treatment will require modification
when the morbid growths, by their irritation or pressure, excite a
considerable amount of inflammation, or even of local obstruction
to the circulation.
   We are not acquainted  with any medicinal means of correcting
those alterations of  vital properties in the molecules or textures
from which  morbid growths take their rise.  The same sponta-
neous power  which places these growths beyond  the controlling
influence  of the  laws of textural nutrition, places them beyond the
reach of general remedies,  The surgeon can in some instances re-
move the diseased part by the  knife, and can  sometimes further
 modify its properties  by  the direct  application  of escharotics  or
 caustics,  which  destroy the morbid cells or germs which are the
roots of the growth;  and  where this can be  effectually done with-
 out serious injury to other living parts, the cure may be complete.
 It is doubtful whether the physician possesses any  means of aiding
 the surgeon in these cases, or of controlling morbid growths which
 are beyond the  reach of the surgeon, farther than those calculated
 to promote the general health of the body.
   In many instances, the secondary pathological changes induced
 by  morbid growths, such  as inflammation, congestion, dropsy,
 flux, &c, are the chief objects of treatment, and may often  receive
 much  benefit from  the usual remedies; but  the extent  of tins
 benefit is commonly limited, as to extent and time, by the  perma-
 nency and intractability of the morbid growth, which is their
 cause.   Thus,  with encysted dropsy of the ovarium, peritonitis,
 ascites, and oedema, obstruction of the intestines, and other secon-
 dary functional disturbances, generally admit of relief for  a time ;
 but as the ovarian tumour  remains, and increases in spite of all
  remedies, the resulting disorders recur again and again, and at last
  prove fatal.   But the growth  of the  cysts themselves, although
  generally progressive, is  sometimes very capricious — being some-
  times very rapid; in other instances, even in the same case, it may
  remain stationary for years.   Nay, cases are not wanting, although
  rare, in  which encysted tumours have altogether disappeared : as
  after the operation of tapping, or even spontaneously,  by  rupture,
  into  some of the natural cavities.   But such instances, although
  they show a variety, exhibited by morbid growths, not to be  for- 
STRUCTURAL DISEASES.
339
gotten in connexion with prognosis as well as treatment, are to be
considered rather as exceptional cases, than as those following the
usual rule.
                        SECTION VIII.

                    MALIGNANT GROWTHS.

  579. Malignant  growths are distinctly organized structures,
arising in various textures of the  body, invading these textures
with their  own  peculiar substance, and often appearing succes-
sively or simultaneously in various  parts of the body.  They prove
injurious, and eventually fatal, not  merely  by their bulk and posi-
tion (§ 569), but also by the change of structure which they may
induce in various organs; by the intractable ulcerations and fun-
gous wounds to which they tend ; and, lastly, by a wasting and
deleterious influence which  they seem to exercise  on the whole
functions and structures of the body.   In all these points, the most
malignant growths  exhibit a character perfectly distinct from the
more simple, harmless growths, hitherto described;  but it must be
observed, that the degree of malignancy varies very much in dif-
ferent cases, by one or more of the preceding characters  being
absent, or not yet well developed ; and consequently, that morbid
growths or tumours  are occasionally met with, which  present a
doubtful or  intermediate character  between non-malignant  and
malignant.
   5S0.  The names  cancer and  carcinoma (from the supposed re-
semblance of the diseased structure to a crab, cancer, x*fK/voc)  have
been long applied to the whole genus of malignant growths, which
comprehends the following varieties; —Scirrhus; mammary,
pancreatic, and solanoid sarcoma; encephaloid or  medullary
sarcoma ; fungus  haematodes ; and colloid or  gelatinous cancer.
 That these are  all  varieties of the same disease may be inferred
from the fact, that they more or less resemble  each other in the
characters of malignancy  above  described;  and that they fre-
quently occur in the same subject, either simultaneously in different
parts, or successively in the same part.   Thus a person  who has
long been affected with scirrhus of the breast, often dies with me-
dullary sarcoma in the liver or lungs; or after a scirrhous tumour
has been removed from any external part, an encephaloid or fun-
gous disease may subsequently appear in  its place.   The varieties
may, for the most part, be traced to  different degrees of activity in
the specific or cancerous matter, that may now be stated to be the
materies morbi, and to the varied changes in the new growth, and
in the  implicated textures which  this matter, thus differently ac-
tive, can produce.   Of these  varieties, it  may  be  said  generally,
that  scirrhus, and  perhaps  the  mammary and the pancreatic sar-
coma, exhibit a chronic character, with less activity and tendency 
340
WILLIAMS'S PRINCIPLES OF MEDICINE.
 to increase locally or to  spread through the system;  whilst the
 others constitute  the more acute forms of  cancer, causing  more
 rapid growth in the parts first affected, and more speedily appear-
 ing in other parts of the body.
   5S1. The peculiar matter of cancer is distinctly a structure, con-
 sisting of nucleated cells and molecules, contained in an areolar or
 fibrous web of very various density.  Of these, the cells must be
 considered  the first elements;  and although they present  some
 variety in  form, they are constantly found in  every kind of cancer.
 These cells are chiefly globular, and  retain that shape in the soft,
 gelatinous  kinds of cancer; but in others, many are caudate or
 spindle-shaped, as  if in the process of transformation into fibres.
 [Miiller.]   In scirrhus, and other more solid  and chronic forms of
 cancer, the fibrous structure is  more abundant, and  is very per-
 ceptible to the naked eye, forming glisteningstriae or bands radiating
 through the mass, of cartilaginous  hardness  ; the cancerous  cells
 and numerous granules are seen between  these fibres, and accom-
 pany  them  to their outermost  branches.  In the cerebriform or
 medullary kind of cancer, the nucleated cells are very numerous;
 and the texture in which  they are  contained is  cellular, and  well
 supplied with vessels.   This is the  species in which the growth is
 most rapid, and in which, from the extravasation of blood in the
 loose new texture, a bloody aspect is given to parts of it, whence
 the name fungus haematodes.
   582. The intrinsic disposition to grow, even  at the expense of
 the  nutriment of other parts of the  body, which was mentioned to
 be a character of some formations not distinctly malignant (§ 574),
 is exhibited in a much higher degree in malignant structures, the
 increase of which may take place most rapidly when all the natural
 textures are wasting away.  This fact again  suggests the idea of
 an independent vitality possessed by these structures, in virtue of
 which, like parasitic animals or plants, they luxuriate at the expense
 of the whole frame.  The question next arises  — Are these growths
 truly parasites, arising from ova or seeds derived from without the
 body, and  after entering  it, and finding a proper nidus or  soil,
 taking root or becoming developed as a distinct being, like worms
 or  hydatids, only  drawing its  nourishment from the fluids  and
 solids of the body ?  If it  be objected that malignant growths are
 too closely  attached to, and too  much identified with, the textures
 of the body to permit the notion of  a  distinctness of being, it may
 be  replied, that  cancerous cells,  their most  distinctive  part, are
 often loose  and unattached: they  propagate themselves by the
 production of young cells within them; and  it  has been proved,
 by an  experiment  of Professor Langenbeck, that the cancerous
pulp containing these cells is capable of propagating cancer in
 animals on being  injected into their veins.   This positively  identi-
 fies cancer with contagious diseases, respecting the causes  of which
 we formerly noticed questions like the present, as  to their parasitic
nature (§ 99).  Contagion  is not, however,  a common  cause of 
STRUCTURAL DISEASES.
341
 cancer; the only example ever adduced being the rare one of the
 penis  becoming infected by a carcinomatous os uteri.   Further, it
 has been well remarked by Dr. W. Budd,* that the causes which
 have been supposed to induce cancer are not  such as  can, in  any
 intelligible way, favour the introduction of germs from without the
 body.  Thus, in chimney-sweeps and  others, the continued appli-
 cation of soot has been observed to be followed by the occurrence
 of cancer  in  the  scrotum, in  such a number of cases, as  to justify
 the interference that  it has been the  exciting  cause.  The often
 repeated contact of a  tobacco-pipe with the lip has also been con-
 sidered a cause of cancer of that part.   But neither of these causes
 can, in any conceivable way, promote  the  development of cancer
 from extrinsic germs.
   The alternative that presents itself is, that cancerous growths
 may arise from a peculiar perversion of the natural nutritive pro-
 cess, similar to those  modifications  which we have  been induced
 to suppose are the causes  of  the more peculiar kinds  of common
 growths ; but in the  case of malignant disease, the perversion is
 much greater in degree, and shows itself, not only in its origin, but
 in its whole  subsequent history.  It can be  conceived  possible,
 that causes long acting locally, as the soot on the scrotum of chim-
 ney-sweepers, the tobacco-pipe on the lips of inveterate smokers,
 the irritations of the  stomach connected with habitual dyspepsia,
 and of the  uterus from  irregular  menstruation, &c, may  induce
 this extraordinary alteration in the molecular nutrition of these
 parts; but we cannot hereby at all explain the peculiarity of this
 alteration, which must therefore  be viewed as an ultimate  fact in
 connexion with  nutrition.   In other  words, if we assume that
 cancer cells are modifications  of the natural cell-germs by which
 textures are  produced and nourished, we do not thereby explain
 (or refer to a known law) the extraordinary anomalies of the in-
 dependent vital properties and consequent growth of these modified
 cells, which are  obviously different from that of texture cells in
 general, and derive much of their  destructive effects from such
 difference.  It remains for future investigation to establish the law
 of that difference.  We have before stated, that Dr. Hodgkin has
 proposed  a plausible  hypothesis with  regard to these and other
 growths, that they originate  in  cysts  (not cells or  microscopic
 cysts, but larger ones,  which comprise  these) ; and that the  multi-
 plication of these cysts within each other, their prolongation into
 radiated fibres, their  pressure  on adjoining textures, and conse-
 quent  inflammation, induration, ulceration, atrophy,  or gangrene
of these textures, comprise the whole history of malignant growth.
What appears to me to be chiefly wanting to establish Dr. Hodg-
kin's views is, a more distinct demonstration of the supposed cysts,
which, at the commencement,  or at the outer limits  of cancerous
growths during their spread, ought to be distinctly visible.

  ♦ Remarks on the Pathology and Causes of Cancer, Lancet, May 28, 1842.
           29* 
342          WILLIAMS'S PRINCIPLES OF MEDICINE.

  583. But although the  precise origin  of malignant growths is
still a matter of uncertainty, some  important practical facts may
be gathered from  their pathology.  Their microscopic  structure
and history pretty clearly  show that they are of local origin ; that
they extend by the multiplication of their cells, which, by pervert-
ing the nutrition of the adjacent parts, cause the growth of the
tumour;  that they ultimately infect other parts of the  body,  by
spreading to the nearest  lymphatic glands, and by the mixture of
their cell-germs with the blood (§ 259), which form new tumours
in the liver, lungs, or other vascular  parts  (the same as those in
which purulent deposits take place, and for similar reasons, § 470) ;
or the cancerous matter is sometimes found in clots within blood-
vessels, or in the coagulable lymph effused by inflammation.*
   But the history of malignant  growths  comprises not  only that
of the development of the cancerous structures in different degrees
and  forms, but also their effect  on  the  adjacent textures; and it
seems to me possible, by a  due  regard  to these two elements, to
explain  much  of  the varieties which  cancerous disease presents.
Thus scirrhus is the slowest, form of the disease, because it gene-
rally occurs in persons above the age of forty, in whom the tex-
tural nutrition is tardy, and the cancerous matter is but slowly de-
veloped : the effect on  the  adjacent  textures is to excite inflam-
mation of a chronic form, and  therefore leading  to  induration,
and  often to contraction (§ 479), and  more  or less obliteration of
the natural textures.  Hence, the hard, knotty, corrugated swelling
of scirrhus  of the  mamma,  rectum, pylorus, &c, which may  be
attended with more or less pain  of  a peculiar stinging or lancinat-
ing character, besides various functional  disturbances (obstruction
to the passage of food or fasces, severe dyspepsia, vomiting, &c).
The  continuance of irritation in the  indurated parts leads  (as usual)
to ulceration (§ 466).  This constitutes what is called open cancer,
with ragged, inverted, or everted edges, and a fungous or sloughy
interior,  discharging  a  dark,  offensive,  ichorous  matter.   That
such  ulcers should be wholly  incapable of healing is  quite  in-
telligible, when it  is remembered  that  its walls  are composed
of the cancerous  structure  and  the  compressed  remains of the
natural  textures, whose  secretions are  too poor and too  much
perverted to afford euplastic secretion.   The ulcer  may  prove
an outlet for the increasing cancerous matter;  and if the  discharge
be checked by external means, the disease is more likely to spread
or to attack other  parts: as the ulceration destroys the  indurated
mass, and thus removes the barrier between the cancerous germs
and  the  healthy  textures, there is  greater chance of  the  body
becoming more generally infected.  Hence, too, from the  multi-

  * In a case (which Ilately saw with Mr. Avery) of malignant disease of the lungs
and deep cervical glands, involving the 8th nerves, there had been recent pleurisy,
and the bands of false membrane were glistening, and grated under the scalpel
from the presence of cancerous fibres. 
STRUCTURAL DISEASES.
343
plication  and  diffusion  of the germs,  the  secondary  malignant
growths that may appear in  other parts are  often  of  the softer,
more rapidly growing kinds.   The  influence  of scirrhous cancer
on  the whole  frame, although more slowly induced, perhaps for
this very reason, is  carried to a  greater degree than that of any
other  form  of cancer.   Emaciation sometimes reaches a  point
unequalled in  any other  disease ; and  the wasting, of which this
is the sign, extends to the  composition as well as  to the bulk  of
organs and textures.  Thus bones lose much of their animal matter,
and become  so brittle, as  sometimes to be  fractured from the
slightest violence.   All  membranes become extremely thin ; the
omentum often wastes away, excepting a few threads.  The lungs
exhibit a remarkable lightness, in weight and colour ; and I have
seen the  old  cicatrices or  consolidations, so  frequently found  at
their summits, thinned and almost as pliant as other parts of  the
pulmonary texture.*   But nothing  is  more remarkable than  the
exsanguine state of the  textures generally; and this condition is
obvious during life in an extreme pallidity, often associated with
a sallowness or  peculiar  lemon-tint of complexion, that has been
observed to be peculiar to cancerous subjects.
   Scirrhus chiefly occurs above  the age of .forty ; and the more
 advanced the age, the slower generally is the progress of the dis-
 ease.    It has been  remarked, by  Sir Charles Bell,  Sir  Astley
 Cooper, Mr. Travers, and others, that scirrhus of the breast, which
 will run a comparatively rapid course at the age of forty-five, will
 remain stationary for years, and hardly appears to  shorten life at
 the age of sixty or seventy.   This shows the share which activity
 of textural nutrition  has in causing the increase and dissemination
 of cancerous  disease.  It is under such circumstances that opera-
 tions  for the removal of the  disease have  been most successful;
 but it must be remembered, also, that  in  such cases they are  less
 strongly called for.
   584.  The  pancreatic, mammary,  lardaceous, (or pork-like,)
 and salanoid', (or potato-like,) forms of cancer appear to be inter-
 mediate  between  scirrhus  and  encephaloid  disease,  increasing

   * It appears to me, that the rare coexistence of tubercle with cancer, as noticed
 bv some writers, is to be ascribed to the former being  removed by absorption,
 during  the extraordinary wasting  of textures which attends chronic cancer. 1
 have twice found, in the  bodies of persons who died of cancer, considerable re-
 mains of tuberculous deposit at the apex of the lungs, without any tubercles in
 other parts. In one case, masses, partly caseous, partly calcareous, of the sizes
 of a pullet's and a pigeon's egg, were thus found encysted by a thin membrane.
 In another, a cavity communicating with the bronchi, traversed by a band of
 dense tissue, like that found in tuberculous cavities, and lined with a thin, smooth
 membrane, was  in the middle lobe. In all these cases, the other parts of the
 lungs were free  from tubercles.  Now, it does not appear probable that such con-
 siderable tuberculous deposit should  have taken  place without some in other
 narts also  We meet with no case of recent tubercle thus limited to one portion
 of the lun'cr.  These and similar facts connected with the emaciation of old age,
 seem to me to furnish strong arguments in favour of the absorption of tubercles. 
344          WILLIAMS'S PRINCIPLES OF MEDICINE.

more rapidly than the former, yet approaching to  it in  firmness.
They are attended with less pain, from the smaller degree of ten-
sion and induration which  they cause in the implicated textures.
For the same reason, they are less disposed  to ulcerate (§ 466)
or slough  (§ 474) ; and  they  commonly  prove fatal, either by
their growth and encroachment on  some vital part, or by leading
to the dissemination of  cancerous  deposits in other  parts of the
system.
  5S5.  Encephaloid, (brain-like,) or  medullary sarcoma, is the
acute or rapid variety of cancerous growth.   It occurs chiefly in
young and  middle  aged subjects, and in the  most vascular tex-
tures ; and it may be  fairly connected with the activity of their
molecular nutrition.  This  maybe the cause of the rapid increase
of the cancer-germs or cells (if these be  indeed mere modifica-
tions of the cell-germs of  textures);  but much of  the  speedy
growth and early dissemination of  this variety of cancerous dis-
ease, must be attributed to an active plastic process, which the pre-
sence of the cancerous matter excites  in  the vascular  textures  in
which it lies.  The mass of encephaloid tumours comprises false
membranes, lymph, and even coagula of blood in various degrees
of organization : among and between these are found  the cancer-
rous cells, which luxuriate and rapidly multiply in so fertile a soil.
It is in connexion with tumours of this kind that the fact before
noticed has been observed, that coagula  in the neighbouring veins
have exhibited the encephaloid appearance ; and so  has  coagula-
ble  lymph, produced by  inflammation of serous membranes or
parenchymata of organs.  The  speedily destructive influence of
this  kind of cancer is mainly to be  ascribed to the rapid dissemi-
nation  of  the cancerous matter, and  the bulky depositions which
it induces around it, which, although organized, and highly vas-
cular, are beyond the controlling influence of the powers of assi-
milation or absorption,  and consequently stuff,obstruct, and com-
press organs to a fatal extent.   The facility of growth  in these
tumours receives some  explanation  in the varicose condition of
their vessels, as  ascertained by Mr.  Kiernan, and their free com-
munication with arteries (§ 420), as  pointed out by Schroeder Van
der  Kolk.   The  same circumstance, together  with the  general
softness and looseness of their texture, accounts for  the facility
with which hemorrhage takes place into their substance  (§ 357),
causing an appearance that has led  to the  use of the texm fungus
haematodes.  These forms of disease commonly prove fatal before
the  emaciating effects, so remarkable in scirrhus, have advanced
far.
  5S6. The colloid or gelatinous (areolar of Cruveilhier) variety
of cancer seems to me to represent the cancerous element almost
in a separate state, little mixed with natural tissues or their pro-
ducts.   According to Miiller, it consists chiefly  of cells contained
in a  very slight loose web ; the cells are larger and rounded than
usual, and contain  small  cells, which also contain  cell-germs. 
STRUCTURAL DISEASES.
345
The peculiar germinal principle of cancer is here, therefore, very
abundant and piolific; but the nutritive secretion of the surround-
ing textures is not equally copious : therefore no distinct growths
are formed ;  but the gelatinous matter is found infiltrated into the
webs of textures, chiefly in connexion with advanced stages of
other forms of the disease.
   Further varieties  have been described,  by Dr. Carswell  and
others,  according to the  particular form  which the cancerous
growth assumes, such as the tuberiform, stratiform, rami form,
&c.  They are probably connected with the anatomical construc-
tion of the parts in which they  appear, together with the quan-
tity and rapidity of development of the new growth.(a)
   587.  Another morbid production that has generally been classed
among malignant growths, because  it  affects many  textures and
may supersede them, is  melanosis, black cancer, ox black tubercle.
It  most commonly occurs  in the form of  a loose cellular tissue
filled with the peculiar black matter suspended in  a serous liquid ;
but sometimes its substance is quite compact, and resembles crude
yellow  tubercle, or the lardaceous  form of cancer.  I have a draw-
ing which I made of a lung exhibiting a combination of encepha-
loid disease with melanotic tumours, the latter of compact texture,
like nodules of pulmonary apoplexy, and  varying in colour from a
dark bistre brown to a deep jet black.  The combination of mela-
nosis with carcinomatous tumours has also been noticed by  Cru-
veilhier and Carswell.  Andral describes melanosis to occur in four
forms : — " (1) It pretty frequently constitutes masses, encysted or
otherwise;  (2) the matter which composes  it may, like the tuber-
cular matter, be  infiltrated  into different tissues;  (3) it may  be
spread like a layer, of greater or less thickness, on the free surface
of membranous organs; (4) it  may exist in the fluid state, either
pure or mixed with  other fluids."*
   The peculiar characteristic of all these forms is the black matter,
which, from the analyses of Dr. Fyfe, M. Thenard, and  M.  Foy,
appears to be a hig-hly carbonized  insoluble matter, supposed  to
be altered colouring matter  of the blood.   It has been compared
by Andral to the black pigment of the eye, and he considers it to
be identical with the black matter commonly found  in the lungs
and bronchial glands. The colouring matter of the blood certainly is
sometimes changed into a  perfectly black matter, as in the black
vascular strige and patches  in the  intestinal canal, particularly in
chronic inflammation, where the blood has been effused or retained
   (a) In a preceding note (p. 327), the proportional frequency of
tubercle in the lungs to that of tubercle in other tissues and organs
was stated.   The proportion  of cancer is as follows:—Cancer  of
the lungs occurs in the proportion to cancer of the liver, as 18 to
12 ; and to cancer of the brain, as 18 to IS.

           *  » Pathological Anatomy," (Transl.,) vol. i., p. 249. 
346          WILLIAMS'S PRINCIPLES OF MEDICINE.

in vessels,  and altered by the intestinal  secretions  and  gases.
These black  appearances  are called  by  Dr. Carswell  spurious
melanosis.   Again, the black pulmonary matter is merely a car-
bonaceous  powder contained  in the interstices  of the  textures,
and sometimes in the vessels of the lungs and bronchial glands ;
but whether it also proceeds from the colouring matter of the blood
in an altered state, or is truly a  deposit of carbon, is uncertain.
All that is requisite to produce a  carbonaceous deposit in the
colouring matter of the blood  is  the  abstraction  of a certain
amount of hydrogen, which the mineral acids are capable of affect-
ing ;  and it seems not improbable that  such a change takes place
naturally in the formation of black  pigment through the opera-
tion of peculiar cells (pigment cells), and as a result of disease  in
melanosis.
   But this production of black matter  may co-exist with various
modifications of the  nutritive process;  plastic, as in  cellular and
membranous melanose tumours; cacoplastic, as in the hard black
tubercle, and in the black consolidation of chronic pneumonia; and
aplastic, as in the combination of black with opaque caseous  mat-
ter, not unfrequently found in the lungs and bronchial  glands.  So,
too, it may be, as  we have seen, combined with  various forms of
malignant disease; but, with Andral, I hesitate to class simple me-
lanosis with malignant growths.
   588. The  treatment of malignant disease has been  generally
considered to  belong  rather  to surgery  than  to  medicine, and
yet the  utility of removing  malignant  growths by operation has
 been generally deprecated by surgeons down to the present time,
 when they may again  learn, chiefly from the investigations of phy-
sicians, when and why operations may  be expected to be success-
 ful.  The  indications  of  treatment which are  suggested by the
 foregoing account of malignant disease may be summed up under
 three heads: — (1) to  extirpate the malignant growth;  (2) to  re-
 tard  its development;  and (3) to counteract its effects.
    The complete extirpation of malignant growths can  be effected
 only when they are quite local, so that  when  removed by the
 knife or by caustic, no root nor stray germs of the  disease shall
 be left behind.  We have adduced  reasons to  suppose that at its
 first origin cancer is entirely local, and that if  it be  completely
 excised at an early period,  a  cure  may be effected.   For this
 success, it is essential  that every cancerous cell  be removed ; and
 Dr. Hodgkin has recommended the careful examination  of the
 portion removed, to see  that it contains on its surface none of
 those grains consisting of  an  aggregation of  cancerous cells,
 which can be seen even  with the  naked eye in  cancerous struc-
 ture.  Dr. W. Budd recommends the  use of the microscope for
  the same  purpose : " If the characteristic cells were found  on the
 cut surface  of the  portion removed, it would be morally certain
 that others have been left behind, and that the extirpation is in-
 complete, although, on the other hand, the absence  of these cells 
STRUCTURAL DISEASES.
347
would be by no means so sure a guarantee of their entire removal.
Such an examination would, however, always be a matter of great
interest to the surgeon."*  The best security would lie in the ope-
ration being performed before the constitution has been in any de-
gree impaired by the disease ; and  particularly before any neigh-
bouring parts,  especially lymphatic glands,  have  shown any
indications  of disease.  The best chance will therefore be afforded
in cases in which the growth is most chronic and inactive, and of
the smallest extent, as  in scirrhus  of the lip, skin, or breast.  If
any cancerous texture or germs are left behind, the operation is
likely to do harm instead of good, by bringing them into activity,
 and developing the acute form of  the  disease.  Cases have  oc-
 curred in which a cancerous breast has been completely removed
 by a spontaneous sloughing; but such an event is extremely rare.
 Cauterization is less  advisable than excision, because  less  ma-
 nageable.
    589. The second indication, to  retard the development of the
 malignant growth,  is chiefly  to be attempted by  means which
 diminish the circulation through the diseased part.  Repeated local
 bleedings have been found useful, partly perhaps in this way, but
 more by relieving the inflammation excited by the growth.  The
 best means of staying the growth of malignant disease is by pres-
  sure, which has long had many advocates.  Such a kind and de-
  gree'of pressure as will reduce the circulation through the part to
  the lowest degree compatible with its life, will pretty surely arrest
  the increase of the morbid growth, by depriving it of its nutri-
  ment  But for the utility of this measure  it is equally necessary
  that the  disease  shall  not have  extended to other parts besides
  those to which the pressure  is applied, otherwise  in those parts,
  which are  commonly internal, the growth will proceed with an
  increased rapidity, proportioned to its  suspension by the pressure
  on  the  outward  part.   The best means of applying pressure
  are  those contrived by Dr. Arnott, especially the slack air-cushion
  under a compress.  It is very doubtful that we possess any means
  of influencing malignant growths through the constitution.  Various
  medicines have enjoyed an  ephemeral repute for their efficacy in
  cancer   Of these, conium has been  one of the most favourite.
   Dr  A *T Thomson considers the  iodide of arsenic to possess  some
   cower in controlling  the increase of cancer.  But it is  doubtful
   that any of these remedies do more than soothe irritation, and re-
   strain common inflammation and its results, with which malignant
   arowths  are generally  complicated.
   g  5 Jo The third  indication, to  counteract the  effects of morbid
   growths, is more commonly the object of treatment; but the means
   of fulfilling it fail  more and more as the  disease advances.  The
   use o  narcotics of every description, general and local, to soothe
   Te nain and irritation, and of occasional  local antiphlogistic mea-
   sures to remove inflammation and congestion, is commonly ad-

                          * Lancet,  May, IB42. 
348           WILLIAMS'S PRINCIPLES OF MEDICINE.

mitted in palliation of malignant disease ;  but the importance of
tonics and nutritive diet to counteract the increasing cachexy and
emaciation is not so generally regarded.  Yet these have appear-
ed to me to have considerable efficacy in supporting  the constitu-
tion and supplying it with strength against the enemy that is prey-
ing on its vitals.  Preparations of iron, when  borne, are the best
tonics.(fl)
                         SECTION IX.

                   DISORDERS OF  MECHANISM.

   591. Many structural diseases arise from changes in the me-
 chanism of organs, which are not precisely implied in any of the
 preceding elements.  It  is quite needless to enter into a detail of
 these  alterations of mechanism; but to  complete our key to  the
 elements of disease it will suffice to cite a few examples.
   Hollow organs are liable  to dilatation from an undue accumu-
 lation of matter within them.  Thus, the  heart, arteries, and veins,
 the air-cells of the lungs, portions  of the intestinal tube, the blad-
 der, &c,  become distended  when there  is an obstruction  to  the
 passage of their respective contents, or when the expulsive  power
 by which they are  contracted is weakened; and such distention,
 if long continued or frequently repeated, becomes a permanent
 dilatation.
   Parts may become overstretched and relaxed by a loss of natu-
 ral cohesion or elasticity;  thus, ligaments,  tendons, and fascia;,
 become relaxed and ineffectual in binding together or connecting
 the parts to which they are attached.
   592. Contraction is the opposite of dilatation.  It may consti-
 tute stricture, and lead to the partial or total  obstruction of parts
 of the canals of the intestines, urinary and respiratory apparatus,
 vascular systems, &c.  The  influence of contraction  of the  tex-
 ture of organs and  of serous  membranes, we have several times
 had occasion to notice as the results of disease.
   593. Parts may be ruptured ox  lacerated, either from previous
 disease or from  violence, and  structural disease is the result.
 Thus,  hollow organs, the  heart or arteries, the stomach, the gall-
 bladder, the urinary bladder have been ruptured with  speedily
 fatal results.   Rupture  of the valves of  the  heart, of portions of
 bloodvessels, of air-cells, &c, injures the  mechanism  of  these
 parts,  and forms an element of structural  disease.
   594. Displacements and compressions  of organs are frequently
 the effect of tumours or effusions, as in the case of the tumour of

  (a) A very good  monograph on cancer,  by Dr. Walshe, has
lately been introduced  to  the notice of the  profession  by Dr. J.
Mason Warren: Boston, pp.  351, 12mo. 
NOSOLOGY.
349
ascites, or ovarian  dropsy, or an enlarged liver, pushing up the
heart and lungs, and  variously compressing and displacing the
abdominal viscera; of an  enlarged heart or aneurism displacing
and compressing the lungs and  air-tubes;  effusions in a  pleural
sac, compressing the lung  of that side, and displacing the heart,
mediastinum, diaphragm, liver, and the walls of the chest.
  595. Contortion of rigid parts is exemplified in rickets, mollities
ossium, and rheumatic nodosities of the joints.  Curvature of the
spine, besides shortening the length of the trunk, disorders  also the
mechanism  of respiration,  by changing the  position of the ribs;
and when the  distortion is great, the function of the heart and
great arteries, and of the abdominal viscera, may likewise  be af-
fected by it.
                         CHAPTER V.

  THE CLASSIFICATION, SYMPTOMS, AND DISTINCTION OF  DISEASES.


                          SECTION  I.

                           NOSOLOGY.

    596.  Having considered the causes of disease, their mode of
  operation, the resulting effects on  function and  structure in the
  ultimate and proximate elements of disease, and  the remedial in-
  fluences which  can be brought to  remove or counteract these
  elements; we have next to notice the manner in which these ele-
  ments of disease affect the several parts and functions of the body,
  the symptoms which they induce, and the  combination or forms
  which they  present,  as special diseases.   In  order thus to  allot
 together in distinct divisions the  wide domain of disease that  has
 been displayed bv general pathology, it is necessary to define spe-
 cial diseases—that  is, to designate  their  peculiarities by short
 descriptions, and to group and subdivide them in classes, orders,
 genera,  and  species.   This classification and definition of diseases
 is usually implied by the word Nosology.
   597.   Diseases  may be classed  in different ways.    The first
 method  attempted was a classification according  to their  most
 prominent phenomena or symptoms.   Of this  kind was  the sys-
 tem of Sauvage, who divided diseases into  ten classes: — vitia,
febres. phlegmasiae, spasmi, anhelationes, debilitates, dolores, vesa-
 nise,fluxus, cachexia;.   The classifications of Linna;us, Vogel, and
 Sagar, were  also ofthis kind, which may be termed artificial; and
           30 
350          WILLIAMS'S PRINCIPLES OF MEDICINE.

Cullen's division was a strained simplification of the same descrip-
tion of arrangement, condensing all diseases into the four classes :
— pyrexiae, neuroses, cachexias, and  locales.
  The chief objection to  this, which  may be called  symptomatic
nosology, is that it regards symptoms as the essence of diseases,
whereas they are really extremely variable, both in their kind and
severity, and by no means uniformly correspond with  the nature
or with the amount of the real change  of function and structure
present.  Hence, too, similar symptoms, from the  most diverse
causes, are classed  together,  although they  may  require quite
opposite plans of treatment; whilst diseases that are really kindred
in their nature, are widely separated, because they differ in  their
symptoms.   The artificial method of classification  is  admissible
only as a provisional means of arranging subjects  in  a  conven-
tional way, until the true nature of these subjects is investigated ;
when this is done, or even as it  advances, the artificial method
should give place to the natural one, which is not a mere glossary
of names, (or symptoms,) but in itself expresses the most import-
ant points of knowledge of the  nature of the subject.
  598.  The true foundation of a natural classification of diseases
is in a correct pathology,  or knowledge of the intimate  nature of
diseases ;  but the  subdivisions are  conveniently determined by
the chief  seat of the disease, or by  other of its  more  prominent
characters.  The classification of Pinel approaches to this standard,
although  it is necessarily imperfect from the infant state of patho-
logy at his  period.    He  divided diseases into five classes : —
fevers, inflammations, hemorrhages, neuroses, and  organic affec-
tions.
  Pathology may be applied to the classification of  diseases  in
two modes.   In  one, it  is the first  step  in the arrangement, all
diseases being distributed in  classes  expressive of the several
pathological  elements affecting the  systems defined  by general
anatomy.  Thus, according to the groups of pathological elements
which we have reviewed, the  classes might be — diseases of the
muscular system, those of the  nervous system, of  the secernent
system, of the blood, of  the vascular  system,  and of nutrition.
The subdivision of these classes into orders would  be determined
by the individual  pathological elements: thus, diseases of the
muscular system would  be divided  into  those of irritability and
those of tonicity, with the generic  subdivision according to excess,
defect, or perversion; and, lastly, the  specific distinctions would
be made according to the organ or locality affected.  This arrange-
ment is not suitable for clinical or practical purposes, because dis-
eases  are generally too  compound  to admit of being classified
according to their  elements:  they  commonly  comprise several
pathological elements, and the proportions of these  elements vary
with the  progress of the  case.
   599. The  other  mode of  using pathology in nosology, is  by
making it subservient to establish those divisions or subdivisions in 
NOSOLOGY.
351
which the character of the elements of diseases affords an obvious
and  natural  mean of distinction, which  may be useful in their
diagnosis and treatment, whilst the remaining divisions are derived
from the situation or other circumstances of the  diseases.   Thus,
diseases may be classed according to their chief locality, the organ
or set of organs which they affect.  Thus, as classes of disease, we
may have, diseases of the organs of respiration ; diseases of the
organs  of circulation ; of the apparatus of alimentation;  of that
of urinary excretion and of generation;  of the nervous system ;
of the organs of locomotion ; of the skin; of the blood ; and lastly,
general diseases, having no defined seat.  The division of these
classes  into orders is founded on  pathology : thus, each  class com-
prehends functional diseases, subdivided into diseases of  irrita-
bility, tonicity, sensibility,&c,and secretion; and inflammatory
 and  congestive diseases; and  diseases of nutrition (structural).
 A further division into genera and species is made according to the
 anatomy of the parts: thus, of the class,—diseases of the  organs
 of respiration ; order, functional disorders ; genus, irritability —
 the species  would be spasm or  paralysis of the  larynx, of the
 bronchi, &c.  But in  general  diseases, the subdivisions must  be
 altogether pathological, or founded on causes or symptoms :  thus,
fevers  are distinguished into  inflammatory, eruptive, adynamic,
 or contagious and malarious, or intermittent and continued, as
 each of these  modes of distinction becomes most available.
    This last classification, although it may be less pure and methodi-
 cal than others, is the  most  useful in practice, because  it most
 closely follows nature ; and setting aside more minute and  difficult
 distinctions, it leads  to the seat and nature of the disease, and
 renders available those general  principles in pathology and thera-
 peutics which form the foundation of rational medicine.   A chiet
 recommendation of  this kind  of nosology, or arrangement ol indi-
 vidual diseases, is, that whilst it includes all diseases hitherto dis-
 tinguished, it points out others  which may and do occur, but for
 want  of distinct pathological views and names have been con-
 founded with others  more prominently defined.
    600 The  definitions by which individual diseases are  desig-
 nated  mav refer either to the pathological nature of the disease or to-
 ils characteristic symptoms, or to both, and in some instances, the
 causes or results of the disease form a characteristic part of Us his-
 tory  It should be remembered that  the great purpose of nosology
 is to arrange  and define diseases in such  a manner that their true
  nature, with  the chief points of affinity and difference between
  each o her, may be expressed by the arrangement and definition ;
  and whether these  points of affinity or  difference are most mani-
  fest in the causes, nature, or symptoms of the diseases, the  arrange-
  ment  and  definition should duly regard them   Thus besides its
  chief  peculiar symptoms, the definition  of a distinctly infectious
  dtase  as carbtina, shall  express its  infectious character;  that
  of a  disease indubitably caused  by marsh miasmata, as ague, 
352
WILLIAMS'S PRINCIPLES OF MEDICINE.
should imply this fact; whilst, by both being classed  as general
diseases, and in the order fevers, the one of the genus eruptive, the
other of the genus intermittent, much of the nature of the dis-
eases, as well as of their distinguishing characters, will be set forth
by this nosological arrangement.   The further that our knowledge
of pathology is advanced^ the more considerable a part  will it form
in our nosological  systems ;  but  in the  meantime  it  is  better to
render our  classification and definitions as useful as  possible by
deriving  them from all  the most available sources of  informa-
tion, than to  keep them  imperfect and inapplicable until science
is sufficiently advanced to supply us  with  a system that is quite
pure.
  As we do not enter upon special pathology, or the history of in-
dividual diseases, it is unnecessary to proceed into details of noso-
logy.   The foregoing remarks are intended merely to explain the
objects of nosology, and  to introduce the two  associated  subjects,
semeiology and diagnosis.
                        SECTION II.

                 SEMEIOLOGY AND DIAGNOSIS.

  601. Semeiology treats of signs* and in medicine, of the signs
of disease.  The word symptom is commonly used^ in the same
sense as sign ; but, as  its etymology implies,! it is a more vague
expression, signifying coincidence or co-occurrence rather than a
direct or constant  connexion.  It  has been  attempted  by some
writers, (particularly  French,) to restrict the word symptom to the
phenomena manifested by present  disease only :  but this is con-
trary to the usual custom by which we speak of precursory and
consecutive symptoms, symptoms  of health, &c.   Again, some
have confined the term symptom to the phenomena depending on
vital properties, whilst those phenomena of disease  which are
more  directly physical  they call signs.   This was  the sense  in
which Laennec used  these words, and others have followed his
example.  Although this acceptation of the  words is not in strict
accordance with former  usage  or  with their etymology, yet  it
would be convenient for conventional use ; and  to render it more
precise, it  will be well to prefix the epithets vital and physical, as
first suggested by Bayle, and partially  adopted by Laennec.
  Let us then understand the word sign of disease generally to
imply, anything  by which  the presence of disease may be made
known.  A symptom is any phenomenon which becomes obvious
in the course  of disease : it may thus often prove to be a sign ; but
many symptoms are of such uncertain connexion with a particular
   * "Sign, that by which anything is known." — Johnson's Dictionary.
   f luy.n'rufAdi, from a-vv, with, and vtlcv, to fall. 
SYMPTOMS AND  SIGNS OF DISEASE.
353
disease, that they cannot be  said to make known the presence of
a disease, and therefore they cannot be called signs.  The more
specific designation of physical signs [symptoms] and vital symp-
toms will succeed better in attaching a distinct meaning to the dif-
ferent  phenomena of disease; and by stating briefly the grounds
ofthis distinction and the proper application of the terms, we may
be able to point out the respective value of each class of pheno-
mena to which they are properly applied.
  602.  Physical sia;ns [symptoms] are those physical properties of
the body, or of a part of it, which are perceptible to any of the senses
of the observer.  Thus, the form, size, colour, firmness, or softness,
weight, heat, and odour, of the whole body, may be said to give physi-
cal  signs or evidence of its condition, whether in health or in disease.
So, also,  the form,  size, colour, resistance, position, temperature,
smell, and acoustic  properties of a part of the body, afford physical
signs of its  condition, whether in health or in disease.  Thus, the
appearance of an external disease, the feeling of a solid tumour,
or of the fluctuation of liquid in the  abdomen, listening to sounds
produced by or  in diseased internal parts, furnish us with physical
signs of the presence of disease.
  The difference between the signs of health and the signs of dis-
ease is determined  by our knowledge of what is usual in health ;
and this knowledge may be  derived (1) from general observation
or  experience of healthy standards, or (2) from anatomical  and
physiological  knowledge of what the phenomena of health ought
to be ;  or (3)  from a particular knowledge of the standard of health
in any individual case.(a)
  (a) There is no small laxity of dialectics in the author'sobservations
on " semeiology and diagnosis" in this section, and in " prognosis"
in the following chapter.  They partake more of the character of
hurried notes than of carefully expressed axioms, or even of con-
ventional explanations, which have received the sanction from age
to age  of the most careful and  learned teachers.  We are  afraid
that°this want of attention to accurate definition is an evidence of .
the somewhat empirical nature of English medicine.   Facts are
sought out with commendable industry and with no small success,
but they are not arranged after any natural method, or, this being
generally impossible, after any satisfactory system.  The past or
Hippocratic medicine  is too much overlooked, if not despised, and
certainly no adequate  pains are taken to connect it with the pre-
sent.   One of the bad effects of this disjunction is an unjustifiable
curtailment of the legitimate, time-honoured, and really productive
domain of pathology, and its restriction to a small, and not always,
however rash  may seem the assertion, most important  section,
viz., a  bald observation of anatomical lesions, and their immediate
symptoms in disease and appearances after death.
  We had occasion (note to p. 31) to criticise the author's separation
           30* 
354         WILLIAMS'S PRINCIPLES OF MEDICINE.
  All of these healthy standards of comparison are available: the
first is less exact than the other two ; but it is often available for
of etiology from pathology proper, of which it forms an integral part.
What progress, for example, could we make in describing the patho-
logy of small-pox, if we were silent respecting its cause.  On the
present occasion we have to animadvert on the careless manner in
which he speaks of sign and symptom, of semeiology, diagnosis and
prognosis; confounding together things of different import and appli-
cation, and tending to keep up a faulty view of the most interesting
parts of pathology, for such, assuredly, is semeiology.  Even  in
professedly systematic works, as in the " Principles of Diagnosis"
by Dr. Marshall Hall, we look in vain  for  a  clear  definition,  as
preliminary, at least, to a suitable understanding of the subject.
On the contrary, the student  is at once both  perplexed and misled
by the following passage : " With the diagnosis must be associated
correct views of the nature of the disease, or the pathology" (page
149, Amer. Edit.), just as if diagnosis, itself a division of semeiology,
were not, as such,  an integral part of pathology.  We may well ask,
how  the nature of a disease  is to  be ascertained, if not, among
other means, by an observation of all the symptoms, so as to esti-
mate  from them,  collectively, the distinctive  value  of  the signs
which they furnish, and from these signs the diagnosis ; so that we
can separate, in our minds, the disease before us from other dis-
eases, and in this  difference learn, to a certain  extent, its nature.
  The author, when he wishes us "to understand the word sign
of disease generally to imply anything by which the presence  of
disease may be made  known," and " a  symptom  as any pheno-
menon which becomes obvious in the course of disease," is at vari-
ance with the  most authoritative  opinions and practice of syste-
matic writers,  who understand these words,  sign and symptom,  in
a sense the  very reverse of that attempted  to be conveyed in the
text.   Our  own views on these  points will be  conveyed to the
reader by our transcribing part of a lecture written about twenty
years ago, and forming one of a series on  General Pathology, in-
cluded in a course of the Institutes  of Medicine.  He who is ac-
quainted with  the work of Double (Semeiologie Generate), will see
that we  have followed very closely this author in his mode of pre-
senting the subject.
  " Both the physiological or healthy state, and the pathological
or diseased state of the body, are manifested  to our senses by a
series of movements and  operations, which are frequently desig-
nated by the same words—of course misapplication and error must
be the result.  To each isolated movement or action of the healthy
or physiological state, we ought, in  justness,  to apply the word
phenomenon.   Thus, for example, we should say that  it is only
since the discovery of Harvey that we  can account for the pulsa-
tion of the arteries, and some other phenomena  of the circula-
tion.  In disease, on  the other hand, the movements or actions,
considered  separately, take the name of symptom; hence we say, 
SYMPTOMS AND SIGNS OF DISEASE.
355
obvious disease.  Thus, a jaundiced hue  of the  body, extreme
pallor, or great emaciation, afford  to the common observer physi-

that pain of the side is one of  the symptoms of pleurisy and not
one of its phenomena.  A symptom then is every isolated effect or
change supervening in the human  body, in its diseased state, and
which can  be rendered evident to  the  senses of the physician or
the patient.  It is not to be confounded with the disease or its
causes, which attack and alter the functions, whilst the symptom,
being entirely isolated, has no power  on them.  It is only a part
of the disease, which is properly called by Sauvages a concourse
of symptoms.  The  symptom is essentially allied  to the  disease,
and follows it as necessarily  as, to use the comparison of Galen, the
shadow does  the body.  It has been very generally, but errone-
ously, confounded  with  the term sign.  The symptom  falls, of
itself, directly under the notice of the physician or  his patient, and
is perceptible  by the external senses, whilst it requires  medical
judgment,  if  not genius, to form deductions, so as  to  convert
symptoms into signs, and to learn thence what is  obscure or con-
cealed, the present or  the past, in disease.   Subsultus tendinum,
for example, is a symptom,  which is observable both  to  the by-
standers and the physician, and is the effect of nervous  irritation-
met with in hepatitis as well as in low fevers—merely a symptom
 in  the first, it is an unfavourable sign in the latter.   An occurrence
 mentioned by Galen, of himself, places this difference in a still
stronger light. Being dangerously ill,andhearing two of his friends,
in  attendance on him, converse respecting some symptoms which
 they observed in him, such as redness of the face, haggard look,
 inflamed and sparkling eyes, he immediately cried out for them to
 take care,  that he was'threatened with delirium, and he demanded
 that  they should administer to him some remedies  in consequence.
 Here the assistants saw but the symptom, Galen alone deduced the
 sign  of delirium.
    " Involuntary discharges  of fasces and urine is a symptom of
 great muscular debility ; but in low fevers is an alarming if not a
 fatal sign.                                          .
    « Symptoms are the basis, the elements of signs, and, in this re-
 spect cannot be neglected by the physician.  Agreeably to the rule
 which applies through all nature, that there is a necessary and in-
 timate connexion between the qualities or internal faculties of sub-
 stances and beings, and their external character, we find an analo-
 gous dependence between the symptoms and the nature of diseases.
 So that the symptoms properly studied and meditated on, cannot
 fail  to make  us acquainted with the disease, the  causes  which
 more specially gave origin to it, and the general properties  which
 it  most behooves us to  know;  the sum of  the dangers or  hopes
 which it  may offer, and the treatment necessary to oppose it.
 Soon however, in bringing together these symptoms, in comparing
 them'with each other, and submitting them to our  previous notions
 of the ^neral march of  diseases, their character and termination, 
356
WILLIAMS'S PRINCIPLES OF MEDICINE.
 cal signs of disease which cannot be mistaken.  But slighter de-
 grees of the same signs may become manifest only to those who,

 we form, from the whole data, consequences and conclusions, which
 are what we have termed signs.
   " These conclusions are referable — 1st, to a knowledge  of the
 disease, or of its nature, and are called  diagnostic signs :  2d, to
 a knowledge of the probable events which are the consequence
 of it — these are the prognostic signs.  To these some have added
 a third division, or commemorative signs, which relate to all  the
 circumstances antecedent to the disease, or of its  precursory phe-
 nomena.
   " As diagnostic signs differ in the degree of their importance, they
 have been  distinguished  as pathognomonic, common, and acci-
 dental. The first, or  pathognomonic signs, are in such close rela-
 tion with  the disease, that they cannot be  separated from it,  and
 without their  presence it would not exist; hence they have also
 been called characteristic, or essential, such are the acute pain of the
 side, dyspnoea and dry cough in  pleurisy.  These signs ought to
 be in  sufficient number, and in  accordance  with  each other, to
 establish positively the diagnosis of the disease.
   " The common signs are displayed in many affections of a diverse
 nature, without being peculiar to any.   It is for this reason that
 they have been called  equivocal, and are regarded as insufficient
 to make us acquainted with the real existence of any lesion.   We
 may cite,  as examples of  common signs,  headache, redness of the
 face, frequency of the pulse, heat of the skin,  &c.
   " As to  accidents or accidental signs, they are symptoms which
 have no necessary connexion with the disease, as  they sometimes
 are met with during its course, and at  other times  are  not  ob-
 served : such are  sweats, hemorrhages, diarrhoeas." (M.S. Led.)
   Rostan  (Cours de Me'decine  Clinique, &c, t. i. p.  90), exhibits
 the elements of diagnosis, briefly, yet lucidly, in the same manner
 with that  of the preceding extract.  " Independently of the know-
 ledge of man in a healthy state, three things  are  indispensable,"
 says M. Rostan, " in  order  to enable us to  give  a correct dia-
 gnosis : first, a knqwledge of the changes which supervene in  the
 functions  and organs, in  a sick  man ; which  constitutes sympto-
 matology : in the second  place, the conversion into signs of those
 diverse changes, that is to say, the appreciation of each of these
phenomena, a knowledge of what  they  signify ; this  is what is
termed semeiology : in the third place, a knowledge of the charac-
ters of the different diseases that affect the human  species, of the
traits by which they differ from each other, which constitutes pro-
perly special diagnosis."
   In his not distinctly including prognosis as a part of semeiology,
we may criticise Rostan, since the former is but a foretelling of the
result of a disease from the natural language, as we may call it, of
 signs.
  Schill, in  his Outlines  of Pathological Semeiology, (Spillan's 
SYMPTOMS AND SIGNS OF DISEASE
357
by previous acquaintance,  know  more  exactly the  standard of
health in the individual, and can distinguish a change in colour or
Translation, Amer. edit., p. 17,)when speaking of
of Signs," exhibits, in quite a succinct manner, th
                                             the " Formation
                                         ., the limits and cha-
racter of semeiology.   He is disposed  to  give a more enlarged
meaning to phenomena than that laid down in the extract from
our MS. lecture, and one which will probably prevail  in medical
composition.
  " Semeiology, by using its materials in this way, and by giving
to the phenomena a diagnostic, commemorative, and prognostic
signification, forms signs from them.  By phenomenon is  meant,
every change of the organism tending to disease, or  even within
the boundaries of health, perceptible by the  senses of  the  person
observing, or the feelings of the  individual observed.  The  idea of
symptoms refers to that which is perceptible in the diseased organs
and functions.  From the phenomena and  symptoms arise signs,
when they stand related to a present, past, or future morbid state,
so that they are  connected according to  physiological  or patholo-
gical laws, or even according to mere experience, with a determi-
nate species, course, and seat of a morbid process.   The discovery
of the phenomena is the business of the senses; the formation  of
signs is the business of  the judgment supported by experience, and
requires nosological knowledge.  This  operation  has been justly
considered as the most  difficult,  and at the same time the most im-
portant, in medicine."
   Chomel (Chap, vii.)  may be cited in further proof of the position
with which we set out in these remarks, that symptom has a different
signification from sign, and  ought not  to be confounded with it.
Every change perceptible by the senses, which has supervened in
any organ or function, and connected with the presence of a disease,
is a symptom. Symptoms ought never to be confounded either with
phenomena or with signs.  Every action, or change occurring in either
the healthy or diseased  body is a phenomenon — a definition iden-
tical with that of Schill just now stated. Phenomenon belongs to
health as well as to disease, whereas symptom is always the effect
of disease.  Where there is no disease there is no symptom.   Er-
roneously, therefore, continues M. Chomel, have many authors
employed the language precursory symptoms, consecutive symp-
toms.   This  last error, as well  as that  of  applying symptoms to
health,  has been committed by the author in the text (§ 601).
   M  Chomel then proceeds to  point out the difference between
symptom and sign, using nearly the same words and form of illus-
tration with those given by us in the lecture as above.  Symptom
fsays M  C.) is simply  a  sensation, which becomes a sign only by
a particular process of  the mind.  The latter consequently  belongs
to the judgment, the former to the senses.  A  symptom is recog-
nisable  by every body  ; the  physician  alone detects the signs in
the symptoms.   As there is  no  symptom which may not  become 
358          WILLIAMS'S PRINCIPLES OF MEDICINE.

in flesh from that standard.   Again, in  local disease : a large tu-
mour or swelling in a part is a sign of disease obvious to every

a sign to the physician, and as signs  belong equally to health and
disease, it has been said that  " every symptom is a sign ; but that
every sign is not a symptom."   Gaubius had long ago expressly
declared, that symptoms can only be predicated of the sick man.
On the other hand, both he and Boerhaave admit semeiology or
semeiotics to include the signs of health as well as those of disease ;
a latitude  of signification followed, as we have just seen, by recent
continental writers (see note,  ante, p. 30).
  The propriety of affixing to the epithet precursory, the term of
signs or even phenomena  is  evident from the fact that, although
clearly indicative of disturbance or disorder,  and deviation, of
course, from health, yet they have  but  a remote  resemblance or
analogy to the disease which is about to be developed, and cannot be
called symptoms, which latter show direct lesion of organ or func-
tion, constituting a part of the  formed and fixed disease. Disinclina-
tion to either mental or bodily exercise, pains in the head, back, and
limbs, rigors alternating with flushes, are precursory phenomena,
common   to  diseases which  are distinguished  afterwards  by the
most opposite symptoms.
  Signs, then, are precursory, diagnostic and  prognostic, and  of
them mainly is  diagnosis, and exclusively prognosis, formed.  We
cannot, as the author has done in the text, speak of diagnostic and
prognostic, as applicable to symptoms (§ 610) ;  nor can we define
prognosis  to  be " the observation of good  and bad symptoms"
(§ 616).   He had not looked into Celsus before  advancing such
an opinion.   This writer  uses the  word signs, signa, exclusive-
ly, in connection with, and as furnishing the  elements for, pro-
gnosis.  He points out the signs of  bad health, the good and the
bad signs  in disease,  and those indicating instant  death, also the
signs of imminent insanity, those which justify hope, or indicate
danger in various diseases.   (Lib. ii. Sect, iv.-viii.)  Baglivi em-
ploys the word in the same  sense, as when writing (De  Pleuri-
diet — Opera  Omnia) he tells us : the signs derived from the pulse
do not furnish a certain prognosis.*  We might refer to a remark
of his a few lines lower down, to show that a sign is often not de-
ducible from  any of the recognised symptoms of a disease, and
could not, therefore, without  creating great  misconception, be
spoken  of as synonymous with it; as when he says, that  if with
obstructed breathing, the patient, at the same time, desires to sit up
in bed, nor will consent to lie down, because he feels as if he were
suffocating, that  is a fatal sign.  So, also, speaking of  the signs
furnished  by inappetency, Baglivi writes:  " No other  good signs
make  me sanguine, unless they be joined with appetite."t  And

    * Signa vero  ex pulsu petita, non adeo certam prognosim exhibent.
    f Nulla alia bona signa me exhilarant, nisi conjuncta cum appetentia. 
SYMPTOMS AND SIGNS  OF DISEASE.
359
one ; but a smaller or more deep-seated tumour may be discovered
only by those who  have an accurate knowledge of the healthy
anatomy of the part, or by those who  by previous observation
have made themselves familiar with the shape and feel of the part
in health.
   603. Another  standard available to  distinguish the physical
signs of disease from those of health is a comparison of parts that
are naturally symmetrical.  Thus, a slight swelling  in  one limb
may be readily discovered by comparing it with the correspond-
ing part of the opposite limb.   A projection or contraction of one
side of the  chest may escape  observation until  the two sides are
compared by inspection or by measurement, which will detect the
difference between parts that  are  naturally alike.   This standard
of symmetrical comparison is  applicable, not only to all external
parts and to organs of  animal life, but also to some internal parts,
which, although not strictly symmetrical, are so  far equally distri-
buted on the  two sides as to give symmetrical properties to the
 exterior.  Thus, the lungs, in health, fall so equally on both sides
 of the chest, that they give corresponding  motion  and acoustic
 properties  to  both ; and  percussion  or  respiration yields similar
 signs on both  sides.  So, when disease affects one side, it changes
 its physical signs, and  their difference  becomes obvious by com-
 parison with the signs of the healthy side.  A certain degree of
 uniformity also results from the position of the viscera m  the ab-
 domen, so  that (making allowance for the greater bulk of the liver

 again, he remarks, that the rigor is a good and critical sign which
 is accompanied with a coction of the urine, and resolves the fever
 and mitigates the symptoms.  Good breathing is declared by him
 to be one of the best signs in small-pox.         .,.-,-
    Huxham (Opera Physico-Medica, t. iii. p. 93) in his  disserta-
 tion on Malignant Angina, speaks of the necessity of an accurate
 and faithful description of diseases and of their symptoms (eorum
 slmptomatom), and method of cure ; and adds, that this is still more
 requite,  when  a new  or unaccustomed disease occurs, whose
 peculiar pathognomonic  and  diagnostic signs (cujus signa pecu-
 VZia  pathoglomonica  et   diagnostic)  are  to be described
  He often introduces the term presage (praesagium) but not symp
  torn  for sign, in connection with prognosis.
    Tt  wnl have been seen, from the foregoing statements and .pec.-
  acations,  taken  in connection with those in note io  §4 p. 29,
  and we have only referred to the works  now  on our table, that
  tereTsneaHy entL concurrence in opinions and definitions among
   hTcmefsystematic  and some of the best  practical writers, on
   „e ex ent a^d Tnbdivisions of pathology, and also on the meaning




  evWence of necessity for deviations in this particular case. 
360
WILLIAMS'S PRINCIPLES  OF MEDICINE.
  ou the right side) any considerable difference in the shape or re-
  sistance of the two sides may be interpreted to be a sign of disease.
    604. For organs which are not symmetrically placed, previous
  knowledge of their natural structure, position, and physical proper-
  ties, is necessary.  Thus, we  cannot  know  the  physical signs of
  diseases of the heart and liver, without having a healthy standard
  to compare them with.   This  standard is soon supplied by the ob-
  servation of  the signs in health,  and our knowledge of it may be
  much assisted by a familiar  acquaintance with anatomy and phy-
  siology, which teach the  healthy condition and functions.   Thus,
  anatomy teaches us that the heart lies  behind the lower half of
  the sternum  and the adjoining parts of the  cartilages of the left
  ribs from the third to  the sixth;  and physiology makes  us ac-
  quainted with its regular double  sound heard in this region : these
  furnish a  healthy standard,  and when we compare it with a case
  in which the impulse of the heart is felt to beat over a much wider
  space, and the sounds are  irregular and masked  by grating  or
  blowing murmurs, we at once discern these phenomena to be signs
  of disease.  Again, anatomy informs us that the liver in a healthy
  adult extends little, if at all,  below the margins of the ribs on the
  right side;  and the  knowledge of this fact points out as a sign  of
  disease such dulness on percussion and resistance to pressure below
  these  ribs as  arise from the  liver reaching much below its usual
  situation.  The knowledge of the healthy mechanism and functions
 of the apparatus of respiration, circulation, digestion, and excre-
 tion, is in many respects necessary to enable us to distinguish the
 signs of disease from those of health; it will guide us to refer the
 signs to their true causes; and it may often suggest the particular
 signs which may be expected to arise from a particular lesion.
   605. Physical signs are phenomena taking place in the body, in
 accordance  with  physical laws.    It is  therefore obvious, that
 a knowledge of these laws, as  well  as of the  mechanism of the
 body, will assist us to interpret these phenomena; to explain of
 what they are signs, how they are  caused, the variations which
 they  may present,  and the best  mode  of  appreciating them.
 Thus an aneurism of the arch of the aorta  may be chiefly de-
 tected  and studied through the physical  signs which it produces.
 It forms a  tumour under or near  the top of the sternum, pul-
 sating  in a distinct  manner,  and with a peculiar sound ; this
 tumour may press on the air-tubes in such a way as to alter their
 shape, and by partially obstructing the passage of  the air through
 them, may also change the sound of breathing in a particular way :
 by compressing the veins, it may also throw their current into un-
 usual sonorous vibration;  or  by a  more  complete obstruction, it
may cause the veins to swell  in a remarkable degree  above the
tumour: by its enlargement,  the  aneurism  encroaches  on  the
lungs, the walls of the chest, the muscles, nerves, bones, ligaments,
&c, in  such  a way, as to alter their physical properties and posi- 
SYMPTOMS  AND SIGNS OF DISEASE.
361
tions, and thus to produce various physical signs.  Now, all these
physical signs are phenomena produced in the altered mechanism,
according to certain laws; and  it is plain, that  a knowledge  of
these laws must  greatly assist us to understand the signs, and to
trace them to their true causes.  Nay, even the aneuristnal tumour
itself, in its  production, increase, and intrinsic signs can be rightly
understood  only through a knowledge of hydraulics and dynamics,
in connexion with the structure of the heart and arteries in health
and disease.
   606.  Vital symptoms are those phenomena which depend  on
 vital properties of a part or parts of the body.  Thus irritability,
 tonicity, sensibility, excitomotion, secretion, and the more complex
 functions resulting from  combinations of these elementary vital
 properties (\ 104), in a natural state, produce the symptoms of
 health;  in  an altered state, constitute the  symptoms of disease.
 Hence vital symptoms have also been called functional symptoms,
 and physiological; but both these terms are objectionable, because
 both function and physiology relate likewise to physical properties,
 and  would, therefore, include physical signs.
    Vital symptoms are often less confined to a part than physical
 signs ; because the vital properties of the whole system are in  ge-
 neral connexion ; thus the irritability of the heart  spreads its in-
 fluence throughout the vascular system ; the sensibility of one part
 affects the  nervous centres, and may  produce sympathetic symp-
 toms in other parts (§ 156) ; disordered secretion  has  effects on
 other parts (§  162-7, &c.);  so  that vital symptoms  are o ten
 generally distributed throughout the body.  For this reason, they
 have been sometimes called general symptoms, to distinguish them
 from physical signs, which are  chiefly local;  but this  appellation
 is not exact, inasmuch as vital symptoms are sometimes entirely
 local:  as in the case of pain, spasm, &c; and we have already
 mentioned, that physical signs are sometimes quite general through-
 out the body, as those of the yellowness of the whole  surface in
 jaundice, the swelling of the body in dropsy, &c.
    Vital symptoms are sometimes called rational, because  i  pie-
 sume) their connexion with their cause is rather a matter ot mter-
  eTe than of direct observation : but this is the mostabsurd texm
 of all; for  observation is necessary to teach us the value as much
 of symptoms as of physical signs ; and physical signs are of little
  use without a proper exercise of reason upon them.
    607. Vital symptoms maybe  exemplified in pain, «nea«nej«,
  altered and impaired sensations, which arise res;pectively   om ex-
  alted, perverted, or defective sensibility (§  1^-136) , in spasm
  and pamlysis, which proceed from excessive or de Active contrac
 tilitv (k 110—US), or excitomotory powei  (§  J3?-1^' H1
  com*  which is caused by irritation or undue excitability of the ex-
  cuomotory nerves of the air passages and  muscles of expiration
  m vomit L? which depends on irritation or undue excitability of
  the■ sSmaS and the excitomotory  nerves sympathetically allied
             31 
 <}62        WILLIAMS'S PRINCIPLES OF MEDICINE.

 with it; in dyspnoea, which arises from a feeling of want of breath
 (§ 234) ;  in fever, which comprises an accelerated pulse, hot skin,
 diminished secretions, &c. (§ 437.)
   Symptoms may further  be  found in the state  of the different
 bodily functions in which vital properties are concerned.  Thus the
 state of the pulse is an important source of symptoms : a frequent
 or a slow  pulse indicates an increased or deficient excitement or ir-
 ritability of the heart (§ 113, 117); a strong or weak pulse  implies
 an increased or diminished strength  of the  heart's contractions
 (§ 112, 116).  A hard or sharp pulse  is in part dependent on an
 increased  tonicity of the arteries (§ 121); whilst a soft, compressi-
 ble, or liquid pulse, depends on a diminution of this property
 (§ 123).   Irregularity in the rhythm of the pulse arises from an al-
 teration in the vital  property of irritability in the heart, commonly
 connected with loss of strength.  These various conditions of the
 pulse are  sometimes the result of various diseases directly affecting
 the vital  properties of the  heart and arteries themselves ; but more
 commonly they are induced bydiseases of other parts,sympathetical-
 ly or through the blood  influencing these organs, as in inflammatory
 fever  (§ 437).  Thus, in diseases of the heart and arteries, the  pulse
 has more of the character of a physical sign ; whilst in other disor-
ders, it is rather a vital symptom, depending on further vital pro-
 perties.
   The state of the skin is another source of symptoms chiefly con-
nected with the vital properties of the superficial vessels and secer-
nent apparatus, and of the general circulation.   Thus the heat and
dryness of the skin in fever arise from  accelerated circulation with
diminished perspiration.  When the skin is cold, the circulation is
weak ; when warm, it is active ; and the occasional  occurrence of
perspiration in both these conditions shows that another vital pro-
perty, that of secretion, is  concerned in causing the symptoms,
 dryness and moisture of the skin.   The signs furnished by the skin
 are physical, so far as regards the condition of the skin itself; but
 they are vital symptoms in relation to  the stage of the circulation,
 of distant  organs, or of the system at large.
   Many important  symptoms  may be derived from  the appear-
 ances of the tongue.   These appearances, when arising from pri-
 mary disease in  the tongue  itself, may be considered as physical
 signs of its condition.  Thus, when the  tongue is  inflamed, it is
 first red and swollen, and afterwards becomes covered with a film
 or fur, which, separating in patches, leaves the surface red, and
 smoother than before.  But in a great many diseases, the  tongue
 becomes red, swollen, furred, or brown and dry, from causes act-
 ing through the system;  and  these secondary  affections  of the
 tongue constitute symptoms of these diseases.  The connexion be-
 tween febrile and other general  diseases, and the appearances
 which they produce in the tongue, is not well understood; but it
 probably depends on changes in the secretion of the mucous mem-
 brane covering the tongue and  adjoining parts. 
SYMPTOMS AND SIGNS OF  DISEASE.           363
  The alvine excretions furnish symptoms of great importance in
various diseases.  When excessive in quantity, liquidity, and fre-
quency, they constitute diarrhoea, which may be  primary — that
is, a disease in itself (§ 374); or secondary, and, therefore, a symp-
tom of disease, as in cholera and mucous enteritis.  As a symp-
tom,  it presents further varieties in its character, whether fecu-
lent, bilious, mucous, watery, &c.; and  these varieties indicate
respectively, accumulation of faeces, or excessive secretion of bile,
mucus, or watery fluid, in the intestines.   The opposite condition,
that of costiveness,  is also a disease itself, and an important symp-
tom in many diseases, indicating defective  peristaltic action, de-
fective secretions, or  both, in  the intestinal tube.   The quality of
the evacuation supplies symptoms in regard to colour, shape, odour,
&c., which often lead to a knowledge of the nature of disorder
in the alimentary canal or in the system.  Thus,  clay-coloured fasces
indicate defective secretion from the  liver; those very  dark in
colour may denote  the presence of  diseased bile or altered blood;
vermiform  motions may indicate stricture or  contraction of the
 intestine ;  and so forth.
   The urinary excretion is a valuable source of symptoms, not
 only of  diseases of the  parts connected with  it, but of disorders
 of other organs, and  of  the whole system.   Being  the chief
 emunctory through which foreign effete, and  superfluous matters
 are eliminated from the blood (§ 254), it is  continually exhibit-
 ing changes in quantity and quality, in colour  and specific gra-
 vity,  in its sediments, and  in  the effect on it of different chemical
 re-agents.  All these changes furnish symptoms of disease, several
 of which  have been already noticed in connexion with various
 pathological  elements (§ 167,  176,249,254,255,257,260,309,
 384,  385,  448, &c).
    608.  The foregoing examples of sources of symptoms are given
 merely  to illustrate where and how symptoms are to be sought
 for ;  to  complete  the list, it would  be  necessary to notice every
 function of every part of the  body, and the  symptoms which they
 furnish, which would fill a considerable volume.
    As a knowledge of the mechanism of organs, in health and m
 disease, and  of the  physical laws which operate in  them, is the
  best aid to the study of physical signs, so  an accurate acquaint-
  ance with  the structure and  functions of the healthy and diseased
  body, and with the vital laws which influence them, is the best
  cmide to   the  knowledge  and explanation of vital symptoms.
  These symptoms  are often obscure and unintelligible,  because
  physiology and pathology is imperfect;  but in proportion as these
  sciences are  advanced, their application to  semeiology and dia-
  gnosis will be more complete.  In the  meantime, much of our
  knowledge of symptoms rests chiefly on  mere experience ; and
  until the results of experience can  be arranged  m a more scien-
  tific manner, they may be parcelled numerically, in order to ap-
  proach their laws  by empirical  means.    But  to  render this
 statistical or numerical method of studying  symptoms at all safe, 
364          WILLIAMS'S PRINCIPLES OF MEDICINE.

it is necessary that the numbers of observations should be very
large, that  they should be applied to similar cases, and  that the
majorities which establish the rule  should  very greatly prepon-
derate over the exceptions.
  609. Physical signs and vital symptoms respectively have their
value in making known the nature and extent  of disease.   Phy-
sical signs  are  more certain, because they appeal more directly
from the seat of disease to the senses; depending on simpler and
more  constant causes, physical properties, they are more constant,
and less  subject to variation  than  vital  symptoms, which result
from  more complex, and therefore more variable, vital  proper-
ties.   Thus, of  the signs  of inflammation, the redness,  heat,
and swelling, are physical signs, and more certainly prove the
existence of inflammation than does pain, which is a  symptom
depending on the vital property, sensibility, and which maybe pre-
sent where inflammation  does not exist (§ 136); and may fail to
occur when inflammation is present (§ 433).   The  physical signs
of a structural disease  in the  lungs or heart are better evidence
of its existence-, and of its nature,  than  cough, dyspnoea,  pain,
palpitation, &c.; because we know that these symptoms may arise
from merely nervous or other causes, without the presence of any
alteration of  structure.  Yet  vital symptoms, although less sure
and constant  than  physical signs, are  often more delicate, being
present before physical changes  become  appreciable; and when
they coexist  with  physical signs, they indicate  the  nature  and
amount of disorder of the vital properties of the  part, and of the
whole system.  Thus, feelings of chilliness and discomfort, which
usher in the fever accompanying tonsillitis, are sometimes present
before the throat exhibits the physical signs of inflammation.   A
slight cough is often present in the early stage of phthisis, before
the physical signs of tubercles can be  distinguished.  Crepitation
heard in the posterior regions of the chest is a physical sign of en-
gorgement of the lung with liquid in the minute tubes; but we
must  refer  to  the  vital  symptoms  to  determine whether the
engorgement is  inflammatory or only congestive.  The physi-
cal signs of consolidation of the lung, and  of valvular disease of
the heart, are very distinct; but in order to determine whether
these affections have arisen from present or  recent inflammation,
or are the results of old disease, it is necessary to consult the vital
symptoms : and this  determination is of great  importance to the
prognosis and treatment.
   In short, it is obvious that both classes of signs ought to be care-
fully taken into account:  and the more fully the physical and vital
properties which constitute them are understood, the more availa-
ble will signs and symptoms be to instruct us as to the nature and
treatment of disease.
   610.  Besides into physical and vital, various divisions of symp-
toms have been made ; but they are of little real utility, and it  is
unnecessary  to  do  more than enumerate  them.  Symptoms are
local, or general, or constitutional, according to whether they are 
DIAGNOSIS OF DISEASE.
365
confined to  the  diseased  part, or  affect more  or  less the whole
system.  Symptoms are idiopathic, when directly proceeding from
a primary disease ;  they  are sympathetic, or secondary, when
arising- from secondary disorders,  or those produced by the pri-
mary disease.   Premonitory or precursory symptoms  are  those
which precede  the  full development of disease,  and commonly
result from  the first  operation of its cause ;  hence they  are called
symptomata causae.   Commemorative symptoms are those deve-
loped  in the previous history of  the disease.   Anamnaestic axe
those which relate to the  previous  state of health.  Signs  have
been divided into objective, those which present themselves to the
scrutiny of the practitioner ; and the subjective, those described by
the patient himself.   The objective have been further divided into
the active or dynamical,  those that require some action or motion
of the patient to discover them ; and the passive or statical, those
 which are obvious without such action. Symptoms are designated
 by the epithets, diagnostic,prognostic, and therapeutic, when they
 are specially applicable respectively to the  distinction, the deter-
 mination of the event, and the suggestion of the treatment of dis-
 ease.   Symptoms are positive, when they consist of phenomena
 actually present; negative, when  they consist in  the  absence of
 phenomena.  Of diagnostic symptoms, those are called pathogno-
 monic oxpathognoslic, which are peculiar to one disease. A single
 symptom or sign   is rarely, if ever, pathognomonic; but  two or
 three taken together often are so.
    611.  The diagnosisof  diseases is the distinction of diseases from
 one another.  It may relate to diseases in their essential nature or
 pathology, or  to those groups  of  symptoms  that are  classed as
 separate diseases by nosological arrangements (§ 597).  In other
 words, the object of diagnosis is, to determine either the intimate
 nature and seat of a disease, or its name and  place in a classifica-
 tion of phenomena  grouped under  the name of special diseases.
  According to the nosological arrangement which  has been recom-
 mended as the  best at  present (§ 600), the division into  special
 diseases is, as  much as is practicable, founded on pathology, or
 the essential nature of disease; and diagnosis should also  have a
 corresponding  reference to  this subject.  But as  it  has been ad-
  mitted that pathology isnot sufficiently advanced to be the sole basis
 of nosolo^v, so we  must avail ourselves of other sources of infor-
  mation hiregard to  diagnosis.  Accordingly, much of the materials
  of diagnosis are the results of simple observation of cluneal expe-
  rience ; and where these cannot be analyzed by any more rational
  mode they may be measured or valued by the numerical method,
  or counting and calculating the results in a large number of cases.
  Thus diagnosis is chiefly derived from semeiology, and the results
  of clinical experience, arranged by pathology  and statistics.  In
  some instances, the causes and the treatment of disease give aid in
  the diagnosis.   Thus the malarious character of  a  patient's resi-
  dence, and the efficacy of  quinine in curing him, will contribute
  important evidence as to the nature of his disease.
             31* 
366
WILLIAMS'S PRINCIPLES OF MEDICINE.
  612. Diagnosis may he general or special.   General diagnosis
comprehends the distinction between the principles or elements of
disease (§ 104);  as, for example, between congestion and inflam-
mation ;  between  nervous irritation and structural disease,  &c.
This is properly a  branch of general pathology;  and if time had
permitted, would have  been introduced here.  Special diagnosis
relates to the distinction of diseases according to their chief seat,
where they have one (§ 599), or according to some other specific
difference,  where they have no particular head-quarters.   Thus
the special  diagnosis of inflammations is between inflammation of
the parenchyma of an organ and that of its investing membrane ;
or between an intermittent and a continued  fever.  Special dia-
gnosis also follows  and distinguishes diseases in their further dif-
ferences of seat or character;  as the  part or extent of a paren-
chyma or  membrane inflamed, the  type of  a fever,  &c.   Thus
special diagnosis is a branch of special pathology, and should be
aided  by an  accurate  and  practical  nosological arrangement.
The  mode of distinguishing  between two diseases which resem-
ble each other has been absurdly called differential diagnosis.
It consists in pointing out the  signs which are  essential to the one
and not to the other.  The signs called pathognomonic, where they
exist, are the chief guides in differential diagnosis.
  613. The modes of investigating and distinguishing diseases will
vary much in different cases, according  to the  class of symptoms
that first  present themselves.  This  may  be illustrated by the  fol-
lowing problems : —
  General  pathology having pointed out the  general nature of a
disease, it  is required  to  determine its precise  seat.  Example.
In a case in which fever, hard  pulse, buffed blood, and local pain
indicate inflammation, the seat of the inflammation is  determined
by the chief place of pain or  uneasiness, (in the chest or side,) by
the function most disturbed, (difficult breathing and cough,) to be in
the organs of respiration ;  by the secretion proceeding from  the
part,  (rusty, viscid  expectoration,) and from  the physical signs
(impaired breath-sounds and stroke-sound in part of the chest, with
crepitant rhonchus), to be in the parenchyma of the lungs;  that is,
pneumonia.  General pathology  here  commences the diagnosis
which is completed by reference to  symptoms explained by phy-
siology and special pathology.
   Previous history, prominent symptoms, or physical signs, having
pointed out the seat of a  disease, it is required to determine its
nature.  Example. A person suffers from severe pain at the  epi-
gastrium;  the  previous occurrence  of symptoms of  indigestion,
and  the  situation  of the  pain, plainly show the disorder  to  be
seated in the stomach: the nature  of  the  disease (whether ner-
vous or  inflammation, &c.) is to be determined by general patho-
logy ; guided by this, and finding  an absence  of symptoms of
inflammation, no increased heat of surface, no acceleration of the
pulse further than  what the pain would cause, and no increase of
the pain  on the  imbibition of warm or stimulating liquids;  and 
DIAGNOSIS OF DISEASE.
367
finding  symptoms of predominant nervous properties,  and  the
sudden  attack, intense  character, and transient duration  of the
pain, which distinguish nervous and spasmodic affections,  we de-
cide that the disease is gastralgia or gastrodynia, and not gastritis.
The diagnosis which is begun by local symptoms is completed by
reference to the principles of pathology.
  Lastly, which  is a common case, symptoms being too  few or
too inconclusive  to  declare the  diagnosis, both  the seat and the
nature of the disease are to be determined.  Example. A  person
complains  of general  uneasiness,  weakness, and chilliness, with
various functional symptoms, but  none of a prominent character.
Clinical experience has taught the practitioner that such  are the
symptoms  of  incipient fever;  and  he  proceeds  to investigate
further the nature and cause of the fever.  If he finds, on close
examination of the functions and  physical condition of the dif-
ferent organs, that one is  the seat of marked inflammation, and
that  the fever is not typhoid, he  judges that  the  fever is symp-
tomatic of the  inflammation ; but if signs of marked  local in-
flammation be  absent, yet the  fever continues with increasing
symptoms of depression, weak frequent pulse, brown dry tongue,
sordes  on  the  teeth, low  delirium, &c,  he recognises typhoid
fever, resulting  from the  influence of a  morbid poison  on the
 system (§  105).
   614. Thus, every department of medical knowledge is brought
 to bear on diagnosis ; and  in no branch is the information, as well
 as the judgment, of the practitioner more brought to a test. Natural
 shrewdness and  tact, with  some general knowledge of the nature
 and  treatment of disease,  may sometimes enable a comparatively
 ignorant person  to practice medicine with an  appearance  of suc-
 cess ; but  such a person can make no hand of diagnosis;  and he
 wisely either evades the whole subject or expresses his opinions in
 va^ue  terms, and scrupulously  avoids their being brought to the
 test  of the scalpel.  The well-informed practitioner, on the other
 hand, feels that  this is the  subject which requires the full applica-
 tion of his mental powers  and knowledge, as well as the keen ex-
 ercise of his powers of observation ; and in proportion as  his senses
 are  practised in observing, his information well arranged  in rela-
 tion to what  he observes,  and his judgment matured in discrimi-
 nating and deciding the results, so will he be successful in forming
 his diagnosis, and in applying it to prognosis and practice.
    615  In investigating the symptoms of a case with  a  view to
 diagnosis, prognosis, and treatment, the observation is first drawn
 to those which at once declare themselves in the aspect  of the pa-
 tient the  expression of the countenance, the complexion, the pos-
 ture/the manner of the movements, speech, &c.; and these give
 important information to  the observing practitioner at  first sight
 and whilst he  is interrogating the  patient  After the first few
 statements of complaints,  which are generally volunteered by the
 natient, the questions should be directed to the history of the ali-
 ment including tixe previous state of health and habits, with regard 
368          WILLIAMS'S PRINCIPLES OF MEDICINE.
to food, clothing, occupation, residence, &c, any former illness, the
mode of the present attack, and  its supposed  cause, the former
symptoms, and treatment, if any has been employed.  The answers
to these questions will direct the inquiries in  the most  searching
manner with regard to the present state and symptoms.  The
mode of investigating these will  partly depend on the clue given
by the answers to  previous questions; but the practitioner  must
not permit himself to be so far led  by the patient's statements as
to omit to examine the state of all the  important organs and their
functions.  The nervous system and its functions (sensorial, sen-
tient, excitomotory, and sympathetic) : the organs of circulation
and their functions (pulse of heart and arteries, capillary circula-
tion of surface and visible parts, temperature, state of veins, &c.);
the organs of respiration and t heir functions  (breathing, cough,
expectoration, voice, arterialization of  the blood);  the organs of
digestion and  their functions (tongue, appetite, digestion, &c.);
the organs of secretion and  excretion and their functions (liver
and intestines, kidneys, bladder, and the skin); the functions of
nutrition and assimilation (to be judged of  by the condition of
the  flesh and comparative weight  of  the body); the organs of
locomotion and their functions; the organs of generation and their
functions ; are severally to be made the subjects  of inquiry and
physical examination to such an extent as  may be requisite to
inform the practitioner of their true condition and connexion with
the past or present disease.
   The object of a complete investigation of the state of the patient
is not merely to determine the particular disease under which the
patient labours, but to discover what is healthy as well as what is
morbid  in his condition.  The  prognosis, or estimation of the
amount and event of the disease, and the application of treatment,
requires this full investigation.  We have to consider, not merely
disease in the body, but the body in disease :  and it is by losing
sight  of this great, practical  axiom, that minute  or microscopic
inquirers, who may  be singularly successful in special  diagnosis,
signally fail in prognosis and in practice.(a)
  (a) We subjoin as a useful aid, if not absolute guide, in our ex-
amination of the sick, in order to establish a  correct diagnosis, a
tabular  view, taken from  Martinet's Pathology  (Quain's trans-
lation).  But we must first ask the reader's attention to his intro-
ductory remarks  on diagnosis, in which will  be  seen still farther
proof of the distinction made between symptoms and signs.
  " Diagnosis is the most important part of pathology, for it not
only enables the physician to ascertain the nature of diseases, but,
also, the treatment best adapted for their relief.  Hitherto we have
limited our attention to the study of symptoms, in order to distin-
guish the different phenomena which diseases present during their
progress.   We  now proceed to assign a value to these phenomena,
and appreciate them as signs, whereby an observer may be enabled, 
PROGNOSIS.
369
                        CHAPTER  VI.

  PROGNOSIS—FOREKNOWLEDGE OF  THE RESULTS OF DISEASE.

  616. Prognosis is that knowledge  by which we  are enabled to
foresee the  course, duration, and event of a disease.   Like  the
treatment of disease, it may be either empirical ox rational.
  Empirical prognosis is that which is founded on experience or

in a given affection, to ascertain  what organ suffers, and the nature
of its derangement."
  Tabular View.—" After having  marked the name, sex,  age,
physical conformation, constitution, temperament, and profession
of the patient, we should  pass successively in review —
History
 of the
Family
Previous
 History
History
 of the
 Patient
Ascending
Descending
Collateral
1. History of
  the present
  Disease, con-
  sidered in its
During
Health
During Dis-
ease, observ-
ing the Criti-
cal Periods
Causes
 Previous cir-
 cumstances
 Attack
 Progress
 Termination
 Present
\__condition
fHabits
 Regimen
 State of
 Functions
 Sympathies
Constitution
Temperament
Idiosyncra-
   sies
 relative to
 ffnfancy
 | Puberty
j Adult age
S Critical pe-
 j   riod
 l^Old age
 < Predisposing
 > Occasional
 (Active
J Passive
\ Ataxic
 [.Refractory

r Sanguineous
< Lymphatic
(^Nervous

 f Morbid Sus-
 | ceptibility,
\ Hygienic
 I agents, Medi-
 cinal agents. 
370
WILLIAMS'S PRINCIPLES OF MEDICINE.
observation only, without regard to the nature of the  disease or
the reasons which determine the results.  It consists in the obser-
2. Present state
f Habit of Body.—The Skin.
 Face.
 Intellectual System.
 Apparatus of Sensation.
            Digestion.
            Respiration.
            Circulation.
            Locomotion.
            Secretion.
(_           Generation.
                  Health.
3. Termination in   ■? Other Diseases.
                  Death.—Morbid appearances."
  One of the chief causes of fallacy in medical histories, is the im-
possibility of always eliciting the facts of the case from the patient
and his family or friends, as far as their knowledge and intelligence
may be supposed to furnish valuable data.  Either from inherent
stupidity, or the stupefaction or  bewilderment induced by the dis-
ease, the patient is often incompetent to give  suitable answers to
the physician, as to the nature of his present feelings, the period of
his sufferings, the condition of his functions of excretion, — from the
bowels, kidneys, and  skin.   Reference must then be  made to his
family or other friends in the sick room, some of whom are more
intent on giving their own crude pathological notions, and hopes
and fears about the kind of treatment to be pursued, than on reply-
ing carefully and accurately to  the  questions propounded by the
physician.   If there be suspicion of bad habits having mainly contri-
buted to,or directly caused the disease,inquiries should be postponed
until they can be made of the friends or attendants in another room.
   Continually  the physician  must  be prepared for  misconcep-
tion  and positive  deception, respecting the causes, progress, and
results of treatment of the maladies of his patients.   If he  is not
clear in his words and fashion  of inquiry, their  drift will be mis-
apprehended and wrong answers given.   Sometimes he is mis-
understood.   Sometimes the  truth in  a  most important point  is
withheld; sometimes a positive  untruth told ; and, in both in-
 stances, by persons whose moral  code in  other matters is unex-
 ceptionable.  With  a  knowledge of all these difficulties he will
 feel himself called on to repeat,  from day to day, the same questions
 until he is satisfied ; and, still more,to institute, himself, so thorough
 an examination of his patient as to leave little  to be derived from
 other collateral sources of information.
   In instituting inquiries of the patient, the period of remission of
 fever or of paroxysm of pain, should, if possible, be chosen, when
 the replies can be made more calmly and with greater probability of
 their being accurate.  But, on the other hand, when it  is desired
 to acquire, from personal observation, a knowledge of the  most
 distinctive  and violent features of  the disease, the time of its ex- 
PROGNOSIS.
371
vation of the good and bad symptoms [signs]; that is, those symp-
toms which have, in a great majority of cases, been followed re-
spectively by a good or a bad result.  This mode of prognostica-
ting the events  of disease  was  the only one  attainable in  the
early  stages of medicine.   The "prognostics"  of  Hippocrates
chiefly consisted in the enumeration of good and  bad  signs; and
the frequent truth of the distinctions which he has made  on these
points show the extent and accuracy of his observation or of  the
sources from which  his information was drawn.  In a limited
sense, the same faculty of empirical prognosis is often acquired by
nurses or other  non-medical attendants of the sick.  These  can
often tell  when a  patient is getting  better or worse, by the appear-
ance  of the countenance, the state  of the voice, the mind, the
strength, the breathing, the excretions, &c, whilst they may be in
total  ignorance of the nature of the disease and why the signs are
good or bad.  This  kind of prognostic  knowledge,  although it
may  be useful in  enabling a  person to pronounce a patient better
or worse, falls far short of that which ought to be expected of the
scientific practitioner, who should not only have a greater number
of prognostic symptoms within his reach, but should be able to
 foresee them, so as to anticipate, and, if possible, to influence them
 in a  favourable manner.(ff)

 acerbation  should be selected by the physician for his visit.  As a
 general rule, when he cannot see his patient twice a day, he should
 vary the  periods of his visit, so as to have it in his power some-
 times to observe the symptoms in the exacerbation, and sometimes
 in the remission.
    As our opinions of the extent to which disease is actually present
 are based on a comparison of its symptoms with the signs  of health,
 it is desirable to ascertain as nearly as possible the normal state of
 the functions of our  patient.   Modifications in the physiognomy,
 carriage, or posture, voice, character of  mind, circulation  and
 respiration  are hardly noticeable  by the physician, who sees his
 patient for the  first time,  although quite  manifest  to  him who
 has  had  opportunity for making  the  comparison.   One patient
 will have  had habitually  a full,  tense,  and frequent  pulse.  In
 another the pulse will be wanting in one wrist, owing to the course
 taken  by the radial artery.  Sometimes a person has laboured
 under a slight paralysis of one side of  the face or of one limb, or
 habitual twitching of some of the features,  without any  noticeable
 deviation from the general  health;  and, of course, without  these
 infirmities belonging to or being  connected with  diseases, for
 which a physician is consulted.
    (a) Irrespective of the utility of the thing, predictions, even occa-
 sioinlly verified, always excite attention  and not seldom wonder.
 Successful prognosis will win for a physician more reputation in a
 community than carrying out successfully  the indications of cure.
 The earliest records of medicine abound in prognostics, materials for 
372          WILLIAMS'S PRINCIPLES OF MEDICINE.

   617. Rational prognosis is the estimation of the importance and
tendencies of a disease from a knowledge of its causes, its truena-

which were afforded by the custom among the Greeks of suspend-
ing votive tablets in the  temples, containing a short description of
the disease.  In the works of Hippocrates, or of those commonly
attributed to  him,  the  Prenotiones Coacae derived their  origin
from this source.  To the same purport are the prognostics, prorr-
hetics, and  many of the aphorisms of this writer, who has left
us, in them, " a rich treasure of truths and a pattern how one
should employ experience obtained by true observation."  It must,
therefore, be a matter of deep regret, that so  admirable an example
has been so imperfectly followed, and, in many respects, neglected.
Hippocrates, it is true, was content to  observe the natural course
of diseases, or that slightly interrupted by the administration of
medicine ; but now, when heroic measures are had recourse to
in order to arrest disease, and at  any rate greatly to modify the
signs in its  progress, it may be alleged, that  neither are his pro-
gnostics applicable, nor the materials for making them, in his fash-
ion, any longer procurable.  Such a view is, however, exceedingly
fallacious, since it assumes that which remains to be proved, viz.:
the power of  active medication to shorten the course of diseases
generally, and  to deprive them of their distinctive  features.  A
comparison  of the  descriptions of  diseases  by  Hippocrates
with those made in our  own day, will go far to  show, that, in
their essential  nature and characteristic features, the pictures of
many diseases, their diagnoses and prognoses, as made by him of
Cos, represent accurately those recorded  by careful observers in
our own times.
  But let not the feeling of deserved admiration hurry us into extra-
vagant eulogy: while we attribute  so much to  the Hippocratic
ages and schools, we mustnot commit injusticeon modern physicians
by denying their services in extending the domain of diagnosis, and
thereby furnishing more and better materials for prognosis; since
the accuracy of the latter must greatly depend on the completeness
of the former.   Great and important facilities have been furnished,
of late  years, for our detecting diseases of the respiratory apparatus
and of the heart, by means of percussion and the stethoscope ; and
those  of the brain and nerves, by the aid of comparative physio-
logy and morbid anatomy; so that symptoms of small meaning
are now made signs full of import.
  A careful study of prognosis, by apprising us of the duration of
a disease, and its several stages of invasion, increment, and decline,
as well as the kind of crisis by which  it most commonly terminates,
would  be a good corrective to the nimia medicina, the polyphar-
macy so much in vogue.   It  would restore physicians to their true
position of ministers of nature, in their selecting remedies to mo-
derate  or excite, as the case may be, the play of the functions and
organic properties; without insisting on the continued manifestation 
                         PROGNOSIS.                       373

ture and symptoms, and of the power of treatment in regard to it.
Like rational diagnosis (§ 614), it derives its evidence from all avail-
able sources, and makes the best use of this evidence by analyzing
it, and thus determining its  value.   Thus, in the early  stage  ot
inflammation of the lung, the discovery of the nature and seat  of
the affection at once shows the presence of a serious disease, what-
ever may be the state of the present symptoms. The practitioner, in
forming a  rational  prognosis, takes into account the extent of the
inflammation, knowing, from experience as  well as from reason,
that this is a source of danger: he  considers the duration of the
attack, and from the  signs  and symptoms judges whether  it is
increasing or not.  These considerations may give him  some  in-
sight into the severity of the disease,  but his prognosis is to  be
determined by further conditions.   He knows, by experience and
of therapeutical actions and their substitution for physiological ones.
Now, that our prognosis of phthisis, based on an improved dia-
gnosis, is so clear, how much needless suffering issaved to the patient
by a more restricted administration of drugs.  When these are pre-
scribed, it is with a knowledge of the complications that may be re-
lieved or removed by them ; and here, prognosis, connecting in one
view the signs of disease during life with the textural and organic
changes noticed after death, serves as a guide to direct, both when to
administer and when to abstain from remedies.  Signs peculiar to
the existence  of tubercles cause us to withhold medicines in gene-
ral.  Signs indicating collateral lesions and changes  of  tissue, as
pneumonia, haemoptysis, and  pleurisy, and their progress and ter-
mination, point, on the other hand, to remedial measures.
   A careful study of fevers, by connecting diagnosis with progno-
sis, would lead to a similar reserve in the use of certain active me-
dicines, and a rejection of so many inert ones, the immediate effect
of which latter is for the  most part to disturb the stomach and  in-
crease thefeelingsof distressof the patient.  On this subject we might
draw largely from the accumulated stores of the older writers, from
Hippocrates to Sydenham, whose views of coction or maturation,
which should precede a crisis, and the elimination of certain  dele-
terious principles by the depurative organs, are losing much of the
air of  absurdity with which, in  the  pride of false  science, it has
been long the 'fashion to regard them.   The  periodicity of the
functions, in health as well as in disease, was not lost sight  of ni
the prognostics of the older writers;  and the strong probability, it
not inevitable necessity, of alternation of remission and  exacerba-
A careful adaptat.^......---
the animal  economy would require  more care in selection and
more  reserve in their administration  than are deemed  compatible
with the too generally prevalent opinions and routine practice ot
the present time.
           32 
  374          WILLIAMS'S PRINCIPLES OF MEDICINE.

  reason, that inflammation of the lungs, although always a danger-
  ous disease, becomes much less so when it is at a  stage and in  a
  subject in which antiphlogistic remedies can be well borne: thus,
  at an early stage, in a young and vigorous subject, even the most
  extensive inflammations maybe cured by bloodletting and other
  means judiciously employed ; but if the disease has advanced far,
  and the function of respiration has been for some days impaired
  by it; if the subject be feeble from infancy, or from extreme age,
  or from previous disease, from intemperate habits,  from a compli-
  cating disorder, or from any other cause, the prognosis becomes
  more unfavourable, inasmuch as there  is little power in the sys-
 tem to bear the appropriate remedies, or to  withstand the evil
  effects of the disease.
    To take an example of another disease.   In continued  fever,
 certain symptoms have been found by experience to be of an un-
 favourable  character.   The  pathological  practitioner profits by
 this experience, but he analyzes the results and goes further.  He
 knows that the appearance of petechias, congested face, and stupor,
 at the commencement of fever, are bad symptoms, but that they
 are so  mainly  in  proportion  as they arise  from the changed
 state of the blood  induced by the depressing cause of the fever;
 and when, as it sometimes happens, these symptoms appear  with-
 out any corresponding depression of the heart's power, as manifest
 by extreme frequency and weakness  of the pulse, they are by no
 means of such unfavourable import,  but may arise from the ple-
 thora of the subject.  Again :  symptoms referable  to  the excito-
 motory system (§ 153), — such as subsultus, hiccup, and convul-
 sive affections, are generally  unfavourable in  continued fever ;
 but they are so only when arising from the severe operation of the
 cause of the fever on the nervous centres; they are much less so
 when  occurring in a nervous subject, in whom slight causes may
 induce them.  The same remark may be made of a state of stupor,
 which would  be of most  serious import  if dependent on  fever
 alone ;  but it  may be induced  by slight fever, or other cause, in
 an hysterical subject. The  pathologist is prepared for these differ-
 ences, and can qualify his prognosis accordingly.   He can  trace
 the danger of bad symptoms, beyond the symptoms  themselves, to
 those interferences with vital functions which renders these symp-
 toms dangerous, and of which these symptoms are not always the
 true exponents.
   618.  As our limits do not admit of details, it must suffice to
 enumerate the chief circumstances from which a rational prognosis
 may be formed, with illustrative  examples.
   The cause of the disease. — Epidemic, endemic, and infectious
disorders, are chiefly serious in  proportion to the intensity of their
cause.   Thus the endemic of a  hot climate is more dangerous than
that of a cold climate: an infectious disorder  propagated in  close
habitations is more severe, from the concentration of  its cause, than 
PROGNOSIS.
375
one arising from more diluted infection.  By knowing the source
°f the disease, some estimate maybe formed of its future severity.
  619.  The age of the subject. —Acute diseases  are  ill borne at
either extreme of age.  Acute diseases are most common in young
and  middle age.  In old age, the  tendency is to more chronic
maladies.
   The sex of the patient. — Nervous diseases are most common
and obstinate in the female sex ; but they are more serious in the
male sex.  The occurrence of the catamenia is often  favourable,
as their suppression is unfavourable in the course  of a disease.
   The  temperament  of the patient. — In the sanguine tempera-
ment disorders are apt to be  acute; in the phlegmatic  tempera-
ment,  more  chronic ; and  in the  nervous temperament, more
changeable.
   Previous diseases of the patient. — The  same  disease having
occurred before, prevents  or renders slight a subsequent attack, in
the case of eruptive fevers, hooping-cough, &c.; but increases the
tendency and the  danger  in case of apoplexy and most structural
diseases.  Albuminuria and dropsy are more curable, when ensuing
after  scarlatina, than  when after other causes; but rheumatism,
after scarlatina and gonorrhoea, is often unusually severe and in-
tractable.
   Present diseases of the patient. —These generally increase the
severity or intractability of the new disorder, especially if they be
structural.  Thus, infectious  disorders  and  fevers are peculiarly
fatal in persons with diseased  heart, lungs, kidneys, or  brain.  Yet
moderate hypertrophy of  the heart  is rather a favourable circum-
stance in phthisis.  Cutaneous and some other external diseases
sometimes suspend attacks of gout, gravel, diarrhoea, &c.
   Previous habits of the patient. — Intemperance and excesses of
all kinds enhance  the danger of all  serious attacks.  Extreme pri-
vations, or over-fatiguing employments, make persons liable to
fevers and  other  depressing diseases,  and reduce the powers of
reaction against them.
   Condition of the patient at the time of the attack.  — Extreme
weakness or exhaustion from  any cause renders persons bad sub-
jects for most diseases.  Plethora increases the intensity of inflam-
matory affections.
   620  The situation and nature of the disease. — 1 he more im-
portant to life is the part attacked, and the more the disease inter-
feres with its function, the more dangerous will  it be    Thus the
heart the lungs, the medulla of the nervous system, and the  blood,
cannot be extensively attacked without great danger to  life; and
if the disease goes on to affect  structure,  as inflammation, the
danger is prolonged in proportion.
   The extent and progress of the disease. - The greater the extent
of the  disease, the  more serious it will be in case of inflammation ;
but the severity of the symptoms is often not in proportion to  its
extent- intense  and  circumscribed inflammation  causing more 
376
WILLIAMS'S PRINCIPLES OF MEDICINE.
prominent symptoms  than  that which is extensive and diffused.
The progress of disease most materially influences its effect on life
and health.   Thus  the structure  of the  lungs, heart, kidneys, or
liver, may become diseased to a most extraordinary amount, with-
out destroying life, if the advance of the lesion  is very gradual;
whilst, a third or fourth of the same mischief would prove fatal, if
it were induced suddenly.
  621  The character  of the symptoms [signs.] — This is exhibit-
ed in the details of each disease.  Those symptoms [signs] augur
favourably which show a power of moderate and regular reaction,
and a return  of the functions to their natural state.  The removal
or alleviation of  the more distressing symptoms of disease — the
restoration of the natural appetites, and feelings, bodily and men-
tal — the return  of strength — the disposition to sleeping tran-
quilly, and waking at the usual times — secretions that have been
interrupted or diminished being restored, and often  in increased
quantity, as if from accumulation, as in the case of critical perspi-
rations, deposits in the urine, &c.  (§ 448), — are among the chief
signs of approaching recovery.
  622. Bad or unfavourable symptoms [signs] are those which arise
from such an impediment of one  or more  of  the functions more
immediately concerned in the sustenance of life, the circulation  of
the blood, respiration, nutrition, and excretion.   In proportion  as
these  functions  are speedily and  considerably impaired, life  is
threatened, and there  is an  approach to its  destruction, by one  or
other  of  those terminations,  which are called modes of death.
Thus, there is death by syncope — cessation of the circulation ; by
asphyxia, or apnoea  —  interruption  of the respiration ; and by
inanition.   To these  may be added, death by the pernicious  in-
fluence of excrementitious matters, and by poisons, which cause
death in  various modes.  These different modes ofdeath  are most
distinct  when induced so speedily as  to  leave the functions,
which they do not directly  affect,  comparatively  vigorous and out-
living that which has  been chiefly injured.  Thus, in sudden death
from causes stopping  the respiration, the heart continues to act for
some  time, until the  death which has begun  with the breathing
function  reaches it also.
   623. If we further  trace the operation of these different modes
of death, we shall find that they all agree in affecting the blood,
either by altering its  composition, or by arresting its circulation ;
and it is  through one  of these means that death extends to all the
functions.  Thus in  death by cessation of the heart's action, the
circulation is at once  arrested ; hence this is the most speedy mode
of death.  Inanition  obviously operates by reducing the circula-
ting material, and by further weakening the organs by whicn the
circulation is carried on.   Asphyxia  we have already found
(§ 235) both  to impede the circulation and  to alter the condition of
the blood.   Excrementitious matter retained in the blood, and  ex-
traneous poisons, also operate in  various ways : by impairing  the 
PROGNOSIS.
377
irritability of the heart; or by injuring the medullary nervous func-
tion (§ 154), on which respiration depends; or by arresting the pas-
sage of the blood through the capillaries (§ 298) ; or (and this pro-
bably  includes  some  of the former  modes) by  so  changing  the
properties of  the  blood itself, as to render it unfit for its office of
sustaining the life of the functions; and the operation of all poi-
sons, as well as of other causes of death, may thus be traced to de-
fective circulation or composition of the blood.   It is the  more ne-
cessary to keep these points  in recollection, because they  show
why death from disease often takes place without distinctly begin-
ning with any set of functions; but all fail from the want of proper
blood, their natural support.
   624. It will be  useful  to  mention the chief varieties of  the
modes of death  above  noticed, and  to state  their symptoms,
which may become available  as prognostic signs of the approach
of death.
rv,,    .   „„.,..      .,     ( Sudden = syncope.
Death (cessation of function) beginning at the heart  < GratjUal = asthenia.
    —    —    beginning at the breathing apparatus = Asphyxia or apnrea.
    —    —    beginning at the brain = Coma.
    —    —    beginning at the medulla = Paralysis.
    —    —   beginning in the blood =* Necraemia {vtn^o^dead ,■ aipa., blood).

   625. Death by cardiac .syncope, or  sudden  cessation of  the
heart's action, may occur in two ways — 1. By this muscle losing
its irritability (§  116), so that it ceases  to  contract;  and, 2.  By
its being affected with tonic spasm (§ 114), in  which  it remains
rigidly contracted, losing its usual alternation of relaxation.   In
both these  cases, death is  quite instantaneous: the subject sud-
denly  turning pale, falling back or  dropping down, and  expiring
with one gasp.  In the first case, both sides of the heart are found,
after death, distended with  blood;  and if the  examination were
made  soon  after death, the blood in the left cavities would be found
to be  florid.  In the second case, the heart appears small and very
hard ;  the ventricles (or at, least the left) are found so firmly con-
tracted, that the cavity is almost obliterated,and contains no blood ;
the  muscle is very firm ;  but after maceration  in water, or even
without it,  in two or three  days, the walls of the ventricles yield
to the pressure of the fingers, and the cavities may be restored to
their normal  dimensions.   This state of  the heart was  long mis-
taken  for concentric hypertrophy, until Cruveilhier and Dr. G. Budd
pointed out its true nature.
   Although syncope by loss of irritability (paralysis), and syncope
by spasm, appear to be opposite states, yet  they arise from some-
what  similar  causes.   In animals, wounds of the heart are followed
sometimes  by the one, sometimes by the other.  Death by shock,
as from  tearing  off a limb, a violent blow on the epigastrium,
crushing the  brain or spinal marrow, is  sometimes caused  by
spasm, although  more frequently by paralysis ot the heart.   In
sudden death from  drinking a quantity of  raw spirits,, or of very
            32* 
378          WILLIAMS'S PRINCIPLES OF MEDICINE.

cold water when the body  is heated, the  heart has  been found
contracted.
  Syncope by loss of irritability of the heart is  the more common
case ; and, besides in the examples above given, it may be induced
by the operation of large doses of certain poisons called sedative —
such as the upas antiar, infusion of tobacco, and digitalis;  and in
combination  with other effects, by large doses of hydrocyanic
acid, strychnia, oxalic acid,  arsenic, preparations  of baryta, and
various animal poisons.  Mr. Blake found the power of the heart
destroyed by solutions of various saline matters injected into the
veins,  especially  salts  of potass,  magnesia,  zinc, copper, lime,
baryta, and lead ;  but these results  do  not correspond with what
we find of the operation of these substances when  introduced into
the stomach.
  The diseases in  which death by cardiac syncope sometimes
takes place are —those of the heart (but more rarely than is com-
monly supposed) ;  hemorrhagic apoplexy, attended with  much
injury to the substance of the brain  (§ 364) ; anaemia (§ 270) ; and
adynamic fevers (§ 105).  As it occurs suddenly, there can scarcely
be said to be symptoms ; but sometimes an approach to it has been
manifested in previous attacks of common syncope or faintness, in
which the action of the heart becomes weak, irregular, and inter-
mittent; and the partial failure of the circulation is evinced in the
paleness of the face, lips, and general surface, often with cold per-
spiration ;  the failure of the sensorial functions (defectio animi),
loss of consciousness and volition  more or less  complete, some-
times attended with various convulsive movements  (§ 153, 265);
the eyes turning up or becoming fixed or glazed, and the pupils di-
lated.   The different effects  of posture on the form of syncope have
been before noticed (§70) ;  and they may  be presented in cases in
which  cardiac syncope ultimately  proves fatal.   The recovery
from this  faintness  is often attended  with shivering, vomiting,
sighing, gasping, yawning,  and various distressing  sensations of
noises in  the  head, flashes  in the eyes, palpitation, depression  of
spirits, &c.; whilst the pulse regains its strength  and regularity,
and the colour and warmth  return to the surface.  After this may
ensue a reaction, like that which occurs after great losses of blood
(§ 266, 362).
   626. Death by the gradual cessation of the heart's action, has
been termed asthenia (a, not, o-Ssvo?, strength).   This is the mode of
termination of many diseases, especially those which  destroy life
by  exhausting the  strength,   without  any  direct  interference
with the more vital  functions.   Thus, long-continued fevers, deli-
rium  tremens, gastritis, enteritis,  peritonitis,  hemorrhages, and
various discharges of animal fluids — such as diarrhoea, diabetes,
extensive ulcers or abscesses, &c, proving gradually fatal —inani-
tion from want of sufficient food, and  several others, reduce the
power of the heart, and with  it the functions of the  whole body,
to  a lower and  lower state, until  at last the heart flutters and
dies. 
PROGNOSIS.
379
  The symptoms of the approach  ofdeath by asthenia are—in-
creasing weakness of body and mind, whilst there may be no more
marked derangement of any  particular function of either ; in-
creasing  frequency, and diminishing strength of the pulse ;  the
face, lips, and other  parts of the surface, gradually become paler
and paler, or of a death-like sallowness : the extremities lose their
warmth, and  often become cedematous ;  the appetite fails ; the
tongue becomes sometimes dry and brown, sometimes furred, and
the mouth aphthous (§ 483);  the  excretions first are imperfectly
voided;  then  the  sphincters   lose their  power  (the  weakness
reaching their excitomotory function), and involuntary discharges
of urine  and faeces may take place ; and this state of sinking in a
few hours terminates in death.  The symptoms above described
are those of progressive loss of power, not confined to the heart,
but through its failure and that of the circulation of the blood, of
which it is the chief instrument, becoming extended  throughout
the whole frame.   But with this general debility there are often
symptoms of partial excitement and  reaction, which sometimes
mark the sinking state.  Thus a febrile excitement of a hectic kind
 (§ 471)  may come  on, giving slight temporary strength  to the
 pulse, flush 'to the cheek, life to the eye, and a sort of flickering
 reanimation to the whole frame.   Sometimes the excitement is of
 a more partial kind, affecting  the brain, as with delirium ; or the
 medulla, as with subsultus tendinum, hiccup, or other slight con-
 vulsion  ; or the stomach, as with vomiting, &c.   Or in the  sinking
 state, some functions may become obscured before others,  m con-
 sequence  of congestions, effusions, or even  low  inflammations
 occurring in the capillaries of some organs (§ 290), as the  powers
 of the general circulation fail: thus the  death  by asthenia  may
 become somewhat  complicated  with  coma, from  congestion or
 effusion within the head ; or with dyspnoea, from congestion in the
 lun^s ;  or somewhat  similar  symptoms may arise from the  early
 failure of the excreting organs, and the retention of excrementitious
 matter in the blood (§ 249).                            ■„„,._.
    627. Asphyxia or apncea has already been noticed as an  element
 of disease (§234), and its nature and symptoms were then ex
 amined (§ 235); we here advert to it as a mode of death. By dearth
 beginning at the  breathing apparatus, I mean that in which the
 mncuon of this apparatus is the first to fail.  .  " "Pf ^ *
 distinguished from death  beginning at the b/ainf°^u"ae^Cil
 destroys  by secondarily  suspending the fun  tion of  breathmg
 Death bv simple apncea takes place in diseases ot  the  lun  s ana
 air tubes7  n which the entrance of air to the lungs is impeded  by
 SffinE the air-cells or tubes; or  by pressure upoji  hem


  arynsitis, and tumours orgasm  constricting  these tnbes ; oi m
  ctrcumstances mechanically excluding the passage ot air by the
  mouth and  nostrils, as  in smothering,  strangling, hanging, and
  drowning. 
380          WILLIAMS'S PRINCIPLES OF MEDICINE.

  The symptoms of the approach of this mode of death are —
increasing feeling of suffocation or want of breath, which becomes
most distressing  and agonizing as the want is unappeased; the
efforts at respiration are made in a hurried and forced manner; the
face, neck, and other parts of the surface become congested in pro-
portion to the violence of these efforts; and as these efforts are
unsuccessful, the colour of the congested parts changes from red  to
purple, and from purple to livid.   The influence of this congestion
and  partial  circulation of black  blood (§ 235) is soon evident on
the functions, causing  stupor, reduction of temperature,  weak and
irregular pulse, rapid reduction of muscular  strength, and conse-
quently of the efforts to breathe.   Hence the dark hue of the face
may be changed for paleness ; but the lividity of the lips, tongue,
nails, and other coloured parts, remains until death.  In cases  of
speedy death from violence, as hanging, drowning, &c, or from a
sudden  attack of laryngitis or spasm, the respiratory  efforts are
more vigorous, and the congestion and lividity of the surface are
greater, and may remain until death.  But in the slower asphyxia
from diseases of the  lungs  and  air-tubes, the interruption to the
breathing is less complete, the efforts are less violent, the conges-
tion of the surface is less marked, and the functions more gradually
failing together, the symptoms peculiar to apnoea are less marked.
Hence, too, as imperfectly arterialized blood is  circulated through-
out the body, it may cause peculiar symptoms, such as stupor and
low  delirium, partial paralysis, vomiting, relaxation of the sphinc-
ters, and other symptoms of sinking.  This exemplifies what has
been before remarked (§ 622), that the distinctness of each mode
ofdeath generally depends on its speedy supervention.
   As prognostic signs, the symptoms of apncea are more hopeless
in proportion as they are conjoined with those of debility.  The
nature of the obstruction to the  respiration  must of necessity  be
taken into account; and if this be not complete and irremovable,
the congestion and lividity of the surface are not fatal signs, so
long as the strength of  the breathing apparatus and of the heart
does  not  decline ; as  this becomes exhausted, the  means of re-
covery are lost.
   628. Death by coma, or  beginning at the  brain, is caused  by
various influences which primarily destroy  the functions of the
superior masses of the nervous  system.   The chief of these cir-
cumstances  are —obstruction to the circulation through the brain
by pressure,  (as of effused blood, pus, lymph,  or serum, or of dis-
tended vessels in apoplexy, a depressed portion of bone in frac-
tured skull,  &c.) ; by  coagula  within  the  vessels  (§ 267);  by
anaemia. (§ 267); and by various narcotic poisons, such  as opium,
alcohol in large quantities, carbonic acid inhaled  (§  246), and
sometimes the excrementitious matter of urine and  of  bile in the
blood (§ 249).
   The symptoms  of coma  are  those  of interrupted function of
the  brain, insensibility and suspension of voluntary motion, the
heart's action not  being materially impaired.  These  may come 
PROGNOSIS.
381
on  in  different modes.  In apoplexy  and injuries  of the head
they may supervene suddenly, and the patient at once becomes
powerless and senseless, the pulse continues pretty good, although
slower and fuller than usual, or it may be frequent  from mere
sympathy.   In other cases, the  stupor comes on gradually, and
the senses and  mental powers are often irregularly  obscured,
causing dimness of sight, appearances  of  clouds  or cobwebs be-
fore the eyes, muscae volitantes ; various imperfections of hearing,
with noises, or tinnitus auriurn ; numbness and tingling sensa-
tions in the limbs ;  loss of memory, confusion of  ideas, hallucina-
tions,  low delirium alternated  with  stupor (typhomania),  con-
tinued somnolency, &c.  Partial paralysis often accompanies pro-
gressively  advancing coma, sometimes of the lower  extremities
(paraplegia), more commonly of one  side (hemiplegia).   In the
operation  of  narcotics, the  state of coma is commonly preceded
by symptoms of cerebral excitement,  manifest in the usual signs
of intoxication and delirium, which vary in the case  of different
poisons.   For these  particulars, I must refer to  works on toxico-
 logy and materia medica.
   In  conjunction with these symptoms, referable to the sensorial
 and voluntary functions, there are  often symptoms  of various
 affections  of the excitomotory system of the medulla ;  at first they
 are those of excitement, such as convulsion, vomiting, hiccup,
 contracted pupil,  &c. (§ 152.)  Thus, the coma of apoplexy, and
 sometimes the stupor  of narcotism, are occasionally accompanied
 by convulsions (§ 150), general  or local; and I have elsewhere
 (h 153) endeavoured to explain  how these opposite effects on dif-
 ferent parts of the nervous centres may arise from the same cause.
 But in cases  of more extreme coma, the excitomotory power  of
 involuntary motions becomes impaired, the breathing  is stertorous
 and imperfect, the actions of coughing and expectoration are not
 easily excited, deglutition becomes  impossible, the   pupils are
 dilated, emetics fail to excite vomiting, the sphincters are relaxed
 and involuntary  discharges of urine and feces take place.  14iis
 last group of symptoms  was before  noticed  as the  fatal part  ot
 coma and narcotism (S 154).                    .
    I"isI question whether the functions of the bran,  can be com-
 Dleteto suspended for any length of  time without those  of the
 med.Ua  suffering also.   During sleep   there ts not  complete ,n-
 sensib hty or  ulpcnsion  of  volition, for movements are then
 made    consequence of unpleasant  sensations, yet  wtthont the
 Teo being broken.  It is probable that m the trance of nervous


 1"^ t°  h^aSs often Seive themselves as well  as

 oSr^
   "na' '"  ",1,'e fuSnof he medulla  seem to be also impaired,
    Mho" —ng "s s^ "and stertorous, and irriuuion. of the nose
coma
sci
fo 
382
WILLIAMS'S PRINCIPLES OF MEDICINE.
and  eyes less readily than usual excite  the motions of sneezing
and  winking.  It is in proportion as these functions are impaired
that  coma becomes dangerous; and  it is because they are  not
materially impaired in nervous or hysteric stupor, that this is  un-
attended with danger.   It appears probable, however, that coma,
when complete, may cause death by the abolition of sensation
only.  Although the movements of breathing are ordinarily inde-
pendent of the consciousness or  will,  yet such is not the case of
the extraordinary movements which  commonly  take  place  in a
deep breath or sighing, when  the ordinary  action is impeded by
posture, fatigue, or any other cause.   A sensation of want of breath
is then felt, and an effort is made to  relieve  that sensation.   But
when sensibility and voluntary power  are suspended, these sup-
plementary efforts are  not made ;  for want  of them, the respira-
tion  may be insufficiently  performed, and  the lungs may become
congested; this congestion further impairs the involuntary part of
the process of respiration,  and the symptoms  and effects of apnoea
are gradually induced.   Under such circumstances, it is of  great
importance to place the  patient in such postures or other circum-
stances, as shall most favour the movements  of breathing, and to
remove pulmonary congestion by the  proper remedies, should it
arise.
   Snoring arises from a relaxed state  of the  soft  palate, and is of
little moment so long as the movements of breathing are sufficiently
strong and frequent; but when the respiratory  powers are im-
piared, stertor is not only  a sign but a  cause  of obstruction to  the
passage of the air, and should be prevented  as  much as possible
by changing the  posture of the patient.
   The most  dangerous kind of coma, then, is that attended with
symptoms of impaired excitomotory function, these symptoms being
apparent especially  in connexion with the respiration.  In apo-
plexy, contraction of the pupil of one or both eyes is of very un-
favourable import, because it indicates an excitement of the upper
portion of the medulla, whilst the brain is oppressed ; such a com-
bination can only proceed  from  the partial operation of a clot  in
the substance of  nervous centres, compressing one  part and irri-
tating another.
   629. That death should ensue from  injured function of the me-
dulla oblongata and spinalis is  quite intelligible, when it is con-
sidered that on this portion  of the nervous system the ordinary act of
breathing depends.  This mode ofdeath, like the last, is by apnoea ;
but the death, or failure  of function, here begins with the nervous
link  of the chains of actions constituting the process of respiration,
whereas, in  simple  apnoea, it commences with the  mechanism of
the breathing apparatus.
   This death may be called death  by  paralysis,  and as  in other
cases of paralysis of an excitomotory function (§  144), it may be
caused by suspended function, either of the  nervous  centre (me-
dulla oblongata), or of the afferent nerves (par vagum and sym- 
PROGNOSIS.
3S3
pathetic), or of the efferent nerves (phrenic, intercostals, and spinal
accessory), which complete the  respiratory circle.  Of influences
which destroy the function of the  medulla oblongata itself, may
be mentioned, hemorrhagic effusion into its substance or upon it,
fractures of the base of the skull, and any very considerable pres-
sure on the whole encephalon.  Some poisons  seem to affect the
medulla more immediately than the brain.  Thus, animals poi-
soned with woorara, essential  oil of bitter  almonds, conia, bella-
donna, and perhaps some other poisons, are  affected with gaspings
and other signs of impaired function of respiration before they lose
consciousness ; according to the experiments of Sir B. Brodie and
others, they die simply from suspension of respiration, and if this
process  be artificially maintained  for  a  time,  the animals  may
sometimes recover from the effects of the poison.  The  same re-
mark in some degree applies to opium and its active principle, but
less distinctly, for  these early induce coma, and often impair the
action of the heart  also.  Experiments  are wanting to establish
the elementary operation of this and other poisons, as  the func-
tions are now viewed by physiologists.  In some cases in which
I have seen  animals  die from  rapid hemorrhage, the respiration
has ceased for some seconds before the heart's action ; and from
the  peculiarly laboured state  of the  breathing,  and  late retention
of  consciousness, I conclude, that  death  from  hemorrhage, in
some instances at least, is due to suspension of the function of the
medulla.
   630. The  division of the  eighth  nerves  in the neck in animals
illustrates  one mode of inducing death by paralysis.  These are the
chief incident or afferent  nerves from  the  lungs  to the medulla,
transmitting the  impressions which excite the  motory nerves of
the  muscles of respiration.   When they are divided, the breathing
is imperfectly performed, and expectoration and cough cannot take
place ; apncea, therefore, gradually  follows.  Although we  have
not  a result to the same amount exhibited in disease, yet we have
an  approach to it in the dyspnoea, sometimes constant, sometimes
in paroxysms, caused by pressure of tumours on  these nerves, or
by malignant disease involving them.
   631  The  third mode in which  the nervous  link of respiration
may be  broken, injury  to the  excitomotory column of the  spinal
marrow, or its branches, is exemplified in the case of breaking the
neck, or dislocation  of the upper  cervical  vertebrae.  Pithing an
animal effects the same thing.   All parts supplied by nerves from
below the injured portion of the medulla become paralyzed, and
therefore their motions cease.   Diseases in the verteb-rae ^ the spi-
nal  cord, or in its membranes, have been followed by similar re-
sults ; and the functions of the  several nerves  of respiration are
illustrated by these cases. I have known disease affect mg the cord
at the upper cervical vertebra, cause  loss  of i™°tion in aII   aits
below theP neck except the diaphragm, which  is siipphed by the
phrenic  nerve, and through  which tor  a while recitation was 
384
WILLIAMS'S PRINCIPLES OF MEDICINE.
wholly carried on.  The patient afterwards regained power in the
spinal accessory nerve, by which  he was enabled to elevate the
upper part of the chest; and subsequently some power was  for a
time restored to the superior intercostal nerves and muscles.*  In
other cases,  disease of the spinal cord creeps from below upwards,
beginning with paralysis of the lower extremities and pelvis, then
reaching the dorsal  spine, palsying  the intercostals, and at last
reaching the neck.  The advance or retrogression  of all  these
symptoms are of great importance  in the prognosis of such diseases.
  632. Besides the respiratory function, the functions connected
with excretion are dependent on the integrity of the spinal  cord ;
they fail when it is seriously injured, and this failure may furnish
symptoms ofdeath beginning at the spinal cord.  When the cord
is injured only at a point, and remains healthy above and below
it, the injury may merely intercept the transmission of sensation
upwards, or of volition  downwards, beyond  the injured  point.
Hence, there may be loss of sensation, or of  voluntary motion, or
of both, in the lower portions of the body.  If this reach the uri-
nary apparatus, the power of spontaneously voiding urine is lost.
But the reflex or independent excitomotory influence of the spinal
cord remains ; hence, the sphincters and the bladder retain their
power, and  when the catheter is  introduced into the bladder, it
contracts as usual, aided by the voluntary power remaining in the
diaphragm  and  abdominal muscles.  We  have  before  noticed
 (§  149), that under these circumstances the muscles of the  lower
extremities retain and accumulate  their irritability, and although
the will has no command over them, yet tickling, or even touch-
ing them, may excite them  to contract.  The exercise thus kept up
seems to be sufficient to preserve  their nutrition, for they do  not
waste away.
   But it is quite different  if the  spinal cord be extensively in-
jured,  as by crushing, softening, or a considerable effusion of
blood or pus into its sheath.  Its  function then ceases, not only
as  a communicator  of sensation  and voluntary power  to  the
lower parts  of  the  body, but also  as a source of that involuntary
excitomotory power by which the sphincters contract and the uri-
nary bladder evacuates its contents.  Hence,  there  is  constant
dribbling of urine, yet without the power completely to empty the
bladder. The faeces are discharged unconsciously, and without the
power of control.  The limbs are not only insensible and power-
less to the will,but their muscles can no longer be excited by tick-
ling : they lose all motion, and the bloodvessels lose  that influence
which the nerves of all orders exercise upon them.   It is not sur-
prising, under  such circumstances, that the death which has begun
in the spinal cord should spread to the parts whose functions it can
no longer maintain.  The urine, imperfectly discharged, putrefies,
and causes inflammtaion of the bladder, which may gradually  extend
* Med. Chir. Trans., 1843. 
PROGNOSIS.                      3S5
toand stop the function of the kidneys.  The intestines become dis-
tended and obstructed with gas and pent up fseces. The limbs lose
their proper circulation for want of motion and nervous influence on
their muscles and vessels ; their nutrition fails, they become cede-
matous, partially inflamed, livid, and run into gangrene; and  all
these changes are so many signs of the progress of death which has
begun in the spinal cord.
   From the remarkable effect of cold and some poisons on  some
of the lower animals, inducing paralysis of the hinder extremities,
it is probable that these agents are capable of especially injuring
the  function  of the spinal cord, beginning with the remote part.
Has the gangrene of the lower extremities, sometimes  induced by
the  use of ergoted corn,  any connexion with an injured function
of the spinal cord ?
   Death of the medulla supervenes on that beginning with coma
and asthenia in many cases;  and as its voluntary excitomotory
function is the guardian of many processes essential  to life, the
 symptoms connected with it are of great importance in connexion
 with prognosis.
   633. Necraemia, or death beginning with  the blood, are terms
 which I venture to give to those fatal cases in which the first and
 most remarkable change is exhibited by the blood.   In typhoid
 fevers and others of the malignant or pestilential kind, none of the
 solids of the body constantly exhibit such an early change of func-
 tion or of structure as would warrant us in tracing disease and
 death  to them.  It is true, that the functions of many solids are
 impaired — the muscular and nervous systems, secretion, digestion,
 assimilation, and nutrition, all suffer, but the very universality  of
 the affection seems itself to point to some cause more general than
 can be found in any individual function ; and such a cause may
 be  found  in the blood.   The blood, at an early period of these dis-
 eases, when they occur in their worst form, exhibits changes which
 show  that disorder begins with it, and this disorder may reach  to
 a fatal degree.  The appearance  of petechias and vibices on tne
 external surface, the occurrence of more extensive hemorrhages m
 internal parts, the general fluidity of the blood, and frequently its
 unusually dark or otherwise altered aspect, its poisonous  proper-
 ties as exhibited in  its  deleterious operation on other animals
  Ik  25S), and its proneness to pass into decomposition, point out the
  blood as the firs? seat of disorder, and by the failure of its natura
  properties and offices as the vivifier of all structure and function
  F&180 2620% is plainly the  medium  by which  death begins  in
   L body   How  far the" change in the  blood is in  its structure
   M89) and vkal properties (§^201), or in its chemical composiuon
  % 182)  further research alone can determine ; the vivifying fu. c-




             33 
386          WILLIAMS'S PRINCIPLES OF MEDICINE.

of life to the whole body, is itself dead, and spreads death instead
of life.  Almost simultaneously, the heart loses its power, the pulse
becoming very weak, frequent, and  unsteady;  the vessels lose
their tone, especially the capillaries of the most  vascular organs,
and congestions occur to a great amount (§  290, 293); the brain
becomes inactive, and stupor ensues ; the medulla is torpid, and
the powers of respiration and excretion are  imperfect; voluntary
motion  is almost suspended ; secretions fail; molecular nutrition
ceases ; and at a  rate much more early than in other modes of
death, molecular death follows close on  somatic death — that is,
structures die and begin to run into decomposition  as soon as the
pulse and breath have ceased, nay, a partial change of this kind
may even precede the death of the whole body, (somatic death —
Dr. Prichard,*) and parts running into gangrene, as in the carbun-
cle of plague, the  sphacelous throat  of malignant  scarlatina, and
the sloughy sores of the  worst forms of typhus, or the putrid odour
exhaled even before death by the bodies of those who are the vic-
tims of similar pestilential diseases, are so many proofs of the early
triumph of dead over vital chemistry.
   634.  We have hitherto represented an  extreme case ; but there
are many lower degrees in which disease begins with the blood,
and various disturbances and  reactions result.  The causes which
appear thus primarily to affect the blood are especially endemic,
epidemic, and  infectious influences, called poisons (§ 81, 8S, 93),
certain animal and vegetable poisons, as that of the most venomous
reptiles and fungi, and probably some mineral poisons, as sulphu-
retted  hydrogen, selenium, and, in part of its operation, arsenic.
The direct influence of all  these agents is depressing (§ 105), and
when they operate in large quantities, or in  a concentrated form,
the vital powers fall quickly into a state of adynamia or prostration,
which soon ends in  death, as we  have already  described it, the
blood first  and  most constantly manifesting a change.  But if the
noxious influence is in smaller quantity, or more  diluted, the vital
powers react against it (16) in various ways, the object  of which
can often be plainly discerned to be its expulsion from the system.
The shivering,  hot stage, and sweating termination of paroxysms
of intermittent  fever; the similar but less marked series of febrile
movements which occur in slight forms of remittent and continued
fevers;  the profuse and  violent fluxes from the stomach and intes-
tines in cholera, dysentery, and epidemic diarrhoea,  and the similar
discharges induced by poisonous ingesta, are instances of the opera-
tion of vital reaction attempting the expulsion of the noxious mat-
ter and of  that part of  the animal fluids that had  been corrupted
by it.   But these struggles in  many instances constitute serious
diseases, in which life may be  compromised by the violence and
exhausting effect of the reaction as much as  by the prostrating in-

   * See Dr. Symond's interesting essay on "Death," in the Cyclopaedia of Ana-
tomy and Physiology. 
PROGNOSIS.                     387
fluence of the cause of the disease ;  and  in these more complex
affections, individual organs may especially suffer in different cases,
and the danger and the cause of death may be less in the changed
condition of the blood than in the affections  of particular organs,
or the exhaustion consequent upon them, which destroy, not by
necraemia, but by coma, asphyxia, or  asthenia,  modes of death
already considered.
   635. But the injurious effect of these poisons may be still more
 completely prevented  when  their  quantity is  small  and  the
 living powers are vigorous.  A  diarrhoea, a profuse sweat, or a
 free flow of urine, sometimes carries off the commencing disease.
 The intestines, the skin, and the kidneys, appear to be the proper
 emunctories  through  which morbid  matter  is  expelled.   The
 peculiar fetor of the secretions from the bowels in typhoid fever,
 and the beneficial influence of moderate diarrhoea, which removes
 them in the early stage of fever, seem to be an example of the
  elimination of  a morbific matter; and I have  before suggested,
  (§ 404, note,) that the follicular inflammation and ulceration  of
 the intestines in fever  may arise from the excessive irritation  of
  the follicles in the  exercise  of this eliminating  function.  Again,
  with regard  to the  kidneys, it  has been before  mentioned, that
  granular degeneration, which impairs their function, renders the
  body peculiarly liable to  contract  epidemic and infectious dis-
  eases, and  to  succumb under them  (§ 260).*   This renders the
  prognosis  unusually  unfavourable in  these cases.   1 he  same
  remark extends, and for the same reasons, to persons who have
  been habitually intemperate.  On the other hand, those whose
  kidneys are  naturally active more effectually  resist disease, and
  more readily throw off its effects (§448)   In like manner it is
  well known that persons  with  a naturally  dry skin do  not so
  readily get rid of a fever as those in  whom perspiration is readily

  eXC636d'  Besides  the   extrinsic influences  already  mentioned
  (k  r«u\  as first  attacking the  blood, and in  extreme cases in-
    uringi  composWon,  and  causing its death, there are others
  Knatine in  the body itself.  Thus the processes of gangrene
  aKSion^meBiafect  the blood with a septic poison
  ^470 475) and cause death in  a  manner and  with  symptoms
  lie thotlonhe  poisons above noticed.  The  sudden suppres-






                       v.toA in thp ™se of an epidemic erysipelatous angina,
     * This has been exemplified in the case, ot    P             ,ast
   which attacked several patients of the ^rsny^ ^eQled with various dis-
   (1843).  Out of about a dozen cases ^/^P^tendiag to the larynx,and
   eases were attacked, three died from th"^P^XniinSu..
   in all these the kidneys were granular and tne urine 
388           WILLIAMS'S PRINCIPLES OF MEDICINE.

chaemia, or depraved state of the blood (§ 249, 564); so we now
find that, in an extreme degree, it may cause necraemia, or death
of the blood.
   637. The symptoms  which should  make us  apprehend  the
approach of death by necrasmia,  may be gathered from the  pre-
ceding descriptions.  Those symptoms generally  called typhoid,
putrid,  or  malignant, belong especially to  this class  of death.
For example : a congested appearance  of  the whole surface, the
colour being dusky or livid, and extending  to the conjunctivas,
tongue, and fauces;  various, slight, exanthematous, or papular
patches on  the skin, often with petechias ; more extensive hemor-
rhages in form of ecchymoses, or oozing of thin  bloody  fluid from
the gums, nostrils, and  sometimes from  other passages  ; extreme
prostration  of strength, with an obtuse  state  of  all the senses and
mental  faculties,  sometimes combined with delirium  and twitch-
ings of the  limbs; half-closed eyes and dilated pupils; a very fre-
quent, weak, and soft  pulse; frequent  and  unequal  respiration;
no appetite ; intense thirst; a dry, brown tongue, with dark sordes
on the  lips and teeth ;  a progressive fall  of temperature, which
may have  been elevated at first; often cold, clammy,  and fetid
perspiration;  hiccup ;   subsultus  tendinum;  scanty,  offensive
urine; involuntary discharges.
   Some diseases of the same class are modified by peculiar effects.
Thus in malignant cholera, excessive discharges of serum, by
vomiting and by stool, reduce the blood to such a spissitude, that
it will no longer  circulate  through the  vessels; the pulse ceases,
and the surface becomes blue and cold from the darkness and stag-
nation of the blood, and shrunk from the exhaustion of its fluids.
In yellow fever, altered  blood is ejected from  the stomach  in  the
form of what is called black vomit.   But to pursue  this subject
into further details belongs rather to the  department  of special
pathology.
   638. It has been before mentioned, that the complete distinction
of these different modes ofdeath is almost exclusively confined to
cases of speedy or sudden death.   In the  slower dissolution, by
which diseases generally prove fatal, all functions and  structures
are more or less involved ; and the life in all  is dwindled down to
so slight a thread, that when it breaks in one, others  scarcely re-
tain it long enough to enable us to say that death begins distinctly
in any part.(a)

   (a) Although subsequent experiments and observations have
modified some of the views  advanced  in it, yet the treatise of
Bichat " On Life and  Death," will still be long referred to, for
its luminous  physiology and elegant style, by every reader  who
desires to have the subject placed fully  before him. 
PROPHYLAXIS AND HYGIENICS.
389
      CHAPTER  VII.

PROPHYLAXIS AND HYGIENICS.
  639. Prophylaxis is the guarding against a particular disease ;
and hygienics relate to the prevention  of diseases in general, or
the preservation of health.   The former is appropriately connect-
ed with  special pathology; and it should be founded  on a due
knowledge of the causes, nature, and tendencies of diseases, and
of the various means in diet, regimen, residence, and  medicine,
which are capable of removing the causes of disease, or of prevent-
ing or counteracting their  operation.(a)

  (a) Prophxylaxis, literally preservation, is, like pathology, divi-
sible into general and special.  The first imparts  a knowledge of all
the measures through which a vigorous health is  procured and
maintained,  and disease  kept  off. The second  or special pro-
phylaxis teaches  the particular regimen through which tone is
given to an organ  or  organic  system, enabling it to resist the
disease to  which it  would be otherwise exposed:  it points out,
also, the means of protection  against some  one morbid agent, as
vaccination, a prophylaxis against small-pox.   Prophylaxis,  it
will be seen at once, is not so much an independent branch as an
application,  for particular purposes, of hygiene  and  physiology —
a due appreciation, first, of the various substances and agencies m
nature, destined for the sustenance and  well being of the  individual,
 and, second, of the equable play of the functions under  the  opera-
tion of their appropriate exciters; — both of them brought to bear
in aid of pathology, through which we learn the causes of disease
to be removed and other dangers  to be shunned.  Hygiene, phy-
 siology, and that portion of pathology included under the head ot
 etiology, make up, we repeat, the elements of prophylaxis.
   It is with this as with all other  matters in which man s reason-
 ing faculties are appealed to.   Remote and contingent danger  is
 little heeded ; and it is only when it comes near and threatens that
 precautionary measures are thought of and Pureve»uv%^r^eeU
 That which is done in haste and in ear is  however  ejdom weU
 done • and hence, the various prophylactic devices adopted to ward
 off eidemic diseases or  hereditary ones}*™"™S"™°£™
 often crude and insufficient, if not P*81"!6*^
 vating.  On occasions like these we see the dep-larab,e;g«^
 nmoncr  the  ereater  part  of  the  community   of the elementary




 That physicians, the expounders  of the law  at  these  junctures,
33 
390          WILLIAMS'S PRINCIPLES OF MEDICINE.

  640. Hygienics consist in the knowledge and application of
those means, by which the structures and functions of the body

are  often more oracular than wise, and send forth opinions more
calculated to alarm than assure.   Thus, in the case of epidemic dis-
eases, how pernicious the doctrine of contagion, which, by holding
out wrong causes, drives the  people into alarm, itself a powerful
cause of disease, and into measures sometimes the very reverse of
those really required under the emergency. Quarantine regulations
andrestrictions,although  intended to be prophylactic, are often mis-
chievous, because they mislead from the true issue, besides compel-
ling congregations and collections of persons, and thus inviting new,
or  aggravating existing, causes of diseases.   So, likewise, in
endemic diseases, whilst  speculating on some invisible, immaterial
and inappreciable agent, such as miasm, and giving into abstrac-
tions as to its nature and the means of resisting it, the laws of hy-
giene, an  obedience to which would  be the only true prophylaxes,
are overlooked or despised.  If, again, it be desired to impart imme-
diate energy to the economy, so as to  enable it to  resist morbific
causes, what an ignorance of physiology is  betrayed, or used to
be  generally betrayed, in the prevalent fashion  of using strong
 alcoholic drinks, either as  procured from the sideboard, the bar-
room, and petty taverns, in their plain state, or from the shop of the
apothecary and the doctor,impregnated with various bitters. It was
 not known to the people who indulged in  this practice of " keep-
ing off fevers" or other diseases, that strength could not  be either
retained or acquired  by diffusible stimulauts ; but the very reverse,
as  the functions, being hurried into increased and hurried action,
 without the organs  receiving new or healthy blood, must necessa-
rily become weakened, and in consequence more exposed than be-
fore to existing morbid causes, whatever these may be.
   True prophylaxis, not the shifting  expedients of the day, can
only be entered on with a proper foreknowledge of the  probable
 supervention of diseases at a remote  period, and which can only
 be prevented by its requisitions being faithfully carried out.   Thus,
 in   hereditary  predisposition  to particular diseases, as insanity,
 phthisis, scrofula, gout, &c, prophylaxis should be begun  in the
 first period of life, and pursued unremittingly until both  body and
 mind  have acquired  their full maturity, and enjoyed a long period
 of the vigorous exercise of  their functions.  It should consist of a
 carefully regulated system of hygiene, including, under  this head,
 regimen, exercise, proper division  of the hours of  sleeping and
 waking,  active but not  troublesome occupation  of the  mind, and
 breathing a pure air. When the frame is primarily feeble or soon
 becomes so in early life, suitable gymnastic excercises and sports
 are one of the chief parts of prophylaxis.
    Indigenous diseases, which depend on certain states of the soil,
 water, and air, and  sometimes  on a deterioration  or deficiency of
 articles of food, are  prevented  by removal from the unhealthy  re- 
PROPHYLAXIS AND HYGIENICS.
391
may be kept in that normal state which conduces to their continued
welfare — that is, in health  (§  6).   We have found, that both

gion ; or, if this be impracticable, by devising means to mitigate the
extremes  or abnormal deviations of the several agents of hygiene
which have become causes  of  disease.  In low and marshy dis-
tricts, the inhabitants ought to preserve the air of their bouses dry
and of  equable temperature, by means of fire, the greater part of
the year, not even excepting the mornings and  evenings of sum-
mer ; their persons should be protected by warm woollen clothing,
and the  heats of noon and the  cold dews of night equally avoid-
ed ; their digestion kept regular by the use of water  previously
boiled, or, if possible distilled,  and  then aerated, vegetables well
boiled, and farinaceous articles  taken in full proportion with some
 animal food daily ; but excessive repletion to be carefully shunned.
   Prior to the invasion of epidemic diseases, when, as happens in
 the case  of cholera and of influenza, for instance,  we hear of their
 having been previously in another region  or district, prophylaxis
 will consist in a careful adherence to the laws of hygiene, with an
 especial  reference to the  organs more  immediately exposed, and
 to  the season, so as to mitigate its intemperance, whether this be
 of heat or of cold, alone, or  with moisture.
    Moderate confidence, resting on a conviction that one is pursuing
 a course founded on sound hygiene as well as  sound morals, and
 the two  can never be separated, is itself an excellent prophylactic
  It has carried unharmed  through  scenes  of pestilence and death
  many a benevolent person who was solely intent on relieving the
  sufferings of his fellow men.
     In  diseases of occasional   or sporadic occurrence, some one
  cause, among many, is found  to  be more especially operative in
  bringing it on ; as, for instance, excessive  venery, or even in some
  cases its commonest gratification, and  also indulgence in strong
  and  above all angry emotions, are frequently  exciting causes of
  epilepsy.  These ought of  course to be avoided.
   PLiuley stress  can  be  laid on merely medicinal  substan  es for
  permanent prohylaxis,  although on occasions they funh aid
  which  ought not to  be overlooked,-as quuia and is  as
  against periodical fever and congestion of the sp een -and sa^
  of iron against chlorosis and  the  various disorders incident to an
  impoverished state of the blood.  It is probable that a mow cfficien
  prophylaxis  could be procured by persistans in the usof various
  fhe^aplutical agents for a longer period than gen,*a   -^om has
   hitherto required.  More especially shoulu we  peisevere aurin
   ^n'which the V^U™™™*r% ^t
agents, from tne goou eu^ u«.*»&  —           j  •   summer ?
example, of drinking mineral wa ers toi a tew          statislicai
  Facts of a  positive nature, resting on caieumy ma 
392
WILLIAMS'S PRINCIPLES OF MEDICINE.
structures and functions  have the elements of disease in them-
selves, when anything  disturbs their due proportion.   We have
noticed the circumstances which  lead to such disturbance, both in
connexion with the causes of disease, (under the head Etiology,) and
in connexion with its intimate nature (in the division Pathology
proper); and remarks on the means of preventing or counteracting
those circumstances were introduced in the context to a sufficient
extent to suggest  the principles of hygienics.  Want of time  pre-
vents me from introducing here, as I had intended to do,—1. A
brief review of the chief causes of disease, for the sake of pointing
out the means of  preventing their occurrence, or resisting their
operation ;  and, 2. A short account of those circumstances which
most promote the healthy condition  in the  several functions and
structures of the body.(a)

returns and comparisons, for a long term of years, show that pro-
phylaxis on a large scale, by which many diseases are  prevented
and  life  is prolonged in large communities, is best carried out
by a series  of agents and  influences  coming under the  head of
improved civilization.  By this we should  understand the ame-
liorating  operation  of  religion, the  protection  of laws, an im-
proved agriculture, attention  to ventilation, and household and
personal  cleanliness, and  an active interchange of  the kindlinesses
of social life.  We cannot do more now than merely advert to
these points  of prophylaxis on which elsewhere (Regimen and
Longevity, Chap, i., ii. and xv.) we have dilated somewhat more
at large.
   (a) We would gladly, were  adequate time and space  allowed
us, supply from the ample stores in our possession, the deficiencies
of the text, on the subject of hygienics.   As it is, we must content
ourselves with a few observations on  the propositions announced
by the author.
   Public hygiene has not received that full share of attention from
governments,  either national  or  municipal, in  modern times, to
which, on every ground of humanity, Christian kindness, and even
state policy, it is so largely entitled.   When we look at the remains
of the numerous aqueducts of  republican  and  imperial Rome,
her vast  constructions for bathing  and gymnastic exercises, and,
her cloacae or sewers, we cannot but feel conscious of the inferiority
in these respects,  of the people, not merely of the " eternal city" as
she now is, but of modern cities generally. In Great Britain, for ex-
ample, which, were we to credit the assertions of her own writers, may
rightfully boast of being in the van of civilization,and the most active
in diffusing Christianity through the world, the neglect of public hy-
giene is great, and indeed cruel. In cities, towns, and villages, with-
out  number, no adequate drainage and sewerage are attempted, no
provision is  made for  supplying  the inhabitants with water for
even personal ablution, or the removal of accumulated filth and offals.
With such neglect  on the part of those who  ought to  be their 
PROPHYLAXIS AND HYGIENICS.             393
guardians, the people themselves cannot be expected to be atten-
tive to either domestic or personal hygiene, either in the construction
and subsequent ventilation and cleanliness of their houses, or in the
attention to their own  purification and mode of life  generally.
Nor is the  condition in all the essentials of hygiene here specified
any  better  among large numbers of the peasantry or strictly rural
population.  (See Bulletin of Med. Science, April, 1842.)   From
such prolific sources of infection (receiving this word in the sense
already explained in note to p. 50), arise typhous fever, dysentery,
and various complications of diseases of the most unmanageable
character.   Food of bad quality adds  its  share, by permanently
deranging  the functions of  assimilation, and with the  addition of
moist and impure  air, brings  on  scrofula  and  similar  morbid
growths and  transformations.
   In order to take  a systematic view of hygiene we  must divide
its agents into classes.  We should next study them in a twofold
 point of view : first, their beneficial operation when received in due
 proportion and season; and, secondly, their deleterious or patholo-
 gical effects, when received in excess  or with violent alternations
 and extremes.  We might regard them as constituting materials
 either for  hygiene or etiology, according to their mode and time of
 application and use. The classification, which we long followed in
 our lectures on Hygiene and General Pathology, was that of Halle,
 as follows: I. Circumfusa; II. Applicata; III. Ingesta; IV. Gesta;
 V.  Percepta.
   I. Circumfusa include all the agencies  operating on the animal
 economy through the medium of the atmosphere, as heat, and cold,
 moisture,  and dryness, winds, exhalations,  vapours, and electri-
 city ; and next the alternations of these several  states during the
 different seasons, and in certain localities and climates.  Under the
 latter heads we  treated of endemics, in connection with medical
 topography and geography, and  epidemics.  It  was during  our
 investigations in this department of  pathology, that we were  led,
 quite contrary to preconceived notions and explanations,  to doubt
 the reality of the hypothesis of miasm.
   Ingesta, axe all  those  substances, both solid and  liquid, intro-
 duced into the body by the first passages.   In this class are included
 animal and vegetable  aliments, and drinks, both simple  and  pre-
 pared by  artificial means; on all of which it was our custom  to

 ^Excreta, commonly follow ingesta in the usual classifications;
 but as it is not easy to institute inquiries  into them separate from
 physiology as regards  their healthy proportions, on the one hand,
 nor from  general pathology as respects the disorders  on the circu-
 lation and condition of the5 fluids and nervous system generally, on
 the other  we seldom allowed ourselves to rest long on this head.
    Gesta- Actions or functions which are performed by the vo-
 luntarymotions of the muscles, become themes for inquiry under
  ne 1 eads of exercise, passive, mixed, and  active, of gymnastic 
394           WILLIAMS'S PRINCIPLES OF MEDICINE.

training, labour in the field and the workshop, and of diseases of
artisans from defective  exercise of the locomotive organs, and
corresponding languor of circulation  in the viscera.
  Percepta. — Perceptions, or  functions and  impressions which
depend upon the sensibility and organization of  the nervous sys-
tem.   After reference to the genial and salutary excitement of the
senses and brain by their  appropriate stimulants, and their states
of alternate activity and repose, we studied these  functions in their
excessive action, as causes of disease ; under the heads of intellec-
tual exertion, the  passions, and the states of sleeping and waking.
  By this arrangement and  division  of  subject,  we were enabled
to lay before the class (of the Philadelphia Medical Institute) attend-
ing our lectures, a large body of facts  and  useful  deductions on
hygienics and prophylaxis, and to go over nearly the whole ground
of general etiology with its numerous and diversified ramifications ;
in fact, to accomplish that which the author, in the text, proposed
to himself for future performance.
  " A short account of the circumstances which  most promote the
healthy condition  in  the several functions and  structures of the
body," as proposed by the author, is nearly identical with a state-
ment of the conditions for longevity, an inquiry which, in a some-
what summary manner, we instituted on another occasion (Regi-
men  and Longevity).   The main requisites  are, to  be born  of
long-lived parents; a good physical education ;  and of this there
is a greater chance in  the country than in town ; average intel-
lect;  change of scene ; travel and diversified  adventures; addic-
tion to agricultural pursuits, which implies living much in the open
air; a moderate  pursuit  of literature and science;  avoidance of
strong contending passions ; and, hence, we find "that contentment
and serenity of  mind, a well regulated moral sense  and trust in
Providence, are powerful aids to our attaining  longevity."  " It is
impossible to abide by this last condition without leading a life of
some regularity,and marked temperance." (Op. cit.)   To continue
our enumeration of the conditions for longevity :  " There is hardly
one point on which there is such  entire  accordance in  practice
among long livers, as in early  rising, which implies, also, retiring
to bed at a stated early hour in the evening.  Deprivation of sleep
is peculiarly exhausting; no effort at renovation, by  any other
means, can supply its place. Feebleness  of  body, premature old
age, and  insanity, are some of the effects of protracted vigilance."
"The food of those most remarkable for  their longevity has been
plain  and even coarse.   Simplicity of diet is all  important."
   Climate has a notable effect  on longevity.   To say nothing of
 those regions of the world proverbially sickly,  it is  known  that
the extremes of great and prolonged cold near  the poles, and of
heat, in the equatorial regions, are adverse to long life."   Op. cit.,
 p. 381-88.
   We might inquire into the causes and  modifying circumstances
 affecting health, and generating disease,  under the head, first, of 
PROPHYLAXIS AND HYGIENICS.
395
those inherent in, and peculiar to, the individual;  second, of those
external, or adventitious.  Under the first will come age, sex, and
race, to which some may add temperament.  Under the second,
are enumerated climate, season, locality, occupation, and mode of
life in general.   Our remarks on each of these, in the work already
referred to (Regimen and Longevity, p. 389-420), though  brief,
could not well be brought within the limits of the  present volume,
and to that work must we refer  those curious of  learning farther
details on the most momentous of all mere worldly subjects.
THE  END. 
i  JT ,  %.
 
 
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