m^ t»S»»»« !■■ V' ". ■ ' >*;>», if?. ^ trt- \->v.r. ■3£ M-.w.^..,....., M*U . ■>■"/ * .4. ,»4i>:>» *»'*'.*■ Ok Vw< <•'.». I MM /1.C . ■ ' • PRINCIPLES OF MEDICINE. AN" ELEMENTARY YIEW OP THE CAUSES, NATURE, TREATMENT, DIAGNOSIS AND PROGNOSIS OF DISEASE. PRINCIPLES OF MEDICINE. AN ELEMENTARY YIEW CAUSES, NATURE, TREATMENT, DIAGNOSIS AND PROGNOSIS DISEASE. WITH BRIEF REMARKS ON HYGIENICS, OR THE PRESERVATION OF HEALTH. BY CHARLES J. B. WILLIAMS, M.D., F.R.S. $ot % fast Srinsrir fontom Mm IZ n. PHILADELPHIA: BLANCHARD AND LEA. 1864. WB W722p F>l»K MC . "fy/V / A/-. «/ PEEEACE. In this work the attempt is made to place the practice of Medicine on a footing somewhat corresponding with that of Physiology, Chemistry, and other sciences which equally depend on the accurate observation and rational arrangement of facts. If our knowledge of the healthy body, and of its parts and functions, be exact, it ought to be our best guide in the study of the same parts and functions in a state of disease. Yet the habit has long prevailed, and even still has its avowed advocates, of regarding the phenomena of disease as a new and separate order of things, the character and laws of which are to be investigated by themselves, and without reference to the standard of health from which they deviate; as if diseases were independent entities, and as if the body under their influence ceased to possess the same structures and functions which it has in health. Happily, however, such irrational dogmas do not now find much favor with the members of our profession, who, in proportion as they become more enlightened by sound physiology, recognize in it, when combined with careful clinical and pathological observation, the best guide to the under- standing and treatment of disease. It must be admitted that there remain considerable doubt and obscurity in many subjects, both in Physiology and in Medicine, and the science of one and the art of the other must, therefore, still be acknowledged to be imperfect; but no one can dispassionately look back on the progress which has been made in both departments within the last thirty years, without being encouraged to hope for increasing precision in the science and greater success in the art. For an additional proof of the existence of a growing interest and confidence in rational medicine, I may perhaps be excused in referring to the success of the former editions of this work. When first I communicated to my publisher my intention of bringing out a work on the Principles of Medicine, I was by no means encouraged by the intimation that books on that subject did not sell; vi PREFAGE. but no sooner was it discovered that the " Principles" were essentially and intelligibly practical, than the demand for the work became sufficient to exhaust two editions, long before I could find time to replace them. Several editions have also appeared on the Continent and in America. I have now to express my regret that the incessant engagements of my practice have so long delayed the appearance of this edition. In fact, it might have been deferred much longer, if I had not secured the valuable assistance of my friend, and former pupil, Dr. R. J. Mann, who has contributed several articles on recent investigations in Physiology and Animal Chemistry, and has taken great pains in revising the composition of the whole work. To my friend, Mr. George Gulliver, I am also indebted for looking over the chapters on Diseases of the Blood and Inflammation, and for very important microscopic contributions on these subjects. Free reference has been made to various recent authors on Physiology and Pathology; but I would especially mention the works of Dr. Carpenter, Mr. Paget and Professor Rokitansky, as sources from which I have derived much valuable information. It is right to mention that several of the early sheets of this work have been printed more than twelve months, which will account for the absence from them of reference to the most recent facts. 49 Upper Brook Street, August 8th, 1856. • CONTENTS. Preface.............Page iii PRINCIPLES OF MEDICINE. Paragraph. Explanation of the Object of the Work......p. 33 1, 2 Principles of Medicine. Synonyms. Whence deduced. Division into etiology, 3, 4 pathogeny, general therapeutics, and other subjects . . . . p. 33 Definition of Disease . . . . . . • . • . p. 33 5 Standards of comparison. Definition of health. Deviations from health; in func- tion ; in structure. 6 Physiology a standard of healthy function; anatomy—of structure. 7 Definitions of disease. 8 Variations in the standard of health. Examples. CHAPTER I.—ETIOLOGY—ON THE CAUSES OF DISEASE. Section I.—Nature and Division of Causes .... p. 31—40 9 Definition of causes of disease. Antecedent circumstances apt to be mistaken for causes. This error to be avoided by proving their occasional absence, and investigating the intimate nature of disease. Example. 10 Causes of disease intrinsic and extrinsic. Examples. 11 Causes of disease not sure in operation; except those which are very strong. 12 They generally require predisposition. Examples. 13 Causes divided into remote and proximate. Remote divided into predisposing and exciting. 14 Co-operation of predisposing and exciting causes generally necessary. Examples. 15 Exceptions. 16 Predisposition, generally deficiency of natural power of resistance. Examples of 17 the operation of this resisting power. 18 Predisposition from error of function or structure. Other terms for predisposing 19 causes; why sometimes inapplicable. Division and nomenclature of causes conventional. Obscurity of causation. Section II.—Predisposing Causes of Disease .... p. 40—52 20 Classification of predisposing causes. 21 22 I. Debilitating causes and their modes of operation. Imperfect nourishment. 23 Impure air. Excessive exertion of body or mind. Want of exercise, and 24 sedentary habits generally. Long continued heat. Long continued cold. viii CONTENTS. Paragraph. 2•")—28 Habitual intemperance. Depressing passions. Excessive evacuations. Pre- 29, 30 vious debilitating diseases. 31, 32 II. Excitement, examples. III. Previous disease; operating by change of struc- 33 ture; by persistence of cause Examples. 34, 35 IV. Present disease or defective function. Zymotic material in the body. 36, 37 V. Hereditary constitution. VI. Temperaments. Definition and nature; san- 38—41 guine; phlegmatic; bilious; nervous. Diathesis. VII. Age and its predis- 42-46 positions. Infancy, Childhood. Puberty. Full-growth. Adult age. Old 47_49 age; influences exemplified in vascular and nutritive functions. VIII. Sex. 50 IX. Occupation. Section III —Exciting Causes of Disease.....P- 52—95 51 Operation of exciting causes. Division into cognizable and non-cognizable. Classification. 52 I. Cognizable Agents (1.) Mechanical causes: examples of their physical effects. Vital operation of severe injuries. 53 (2.) Chemical causes: extrinsic; intrinsic; modes of operation, as local irritants, as corrosives, as septics, and as chemical alteratives; examples of their effects. 54, 55 (3.) Ingesta. Non-alimentary: condiments; action of salt in excess. Intoxi- 56 eating liquors, use and abuse of. Delirium tremens; principles of treatment. 57 Tea and coffee. Water. Adulterations of food, impure water, medicines, 58 aliment, unfit in quality; a due mixture requisite. Simple principles, such as fibrin, starch, gum, &c, insufficient. Bread the staff of life. Dr. Prout's 59 views on aliments, sanctioned by familiar experience. Extent of conversion of the elements of food by digestion. Dumas's views; objections. Experi- 60, 61 ments of Petroz and Boussingault. Liebig's views. Effects of alimentary principles; albuminous, gelatinous, oleaginous, farinaceous, and saccharine, 62, 63 in defect, in excess, or bad in quality. Adaptation of food to climate, &c. Action of oil, starch, sugar, vegetable acids, &c. Aliment generally, in ex- cess. Defective. Symptoms of inanition. Chossat's experiments on starva- tion. Liability of the ill-fed to zymotic diseases. 64 (4.) Violent exertion, effect on the heart, brain, lungs, and other organs. Par- 65 tial exertion. Exhaustion from fatigue. Want of exercise. 66 (5.) Mental emotion. Strong. Slow emotion. Mental anxiety. Excessive mental exertion. Wear and tear. 67 (6.) Excessive evacuation. Effects. Syncope, cerebral and cardiac. Other effects and resulting diseases. 68 (7.) Retention, diminution, and suppression of evacuations, alvine, urine, bile, &c. 69 Lower degrees common in disease. Suppression of artificial discharges ; of cutaneous eruptions, &c. 70 (8.) Defective cleanliness, ventilation, and drainage. Their prevalence; modes 71 in which they excite disease. Filth, action on skin, &c. Filth in dwellings. 72 Defective ventilation often insidious in its operation. Evil results, in dwell- 73 ings and public buildings. Defective drainage; results of effluvia from cess- pools. London sewers. Untrapped drains. Causes and consequences. 74, 75 (9.) Temperature and changes. Effects of extreme heat or cold. Cold, applied generally and locally. Dr. James Arnott's method of applying cold. Power of the body to resist cold. Burns and scalds. Shock to the system. Ex- 76 periments of Sir A. Cooper and Chossat on cold. Stimulating effects of heat. 77 Partial application of heat. Coup de soleil. Sedative efitcts of cold. IQ- CONTENTS. ix ' tropulsion of blood. Effect on the arteries. Indirect effects of cold. Chil 78 blains and frostbite. Warmth to be restored in benumbed parts, gradually. 79 Mode in which cold excites internal disease. Dr. Alison's views: objections. It acts by deranging the circulation, and chemical changes of the blood. 80 Symptoms of "cold caught" Railway draughts. Fogs. Ozone. Means of diminishing susceptibility to cold. Cold bathing. Water cure. Good and 81 bad effects. Effects of cold proportioned to previous state of the body. Atmospheric changes. , II. Non-cognizable AoENTS.-Zymotic poisons divided into Endemic, Epi- demic, and Infectious. 82 (I ) Endemic Poisons. Proofs of their existence. Sources. Malaria, JNn- 83 84 ture of malaria. Its properties. Localities of malaria. Its virulence in 85' proportion to heat with moisture. Diseases caused by malaria. Periodi- 86 city of their attacks, causes of this. Kinds of malaria. Endemic diseases from cognizable causes. . 87 88 (II ) Epidemic Poisons. Proofs of their existence. Epidemic. Cognizable 89 90 causes distinguished from non-cognizable. Epidemic constitutions or pe- 9l' riods. Nature 0/ epidemic influences. Dr. Prout's observations. Animal- 92 cule origin of Epidemic diseases; Linnaeus; Sir H. Holland, &c. Ehren- berg's observations. 93 94 (III) Infectious Poisons. Proofs of their existence. Modes of infection: by 95' 96 wounds; by contact; by aerial communication: by several modes. Diffi- 97' 98 culties of explaining infection. Analogy of fermentation; of animal and 99 100 vegetable generation; examples. Parasitic view of infection confirmed by 10'l circumstances which promote and check it. Character of cholera infeo- 102 tion Peculiarities of infectious diseases, of endemic diseases, of epidemic 103 diseases. Diseases propagated in several ways. Pestilences. Genera 104 operation of all these causes depressing, but may excite reaction. Effect 105 modified by the weather. Means of checking or counteracting zymotic poi- sons. Antiseptics Stimulants. Tonics. Eliminants. CHAPTER II.-PATHOLOGY (PROPER)-THE NATURE AND CONSTITUTION OF DISEASE. 106 Disease composed of elements. Knowledge of these essential to medical ence Analogy with chemistry, &c. Primary elements of structure and 107 un t-. health^ and diseased. Primary elements of disease. Alterations 08 oi these element in degree, and in kind. Table of primary element, tf 09 lease Table of proximate elements of disease; in excess, defect, and HO pervers'ion. These "elements are the especial objects^ of general paUio- logy....... FUNCTIONAL DISEASES-PRIMARY ELEMENTS. . . p. 97—102 Section I.-=-Diseased Irritability . * HI Irritability. The distinctive property of muscular fibre. Dependent on sup- dIv of blood. Structure of muscular fibre. „2-114 In Excess. Varieties in strength, in mobility, and in duration. Example, 11.- Piuses Remedial measures. 11 o rw in force mobility. Examples. Connection of irritability with 116-118 Defective, in torce, mooing. t 119 nerves not essential. Remedial measures. X CONTENTS. Paragraph. Section II.—Diseased Tonicity.....P- 102—10o. 120 Tonicity; description; function; distinct from irritability; as proved by dif- ferent effects of heat and cold. Long recognized practically. 121, 122 Excessive. Examples; effect on pulse. Remedial measures. Sedatives. Cold. 123,124 Defective. Examples: atony, retarded and dichrotous pulse. Remedial mea- sures. Tonics. 125 Elementary Nervous Functions. Dependent on supply of blood. Influ- enced by poisons; mechanical irritation; heat, &c. Expenditure of ner- vous matter.........P- 106—107 Section III.—Diseased Sensibility.....P- 107 115 126 Sensibility referable to the nervous system, and divided into the centric and local. General. Excessive, from excitement, from disease, from temperament. Pa- 127, 128 thological causes. Remedial measures. Narcotics. Tonics. Anaesthesia by inhalation of chloroform and ether. Mode of action. Cautions. 129,130 Defective. Causes: from disease, age, temperament. Remedies. 131 Perverted. Examples; causes. Remedies. 132 Local sensibility. Variations illustrated by experiment. Pathological causes. 133__136 Excessive, in orifices, in internal organs. Pain and other varieties. Re. 137, 138 medial measures. Local anodynes. Benumbing cold. Defective. Para- lysis of sensation. Remedies. Section IV.—Diseased Voluntary Motion ... p. 115—120 139 Division into general and partial. 140,141 General voluntary motion, in Excess: examples. Phrensy; Hysteria; taran- tulism, &c. Defective: examples. Lethargy; catalepsy; hysteria, &c. 142 Perverted: examples. Chorea; delirium tremens; shaking palsy, &c. 143 144 Partial, excessive. Tricks; fidgets. Defective; pathological causes: exam- 145 pies. Remedies for diseased voluntary motion. Excessive. Narcotics; calmants; douche. Modes of action of these remedies. Remedies for de- 146 fective volition. Stimulants. Mental excitement. Revulsives. Reme- 147 dies for perverted volition. Narcotics; tonics. Remedies for locally dis- eased volition. Electricity, &c. Section V.—Diseases of Reflex and Sympathetic Nervous Influence p. 121—130 148, 149 Natural reflex function: examples. Excessive, in involuntary muscles: ex- 150,151 amples. Involuntary muscles: examples. Convulsions; centric and eccen- 152 trie. Partial, by reflected irritation; spasms; cramp, &c. Irritation of involuntary muscles; the spinal marrow the centre of reflection. 153 Pathological causes of inordinate excito-motion ; irritation of spinal marrow or its nerves; accumulation by rest; from action of opium, &c. Epileptic fits. Action of strychnia and other poisons. Tetanus. Hydrophobia. 154 Defective reflex motion. In coma, asphyxia, sinking, &c. Sleeplessness from exhaustion. 155 Remedial measures for excessive reflex action. Narcotics, nervous sedatives, stimulants, chloroform, tonics. For defective. Stimulants; opium. 156, 157 Reflected or sympathetic sensations. Examples. Spinal and superficial sensi- bility; involuntary reflex action; chorea. Remedies. CONTENTS. xi Paragraph. Section VI.—Diseased Secretion.....p. 130—140 158 Secretion due to a vital property; aided by chemical affinity; not to be ascribed to nervous influence. 159—161 Changes due to altered supply of blood, or to nervous influence. Excessive. 162—164 Effects: forwards ; examples: backwards ; on the organ ; examples. On the 165,166 blood; examples. Relations of bile and urea. Remedies. Depletion and other evacuations. Astringents. Alteratives. 167—169 Defective secretion. Causes. Effects: forwards; examples: backwards; on 170, 171 the organ; examples. Suppression of excretions; uraemia, ckolasmia, &c.; 172, 173 extreme; moderate; in idiopathic and symptomatic fevers, gout, rheuma- 174, 175 tism, and other diseases. Remedies, through the circulation. Special 176__178 stimulants. Alteratives. Tonics. Substitutes for defective secretion. Perverted secretion. Examples. Effects. Remedies. Setion VII.—Diseases of the Constituents of the Blood p. 140 179 Constituents of the blood, when altered, form elements of disease. 180, 181 Enumeration of constituents and modes of alteration. Chemical composition of the blood. Disease of Red Particles......P- 140—148 182—184 Natural offices, composition, and proportions. Excessive. Examples. Signs and effects. 185,186 Deficient. Examples and effects. Alterations; in color; in shape and size; 187^188 breaking up. Arterial change; cause. Mulder's and Carpenter's notions. 189', 190 Mr. W. Jones' observations; explanation. Mr. Gulliver's observations. 191—193 Origin of red particles. Causes of their decrease. Spoilt blood. Disor- ders of spleen and uterus. Remedies for excess, defect, and alteration of red particles. Section VIII.—Fibrin and White Corpuscles . . p. 148—161 194 Nature of fibrin. Structure in washed clot, or lymph ; circumstances inducing 195 fibrillation; composition; an oxy-protein. Purposes: materials of tex- tures. White corpuscles. Excess of fibrin. Examples in inflammation. Signs and effects. Increase of white globules, at expense of red. Defi- 196, 197 cilicy of fibrin. Examples; fluidity of blood, in fevers; in Gaspard's ex- 198 periments, &c. Causes. Effects: hemorrhage; congestion, venous mur- murs, &c. Magendie's experiments. 199-201 Alterations in quality: apparent from character of coagulum, which shows 202 properties of self-coagulation, contraction, and separation. Self-coagula- 203 tion ; varieties and causes; its occurrence within the vessels. Contraction; 204,205 varieties and causes; cupped blood. Separation; causes, varieties. Causes 20o' 207 of the buffy coat. Appearances of coagulated blood. Large clot; small 208 clot. Separated and cupped ; mode of exhibiting these properties. Source 209 of fibrin, and formation of white globules. Increase by inflammation. Ma- terial of coagulable lymph. Varieties. Coagulation of fibrin during life. Vegetation and polypi. 210,211 Remedies for Excess of Fibrin. Blood-letting. Evacuants. Narcotics. Cod oil. Mr. Blake's experiments. 212 Remedies for defect; diet; regimen; stimulants; tonics; antiseptics; oxydating agents. 213—215 Means of altering quality of fibrin ; depletion; alteratives: salines, tonics; diet and regimen. xii CONTENTS. Paragraph. Section IX.—Albumen and other Animal Principles Dissolved in TnE Serum..........p. 161—163 216 Natural proportion and offices of albumen. 217, 218 Excess. Examples. Causes. Remedies 219, 220 Defect. Examples. Effects. Dropsical diathesis. Remedies; by checking waste ; by increasing supply. Section X.—Fatty and other Combustive Matters . . p. 163—166 221 Kinds of fat in the blood. Sources. Sugar in the blood. 223, 224 Excess. Examples. Milky serum. Depends on the presence of unassimi- lated chyle. Fat formed by degeneration of albumen; fatty cachaeniia ; re- medies. Obesity. Defect. Examples. Causes of atrophy; remedies. Section XL—Saline and Mineral Matters . . .p. 166—1C8 225 Thirst caused by salt. Natural, proportions ; uses. Excess—scurvy ? 227 Defect: in yellow fever and malignant cholera. Effect of saline injections. Use of salines in fevers. Treatment of cholera. Section XII.— Water........p. 168—170 228 Natural proportion. 230 Excess. Examples and effects. From too much drink. Deficiency. Ex- 231 amples. Symptoms. Causes. Effects of cholera—of abstinence from li- quids. Remedies for excess and defect. Water cure and dry diet. Drink- ing ; use and abuse. Water increases waste of tissues. Section XIII.—Changes in the Blood by Respiration . p. 170—175 Analysis of changes. Excess. Examples in disease ? Inhalation of oxygen; effects. Defect: the element of asphyxia. Effect proportioned to suddenness as well as degree. Explanation of this. Analysis of asphyxia. Classification of symptoms. Defect gradually induced. Hybernation. Cyanosis : state of the functions; little muscles and much fat; with defective respiration. Emphysema. Remedies for defect; Lowering functional activity. Treat- ment of asphyxia. Stimulants. Warm bath. Promoting respiration. Other means of arterializing the blood. Treatment of congestion of apnoea. 244 Diet in dyspnoea. Section XIV.—Changes in the Blood by Secretion . . 175__182 245 Defective secretion of urine. Experiments of Prevost and Dumas. Effects 246 of diseased kidneys. Views of Frerichs. Acute and chronic albuminuria. 249 Defective secretion of bile. Examples. Effects on blood, &c. Bilious 251 attacks. Perspiratory nature of secretion; checked by cold ; effects. Vi- carious action of skin and kidneys. Rheumatism; increased acid in blood; materies morbi. Remedies to be directed to this element. 252 Treatment of rheumatism ; by nitre; lemon juice; the author's plan. Water cure. Section XV—Changes in the Blood from the Transformation of Chyle and of the Textures of the Body . . 182__188 253 Natural changes imperfectly known. Gout and other lithic acid diseases. 254 Decay of textures. Causes: rich and too highly azotized food. Treat- ment of uraemia. Treatment of cholaemia; of bilious attack. Morbid effects of lithic acid on the kidneys. Nephralgia and nephritis. Gout iQ 232- -234 23 5, 236 237 238 240 241, 242 243 CONTENTS. xiii Paragraph. various forms; irregular; regular; sthenic; asthenic; chronic; chalkstonea of gout. 255 Diabetes. Sugar traced to the blood ; formed in the liver. Sugar often pre- sent in the urine of the aged and asthmatic. 256 Treatment of gout and diabetes, compared and contrasted. Treatment of diabetes. Treatment of gout by alkaline eliminants. Cautions. Local treatment. Fit of gout. Gouty constitution. Gout in the stomach. 257 Azoturia, or excess of urea. Result of decay of texture. Remedies: repose; stimulants; tonics; narcotics; tea and coffee. 258 Fatty transformation in the blood; impairing nutrition. Fatty degeneration. Section XVI.—Toxaemia—Changed Properties of the Blood from the Presence of Foreign Noxious Matters ... p. 189—194 259 The blood the seat of morbid poisons; and of the virus of malignant disease; proofs. Examples of action of morbid poisons on the blood. Decomposing matter a nidus. Poisons of exanthemata ; of typhoid fever, &c.; traced in operation, and with the reacting powers of the system causing the varieties of these diseases. 260 Treatment indicated by the operation of the poison, and subsequent reaction. Remedies to counteract the poisons. To destroy or expel them. To re- gulate and sustain the functions. CHAPTER III.—PROXIMATE ELEMENTS OF DISEASE. Section I.—Anjemia . . ... • • • p. 195—206 261 Explanation of proximate elements of disease. 262—264 General anaemia. Nature, exciting causes, and symptoms. Physical signs. 265—267 Changes in the blood. Symptoms of excitement in anaemia. Explanation 268, 269 of these symptoms. Symptoms of coma, &c. Cases and interpretation of 270, 271 nature of anaemic coma. Nutrition in anaemia. Predominance of nervous 272 symptoms. Fatal terminations. Extraordinary success of remedies in anaemia. Iron and other tonics; modes of exhibition. Regimen and diet. Treatment of nervous symptoms. Venous murmurs. 273 Partial ansemia. Examples. Effects; cause of gangrene; numbness; wasting; degeneration. Treatment. General and Local. Section II.—Hyperemia or Excess of Blood . . . -p. 206 274 Definition and nature. Classification of varieties. Section III.—Plethora—General Excess of Blood . . p. 206—211 275—277 Origin of plethorii. Subjects. Symptoms. Tendencies. Causes. Division 278, 279 into Sthenic and Asthenic. Symptoms of Sthenic. Subjects. Tendencies. 281—283 Asthenic. Symptoms. Subjects. Tendencies. Results. Fever. Gout. 284—286 Remedial measures. Blood-letting ; where unfit. In sthenic, other mea- sures needed. In asthenic, tonics as well as evacuants and eliminants. Diet and regimen. XIV CONTENTS. Paragraph. Local Hyperemia. Excess of Blood in a Part. Section IV.—With Motion diminished. Congestion p. 211—229. 287, 288 Congestion analyzed. Its causes classed. 289 Congestion from venous obstruction. Examples, in health and in disease. Ex- planation of congestion in emphysema 290 Congestion from atony of the vessels. From general debility. Hypostatic. 291, 292 From local debility; over-distension. Examples. From intropulsive ac- 293; 294 tion of cold and malaria. From over-excitement or inflammation. Exam- 295, 296 pies and illustrations by microscope. Stagnation, in the vessels. From 298 arrest of secretion or capillary circulation. Explained by Mr. Graham's law of "Osmotic force." From imperfect respiration. (Is the power of the heart sufficient of itself to maintain the circulation? Dr. Sharpey's experiments. Microscopic examinations; fallacies. Objections to the supposition of spontaneous movement of the blood particles. Dr. Carpen- ter's assumption of the existence of a motory power in the capillaries con- sidered, and admitted as identical with Graham's "Osmotic force.") Ob- servations of Mr. Erichsen. Obstruction to circulation in asphyxia, partly from contraction of the small arteries, but also by suspension of osmotic 299 force in capillaries. Atony of vessels also impedes transit of blood. Ex- 300—302 periments to show the neutralization of force in the flaccid vessels. Cause of long continuance of congestion. 303 Symptoms and effects of congestion. 1. In congested part—Impaired func- 305, 306 tions. Effects on secretion explained. Production of flux. Examples. 307 Considerable congestion required to produce dropsy. Amount of tension 308 and quality of blood determine quality of effusion, liquid and solid. Ex- 309, 310 amples. Albuminuria referred to congestion of the kidney. Reasons. 311, 312 Congestion continuing causes hypertrophy of a peculiar kind. Origin of granular disease and cirrhosis. Other instances. 2. Effects of local con- gestion on the system., .fit of ague deprives it of blood. Examples. In- jury to blood. This congestion may cause cachaemia. 313 Remedies for congestion. Removal of causes, venous obstruction and causes 314, 315 of atony. Posture. Pressure. Friction. Exercise. Astringents and 316, 317 tonics; when applicable. Stimulant remedies. Operations shown by the 318 microscope; when hurtful. Depletion and other evacuants. Haemostasia 319, 320 or counter congestion. Preceding remedies combined or alternated. Pre- vention of congestions by increasing tone. Section V.—Local Hyperemia. Excess of Blood in a Part with Mo- tion increased. Determination of Blood . . p. 229__240 321, 322 Examples in health and in disease. Determination to the head. Examples, 324, 325 with symptoms. The cause of various fits. Determinations caused by 326, 327 stimuli. Physical cause of determination of blood. Enlargement of ar- 328, 329 teries, proved by the author's microscopic experiments. Observations of 330 Mr. Paget and Mr. W. Jones. Cause of the enlargement, a loss of tonicity. 331 Influence of the nerves on the arterial tonicity. Experiments of Bernard 332 and W. Jones. Final cause of determination to supply more blood where wanted. Determination from intropulsion. Subjects of determination. Determination may cause anaemia in other parts. Determination affects any arteries. 333 Symptoms and effects of determination of blood. Parts most subject to it. 334—336 To the head. Explanation of its different effects in different cases. To CONTENTS. XV Paragraph. 3:57—340 the kidneys. To the mucous membranes. To the skin. Other symptoms. 341 Determination if continued leads to hypertrophy. 342, 343 Remedies. Removal of causes. Means which promote the tonic contraction 344, 345 of dilated arteries. Cold. Astringents. Sedatives which restore con- 346 traction of vessels. Derivants. Posture. Evacuants. Blood-letting; 347,348 general and local; its effect seen by the microscope. Cases requiring 349 blood-letting. Remedies to relax the arterial system and quiet the heart. Measures to equalize and strengthen the circulation. Tonics. Section VI.—Results of Hyperemia .... p. 240—266 350 Hemorrhage, flux, and dropsy, results short of inflammation. 351 Hemorrhage from plethora. Examples. Epistaxis, haematemesis, &c, from 352 congestion of venous obstruction. Examples. Pulmonary, bronchial, 353 gastric, &c. From atony of vessels; from posture; from intropulsion of 354, 355 cold. Examples. From determination of blood. Examples. Epistaxis; 356 apoplexy; haematemesis. Additional element of hemorrhage in the vessels 357,358 or in the blood. Blood-vessels diseased. Examples. Blood diseased. 359 Hemorrhagic diathesis. Mode in which blood is effused. By rupture or through the pores? . 360, 361 Varieties of hemorrhage. Sthenic and asthenic defined. Symptoms. Moli- 362 men hemorrhagicum; jerking pulse, how produced. Faintness; reaction. 363, 364 Transition to inflammation. Examples. Local effects and symptoms. 365 Passive hemorrhage. 366, 367 Treatment of hemorrhage. Remedies for hyperaemia. Styptics. Cases 368, 369 requiring a speedy check. Active or sthenic. Passive or asthenic. Me- 370 chanical means. Special styptics. Internal remedies. Tonics, purgatives, and styptics. Action of styptics considered. 373_375 Flux and Dropsy. From plethora. Examples. From congestion. Experi- ment of Lower. Examples in disease. 376—378 From weakness of the vessels. After excitement. Intropulsion of cold. 379 From determination of blood. Examples; active flux; active dropsy. From stimulants. 380—382 Flux and dropsy vicarious. Examples. Circumstances causing hyperaemia 383 to end in these results: in the vessels: in the blood. Combination of these 384 circumstances in anaemia. Diseased blood from defective excretion, espe- cially by the kidneys. Examples and proofs. Cause of anasarca after 385 scarlatina. Changes in the kidneys. Dropsy and flux with albuminuria : 386 why inflammatory: resemblance to rheumatism. Thinness of blood, cause 387 of asthenic dropsy. Dropsy from retention of water and excrementitious 388 matter in the blood. Malnutrition. Proofs. Distinctive pathology of 389 fluxes and dropsy. Causes of each. 390 General treatment afflux and dropsy. Remedies for hyperaemia. Remedies 39I for malexcretion and malnutrition. 392 393 Treatment of fluxes. Removal of causes. Derivants. For sthenic flux; 394' evacuants and depletion; not to be hastily checked. For asthenic flux ; astringents and tonics. Dry and tonic regimen. 395 Treatment of dropsy. Means to remove effusion and restore action of kidneys 396 397 in sthenic dropsy. Means to improve the blood in asthenic. Recurrence 393' of dropsy requires variation of remedies. Circumstances which indicate tapping or puncture. Cautions. Means to prevent recurrence of dropsy. Pressure. Injection of iodine. XVI CONTENTS. Paragraph. Section VIL—Local Hyperemia. Excess of Blood in a Part, with Motion partly increased, partly diminished—Inflammation p. 266—352 399, 400 Inflammation not understood from its elements not being studied. Definition according to its nature; according to its signs. 401 Causes of Inflammation and their Mode of Operation. Predisposing; weakness, or excitement. Exciting causes divided into local and general; 402 direct and indirect. Local irritants; mechanical, chemical, and vital. 403 Examples. Poisons and other irritants in the blood. Predisposition to 404 catarrhs. Indirect causes produce congestion. Causes mixed in operation. 405, 406 Checked hemorrhage and flux. Irritants operate primarily on the nerves. 407 But inflammation is- excited without nervous irritation, and when nerves 408 are divided. Cause essentially acts on vessels, producing sometimes deter- mination first, sometimes congestion. 409 Phenomena and Nature of Inflammation. Difference from congestion; 410 from determination. Essential characters established; increase of blood, 411 with motion increased and diminished. Cause of the obstruction. Views 412 of Cullen, W. Philip, Hunter, Kaltenbrunner, and Alison, considered. 413 Existence of congestion and determination proved. Atony of the vessels 414 one cause of obstruction. Examples and experiments. Another cause of 415 the blood: adhesion of white globules; their increase. Description and 416 production of white globules; Mr. Addison's observations; Mr. Gulliver's. Appearance of frog's web after irritation. Adhesive property of white glo- 417 bules; those recently formed have no cell-wall. The presence and proper- 418 ties of white globules essential to inflammation. Variation in the osmotic force of the capillaries. Share which the red corpuscles take in the ob- struction, questioned by Dr. Hughes Bennet, and Mr. Paget: affirmed by 419, 420 Mr. Gulliver. Conclusions as to the process of inflammation; essentially 421 complex. Effect of obstruction to expend force on the arterial capillaries, and to modify the osmotic force and composition of the blood. This oppo- sition of obstruction to force the cause, both of construction and of destruc- tion of blood and tissue material. 422 Effects of inflammation on vital properties; on secretions. 423 Effusions; liquid; solid; general character; microscopic character. Exuda- 424 tion corpuscles. Elementary solids of inflammatory effusions. Molecules. 425, 426 Granules. Fibrils. Exudation corpuscles. Pus globules. Irregular pro- ducts. Tubercle. Mode of formation of some of these. Variety in their 427 plasticity and organizability. Other effects of inflammation. Softening. Suppuration. Slough. Gangrene. Induration. Symptoms and Effects of Inflammation. Divided into local and general. Local symptoms. Redness; causes; varieties; changes; explained and ap- plied. Heat; cause; indications. Swelling; causes; varieties from tex- ture; position, &c. Pain; causes. Degrees and varieties and their causes. Other sensations. Effects of inflammation on contractility. On other functions and symptoms. Constitutional symptoms. Inflammatory fever. Change in the blood. Cause of the increase of the fibrin and its contractile property. This not the sole cause of inflammatory fever. Pathology of inflammatory fever. Causes. Reaction, irritation, altered condition of the blood. Why some functions are excited and others impaired Symptoms of inflammatory fever. Its varieties; high, low. Type of fever from cause or seat of in_ 428 429, 430 431, 432 433, 434 435, 436 437 438, 439 440, 441 442 443 CONTENTS. Xvii Paragraph. 444 flammation. Explanation of this. Remittent and intermittent fever. Apyrexia. Injury to blood in continued inflammation. Nature and Symptoms of the Results or Terminations of Inflammation. 445, 44(1 Division. The results seldom occur singly. Resolution. Its nature. 447, 448 M^des of occurrence. Local symptoms. Constitutional symptoms of reso- lution. Critical discharges. Lateritious sediments in urine; cause; nature; reason of absence; reappearance of chlorides. 449 Effusion (including adhesion.) Not always a termination. History of ef- 450 fusions in serous membranes. Coagulable lymph. Varieties. Euplastic. 451 Mode of organization. Formation of vessels. Views of Kiernan, Travers, 452, 453 Vogel, Liston. Cacoplastic lymph; corpuscular; (Paget) croupous (Ro- 454,455 kitansky.) Varieties and effects. Aplastic lymph. Causes of these low 456 products. Effusions of mucous membranes. Interstitial deposit. Changes 457, 458 of mucus; purulent and fibrinous ; stricture. Effusion in skin; varieties of cutaneous inflammation exemplified in skin diseases. Effusion in cellu- 459 . lar texture. In parenchymata. Symptoms of effusion. 460 Suppuration and ulceration. Nature of pus. Microscopical characters. Distinction between exudation corpuscles and pus. Alteration by acetic 461 acid; by distilled water. Its want of cohesion. Explanation of this. 462 Liquefaction of tissues in suppuration. Chemical changes. Causes of Buppuration. Circumstances tending to the conversion of the deutoxide of protein into the tritoxide. 1. Intensity and continuance of inflammation. 2. Access of air. 3. State of the blood; suppurative diathesis. Examples. 463 Mode in which they act. Observations of Mr. Paget. Pus in the blood. Process of suppuration explained; death of tissue by pressure; liquefaction and absorption of all but pus globules. Varieties of suppuration. Dif- 464 fused ; Abscess : pyogenic membrane : pointing. Opening and healing of 405, 466 abscesses. Granulations. Ulceration. Varieties. Causes. Softening 467 0f textures. Suppuration a work of destruction, therefore depressing. 468, 469 Symptoms of suppuration. Local: constitutional: varieties caused by limi- 470 tation, or not, of suppuration. Purulent deposits. Nature and causes. No true absorption of pus. Pus frequently in the blood in severe inflam- mation. Cachaemia usually precedes pyaemia. Depression from suppu- 471 ration. Cause of rigors. Hectic fever. Varieties of pus; laudable ; ill- conditioned. 473,474 Gangrene. Process of sloughing; gangrene; and sphacelus. Causes of 475 gangrene; interrupted circulation; noxious agents. Local symptoms and 476 effects of gangrene. Varieties. Constitutional symptoms. Combinations and gradations of the results of inflammation. Varieties of Inflammation. 477, 478 Sthenic and asthenic; symptoms and results. Acute inflammation generally 479 sthenic; symptoms, duration, products. Subacute. Chronic; generally asthenic; symptoms, duration, results. Cause of their variety. 480 Congestive inflammation; nature, symptoms, results. 481 Phlegmonous inflammation ; nature, causes ; type and symptoms. 482 Erythematic and erysipelatous ; local symptoms and effects ; fever; cause 4^3 specific. Pyaemia. Pellicular; asthenic; symptoms; low fever. Plas- tic inflammation of mucous membranes. Aphthae of adults often attended 484 by the growth of a confervoid vegetable. Aphthae of children. Hemor- rhagic inflammation; causes. xviii CONTENTS. Paragraph. 485 Scrofulous inflammation; asthenic ; peculiar symptoms. Microscopic cha- racters of scrofulous matter. Changes which it undergoes. Scrofulous abscesses. Scrofulous diathesis; its external marks; symptoms and causes. Course and results of inflammation in scrofulous subjects in various tex- 486 tures. Conditions of the blood. Gouty andrheumatic inflammations. Na- ture and causes. Gonorrheal inflammation; seat and 'effects. Syphi- 487 litic inflammation ; seat and effects. 488 Treatment of inflammation, best understood from knowledge of its ele- ments and of their counteracting measures. 489 Tabular view of constituents of inflammation. 490 Tabular view of the chief elements of inflammatory disease, and their reme- 491 dies. Comments on these principles of treatment. Remedies for incipient 492 inflammation: 1. for congestion; 2 and 3. for irritation of nerves and ves- 493 sels. Remedies for established local inflammation; 4. for determination 494 to the part; 5 and 6. for obstruction in the part from atonic enlargement of the capillaries, and by adhesion of the white particles with accumulation 495 and impaction of the red ones; 7. Distension of vessels; 8. for effusions 496 497 from the vessels; 9. for increased absorption; 10. for impeded circulation 498, 499 in the part; 11. for increased circulation around the obstructed part. 500 Treatment of inflammation with fever. Local remedies secondary. Chief 501 remedies, general bloodletting; effect. Tolerance of bloodletting; cause. 502, 603 Dr. M Hall's scale of tolerance. Object and mode of bloodletting; in recent inflammation; in confirmed inflammation; in inflammation with plethora; in anaemic subjects; substitutes. Local bloodletting; uses. Re- 504 cent disuse of bloodletting. Evacuants; purgatives ; combinations. Tar- 505, 506 tarized antimony; modes of administration; modes of operation. Mercury. 507 Calomel and opium : modes of exhibition ; modes of operation. Refrige- 508, 509 rants. Salines. Sedatives. Diuretics. Counter-irritation. Antiphlo- 510,511 gistic regimen and diet. 16. Exhaustion. 17.'Depression from poison. 512 Remedies : their modes of action. Stimulants, antiseptics, tonics, &c. 18. Treatment for products of inflammation, liquid and solid ; iodine; nitric acid; cod-liver oil. Treatment of Varieties of Inflammation. 513—516 Sthenic. Asthenic Acute. Subacute. Chronic. Congestive. Phlegmo- 517—519 nous. Erysipelatous. Pellicular. Hemorrhagic. Scrofulous. Treat- 520,521 mentof the scrofulous diathesis and deposits. Cod-liver oil. Rheumatic and gouty. Gonorrhceal and syphilitic. CHAPTER IV.-STRUCTURAL DISEASES; OR DISEASES OF NUTRITION. Section I.—Nature and Classification. ... p. 353__357 522 Arrangement of structural disease. Table of elements. Structural disease 523 often complicated. Objects and mode of natural nutrition. Blood forma- 524 tion. Materials of nutrition, derived from the blood ; changes in which cause variations in nutrition. Relation of nutrition to nervous influence. CONTENTS. xix Paragraph. Section II—Increased Nutrition—Hypertrophy . . p. 357—359 525—527 Affects textures, or organs. Simple hypertrophy; of muscles; examples, of 528 filamentous interstitial tissue; of epidermis; varieties in skin diseases. Complex hypertrophy; uterus ; breasts; brain; follicles; bursas, &c.; liver 529 and spleen. Treatment of hypertrophy. That of the heart curable. Section III.—Diminished Nutrition—Atrophy . . . p. 360—363 530 General emaciation. Causes: divided into those which promote decay and those which prevent nutrition; examples of each. Cause of emaciation in 531 fevers. Views of Dr. Hodgkin; Rokitansky. Drains from the body. 532 Series of causes which prevent reparatory nutrition. When traced to its 533 cause, general atrophy an important sign. Partial atrophy from defective supply of blood. Examples. Treatment of general atrophy; according to 534 its cause ; nutrients and aids to nutrition. Treatment of partial atrophy. Perverted Nutrition. 535 Alterations of texture in kind. Section IV.—Induration and Softening . . . . p. 363—366 536 Both may result from inflammation, or occur independently. Nature of indu- 637 ration. Often accompanied by transformation of tissues or interstitial deposit. Examples. 538 Softening. Specific causes. Common causes. Partial softening; nature. 539 From obstruction of vessels. Examples From antiphlogistic treatment. 540, 541 Treatment of induration and softening, opposite but parallel. Treatment of softening generally tonic and supporting. Action of nitric acid, and other oxidizing agents. Specific causes. Treatment of mollities ossium. Section V.—Transformation and Degeneration of Textures p. 367—375 542 Transformations generally degenerations. Exceptions: skin and mucous 543 membrane. Transformation of muscle Four kinds of progressive degene- ration : Fibrous, granular, fatty, and osseous, or calcareous. Fibrous, resem- bles fibrous tissue, but apt to degenerate further. Muscles and paren- chymatous organs exhibit this change, sometimes owing to interstitial 544 deposit. Granular, a cacoplastic interstitial deposit or transformation; in- vades morbid as well as natural fibrous tissues, and may degenerate farther. 545 Fatty degeneration; fat formed in the proper tissue of the parts, muscular, fibrous, and cellular; observations of Gulliver, Quain, Paget, and Canton. Fatty liver; appearance; subjects; cause. General fatty degeneration: subjects of it. Dr. George Johnson's views of Bright's kidney. Other examples of fatty transformation. Observations of Mr. Gulliver and Dr. Davy. A chemical process like the formation of adipocire proved by Dr. Quain's experiments. Circumstances disposing to the general disorder; as affecting particular organs; often preceded by a cacoplastic deposit; always indicates a degradation of material. Analogy to vegetable matter. Effects. Examples. 546 Calcareous degeneration; tissues most liable to it; a chemical process or petri- faction ; manner in which this occurs; produced spontaneously in old age, 547 or ils a result of inflammation. Effects. Treatment of degenerations. Means of sustaining vital powers. Hygienic measures. Tonics. Altera- tives. Mineral waters. Removal of local disorders. Treatment of fibrous and granular degeneration; of fatty; of calcareous. XX CONTENTS. Paragraph. "376 Section VI.—Deposits in or upon Textures . . • P- 548 Definition of deposits. Nature. Division into euplastic, cacoplastic, and aplastic. 549 Euplastic deposits. Cicatrices. Reparation effected by four modes: imme- diate union of Dr. Macartney; union by first intention ; by new tissue ; by suppurative granulations. Drs. Macartney and Carpenter's account of the organization of cicatrices. Observations of Paget. Reparation by lymph ; 551 by suppurative granulations. Modelling process of Macartney. Reparation by blood. Vascularity of clots. Remedial measures to promote healing of wounds, &c. 553 Cacoplastic and aplastic deposits. Examples of the former; structure; 554 causes, general and local. Cirrhosis. Granular degeneration. Structure. 555 Semi-transparent, gray, and tough tubercle: a degraded kind of lymph. 556 Observations of Gulliver, Addison, Rokitansky, Mandl, &c. Connection with other cacoplastic deposits. Tendency of cacoplastic deposits to con- traction. Farther history shown by examples; effects; intimate nature; 557 reason of granular forms. Degeneration into aplastic, the common tend- ency of tubercle, analogous to fibrous and granular and fatty degeneration. 558 Form of tubercle. Causes: Microscopical and chemical character of granular tubercle. Opaque change indicates aplastic degeneration; causes 559 of this change. Primary aplastic deposits; proof of degraded nutrition ; yellow tubercle, maturation and softening: the converse of contraction. 560 Increase of fat in softened tubercle, and its analogy to fatty degeneration in general. Softening of tubercle attended by the formation of a material offensive to the system. Changes of tubercle from adjoining textures. Quiescence of tubercle; spontaneous changes, withering; blackening; in- 561 duration ; plastery and petrifactive change, absorption of tuberculous mat- 562 ter. Causes of cacoplastic and aplastic deposits; congestion; chronic and asthenic inflammation; degraded plasma of the blood, with defect of red 563 particles. Seat of tubercles. Reasons of the liability of the lungs con- 564 sidered. Relation of tubercles to venosity of blood. External or exciting causes of tubercles; operation explained. 565 Treatment of cacoplastic and aplastic deposits. Elements to be considered. 1. Disordered condition of the blood and its causes. Cachaemia great where deposits general. Remedial measures. Supply of better materials of blood, and removal of those depraved. 566 2. Disordered distribution of blood and its causes. Various kinds of hyper- aemia. Remedial and preventive measures. 567 3. Deposits already present; their effects and changes. Medicine of little power: why? Mercury; alkalies; iodine and iodides; tonics; iron. Sol- 568 vents? caustic alkalies, acetic acid, naphtha, fixed oils. Cod-liver oil. Theory of its beneficial operation, not from its iodine, &c, but as an oil. Confirmation of its efficacy ; doubles the duration of life in phthisis. Best kind of oil, the freshest and sweetest; results of its use in nearly 9000 cases. Objection to the brown oils. Best mode of preparing the oil and cautions. Objection to external use. Directions in the use of the oil. 1, selection; 2, mode of exhibition ; 3, time of exhibition ; diet, &c. Im- portance of other hygienic means. Improvement of the circulation. Means which promote absorption and oxidation. CONTENTS. xxi Paragraph. Section VII.—Morbid Growths......p. 403 569 Definition. Names and divisions. Analogous and heterologous, &c. Section VIII.—Non-malignant Growths . . . .p. 404—410 570, 571 Definition. Serous cysts. Distinguished from enlarged natural sacs. En- 572 cysted tumors. Hygroma. Hoomatoma. Steatoma. Atheroma. For- 57 '■> mation of these. Contents. Complex cystiform tumors. Sarcoma. Fi- brous. Adipose. Chondroma. Erectile tumor. Dr. Hodgkin's view 574 of the cystiform origin of tumors. Pathological cause of morbid growths: 575 altered vital property of constituent cells; where most altered most in- 576 jurious. Hydatids. Proofs of separate vitality; nature and origin; re- production ; Mr. Owen's description. Offsets of natural tissues. Situa- tions. Death; aplastic and fatty deposits around them. Echinococcus. 577, 578 Cysticercus. Distoma. Medical treatment of morbid growths, and their effects. Extirpation of cysts by iodine. Section IX.—Malignant Growths.....p. 410—420 579 Definition. Characters of malignancy ; varies in degree. 580 Cancer or Carcinoma the generic term. Enumeration of species. Varieties 581 traced to different degrees of activity of cancerous matter. Some acute, 582 some chronic. Elementary structures of cancer; cells, forming fibres, &c. Varieties. Disposition to grow at expense of nutrition of the body. Pa- rasitic nature ? germs or ova. Experiments of Langenbeck. Local origin of cancer as a modification of nutrition. Dr. Hodgkin's view. Practical 583 deductions from pathology of cancer. Mode of origin. Cancer contrasted with tubercle. Microscopic diagnosis of cancers ; often uncertain, yet mi- croscopic characters instructive. Varieties of cancer explained by differ- ence in quantity and fertility of germs ; and activity of nutrition in adjoin- ing textures. Scirrhus is the chronic form. Symptoms; tendencies. Open cancer; destructive effects on part, and wasting influence on whole 584 frame. Epithelial cancer; peculiarities. Pancreatic, mammary, larda- ceous, and solanoid, intermediate forms of cancer. Mode of growth. En- 585 cephaloid cancer the acute variety; in parts and subjects where nutrition 586 its active. Cause of rapid growth of encephaloid disease. Colloid cancer, the cancerous element in a separate form. Other varieties from form, &c. 587 Melanosis, black cancer. Varieties. Peculiar black matter, its nature. Pig- ment cells. Altered blood corpuscles. May occur apart from malignant disease. Mr. Paget's remarks. Bronzing of skin. 588 Treatment of malignant growths. Indications. 1. To extirpate them ; 2. To 589, 590 retard their development; 3. To counteract their effect. Means of at- tempting the fulfilment of these. Section X.—Disorders of Mechanism.....p. 421 591 Changes in mechanism, elements of disease. Examples. 592—694 Dilatation. Contraction. Rupture and laceration. Displacement and com- pression. Contortion. XX11 CONTENTS. CHAPTER V.—CLASSIFICATION, SYMPTOMS, AND DISTINCTION OF DISEASES. Paragraph. Section I.—Nosology.......P- 422—424 596 Definition of special diseases. Methods of classification. 597 Symptomatic. Methods of Sauvage, Cullen, &c. Correct pathology the 598, 599 true foundation of natural classification. Method of Pinel. Classification of diseases with reference to pathology. Examples of pathological classi- 600 fications. Why preferable. Pathological definitions of disease. Section II.—Semeiology and Diagnosis . . • • P- 425—435 601, 602 Definition of symptoms and signs. Physical signs. Examples. Those of disease known by comparison with healthy standards. Standard of sym- 603, 604 metry. Anatomical standard. Physical signs explained by physical laws. 605, 606 Vital symptoms. Called also functional and physiological, general and 607 rational. Examples. Sources of symptoms Pulse. Skin. Tongue. 608, 609 Stools. Urine. Knowledge of pathology the best key to symptoms. Sta- 610 tistics an imperfect and temporary substitute. Respective value of phy- sical signs and vital symptoms ; examples. Division and nomenclature of symptoms. 611,612 Diagnosis defined. How founded. Division into general and special. Dia- 613, 614 gnosis, illustrated by problems, and modes of solution. Need of every 615 branch of medicine in diagnosis. The test of ability and knowledge. Ob- jects of examination with regard to diagnosis, prognosis, and practice. CHAPTER VI.— PROGNOSIS. FOREKNOWLEDGE OF RESULTS OF DISEASE.....p. 436—452 616 Definition. Prognosis, empirical or rational: Empirical that of infant me- 617 dicine. Prognostics of Hippocrates. Good and bad signs. Rational pro- 618 gnosis described and exemplified. Circumstances from which prognosis 619 may be formed. 1. relating to the subject; 2. to the disease; 1. Age of the subject; sex; temperament: previous disease ; present disease ; previous habits; condition of the patient at the time of the attack. 620 2. Of the disease. The cause, situation and nature, extent and progress ; the 621, 622 character of the symptoms. Good symptoms. Bad symptoms, signs of impediment to a vital function, and approach of one of the modes of death. Operation of all the modes of death on the blood, proved. Modes of death arranged in table. 625 Death by Syncope By spasm of the heart. Causes: examples. By loss of irritability: causes ; poisons; diseases ; symptoms of approach. 626 Death by Asthenia. Gradual failure of the circulation. From diseases; symptoms of approach. 627 Death by Asphyxia. Distinction. Symptoms. Causes. Varieties in re- lation to prognosis. 628 Death by Coma. Causes: symptoms. Combined with excitement of the medulla. How does coma cause death ? By abolishing supplementary voluntary breathing. Stertor. Medullary symptoms the most serious, and induced where coma is profound. CONTENTS. xxiii Paragraph. 629—631 Death by Paralysis. Injuries to the medulla, to the afferent nerves of re- spiration, to the efferent nerves. Examples. Paralysis of spinal nerves 632 with and without injury to the cord. With injury of cord itself, symptoms and fatal tendencies. 633 Death by Necraemia. Explanation. Proofs of death of the blood. Mode 634 of spreading death to other parts. External causes of nacraemia. Vital resistance to its causes. Symptoms. 635 Modes of elimination of causes of necraemia. Intrinsic causes of necraemia. 636—638 Symptoms of death by necraemia. Slow deaths, more general. CHAPTER VIL—PROPHYLAXIS AND HYGIENICS. p. 453—486 639 Definitions. Prophylaxis connected with special pathology. Hygienics refer 640 to means of resisting disease generally, and to means which maintain the general health. Subjects for consideration enumerated. 641,642 Food. Purposes of; essentials of wholesome food. Wheaten bread; unfer- mented bread. Meat; use and abuse of cooking. Varieties of meat, their constituents and wholesomeness. Fish, poultry, &c.; broths and soups ; 643 eggs and milk ; cheese. Vegetables. Choice of food and hours of meals. 644 Breakfast and luncheon, dinner, tea, supper. Adaptation of meals to habits. Regularity in the hours of meals. Injury from long fasting. 645 Clothing. Purposes. Provisions for alteration in the covering of the lower 646 animals; according to season, weather, and temperature. Materials of 647 dress. Objects in selecting them. To protect from cold; from currents 648 of air; from dampness and dryness. Cautions in changing winter for sum- 649, 650 mer clothing. Summer clothing. Silk vestments, electric influence. 651 Cases requiring additional warm clothing. Coverings for the head. Va- rious cautions. 652 Air and temperature. Beneficial effects of pure air; of change of air, seaside 653 and inland. Travelling: high winds. Dry air; its ill effects; modes of preventing them ; causes; soil; winds. East-wind. Ozone. The sirocco ; 654 effects. Damp air. Effects. Mode of operation. Cold and damp air; morbid effects. Causes of damp air; winds, soil, dwellings. Marine hu- 655 midity. Protective and counteractive means. Temperature; average most healthy. Causes of the oppressiveness of heated rooms. Salutary 656 influence of cool air. Cases requiring additional warmth. Mr. Jeffery's respirator. 657 Ventilation. Modes of ventilating in winter and summer. Dr. Arnott's 658, 659 principles and contrivances. Haden's plan of ventilating the Brompton Hospital. Supply of warm air. Forces used in ventilation. Means and agents for purifying air. 660, 661 Bodily exercise. Beneficial effects of moderate exercise. Directions and 662 cautions regarding exercise, according to age, strength, occupation, &c. Times for taking exercise. 663, 664 Caution as to amount and kinds of exercise, and their effects considered. 665 Mental occupation. Moderate and equal exercise of mental faculties bene- 666, 667 ficial. Adaptation to age; in infancy; mental education and discipline; 668 in youth ; in maturity. Body and mind to be equally exercised ; evil results 669 of neglecting, and good effects of observing, this rule. Variation of occu- pation invigorates the mind. XXIV CONTENTS. Paragraph. 670 Sleep. Effects and nature of healthy sleep. Symptoms ; gaping and yawn- 671, 672 ing. Circumstances which promote sleep : those which prevent or disturb 673 it; nightmare. Evil consequences of want of sleep. Directions to bad sleepers. Means of inducing sleep: Mr. Gardner's; the author's; Dr. 674 Franklin's, &c. Reasons of their failure. Amount of sleep proper ; varies 675 -with age, sex, strength, occupation, &c. Sleep to be limited, especially in certain cases. 676 Excretion. A proper subject for hygienic rules; depends on due activity of 677 many functions. Intestinal excretion. Importance of punctuality and 678 time for its evacuation. Various aids; in diet, exercise; by habitual ape- 679 rients; their safety and efficacy when needed. 680 Urinary Excretion; its importance. Amount and quality varies with diet, exercise, &c. Cold water and other diuretic drinks. Propriety of timely 681 but not too frequent evacuation. Excretions of the skin not fully known; 682 objects specified, promoted by various hygienic means, and specially by bathing, washing, and friction: operation and useful application of these. Vapor and shampooing bath. PRINCIPLES OF MEDICINE. EXPLANATION OF THE OBJECT OF THE WORK. 1. The Principles, Elements, or Institutes of Medicine con- sist of 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 Thera- peutics, or the theory and practice of medicine in relation to individual diseases. 2. The principles of medicine may be deduced in part from a know- ledge of the animal structure and its functions (anatomy and physio- logy,) conjoined with an acquaintance with the agents which cause and remove disease ; they are chiefly arrived at by a generalization of the facts observed in an extensive study of disease itself, whether these be effects manifested in the living or in the dead body. But so far as they have been ascertained, they become more intelligible to the stu- dent if explained synthetically, that is, by describing first the causes of disease, then the operation of these on the body, and lastly, the re- sulting changes in function or structure which constitute the more ele- mentary forms of disease. 3. Etiology, or a knowledge of the causes of disease, appro- priately introduces the consideration of the effect—disease itself; the nature and constitution of which may then be conveniently considered under the head of pathogeny, or pathology proper. This last sub- ject is the one to which I design to chiefly direct attention, and there- fore, it will occupy the greater part of the work; but it will be also combined with such an elementary view of the principles of treatment (general therapeutics,) as reason and experience may supply. 4. A short general view will afterwards be given of the phenomena of disease (sembiology,)—of the division and classification of diseases (nosology,)—of their detection and distinction from each other (diag- nosis,)—of the indications of their probable results (prognosis,)—and of their prevention (prophylaxis and hygienics.) 3 34 DEFINITION OF DISEASE. DEFINITION OF DISEASE. 5. The reader is presumed to be acquainted with anatomy and phy- siology ; without such knowledge not even a definition of disease can be formed. Disease is known only by comparing it with the standard of health, which it is the object of anatomy and physiology to describe. Health consists in a natural and proper condition and proportion in the functions and structures of the several parts of which the body is composed. From physiology we learn that there are certain relations of these functions and structures to each other, and to external agents, which are most conducive to their well-being and permanency ; these constitute the condition of health. But this knowledge implies that function and structure may be in states not conducive to permanency and well-being: states which are deviations from the due balance be- tween the several properties or parts of the animal frame; these states constitute disease. For example, physiology, as well as experience, teaches us, that in health the digestion of food is easily performed and attended by sensations of comfort. But when, after food is taken, there is pain, uneasiness, sickness, eructation, flatulence, or the like, we know that the function of digestion is changed from the healthy standard—is diseased ; and if this diseased function continue long in spite of the employment of remedies which usually serve to correct it, and if on examining the abdomen we find at or near the epigastrium a hard tumor, which anatomy teaches us is not there in health, we know that there is also diseased structure. 6. We find, then (§ 5,) that in this case there is disease of function, known by its deviation from a standard furnished by physiology ; and also disease of structure, which is recognized by departure from a stan- dard supplied by anatomy, (§ 5.) These different kinds of disease may be, and very commonly are, combined: there is seldom structural dis- ease without some disorder of function ; and in many instances func- tional disease is, or ultimately will be, accompanied by change of structure. 7. Looking, then, to anatomy and physiology as expressing the standard of health, we may define disease to be, a changed condition or proportion of function or structure in one or more parts of the body. 8. The standard of health is not, however, the same in all indivi- duals: that which is health to one may be disease to another. Thus to instance individual functions :—The healthy pulse in adults ave- rages 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. Muscular strength and activity, nervous sensibility, and the sensorial powers, vary exceedingly in different individuals, yet all within the limits of health: what is health in one would be deci- dedly morbid in another. Unusual proportions of the different struc- tures or functions to each other constitute varieties of temperament; and although these can scarcely be called morbid, yet they certainly give, as we shall afterwards see, a proclivity to disease. Thus pre- STANDARD OF HEALTH VARIABLE. 35 dominance of sensibility and excitability of the excito motory nerves over other vital functions, constitutes the nervous temperament, which is compatible with perfect health, although it predisposes the individual to diseases of a nervous kind. A preponderance of the nutritive func- tions renders a person florid and bulky, although in perfect health ; but this curries with it a risk of exceeding the bounds of health, and of inducing plethora and obesity, to such an extent as to interfere with the well-being and order of the bodily functions, and so to constitute disease. CHAPTER I. ETIOLOGY—THE CAUSES OF DISEASE. SECTION I. NATURE AND DIVISION OF CAUSES. 9. Causes of disease are such circumstances as essentially precede it, and to whose operation its occurrence is due. In many instances these circumstances elude our observation. In many others, the true cause, if apparent, is combined with other circumstances which have no share in producing the result, disease, and which yet are thence liable to be mistaken for causes. These circumstances are to be sifted, and the true cause discovered, only by the attentive observation of large numbers of cases, in which disease is produced. The non-essen- tial circumstances will then be found to be sometimes absent, and that which is always present may consequently be fairly regarded as the influential cause. But this, as before stated, sometimes eludes obser- vation ; in this case, as well as in elucidating the operation of circum- stances supposed to act as causes, the most useful knowledge may be obtained by investigating the ultimate nature of the disease itself, which will often throw light on its own source. Thus it was at one time a matter of doubt whether the itch could be engendered from filth, as well as from contagion ; but since microscopic investigation has dis- covered the existence of the itch-mite, no doubt remains that this in- sect is the only essential cause of the disease, however its operation may be promoted by filthy habits. 10. The causes, or circumstances, inducing disease, may be intrinsic, or existing within the body, independently of any obvious external in- fluence ; or they may be extrinsic, having their origin without the body. As examples of intrinsic causes may be mentioned excess or defect of some function (such as irritability,) or of some constituent of the body (such as the blood.) Extrinsic causes are very numerous ; they com- prise indeed all the external agencies which can operate on the body or mind, such as temperature, air, moisture, food, poisons, mechanical and chemical influences, and sensual impressions. 11. A great variety of agents and circumstances may thus act on the body so as to produce disease ; but in most instances it seems as if there were not that uniform and constant relation between these causes, and the diseases that result, which we might expect from the analogy UNCERTAINTY OF OPERATION. 37 of the operation of causation in the simpler sciences. In chemistry or in mechanics obvious effects certainly and uniformly follow obvious causes ; in physiology or pathology, no doubt, certain fixed effects also follow certain determinate causes ; but whether these effects become manifest as disease or not, depends on many circumstances, of which often we can take no cognizance. When the causes are of the same nature as those which are operative in physics or chemistry, the ex- pected effects never fail to ensue. Thus, a cutting instrument, a red- hot iron, or a corrosive liquid, invariably produces disease, when ap- plied, because its physical or chemical operation is so energetic that it overcomes all vital properties. Certain poisons and other analo- gous potent agents, which act on, without destroying, the vital pro- perties of living parts, also, if of sufficient strength, pretty constantly produce morbid effects. Thus, opium taken internally causes somno- lency; tartar emetic excites nausea and vomiting; cantharides applied to the surface induce inflammation, &c. 12. But the most common causes of disease are seldom of this de- cided and positive character; they are often present without disease en- suing ; and they are known to be causes only because disease is ob- served to ensue in a greater number of cases when they are present, than when they are absent. Thus, improper food is a cause of indiges- tion, and exposure to cold is a cause of catarrh; yet many persons eat unwholesome food without suffering from indigestion, and many are exposed to cold without "taking cold." But those, who do suffer from indigestion, observe that they do so more certainly after taking impro- per food; and those who are affected with catarrh can often trace it to exposure to cold. The reason for this uncertainty of action is chiefly found in the difference of power which the body exerts in resisting the morbific influence; this power varies much under different circum- stances. Its failure, or irregular operation, constitutes a predisposi- tion to disease. 13. Causes of disease were formerly divided into remote and proxi- mate: the remote include predisposing and 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 dis- ease. The term proximate cause was used by Cullen (after Gaubius) to represent the pathological condition, or essential bodily change, on which the symptoms depend; and it was called a cause of the disease, because diseases were defined by him to be an assemblage of symptoms. But this essential bodily change is a part of the disease rather than a cause, and is therefore better treated under the head of pathology. Discarding, then, the term proximate cause, we have now only to con- sider predisposing and exciting causes. 14. The co-operation of both these kinds of causes is generally ne- cessary to produce disease. A number of persons are exposed to cold: one gets a sore throat; another, a pleurisy; another, a diarrhoea; an- other some form of rheumatism ; and a fifth escapes without any disease at all'. All five were exposed to the same cause, yet it acted differently on all. The first four were predisposed, each to the particular disease, 38 NATURE AND DIVISION OF CAUSES. which attacked them so soon as it was excited by the cold. The fifth had no predisposition, and 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, what is in a smaller degree a predisposi- tion may, when it exists in a greater degree, constitute alone a sufficient cause of disease (§11:) thus a person with a very weak stomach always has indigestion, whether an exciting cause be applied or not. So like- wise 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 fat, raw cucum- ber, 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 fa- tigue : 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 predisposition, and the ague begins (§ 12.) 16. The consideration of these facts throws some light on the nature of predisposition viewed as a cause. There is in organized beings a certain conservative power which opposes the operation of noxious agents, and labors to expel them when they are introduced into the body. The existence of this power has long been recognized, and in former days it was impersonated. It was the archosus of Van Helmont; the anima of Stahl; the vis medicatrix naturse of Cullen. Now with- out supposing it to be aught added .to the ordinary attributes of living matter, we may note its operation in the common performance of ex- cretion : we see it in the careful manner in which the noxious products of the body, and the useless constituents in food, are ejected from the system ; in the flow of teajs which washes a grain of dust from the eye ; in the act of sneezing and coughing which remove irritating matters from the air passages ; and in the slower, more complicated, but not less apt example of inflammation, effusion of lymph, and those suppura- tive actions, by which a thorn, or any other extraneous object, is re- moved from the flesh. 17. This vis conservatrix (§ 16) is alive to the exciting causes of dis- ease ; and in persons in full health it is generally competent to resist them. How it resists them depends on their nature. For instance :— Is cold the cause ? If so the blood is thrown inwardly ; and this, ex- citing the heart to quickened action, establishes a calorific process, which removes the cold. Is the cause improper food ? The preserving power operates by discharging the offending matter speedily by vomit- ing or by stool. Is it a malarious or contagious poison ? It is carried off by an increase of some of the secretions. But if the 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.) 18. In the cases hitherto noticed, predisposing causes consist in ab- sence or deficiency of power (§ 16,) rather than in the existence of anything positive : but sometimes predisposition to disease depends on something positively wrong in function or structure, which yet alone PREDISPOSING CAUSES. 39 scarcely amounts to disease; and this fault may be congenital, or here- ditary, or acquired. 19. It must be observed that predisposing causes operate chiefly through the general system or constitution; hence they are often called constitutional or internal causes, in contradistinction to the exciting causes, which are more commonly external, or acting from without. But these terms are objectionable, because not always applicable. Sometimes the term predisposing is also inappropriate, as in the fol- lowing instance. Several persons are exposed to a malarious or in- fectious poison : some of these afterwards suffer from great fatigue or privation; they then begin to show the effects of the poison: but the others who have not sustained this second influence, escape unhurt. The poison has entered the system in both cases; but in the latter its influence is resisted ; while in the former the subsequent weakening so reduces the powers of resistance that the system yields before the ex- citing cause; but occurring after, this weakening cannot be said to predispose. Hence, under such circumstances, the fatigue or privation is called the determining cause. Dr. Carpenter defines a cause to be a " force or power operating under certain definite material conditions,"1 in other words he consi- ders the antecedents necessary to produce a result as being of two kinds, dynamical and material. But these do not necessarily corre- spond with exciting and predisposing causes of disease, for a variation of force may constitute predisposition, and on the other hand altera- tions in material may become exciting causes. The fact is simply that the division of causes ordinarily adopted among pathologists is conventional and convenient rather than natural and philosophical. What are called causes are really circumstances that are essentially and invariably antecedent to disordered action. Some single circumstance may alone be discoverable ; or there may be two, three, or more, that have been acting simultaneously, or in succession. It is often conve- nient to specify some of these circumstances as predisposing the body to become diseased, others as determining the disease, and others as ex- citing or calling it up. But it is not always easy to say which ought to be termed a predisposition, which a determination, and which an ex- citement. The study of pathology and medicine is more difficult and uncertain than the study of ordinary physics, simply because the re- sults observed are nearly always consequent upon a combination of manifold causes, which are always varying in an infinite diversity of ways. Causes follow effects in the vital actions of the living body as certainly and as surely as they do in the working of the dead masses of Nature, but these causes are interwoven in a more complex way, and are subject to many more modifications. The results observed in pa- thology seem to be uncertain merely because the observer has an im- perfect knowledge of the antecedents and of their workings. When the properties of organized material, and the actions of living substance are as thoroughly understood as the properties of crude and unorgan- ized matter, the organic sciences will be found to be as precise as Phy- sics properly so called. » "Principles of Human Physiology," 1853, p. 5. 40 PREDISPOSING CAUSES OF DISEASE SECTION II. PREDISPOSING CAUSES OF DISEASE. 20. What for convenience sake we agree to call predisposing causes of disease are circumstances which so influence the functions or struc- tures of the body as to render that body unusually susceptible to the influence of particular exciting causes. Predisposing causes are, how- ever, in strict accuracy, different from predisposition. Predisposition is the state of the body which is brought about by the operation of these causes. Predisposing causes make the body unusually susceptible of certain diseases through predisposition in its structures or condition. Now the most important circumstances that operate in this way may be advantageously considered under the following heads. I. Debilitating Influence. II. Excitement. III. Previous Disease. IV. Present Disease. V. Hereditary Constitution. VI. Temperament. VII. Age. VIII. Sex. IX. Occupation. I. Debilitating Causes of Predisposition are the most numerous of all. This might be anticipated from the fact that constitutional strength generally implies power of resisting disease (§ § 16,17.) The circumstances which are most influential in this way are such as enfee- ble the heart, impair the tone of the arteries, and reduce the activity of the secreting organs : often too an unusual susceptibility of the ner- vous system, which increases the liability of the body to suffer. The following are the chief agents of this class. 21. (a.) Imperfect nourishment, either in consequence -of defect in the quantity or quality of the food, or of incapacity of the digestive powers. ^ This in itself causes many diseases, particularly of digestion and nutrition; but it also weakens the power of the general system to resist cold, and produces a liability to low fevers, inflammations, and epidemic, contagious and endemic disorders. Thus the increased sus- ceptibility of the body to the influence of cold and infection, when fast- ing, is generally acknowledged ; the rapid propagation of infectious diseases among an ill-fed population, like the poor Irish, is but too well known : and to the disgrace of our nation it must be acknowledged that insufficient and unwholesome food has been one of the unhappy circum- stances that have contributed to render our brave troops in the Crimea an easy prey to disease and death in various forms. The same cause too, especially lays the body open to the injurious influences that in! duce zymotic disorders. The offensive odor of the breath and excre- tions on the approach of death from starvation, proves that there is exemplified and explained. 41 depravation and incipient corruption in the materials of the body, as well as weakness. 22. (b.) Impure air. The injurious effects of this are manifested in the pallid, cachectic complexion of the inhabitants of crowded cities, even of those who live well and regularly. How strikingly this con- trasts with the ruddy countenance of the hardy and coarsely-fed moun- taineer ! So are the former also distinguished in the greater liability of these classes to diseases, particularly to those of the organs of re- spiration, circulation, and nutrition. No circumstance seems to ope- rate more extensively in favoring the spread and increasing the viru- lence of such pestilential diseases as the plague, typhus, malignant scarlatina, and the measles, than impurity of air. It effects this in two ways. In the first place it weakens the body, and so acts as a true predisposing cause. But in the second place it leads to the con- centration and increased virulence of the poison itself, which is diluted and destroyed by the influence of ventilation and fresh air. The im- perfect performance of the processes of respiration and cutaneous transpiration in close and small habitations makes persons offensive both to themselves and to others, in consequence of corrupt matter which ought to be eliminated being left in the system. This makes the soil fertile (so to speak) for the fostering of the seeds of disease, although it may alone be inadequate to the production of disorder. The evil influence of over-crowding human dwellings has been abundantly and forcibly illustrated during the prevalence of epidemic cholera in our own and foreign lands.1 23. (• 3. Infectious J Poisons. MECHANICAL AND CHEMICAL. 53 I. COGNIZABLE AGENTS. 52. (1.) Mechanical causes, which injure structure; or impede, or derange function. Besides the obvious instances afforded in tear- ing, cutting, pinching, striking, and straining, which produce at once diseases that fall within the province of the surgeon, there are also many mechanical sources of mischief that come under the physician's notice. Long-continued pressure of articles of clothing sometimes produces disease. Tight neckcloths may cause headache or even apo- plexy, by impeding the flow of blood from the head. Tight stays may produce fainting, by pressure on the heart and great vessels, and colic and costiveness and other disorders by obstructing the free passage through the great intestines. Pressure on the epigastrium after a meal, caused by sitting at a desk, may excite indigestion. Long con- tinuance in one position, whether standing, sitting, or lying, tends to obstruct circulation and innervation, and to produce swelling and paralysis of the parts of the body that are beyond the seat of pressure, and this in time may even cause inflammation and death of the parts pressed upon. But mechanical causes may also be operative within the body. A stone in the bladder irritates by its mechanical proper- ties, especially if it be of an angular shape; or it may mechanically stop the flow of urine: so also may a gall stone stop that of the bile. The intestinal canal is sometimes mechanically obstructed by hardened feces, until irritation and inflammation ensue. The stomach is often mechanically irritated by the bulk, hardness, or asperities of its con- tents : and vomiting, indigestion, or inflammation of the organ, may be thereby induced. The air passages of needle pointers, stone-masons, &c, are irritated and inflamed, and at length become altered in structure, in consequence of the mechanical action of particles of stone or other substances, which these men inhale in the course of their em- ployment. Instances of this kind are endless : certain of the structural effects of disease also exercise considerable mechanical influence. Tumors, diseases of the heart and vessels, the lungs and air passages, intestines, and urinary apparatus, and injuries and diseases of the bones and liga- ments, afford abundant illustrations of this mechanical causation of Some mechanical injuries, when extensive, besides their simple ef- fects on structures and functions, directly depress the vital powers ; thus, concussion of the brain, crushing or tearing off a limb, or a blow on the epigastrium, induces fainting and extreme weakness of the heart's action, and may thus even cause death. Slighter mechanical injuries are causes of irritation or excitement, which may be local or general, according to the excitability and extent of the part irritated. 53. (2.) Chemical causes of disease are even more varied than me- chanical, because the several chemical agents are more numerous than the mechanical. We are acquainted with the chemistry of the animal body less than with its mechanism, and therefore can the less clearly distinguish causes which act by chemical properties, from those which have complex relations to vital properties, than we can those which are 54 EXCITING CAUSES OF DISEASE. mechanical. But we recognize chemical irritants in acids, alkalies, and many salts, whether applied to a part, or inhaled in form of gas or vapor. So what are called chemical poisons, such as corrosive sub- limate and other metallic salts, the strong acids and alkalies, iodine, chlorine, &c, produce disease by their known powerful chemical affini- ties, which tend to decompose tissues and disordered 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 decompositions 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-colored and unusually fetid matters by stool ; then, too, may arise a number of disorders, which may in great part be re- ferred to the influence of these injurious chemical processes. There appear to be at least four modes in which chemical agents may excite disease in the body :— 1. By acting as local irritants, as do the diluted acids, alkalies, and various salts, the chemical operation of which is resisted by increased action excited in the part (§ 16.) 2. By acting as corrosives, as in the case of strong acids, alkalies, some metallic salts, chlorine, and iodine, which by their powerful che- mical affinity, so completely overcome the vital affinities of textures as to decompose them and thus to kill and alter the condition of the part. 3. By acting as septics, promoting the decomposition of the fluids or solids of the body, in the same way that ferments or putrescent mat- ters operate on dead organic matter. 4. By acting as chemical alteratives, modifying the changes which take place in digestion, assimilation, transformation of textures, secre- tions, &c, as instanced in the counteraction of acidity by alkalies, in variously influencing the state of the blood and urine by acids, alka- lies, &c.; and in causing the production of hippuric acid in that excre- tion, by the administration of benzoic acid, and the increase of the solid constituents of the urine by the administration of salt, in the in- crease of the sulphates by the exhibition of liquor potassae, (Parkes ;) &c. The operation of chemical agents on the general system will vary according to the intensity of their action, and the extent of their ap- plication. Irritants, if extensively applied, cause feverish excitement. Corrosives, if acting widely, depress the vital powers, like the shock of violent mechanical injuries (§ 52 ;) if more partially, the vital powers are excited to resist them, thus corrosives operate as irritants. Septics, if very powerful, may speedily overwhelm the preserving vital powers of the body, which then speedily passes into a state of corruption, as in the case of extensive gangrene, pestilential diseases, &c.: but if the septic matter be scanty, and the vital powers strong, they are excited to increased action, and the body may by means of accelerated circu- lation, and augmented excretions, get rid of the offensive matter (§ 17.) Such kind of struggle is instanced in typhoid fevers, epidemic cholera, and dysentery, and other toxic diseases, which have received the ap- INGESTA—N0N-ALIM ENT ARY. 55 pellation of zymotic, from the supposed resemblance of their cause to a ferment. 54. (3.) The solid and liquid ingesta are a fertile source of dis- ease, and this in various ways. Their mechanical and chemical pro- perties have already been noticed, (§ 52, 53.) But, they may also cause, disease— a. As non-alimentary matters acting injuriously. b. As aliment faulty, or ill-proportioned, in quality. c. As aliment defective, or excessive, in quantity. 55. (a) Of the non-alimentary matters contained in the ingesta, that are capable of exciting disease, salt, spices, pickles, and other condi- ments, and spirituous or fermented liquors, are illustrations. They are all more or less irritating or stimulating to the digestive apparatus ; and if used indiscreetly may induce inflammations, congestions, and functional disorders of these organs, and, in some instances, irritation of other parts, and of the whole system. Salt in moderation is bene- ficial as an adjunct to food, both on account of its antiseptic and sol- vent properties, and as supplying a part of the acid for digestion, and an alkali which is required in bile and other fluids: but if in excess, it irritates the stomach, retards digestion, and causes feverishness with thirst. Much of these effects is due to the affinity of the salt for the water of the animal fluids, and may be induced by other saline matters beside common salt. Wherever excess of salt is contained in the body, there will be osmosis' and exosmosis of the liquid amidst the adjoining vessels and tissues until the salt is equally distributed among them, and before this is accomplished, there will be such a diminution of the fluids within the blood corpuscles, and on the surface of membranes, as will rea- dily account for the thirst and disturbance caused in the system. Ac- cording to Liebig, salt impedes the deposition of fat. Animals will not fatten on salt food ;—this is a hint for the corpulent. Salt increases the elimination of urine by the kidneys ; it has therefore been supposed to hasten the destructive metamorphosis of tissues. The absence of salt in food, especially if this be vegetable, favors the production of worms in the intestines. 56. Alcoholic liquors act as stimulants when taken into the sto- mach. At first they provoke appetite and enable the organ to dispose of a greater quantity of food; but soon the digestive power fails in consequence of the exhaustion that necessarily follows undue excitement, and inappetency, nausea, or even vomiting ensues. The operation of these agents is, however, soon extended, for they are absorbed into the blood, and their stimulant action is exercised on distant parts, espe- cially on the- vascular and nervous system. As the absorption is ef- fected by the veins, they pass by the portal vein directly to the liver, and hence the function and structure of this organ are particularly apt to suffer from indulgence in spirituous beverages. So too as the kidneys are the natural emunctories through which extraneous matters are eliminated from the system, they get first over-stimulated, and then exhausted, and are injured in their secreting power, and ultimate- 1 Professor Graham; "Proceedings of Royal Society," 1854. 56 EXCITING CAUSES OF DISEASE. ly in their structure also, if repeatedly exposed to the same injurious influence. The heart and vessels also are over-excited at first, and afterwards lose their tone: the processes of assimilation and nutrition are impaired and modified, and all the solids and fluids of the body become in some degree depraved. The nervous system suffers espe- cially from the disordering influence of intoxicating liquors. If a large quantity is taken at one time, it acts as a narcotic poison, in- ducing a short period of cerebral excitement or intoxication, and then insensibility, in which the functions of the brain are more or less com- pletely impaired, and in extreme cases those of the spinal marrow also ; if the influence be insufficient to stop respiration, yet it may so far interfere with it as to lead to congestions in the brain and other or- gans. Hence apoplexy, palsy, phrenitis, or delirium tremens, may follow, and the whole frame may suffer from the effects of the poison. Even when less excessive quantities are taken, the headache, sickness, inappetency, and feelings of wretchedness and depression which com- monly ensue, sufficiently prove that grave disorder has been produced, and that such artificial excitements cannot be abused with impunity. Habitual indulgence in strong drinks causes other kinds of disease, which are so often seen that they deserve especial notice. When taken only, or chiefly, with food, not as a substitute for it, but as a consti- tuent of general "free living," fermented liquors contribute to the production of an abundance of ill-assimilated, overheated blood :' which either finds a vent in eruptions on the surface, or in local hemorrhages or fluxes, or causes various functional disorders, such as palpitation, vertigo, stupor, dyspepsia, and bilious attacks, or sometimes produces gout or gravel. The latter results more commonly follow when the beverages contain much free acid, as well as an abundance of spirit, as is the case with port wine, rum punch, and hard strong beer. The less acid malt liquors, ale and porter, tend rather to induce liver dis- orders, and an abundant deposition of fat in the body. All these con- sequences are promoted by sedentary habits (§ 24) and deficient ex- cretion : for active exercise carries off much of the spirit and superfluous aliment, by an increased elimination through the aids of respiration and perspiration. The most disastrous consequences of intemperance are exhibited in the habitual drunkard, who in proportion as he indulges in liquor, loses his appetite for food, and his power of digesting it. He then drinks and starves at the same time; and the disease which ensues comprises the exhaustion of inanition together with the more direct effects of the alcoholic poison. Thus in delirium tremens, the drunk- ard's disease, besides the permanent restless excitement of the irri- tated nervous system, which adds more and more to the exhaustion, there is fearful weakness of mind and body; and in bad cases even the organic functions are affected, so that the pulse is very weak and fre- quent, the excretions are scanty and depraved, and the respiration is 1 This effect of alcoholic drinks, familiar to all observers, receives additional illustra- tions from the experiments of Dr. Bocker, which shows that they tend to diminish the urinary excretion, and the elimination of carbonic acid by the lungs.—British and Foreign Medico-Chirurgical Review, October, 1854, p. 398. NON-ALIMENTARY—FERMENTED LIQUORS. 57 so imperfectly performed by the involuntary powers that sleep cannot ensue. This exhaustion soon terminates in death, unless the result is prevented by appropriate treatment; and this must comprise, besides opium (the common remedy,) ammonia and other stimulants to the circulation and respiration, purgatives and diuretics to free the blood from the excrementitious matter that has accumulated in it; and fluid nourishment to repair its waste. Without these adjuncts, opium will not only fail to procure sleep, but if given in large doses may even paralyze the remaining powers of life.1 Pernicious as fermented liquors are in their abuse, yet these and other adjuncts to food when taken with careful moderation and dis- crimination, often prove beneficial by aiding the digestion where it is weak, and by counteracting various exhausting and depressing influ- ences, which frequently arise out of the artificial condition and em- ployments of society, especially in large towns and in cold climates. It appears from the observation of Dr. Bocker, that alcoholic liquors used in moderation, prove beneficial in restraining the waste of tissues, and therefore in sustaining the nutrition of the body. In this respect its action is contrasted with that of water and of salt, and resembles that of tea and coffee. {Brit, and For. Med.-Chir. Rev., Oct. 1854.) Total abstinence, therefore, is preferable to moderation, in many cases, rather because it is morally easier to practise, than because it is more salutary in its physical effects. Tea and coffee also, although refreshing and really invigorating ad- juncts to food when used in moderation, may excite disease when taken in excess: the derangements being chiefly those of the stomach and nervous system. Gastralgia, nervous palpitation, or fainting, insomnia, and even mental delusions, have been induced by the too free use of strong tea or coffee. Even water, the simplest, and it might be thought the most harmless of beverages, is not without its positive influence on the animal economy, and if taken in excess, is capable of producing considerable disorder. Besides its effect in distending the alimentary canal and blood-vessels through which it passes, it further accelerates the retrogressive transformation of the blood and textures, as is mani- fest by the increase of matter excreted by the kidneys and intestines. (Bocker, ut supra.) It appears, therefore, that water largely taken i Lone experience has fully convinced me of the danger of an empirical mode of treat- ment in the worst forms of delirium tremens. I have known more than one instance where death has speedily and unexpectedly ensued upon the administration of opium in large doses, ordered to be "repeated until sleep should be procured Vvhen it was procured, it proved to be the sleep of death. Inability to sleep, in this disorder depends upon the exhaustion of the medullary and nervous powers, as named above and perhaps also somewhat on the vitiated state of the blood, which gets loaded with decaying and excrementitious matters that the depressed secerning energies are not able to eliminate. Here stimulants, instead of increased narcotization, are the things needed; and even tonics mav be of service, combined with nutrients in the form of soups, jellies, and fa- rinaceous foods, and also diuretics and aperients. These should be given during the dav and the opiates reserved for the night; and even moderate doses under such cir- nnmstances often prove to be efficacious. I have sometimes found better resul s fol- low from the use of tincture or extract of Indian hemp (which, however, are not always nhta nable of definite strength) than from that of opium, for it calms the nervous system and induces sleep, without impairing the appetite or powers of digestion. The tincture of hop, too, is a useful adjunct to other remedies in this point of view. 58 EXCITING CAUSES OF DISEASE. tends to reduce the weight of the body, and impoverishes the blood, whilst alcoholic liquors have the opposite effect. 57. Disease may be excited by unwholesome articles with which the food is adulterated. To this class of causes belong various poisons; the operation of some of these will be noticed under the head of Modes of Death (see chapter on Prognosis;) but for further details, works on toxicology and materia medica must be consulted. There are some noxious matters occasionally mixed with food, which produce delete- rious effects very gradually. In this way salted provisions, too long used, cause scurvy: ergotted corn has been known to produce dry gan- grene. Lead gradually introduced into the system causes constipation, colic, paralysis, cachexia, anaemia and atrophy. Impure water used as drink, is a common cause of disease. River or pump water near towns often contains decaying vegetable or animal matters, and induces sickness, diarrhoea, dysentery, cholera, and typhoid symptoms. Hard waters, which are impregnated with some of the salts of lime, render the bowels costive, and are supposed to favor the production of cal- culous diseases and bronchocele: brackish waters, containing saline matter, may induce dyspepsia and diarrhoea: chalybeates, containing iron, are constipating and heating.—Any kind of impure water, if long used as drink, may gradually impair the processes of digestion, nutri- tion, and assimilation, even although no obvious disorder immediately results from their use. Under the head of non-alimentary ingesta which may cause disease, we must reckon various medicines : and that not only when injudiciously administered, but even as commonly prescribed : the remedies necessary to cure or relieve many diseases are not uncommonly necessary evils; they remove one disorder by inducing another, and it is well when the evil thus induced is the smaller of the two. It cannot be denied that proofs are frequently met with of the mischievous and morbific effects of the injudicious employment of drugs, and there can be no doubt that many of the boasted achievements of homoeopathy, and other quacke- ries, are really the result of the suspension of the influence of injurious medicinal agents.1 58. (b.) Unfitness in the quality of aliment is another condition whereby ingesta may cause disease. Man is by nature and habit an omnivorous animal; and in general his health is best maintained by an admixture of different qualities and varieties of animal and vege- table food. The insalubrity of the simpler constituents of food, when used separately, even those supposed to be most nutritive, has been i Dr. Mann in revising these pages has favoured me with the following illustration •— "A very interesting case of this kind has just fallen under my notice I was called last week to see a physician, a visitor to this place (Cromer,) for relaxation. I found him in a state of great nervous excitement and trepidation, and full of the idea that he was just going into a state of collapse. On investigating the facts I found he had been taking immoderate exercise in the sun, and eating lobsters and drinking pale ale until attacked witn bilious derangement, and mild continued fever; then he fancied h'e had suffered from malaria, and that the fever had distinct intermissions, so he dosed himself with quinine. When I saw him he had taken sixty grains of disulphate of quinine in a few hours ; the nervous derangement was unquestionably due to the influence of the me- dicinal agent. It was four complete days before the disease thus induced had disap- peared." * INFUENCE OF ALIMENTARY ELEMENTS. 59 well shown by the numerous experiments of Majendie, Gmelin, and others. They fed dogs, geese, donkeys, and other animals, on articles which are generally considered highly nutritive, as sugar, gum, starch, oil, or butter: when any of these were given exclusively, the animals died with symptoms of starvation almost as soon as if they had been kept without food. Even bread, when too fine, is unsuitable for exclu- sive nutriment. A dog fed on pure white bread lived only fifty days, whereas another fed with the coarsest brown bread was well nou- rished, and seemed capable of living an indefinite period. According to the researches of a commission of the French Institute, (the report of which was published in 1841,) animals fed on pure fibrin, albumen, or gelatine, die of starvation, and with reduced quantity and depraved quality of the blood, almost as soon as if not fed at all. Gluten, or vegetable albumen, seemed to be the only simple principle which was able alone to maintain life. The nutritious qualities of vegetable food depend chiefly on the quantity they contain of this azotized principle. Wheaten bread consists of this highly nutritious principle combined with a due proportion of combustible and heat-supplying starch. Hence it is the most sufficient and useful of all the varieties of food, and may therefore well be called the staff of life'. Even animal albumen and fibrin require mixture with vegetable matter to make them properly nutritious as well as wholesome; and gelatine and oily matters are still less available for nourishment without some such combination. In the experiments just alluded to, animals could be supported for a lengthened time on meat or flesh, which comprises several of the ele- mentary principles, although they could not be sustained by any one of these principles given alone. The utility of a due combination of the organic elements in the food used by animals was long since sagaciously pointed out by Dr. Prout, who takes the natural aliment of infancy, milk, as the great type of all proper kinds of nourishment; as it contains albumen, oil, sugar, and water, (not omitting certain salts, especially the chloride of sodium, and phosphate of lime,) so all other kinds of food ordinarily used for sustenance ought to include these elements, or others isomeric (that is, identical in ultimate composition) with them ; and it is certainly true that all combinations of food sanctioned by custom do comprise such ingredients. Bread contains two of them, gluten, which is vegetable albumen, and starch, which is isomeric with sugar; but bread is not relished without butter or some fat with it. Neither does meat, which contains albumen and fat, suit the taste without combination with bread, rice, potatoes, or some vegetable, which represents the amyla- ceous or saccharine principle. The palate likewise craves the addition of a little salt, which promotes the digestion and assimilation of most kinds of food. 59. Much discussion has occurred of late as to the share which each of these constituents of food takes in the actions of the animal economy, and the extent to which they can be changed by the process of digestion and assimilation. Dumas, and the French chemists gene- rally, have maintained that the digestive process only separates and appropriates principles ready formed in the food, and that it does not 60 EXCITING CAUSES OF DISEASE. effect the conversion of one into another. Thus they say that all the albumen or fibrin in the body is derived from the albumen or gluten of the food; and all the fat from fat or oil contained in the nourishment. This view, so far as fat at least is concerned, is opposed by many fami- liar facts, such as the fattening of domestic animals with farinaceous and vegetable foods, which contain very little fat; and it has been com- pletely negatived by the experiments of Petroz and Boussingault, which have proved that geese and pigs during the process of fattening gain more fat than is contained in their food.1 It further appears probable that the conversion of sugar into fat is promoted by the agency of bile; for H. Meckel found that by keeping a mixture of bile and grape sugar at a warm temperature, the quantity of fat in the mixture increased to double in five hours, and more than treble in twenty-four hours. It is pretty certain, therefore, that fat may be formed out of starch or the saccharine principle, and probably from the albuminous also, as albu- men gets spontaneously converted into fat under special circumstances. But there is no decisive evidence to show that albumen or gelatine is elaborated from fat, starch, or sugar, at least under common circum- stances ; and it is certain that these elements alone do not suffice to sustain animal strength or life.2 Baron Liebig has, in a very comprehensive hypothesis, suggested that food not only supplies the plastic constituents whereby the waste of the textures is repaired, and their growth supplied, but that it also furnishes the chief combustible principle of the blood, which is burned under the process of respiration for the support of the animal tempera- ture, and thus protects the histo-genetic (or tissue-making) materials from being consumed. Thus whilst albumen, fibrin, and analogous matters are applied to the purposes of growth and nutrition, oil, sugar, starch, alcohol, and allied matters, like gum and vegetable acids, con- stitute merely combustive material, or fuel, which is converted, through the oxidating processes of respiration, into carbonic acid and water, giving out heat during the change. It is certain, however, that fatty matter is, in a degree, essential to nutrition, being a constant consti- tuent of the nuclei and granules of the primary cells of tissues and of nerve substance. So also as starch and sugar are susceptible of being converted into fat by the agency of the liver, they cannot be excluded from the list of nutritive materials. It is scarcely possible to doubt that the increase of weight and muscular strength that accrues from the continued employment of cod-liver oil can be anything else than a result of direct nutrition by means of oil. 60. The chief alimentary matters may be classed into groups, ac- cordingly as they are albuminous, gelatinous, oleaginous, and saccha- rine, or amylaceous : we have now briefly to consider how an excess, or 1 Dr. Day's Report on Chemistry in Dr. Ranking's Abstract, July, 1846, p. 316. 2 In a very able paper on Vital affinities, by Dr. Alison, (Transac. of Royal Soc. Edin. 1847,) many arguments are adduced in favor of the inference that albumen may be formed in the animal body, especially in vigorous health : the author suggests that am- monia may be the source from which starch and other non-azotized articles of food re- ceive the azote that is necessary for their conversion into albumen. There is much reason on the side of this notion ; it may be seen that I have long entertained a similar opinion in regard to the conversion of gelatine into albumen. ALIMENTARY ELEMENTS. 61 defect, and in some instances faulty quality, of either of these, may operate in causing disease. Albuminous or proteinaceous articles, such as the lean of meat, fowl, and fish, gluten of bread, and casein of milk, supply the albumen and fibrin of the blood, and of the textures of the body. Hence deficiency of this kind of nourishment will produce, first, weakness of the heart and other muscles, and then wasting of these, and of other textures, with diminution of the quantity and richness of the blood. Failure of mus- cular strength, weakness of the circulation, and wasting of the muscular and other structures, commonly result from insufficiency of albuminous food. Excess of carneous food, particularly of the richer kind, butcher's meat, tends to oppress and derange the digestive organs, or to cause plethora, with excited circulation and feverishness, which may even result in hemorrhage, inflammation, gout, lithiasis, &c. Bad quality of albuminous food is peculiarly injurious to persons of weak digestive and assimilative powers: thus the casein of cheese, the fibrin of stale or salted meats, and the gluten of sour or ill-baked bread or heavy pastry, may irritate the alimentary canal and cause dyspepsia and diarrhoea, and even when absorbed, instead of forming good protein material, may degenerate into certain products of animal decay, namely, lithic and lactic acids, urea,' &c. Hence may-arise gout, rheumatism, calculous disorders, cutaneous eruptions, low irritative fever and cachexia. Gelatinous foods, soups, broths, isinglass, and jellies, are by no means so nutritious as albuminous matters; but when combined with bread they satisfy hunger and nourish the body so well that it seems very probable that in a healthy constitution gelatine may assist in the formation of albumen; but when used in excess, or to the exclusion of bread and meat, it ceases to be nutritious, and the strength and flesh waste under its use. Oleaginous nutriment, butter, fat of meat, oils, and oily seeds, not only supply the material for the adipose textures of the body, but also assist in the formation of other structures and secretions*, (oil globules forming a normal constituent in them,) and afford the strongest fuel for the maintenance of animal heat by respiration. From what has been before stated (§ 59,) it may be inferred that fat may also be formed from saccharine and starchy food, as well as drawn from the storehouses of the adipose membrane: and from the researches of M. Claude Bernard it appears that the liver has the power of elaborating both fat and sugar out of the constituents of the blood when neither of these principles is supplied in the food.2 Still deficiency of fat in the food has been observed to induce the following morbid results : loss of flesh, and of the rounded plumpness and smoothness of the surface, > In this statement I disregard the dogma of Liebig that the materials of food serve for respiration and nutrition only, and that urea, lithic acid and excrementitious matters, are derived from the decay of the tissues alone. Daily observation convinces the medi- cal practitioner that in persons of weak assimilation, certain articles of food, so certainly and promptly cause an increase of animal matter in the urine, that there can be no doubt they are the direct sources of the addition. The observations of Lehmann support the same conclusion.—Physiological Chemistry; translated by Dr. Day, 1851, vol. i. p. 1861. » L'Union MSdicale, 1850. 62 EXCITING CAUSES OF DISEASE. which becomes skinny, wrinkled, and often dry and scurfy; brittleness of the hair and nails ; deficient secretion of mucus at the orifices of mucous passages, of cerumen in the ear, and of synovia in the sheaths and joints; insufficient formation of bile, and consequent impaired digestion and flatulent fetid and irregular feculent excretion ; with diminution of the power of sustaining animal heat. On this account the privation of oily food is more injurious in cold seasons and climates than in the reverse, often even aggravating the morbific operation of external cold. Excess of fat food may disorder the stomach by its indigestibility, becoming rancid, and causing heartburn or sickness, and sometimes a bitter bilious taste; for much fat seems to induce a regurgitation of bile into the stomach, probably to assist its digestion (Beaumont) and absorption (Matteucci.) If the fat is carried into the blood, it may cause inconvenient obesity by its accumulation in the adipose texture of various parts of the body; or if the subject be natu- rally lean, and incapable of accumulating fat, the superfluity must be got rid of, and the natural emunctories, the sebaceous follicles of the skin, and the liver, then become disordered; hence appear acne and other follicular diseases of the skin, and various bilious disorders. These results are the most readily produced in sedentary persons, in whom the exercise of the lungs is insufficient to consume the superfluous fat. On the contrary, those who use active exercise can often take considerable quantities of fat with impunity, and sometimes with ad- vantage. For similar reasons, oily food is better borne in cold than in hot climates and seasons : thus, as Liebig has pointed out, the Lap- lander relishes train oil, which serves to sustain the wTarmth of his body; whilst the Italian in a sunny climate prefers the less combustible food, maccaroni and fruit, which nourish without heating. The Esquimaux . surprise travellers by the enormous quantities of blubber that they can consume; but the Indian is easily satisfied with rice and other light farinaceous vegetables. The quality of oily matter in the food is an important element in its morbific effects; such substances as are most prone to chemical change, or to become solid, are more likely to disagree than others. Thus stale or tainted butter or fats, and rancid oils, are peculiarly offensive to the digestive organs, both on account of the production of injurious acids (butyric and oleic,) and because their thickness renders them in- capable of the minute division necessary for their absorption and ap- propriation by nutritive process. On the other hand, cream, fresh butter, mild fat, and sweet salad oil, agree well and nourish, especially when intimately blended with farinaceous or succulent vegetable mat- ters: and the cod-liver oil, when fresh and free from rancidity, is borne by the weakest stomachs. It is possible that the easy digesti- bility of certain fats is partly due to the facility with which they form emulsions with the pancreatic and other secretions of the alimentary canal. Thus cod-liver oil and the fat of bacon are among those most easily borne on the stomach, and I am informed by Dr. Lyon Playfair that these both possess the important property of saponifying with the alkaline carbonates, whereas other oils unite only with caustic alkalies. Amylaceous or starchy foods, such as arrowroot, sago, tapioca, and ALIMENTARY ELEMENTS. 63 many kindred farinaceous preparations, although isomeric (i. e. consist- ing of the same elements) with saccharine matter, are not quite similar in their physiological effects. Like it, they probably supply a fuel for the process of respiration, rather than sustain the body by nourish- ing the textures, and so save them from the consuming influence of the oxygen absorbed through the lungs ; and if taken in excess, they may either lead to the formation of fat, (§ 59,) which is deposited in the textures, or passing into fermentation, they may give origin to acetic, lactic, and oxalic acids, and other matters of an injurious kind ; this latter effect occurs more often with saccharine than with amylaceous food. On the alimentary canal too their effects in some degree differ, excess of amylaceous food impairs the action of the intestines and the secretion of the liver, whereas sweet things often relax the bowels and cause a redundancy of bile. These different effects of saccharine food are probably connected with its occasionally containing, or forming, vegetable acids; which irritate the alimentary canal, and which may thence cause dyspepsia, diarrhoea, diabetes, rheumatism, oxaluria, and other disorders of the same class. Amylaceous and saccharine matters being the mildest materials of food, serve to dilute the stronger articles fibrin and oil, and to render them both more palatable and more digestib'e; when, therefore, the former are deficient, the latter are more apt to disagree, and to fail to nourish. In common with other vegetable principles, such as gum, vegetable jelly, extractive, &c, they also contain alkalies combined with vegetable acids, compounds which are decomposable in persons of strong digestion, the alkali then becoming useful in counteracting the acidity which results from the processes of transformation con- tinually proceeding in the body. On this account fruits, and other vegetables, assist in neutralizing and eliminating lithic acid, and in preventing the occurrence of gout and gravel. This view is in accord- ance with the statements of Prout, Liebig, and Wohler ; but I believe it only applies to the case of persons whose digestion is strong; for where this is weak, I find that vegetable acids and fruit commonly in- crease the acidity of the urine, and are therefore injurious:1 whether they do this by passing unaltered through the circulation, or by irri- tating the prima vise, and thus leading to an usual development of hy- drochloric and other unchangeable acids, I cannot say, but the latter course would appear to be the most probable. But there is some reason to suppose that vegetable acids have an influence on the blood before or while they undergo the combustive process ; for whether alone or in combination with an alkali, they certainly exercise an operation on the body more cooling and antiphlogistic than can result from the alkalies which they contain. Thus sub-acid fruits and drinks are found refreshing and really cooling in fevers; and lemon-juice even in large quantities is now generally acknowledged to be powerfully antiphlogistic, especially in rheumatic and gouty inflammation. That this property depends on an eliminating power of the vegetable acids and of their salts is possible, but it may be connected with some direct chemical 1 This has been confirmed by Dr. Bence Jones, who found that large doses of tartaric acid render the urine more acid than usual.—Phil. Trans., 1849. 64 EXCITING CAUSES OF DISEASE. action by which the materies morbi in the blood is decomposed and thus deprived of its irritating influence. 61. The selection and combination of articles suitable for food would be a difficult task, requiring much scientific knowledge and calculation, were it not that Nature has supplied us with a trustworthy guide, which happily points out the varied wants of the system in changes of season and diversities of circumstance. The appetite and taste generally in- struct us pretty safely as to what are the best proportions in which the different kinds of food should be mixed ; but they must not be per- verted and pampered by condiments and refined modes of cooking. These expedients coax and deceive the appetite and taste ; and if these guardians of the nutritive department are cheated, it is no wonder that the department itself becomes deranged. 62. (hloKistic treatment, but rather by mild tonics, and locally ■T^tS"^ of topical narcotic applications, tepid or cold spong- "t ^^i^MTrf^f^Uy yield to the free exhibition of quinine and other ♦• »JSand tonic remedies; but during the paroxysm narcotics not only give ternpo- ft ,PrIhef bufbv reducn?rthe general sensibility prepare the system to bear tonics and rary relief, but by rea™ngui %rovided they do not arrest the secretions. Its tendency thus expedit the *^*™£^£[ objectin to the employment of opium, which is Thuf con.bSons^f opium or morphia with mercury, antimony, ipecacuanha, eolchioum, anTsalinVs often agree better than the narcotic m its simple state. 110 ELEMENTARY NERVOUS FUNCTIONS. that of opium and alcohol; but is more speedy and transient, because it passes freely and directly through the lungs into the arterial blood, and so affects the brain, and because it is as promptly dispersed from the blood and lungs when fresh air only is breathed. It has been maintained by many, that these anaesthetic inhalations operate only by interference with the respiration, inducing a degree of asphyxia; but so far is this from being the case, that their best effects are produced when the respiration is steadily maintained ; and I believe that the great end to be aimed at in the administration of chloroform, is to nar- cotize, as far as possible, without too much embarrassing the breathing. This it is difficult to accomplish without a freer supply of oxygen than atmospheric air contains ; and I should hence expect safer and more satisfactory results from the inhalation of a mixture of chloroform on ether vapor with oxygen gas, which might be continued with safety for a much longer period than a mixture of vapor and air.1 Since the anaesthetic properties of chloroform were discovered and applied by Professor Simpson, the use of this agent has in a great measure super- seded that of ether vapor, being more manageable and agreeable, when inhaled, and more potent in its stupefying powers. There is, however, one peculiarity of its physiological influence, which while recommending its employment in some instances, renders it highly hazardous in other cases. It often weakens the action of the heart, and has induced fatal syncope, where there was fatty degeneration of the organ. Whenever there is great exhaustion of the heart's power, and especially if there is also suspicion of the presence of degeneration, or other extensive organic disease, chloroform is a less eligible anaesthe- tic than ether, which is more stimulant. In all case where the stupefy- ing action is needed to be maintained for a considerable length of time, much circumspection should be used; the state of the pulse should be carefully noted, and the inhalation be immediately suspended so soon as insensibility to pain is induced. Although the chief influence of chloroform inhalation is transient, yet in consequence of its saving the nervous system from the shock of intense temporary pain during a paroxysm of suffering, it often pre- vents that consequent nervous irritation and exhaustion which is highly injurious to the vital powers, and which predisposes to a return of the painful attack. In neuralgic and painful spasmodic affections chloro- form not only is a valuable agent, in so far as it procures temporary relief, but also because by the removal of one of the paroxysms it may break the habit of diseased action," and so effect a permanent cure. 129. (2.) Deficient centric or general sensibility is exemplified in its extreme degree in the coma, induced when the circulation in the sensitive centre of the nervous system is impeded by pressure, conges- tion, or other obstruction2 (§ 52,) or in the stupor caused by narcotic 1 Since this suggestion was first made, Dr. Abraham, of New York, has succeeded in restoring a patient who was asphyxiated and pulseless under the influence of chloroform, by the employment of artificial respiration with oxygen gas.—Canada Medical Journal, Jan., 1853. 8 Dr. Fleming has produced somnolence and temporary insensibility by pressure on the carotids in the neck, and he thinks that this expedient might be resorted to for the pur- DEFICIENT CENTRIC SENSIBILITY—COMA. Ill influence. Thus when a person is in a fit of apoplexy, or poisoned by opium, he has lost all feeling, as well as power of voluntary motion. If the blood becomes impure by the retention of excrementitious matter, as on suppression of urine, a like stupor occurs (§ 68.) Anaesthesia —that is loss of sensation—very rarely exists without loss of motor power. But short of these degrees, there are persons who congenitally (§44,) from disease (§ 31, 34,) or from age (§48,) are somewhat defi- cient in sensibility—feel less than other folk. All their feelings are obtuse and their actions slow; they have neither intense suffering, nor intense pleasure. Such persons have also little irritability, but much tone of fibre, and they 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. There is one highly important difference between them and the over-sensitive:—disease when it occurs, may in them be latent, advance far, and become even dangerous before it is felt; and may imperceptibly increase until it is incurable, 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 should consist in attempts to remove these states by deple- tion, derivation, and other means to be hereafter mentioned under the head of disordered circulation. Where there is no actual disease pre- sent, but merely a torpor of the sensitive function, mental excitement, bodily exertion, dashing with cold water, vigorous friction, and the application of strong stimulants or excitants to the skin, are the best means of arousing the nervous system from its state of lethargy. ^ The insensibility produced by narcotics, and retained excrementitious matters, should be combated by measures calculated to eliminate the stupefying matter through the natural outlets, as, for instance, the ad- ministration of purgatives, diuretics, emetics, &c. It is remarkable how promptly drastic purgatives sometimes effect the restoration of sensibility, in stupor resulting from imperfect action of the kidneys. ^ Hysterical stupor yields as readily to the influence of turpentine or \ assafoetida enemata. It is doubtful whether we have any medicine j capable of directly increasing sensibility. Strong tea and coffee per- haps have the best claim to such a property. What effect would arise from electrifying the spine and occiput? Stupor and impaired sensi- bility sometimes occur in a state of anaemia; this is seen in cerebral syncope, and in children or females who have lost much blood, and is immediately caused by stagnation of the blood in the brain. Under such circumstances, the pallor of the skin and weakness of pulse indicate that stimulants afford the best chance of restoring sensibility. 131. (3.) Perverted centric, or general sensibility is often mani- nose of preventing or relieving pain (Brit, and For. Med. Chir. Rev April, 1855.) I Lve some doubts»whether the amount of pressure required to arrest the flow in the caro- tids mav not have injurious results, both on the vessels themselves and on the circulation in the brain afterwards; but the experiment is most instructive in its relation to sleep and coma. 112 ELEMENTARY NERVOUS FUNCTIONS. fested by persons in whom there is also increased sensibility (§ 126;) its character is presented in the peculiarity of the sensations which are experienced. Thus feelings of tingling, prickly heat, trickling cold, in various parts ; of a lump in the throat, a hot ball in the side, a fluttering at the stomach, and illusions of the special senses, severally and variously affect persons whose sensibility is modified more in kind than in degree. Such patients may also have a depraved appe- tite, craving for sour things, cinders, mortar, and all manner of filth. These symptoms generally occur in females, often in connection with irregular menstruation, and therefore are called hysterical; but their pathological cause must be sought in the nervous system, the functions of which become deranged, probably from irregular supply or bad quality of the blood supplied to them. The remedial measures indi- cated for this condition are therefore such as are calculated to remove this cause: chalybeates and other tonics, pure air, nourishing food, and all influences which improve the quality, and equalize the distribution of the blood. Narcotics and sedatives may be useful as temporary palliatives. In rare cases, the general sensibility is perverted in con- sequence of structural change in the nervous centres, as for instance in softening of the brain; strange and distressing sensations are then experienced in every part of the body. DISEASES OF LOCAL SENSIBILITY. 132. The sensibility of every portion of the body depends upon its structures preserving their due relations with the nervous centres by means of the nerves. In some instances change of state in those centres themselves modifies the sensibility of the parts that are fur- nished therefrom ; this is instanced in cases of local pain or local anaes- thesia attending on limited lesions of the brain. More commonly, however, alterations in the sensibility of parts depend on the condition of the conducting nerves which are media of communication between those parts and the nervous centres. The feeling of a part affected in this way may be excessive, deficient, or perverted. This may be illustrated by experiment. By irritating or striking a nerve, pain is produced in the part to which it is distri- buted, and the sensibility of the part remains exalted—that is, it feels tender or painful afterwards. By pressing on the nerve, a new and perverted sensation of tingling, pricking, and 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 tumor, 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 structure connected with it, may likewise modify the sensation of parts. Thus inflammation of the sheath of the ischiadic, or trifacial, nerve may cause, first neuralgic pain, and afterwards numbness in the parts to which the nerve is distributed. There are other painful affections which are to be considered and treated as cases of exalted sensibility; such are the (as Dr. Billing observes, erroneously so cllled) irritable breast, testicle, uterus, &c. 133. But the function of sensation depends on the due supply of LOCAL SENSIBILITY—EXCESSIVE—REMEDIES. 113 blood to the extremities, 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 or- gans of special sensation, the senses are modified, together with the common feeling: thus in disease of the optic nerve or retina, there are intolerance of light, perception of specks, [muscse volitantes,) clouded vision, or even blindness; in diseases of the ear, ringing and beating noises, or deafness,—as well as itching, tenderness, and pain, which are modifications of common sensation. 134. At the external orifices of the body, and in the linings of its interior passages, there are peculiar kinds of sensibility connected with the functions of ingestion and egestion; modifications of these become elements of disease. As examples of excessive sensibility in such may be enumerated thirst, craving, nausea, tenesmus, and urgent micturition : of impaired sensibility, anorexia, and loss of feeling in the rectum and urethra. 135. In considering internal parts, we have only to notice sensibility exalted by disease. We do not know that they naturally possess any feeling. We are not at all conscious of such ordinary processes as the passage of food and feces in the alimentary canal, of the move- ments of the lungs, of the heart, or of the blood through the vessels ; but under the influence of disease we become painfully sensible of several of these motions. Thus excessive sensibility is developed by inflammation, as shown in pleurisy, peritonitis, meningitis, &c, or by irritation of a mechanical or other nature, as evinced in colic, biliary and urinary calculi, gastralgia, and perforation of the stomach or in- testines, &c. It is very remarkable that pain, which is perhaps severer than any other, should arise so suddenly in parts which give no evi- dence of common feeling. Numerous other morbid sensations arise in connection with nervous disorder of internal organs; thus dyspeptic and hypochondriacal patients describe extraordinary feelings of heat, cold, weight, dragging, sinking, &c, in the abdomen, chest, and head, which seem to be the result of exalted and perverted nervous sensibility. 136. In many instances we have to regard pain, merely as a symp- tom, which is only to be removed by means tending to remove the cause, that is the lesion which produces it (§ 132, 133 ;) but_ in many cases, on the other hand, pain, although a symptom, is an important element in the disease itself, and one against which remedies must be expressly directed. Thus it is, in neuralgia, gastralgia, nephralgia, colic, dysmenorrhoea, and perforated intestine. So long as the exces- sive pain lasts, all the functions suffer (§ 66,) faintness and exhaustion are apt to ensue, and if no relief comes, the prostration may be fatal. Here, to mitigate or remove the pain is a first and pressing indication. 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 irritation of the stomach or windpipe, cause such distressing efforts at straining, vomiting, and coughing, that the vital functions are thereby kept in a state of disturbance, until the strength is exhausted. Here it is 8 114 ELEMENTARY NERVOUS FUNCTIONS. necessary promptly to direct the treatment towards the pain on account of its immediately pernicious effects. 137. Remedial measures.—When excessive sensibility depends on inflammation, antiphlogistic measures will be those most calculated to remove it. Where it lingers after the inflammation, is more than it can account for, or is independent of it, then anodynes become the chief remedy. The most powerful of these is the vapor of chloroform or ether inhaled as above noticed (§ 128,) or externally applied : in either way it often serves for the mitigation or removal of local pain of a temporary character. If the case admit of the direct application of . chloroform to the seat of pain, as when the skin or other superficial texture is affected, the chloroform may be applied on a piece of cotton or flannel covered by the hand, or by oil silk; or it may be rubbed in as a liniment mixed with an equal quantity of almond oil. Professor Simpson (to whom we owe the discovery of the anaesthetic power of chloroform) has recently found carbonic acid gas to be a very efficient local anodyne in cases of uterine neuralgia. He considers that the utility of the natural douches at Ems in painful uterine complaints may partly depend on the quantity of carbonic acid which they contain. The power of effervescing draughts and carbonated waters in relieving sickness may fairly he ascribed to this property of the gaseous acid; which is probably also what reconciles the stomach to the copious draughts of many kinds of mineral waters which would scarcely be tolerable without it. Perhaps the soothing influence of the yeast poultice may be ascribed to the same ingredient. As carbonic acid gas is readily procured, its application deserves further trials. The most potent of the fixed anodynes are opium and its active prin- ciples ; but these possess certain injurious influences (they arrest the secretions) (§ 70,) which sometimes render them less eligible than the weaker narcotics, hemlock, henbane, stramonium, belladonna, and In- dian hemp. The stronger preparations of aconite, and its alcaloid, and tobacco, are powerful anodynes, and are very valuable as outward applications; but their depressing operation on the heart renders them unsafe for internal exhibition unless under very careful superintendence. One of the most effectual methods with which I am acquainted, for re- lieving severe local pain, is the endermic application of morphia; for this purpose a blister is applied to the painful part, and when it has fully risen, the cuticle is completely removed, and the denuded surface sprinkled with from half a grain to two grains of a soluble salt of mor- phia (the acetate or hydrochlorate) in fine powder; this may be repeated once or twice daily, according to the urgency of the pain. After the first irritation resulting from the application, the effect is anodyne, and then narcotic on the system, and less of the consequent injurious effects follows than when opiates are given by the mouth. The appli- cation loses all power, so soon as the blistered surface becomes dry. Counter-irritation and warmth also serve to relieve pain. The pain of gastrodynia may often be removed by applying a sinapism to the pit of the stomach—that of colic and dysmenorrhcea by hot fomentations or bags of hot sand or salt, &c. Benumbing cold, produced by the ap- plication of a freezing mixture (pounded ice and salt) to painful parts, LOCAL SENSIBILITY—VOLUNTARY MOTION. 115 is recommended by Dr. James Arnott as a very efficacious anaesthetic, and the plan seems to have answered in his hands; but great care should be taken lest the living structures and vital functions be injured through congestion or obstructed circulation induced by this means. In some cases, painful feelings are removed by making such pressure on the part as serves to counteract tension, and diminish, without stopping, the flow of blood through it. Painful affections occurring with a weak circulation, particularly if intermittent in their attacks, are often removed by tonics : thus neuralgia is successfully treated with quinine and iron, and hemicrania with quinine, bebeerine, or liquor arsenicalis. 138. We are not possessed of equally efficacious means of restoring lost sensibility. Stimulant applications and frictions are serviceable where the defect arises from deficiency of circulation in the part; and tonics, especially of the chalybeate kind, are useful where there is an insufficient supply of good blood to the nervous centres and nerves. I have recently employed an acid phosphate of iron with advantage in such cases. Strychnia or cantharides given internally, and electricity used topically, may perhaps have some little effect in exciting the func- tions of the dormant nerves, but they certainly affect the motor func- tions more than the sensory. SECTION IV. DISEASED VOLUNTARY MOTION. 139 The functions of certain portions of the nervous apparatus, by which they convey the impulses of the will to the voluntary muscles, may become disordered, and may so constitute an element of disease. Some of these disordered manifestations have already been noticed under the head of diseased irritability (§ 113;) and it was there ob- served that the fault is more commonly in the nervous influence which excites the muscles, than in the condition of the muscles themselves. This is the case in most convulsive diseases, and in those cases of pa- ralysis which depend on injuries of the voluntary nerves, or of those parts of the spinal and cerebral system which are the channels of voli- tion A brief illustration of these affections may be given m a form corresponding with what has been said of the disorders of sensation. As in the case of diseased sensibility, so disordered motor power may depend on the condition of the nervous centres which originate that power or on that of the nerve-trunks and branches which convey it to the'muscles. The first class comprises disorders of centric or gene- ral volition; the latter disorders of local manifestations of the power. DISEASES OF GENERAL OR CENTRIC VOLUNTARY POWER. 140 The voluntary motor power may be said to be generally in ex- cels when the brain is excited by strong emotions or feelings (§ 66,) by stimulating liquors (§ 56,) and by the hurried circulation ot phrensy 116 DISEASED VOLUNTARY MOTION. or phrenitic delirium. Hysteria, which constitutes in itself a micro- cosm of all the nervous disorders, furnishes analogous examples. The strength and rapidity of movement displayed in hysterical cases are sometimes astonishing; yet such movements are obviously voluntary, for they are often performed rhythmically, or to a tune, as in dancing. The dancing of tarantulism, and the extravagant exertions of the fanatics called Jumpers, probably arise from erethism of the part of the nervous system concerned in the production of voluntary motion. A naturally high voluntary power, yet short of disease, is evinced in the energetic and active movements of persons, who excel and delight in feats of strength or agility. Mere muscular strength will not suffice without nervous energy to act on it. Most individuals, when in the vigor of health, are conscious of an energy, which at times prompts them to ac- tive exertion, and which is very like an overflow of voluntary motor power. A morbid excess of the same is commonly exhibited in those fidgety persons who are constantly in motion, and to whom a state of rest is almost an impossibility. 141. General volition is more or less deficient in apoplectic coma, stupor from pressure, congestion, and other causes ; intoxication from opium, alcohol, and other narcotics, where other nervous properties are also impaired (§ 129 ;) in trance, catalepsy, and nightmare ; in a less de- gree also in cases of lethargy and of 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 fable of the power of the Gorgon's head ; and the signification of the expres- sions, 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. Slight de- grees of this lowered state of volition are instanced in those periods of languor which visit individuals suffering from indigestion, or during an oppressive condition of the atmosphere. Extreme weakness of a por- tion, or the whole, of the body is sometimes exhibited in a class of hysterical patients, in whom it is difficult to say whether the want of power, which approaches to paralysis, is in the muscles or in the volun- tary nerves. The powers of the voice and of the lower extremities are the most prone to fail, but there is commonly also great loss of vigor in other parts of the body; and as the inability or indisposition to ex- ertion may last for months, or even for years, the muscles will waste for want of use unless their nutrition be promoted by electricity, fric- tion, and other like agencies that promote the circulation. The sudden loss, and as speedy recovery, of motor power, which has occurred in some of these cases, in some instances obviously from mental influence inclines me to rank them among instances of defective volition. 142. Examples of perverted voluntary power are afforded in chorea, delirium tremens, mercurial tremor, shaking palsy, and some analogous affections called hysterical. In these volition may also be defective • (§ 141,) but it is not always so ; sometimes it is even more energetic than usual; but each act of the will is perverted in its performance, and when it sets muscles in motion, they are the wrong muscles, or too many are moved, or too forcibly, or irregularly, so that the resulting action is VOLUNTARY MOTION—DEFECTIVE—PERVERTED. not in accordance with the will. This morbid state is also exemplified in the persons of many who are called nervous, and whose voluntary movements are performed with undue precipitation and trepidation. The pathological cause of these irregular excitements of the nerve-force probably lies in the relations that connect the motor ganglia and nerves, and the blood which sustains their function and nutrition: a deficient supply and depraved quality of the blood especially induces the morbid excitement, instead of sustaining the normal function. PARTIALLY DISEASED VOLUNTARY POWER. 143. We can scarcely point out examples of partial excess of volun- tary motion. The convulsive movements of voluntary muscles are quite involuntary actions, and have been already noticed under the head of diseased irritability (§ 113 ;) but it was there mentioned that they may arise from irritation of the nerves, independent of the influence 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 can- not be said to be wholly involuntary ; but are the results of a wilful impulse perhaps too strong to be easily resisted. Something bordering on the same thing is also exhibited in certain habitual movements or tricks to which some persons are addicted, and which, although real y voluntary, become, through indulgence, spontaneous and constant, to the great annoyance both of performer and observers, and then require a great exertion of self-constraint for their control. 144. Partial deficiency of voluntary motor power is very common; and, like local deficiency of sensibility, may be traced either to partial disease of the motor (anterior) columns of the medulla, and their pro- longations-^ 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 volun- tary motion in an extremity or 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 motor power of those parts supplied with spinal nerves from below the diseased point. Thus a lesion in the lower cervical portion may paralyze the upper and lower extremities and whole trunk, (except the diaphragm, which is supplied by the phrenic nerve:) but a lesion in the dorsal or umbar portion paralyzes only the lower half of the body (paraplegia,) or lower ex- tremities. The mischief may, however, be more partial paralyzing 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 maybe structural change such as tumors effusions, or hemorrhage, or it may only be an altered state ot hTblo'od vessels of the part. In all these instances either the struc- ture is injured, or the blood is prevented from duly supplying it with healthy nourishment. Another occasional cause of partial paralysis, 118 DISEASED VOLUNTARY MOTION. is the presence of poison in the blood or in the nervous tissue, as in the case of lead palsy. Severe cold, or continued pressure, will impair voluntary motor power in a limb, by checking the free flow of blood, which is essential to the maintenance of the proper function of the nerves as well as of the muscles. Hysteria affords numerous examples of impairment of volition in parts, as in loss of voice and power of arti- culation, retention of urine, paralysis of limbs, &c. ; these affections often come on quite suddenly, and may as suddenly cease. 145. Remedial measures.—Excessive voluntary power, as an element of disease, rarely calls for separate treatment. Where it occurs as a portion of the excitement of the nervous centres, it may be reduced by sedative influences of different kinds—depletion, antimonials, and cold to the head, being the most effectual where the excitement is attended with determination of blood; morphia, codeia, and other narcotics, where the excitement is more purely nervous. Inhalation of chloroform is as effectual in depressing the functions of the motor, as it is those of the sensory portion of the nervous system ; but as it has a tendency to cause some congestion in the nervous centres, it is not a safe measure when there is any sign of vascular fulness or excitement.1 There are several milder narcotics which often prove useful in calming nervous excitement, and in tranquillizing the inordinate movements to which that leads—such are henbane, lettuce, sumbul, camphor, and valerian. These are all very safe medicines, but apt to lose their powers very soon upon repetition. The violent exertions of maniacs are often wonder- fully controlled by the application of the cold douche to the head, by the administration of nauseating doses of tartar emetic, and by the ver- tiginous effects of swinging. The vehement movements of persons affected by fanaticism and tarantulism commonly end in exhaustion ; they might probably soon be checked by a timely ducking with cold water, a remedy so often successful in hysteria. In all these different remedial measures, addressed to excessive mo- tor nerve-force, three modes of action may be traced : 1. A sedative influence exercised on the circulation of blood which supplies the ner- vous centres or branches. 2. A sedative influence exerted directly on the nervous functions. 3. An indirect sedative influence coming in the form of exhaustion after continued excitement. The latter influence is mostly of use in preventing convulsive affections that result from superabundant motor power : habitual and regulated exercise proves efficient in this way, by expending the superfluous force. In fact, hys- terical convulsions of the ordinary kind seem to be a natural expedient for the discharge of pent-up accumulated force, and although they be- come injurious from frequent repetition, they are often productive of relief to the system at the time. 146. The treatment of deficient voluntary power consists in means calculated to excite the nervous centres, either directly, or through the medium of the circulation. Agents which restore free circulation of 1 I learn, however, from Professor Simpson that he has used chloroform inhalation for many hours in infantile convulsions, with no other than a composing effect. In one in- stance a child was kept more or less under the influence of chloroform for three days, to remo-ve recurrent convulsions, and ultimately recovered. DEFICIENT—PERVERTED. 119 healthy blood through the nervous centres and the nerve-branches ge- nerally, increase voluntary power. Thus a stimulant draught raises the failing strength of a fainting person. By warmth and friction, one who is benumbed with cold recovers the use of his limbs. Sleep, or rest, restores voluntary power exhausted by fatigue. Sudden and powerful mental excitement, as from a fright, has been known to recall voluntary power which had long been 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 upon a table near; the power, however, did not remain, for she could not get down again. More permanent cures of this kind have been effected by the excitement of religious fanaticism, as in the cases of the supposed miracles of Prince Hohenlohe, Miss Fancourt, &c. As we have seen that mental excitement sometimes causes excessive voluntary motion in healthy persons (§ 140,) so we perceive that, suddenly applied, it may restore the power of effecting it where this is deficient. Thus the dread of branding by a hot iron, 'of the application of a large blister, or even of a douche bath, has some- times cured hysterical palsy; and a sudden emotion of surprise has been known to restore a lost voice. But in some cases volition is defective in consequence of pressure on, or congestion in, the brain, which then prevents the due motion of the blood through the organ, as in plethoric lethargy, or apoplectic coma : here depletion and derivation sometimes answer in restoring the power. There is also a form of palsy due to anaemia, or deficient sup- ply of blood to the nervous centres; this may be removed by an op- posite mode of treatment, comprising the administration of stimulants as temporary means of restoring the circulation, and of chalybeate tonics, which act more tardily, by augmenting red blood. In the lethargy of narcotism and asphyxia, volition is often restored by means which ex- cite strong sensations and reflex actions, such as dashing cold water on the face and chest, the application of ammonia or other stimulating vapors to the nostrils, electric shocks, tickling, stinging with nettles, &c, and although the influence of these is only temporary so long as the stupefying influence remains in the blood, it may nevertheless prove sufficient to prolong life until this influence can be got rid of by other means. The trance or coma of hysteria may often be re- moved by a turpentine injection, or croton oil purgative, which acts both as a revulsive to the vessels, and a stimulant to the nerves; I have also found the same measures answer in the stupor of anaemia re- sulting from deficient action in the kidneys; doubtless they effect the elimination of the excremental poison through the intestinal glands. Urea has been found in the intestinal discharges in cases of suppressed urine. Perverted volition requires different methods of treatment according to its precise nature; the state in delirium tremens is best corrected by narcotics, especially opium ; in chorea, by nervous tonics, especially iron and zinc. In delirium tremens there is much involuntary tremor and agitation, independently of all affection of volitional powers, but these are much increased whenever any attempt is made to perform 120 DISEASED VOLUNTARY MOTION. voluntary actions. Neuro-sedatives are best suited to the alleviation of this nervous excitement, as has been already explained (§ 56.) Such remedies, however, may fail until the blood is relieved of the irritating matter, the presence of which keeps up the morbid excitement. The same remark is applicable to many cases of chorea, which are not re- mediable by tonics, until after the administration of purgatives and other evacuants. The connection of chorea with rheumatism has been frequently noticed, and I have found that such medicines as are useful in rheumatism (for instance iodide of potassium, colchicum, and aconite) promote the cure of chorea in a very marked degree. Its completion is, however, even then to be looked for from the salutary operation of tonic remedies which have a remarkable effect in steadying the nervous functions. Hence iron, quinine, and their combinations,.are the re- medies from which the most lasting benefit is to be anticipated.1 These tonics operate in various ways; they enrich the blood, and equalize and sustain the circulation, thus conducing to support the nutrition and stability of the nervous structures. 147. The treatment of locally diseased voluntary power should ge- nerally commence with attempts to remove the cause, which, however, is found to vary too much both in seat and nature, to admit of any precise enunciation of remedial measures. The treatment of defective voluntary power comprehends the complex subject of the management of paralysis, which commonly comprises means calculated to restore the circulation through the affected part of the nervous system to its proper state, and sometimes, also, the use of agents which stimulate the part, such as electricity,2 rubefacient frictions, and blisters. Strych- nia and cantharides, given internally, are supposed to have a directly stimulant action on the motory columns and nerves.3 1 Mercurial tremor affords another good illustration of the principles of treatment here laid down. Iron is its best antagonist, but the administration of this remedy is rarely effectual until the mercury has been, to a certain extent, eliminated from the system through the excretions, and in promoting this object the influence of iodide of potassium is invaluable. I believe the beneficial influence of many of the celebrated mineral waters to be connected with their combination of the eliminant with the tonic power. 2 In the use of electricity as a means of restoring the lost power of a palsied nerve it may be well to bear in mind the observation of Professor Matteucci (Lectures on Physical Phenomena, &c, p. 262,) that a direct current of electricity, from root to branches, ex- hausts nervous power: whereas an inverse current, from branches towards the nervous centre, causes an accumulation and increase of power where it has been previously ex- hausted. Now as the object in electrifying a paralyzed lirab, is not only to develop nervous force where it is weak, but also to exercise it in producing the contraction (and thereby the nutrition) of the muscles, it would seem desirable to alternate the direction of the electric current, from inveise to direct, giving however a much greater amount of the former than of the latter. » Phosphorus is a reputed restorer of nervous power, and from its admitted existence as a constituent of nerve matter, I have been induced to test its properties I first administered it in doses of one-twentieth of a grain dissolved in a little oil In a few days the feces became luminous in the dark, and in a few more days I was compelled to suspend the administration in consequence of supervention of jaundice. This happened in two cases (one, hemiplegia, and the other great nervous debility) and seems to me to demonstrate that phosphorus exerts some specific action on the liver or its ducts There was no improvement of nervous power. I have, however, given phosphate of iron' dissolved in an excess of phosphoric acid, with better effect. This is an agreeable as well as efficient, form of the medicine, but it must be recently prepared, as the insoluble phosphate is soon precipitated. EXCESSIVE EXCIT0M0TI0N. 121 SECTION V. DISEASES OF REFLECTED AND SYMPATHETIC NERVOUS INFLUENCE. 148. The nervous power by which various movements and processes connected with organic life are excited, may be disordered, and its al- terations thus become remarkable constituents in many diseases. The contractions of all the sphincters,—those of the oesophagus, the glottis, the iris, and the eyelid, and the regular action of the muscles of respira- tion, seem to be sustained, independently of the will, by a nervous in- fluence conveyed first by afferent nerves from the several parts or surfaces to the spinal marrow, and reflected from it through the efferent nerves to the muscles connected with the parts. The full establishment of this important physiological principle we owe to Dr. Marshall Hall. 149. Increase of this involuntary excitomotory power is instanced in the spasm of the throat, and sometimes of the sphincters, which occurs in hydrophobia, tetanus, and some hysterical affections. The hurried respiration, convulsive cough, violent retching, and hiccup, which are occasionally presented in these and other nervous diseases, may also be in part traced to an undue influence of the excitomotory nerves of organic life. These actions are sometimes 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 mainly where either there are no such sensations, or where these bear no due proportion to the violence of the excited actions, that we are warranted in the conclu- sion that the excitomotory function is itself exalted. A similar exaltation of the excitomotory function, independent of the influence of sensation and volition, is exemplified when the volun- tary muscles are deprived of sensation and voluntary motion by disease in the brain itself, or by cutting off the communication between the brain and spinal cord, without extensively injuring the structure of the latter (§ 118.) 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.1 This phenomenon is sometimes so readily produced as to be a cause of much disturbance to the patient, the mere touch of the bedclothes exciting troublesome startings. The same thing occurs in hemiplegia, but less distinctly, as the cerebral influence is rarely here so completely intercepted. I have known, however, the convulsive motions of a paralyzed limb to become so violent in a hemi- plegic patient, that it was necessary every night to fasten it down to the°bedstead to enable the patient to get sleep. i The same phenomenon is exhibited in a high degree in the decapitated frog, in which touching the surface excites convulsive movements A still more interesting illustration sometirnes 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 ot the reflex or spinal function. 122 REFLECTED AND SYMPATHETIC NERVOUS INFLUENCE. An instance of involuntary excitement of the muscles occurs in the symptom commonly called "fidgets," which often arises from reflected irritation set up primarily in the lower part of the intestinal canal, or in the uterus : another is seen in the sudden retraction of the testicle by the contraction of the cremaster, in diseases of the kidneys, and other urinary organs, on touching the inner part of the thighs. ^ 150. Under this head we must also glance at convulsions, which, ac- cording to Dr. M. Hall's views, and consistently with the phenomena of disease, may be referred to an irritation of the true spinal system. This irritation may be centric, as seen in epileptic and apoplectic con- vulsions from disease in the head, and in those caused by loss of blood: in these cases, the spinal and prolonged medulla being in some pecu- liar state of irritation, the excitomotory influence radiates therefrom to the limbs and muscles generally. Or it may be eccentric, commencing with irritation of the extremities of some afferent nerve, which is then transferred to the spinal centre, and then again reflected thence gene- rally or partially. Convulsions arising from teething, or uterine, intes- tinal, and renal irritation, are of this nature, and a slighter degree of the same state of things is exempli6ed in the rigor caused by the sud- den impression of cold on the surface, or by passing a bougie into the urethra of a nervous person. The centric and eccentric causes of con- vulsions, however, often co-operate. The centric excitomotory power being exalted by various influences, its overflow or discharge does not take place until provoked by some occasional irritation transmitted from some nervous extremity. In this view the exalted excitomotory power is the predisposing, and the distant irritation the exciting cause, of the convulsion.1 151. Partial spasms caused by reflected irritation, are exemplified in cramp in the legs, excited by the presence of acrid matter in the colon, in diarrhoea, and cholera ; spasm of the glottis from a bone stick- ing in the pharynx, &c. More familiar examples of the same class of reflected irritation are found in sneezing from irritation 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 forgotten that all these latter examples are connected with obvious sensations ; they imply increased excitomotory influence only in the cases in which the resulting action is out of proportion to the sensations. 152. But some of the most remarkable instances of reflected irrita- tion are displayed by the altogether 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 the presence of irritating matters in the stomach, intestines, kidneys, or other viscera (§ 51, 54 ;) nay, we shall hereafter find, that the heart is 1 Some modern physiologists conceive that the sensory ganglia are the primary seat of epilepsy, and that this is proved by the obliteration of consciousness, and the occurrence of clonic spasm, identical with that which is produced by mechanically irritating these organs Sometimes the irritation is propagated upwards, and cerebral disturbance re- sults; at other times it is propagated downwards to the spinal cord, and then convulsive movements occur. CONVULSIONS—SPASMS. 123 liable to be excited by considerable irritation applied to 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.1 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 move- ments are due to the direct nervous connection which the great sympa- thetic nerve establishes between the several organs; but this^supposi- tion assumes, what experiment has not proved, that the ganglia of this nerve are either centres of reflection,2 or that they are sources of ner- vous 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 the other, examples of reflex action that we have been considering, although the sympathetic nerves are the medium of har- monization.3 153. When phenomena of inordinate reflex action are general or extensive, as in convulsions, tetanus, and paraplegia, they must be re- ferred to an undue excitement or erethism of the spinal and prolonged medulla ; but more partial phenomena may arise from similar excite- ment of a small portion of this organ alone, or of the incident (afferent) nerve of the part which occasions the phenomena, or of the excitomo- tory (efferent) nerve of the part which exhibits them. If we seek to know the causes of this excitement, we shall find that it is sometimes referable to an increased flow of blood through the spinal marrow or its nerves, or through the branches of the sympathe- tic 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 of blood through the medulla being increased in proportion as that through the brain is im- peded : considerations based on ascertained causes of convulsive parox- ysms and on the mode in which the encephalic arteries are distributed, countenance this supposition.4 It appears, from an experiment of Sir 1 Miiller's Physiology (by Baly,) p. 737. . * It is now generally conceived that the special office of the sympathetic nerves is the production of an influence that harmonizes the chemico-vita processes ot the system (Nutrition, secretion, &c.) with themselves and with the operations of mind.-Carpenter a Human Physiology, 4th Edition, p. 864. _ s Carpenter's Human Physiology, 4th Edition, p 7»U. « The explanation of epileptiform attacks, here proposed, deserves at least, some con- sideration. It was first suggested to me by observing the symptoms of an epileptic patient who had a sort of tumor on the vertex (which proved to be of hydatid nature) projecting Through an opening in the skull. As this tumor lay in contact with the brain pressure could be communicated through it to this subjacent organ. A shght amount of pressure caused lethargy, or somnolency, in the patient; a greater degree produced stupor and convulsions. S milar results have been obtained from experiments on animals. Shght nrelsure impairs, without arresting, the circulation through the cerebrum The stronger nresJure stops it altogether, and directs the current of blood which ought to pass there, Son the arteries of the cerebellum and spinal marrow; the functions of their ganglionic KSy become Proportionally excited. This then preosely corresponds with Thephenomena ogf the epileptic fit. The .light attack (petit ma) consists simply of a tran- ent stupor passing, like a momentary cloud, over the sensorial powers. The severe fit 124 REFLECTED AND SYMPATHETIC NERVOUS INFLUENCE. Astley Cooper's, as well as from the occasional occurrence of convul- sions during syncope, that an arrest of the arterial current sufficient to cause suspension of the cerebral functions, causes a momentary excite- ment of the medulla. In other cases, the excitement seems to be of even 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. This agent, indeed, seems to be electively attracted by the affinities of the spinal ganglia, as opium and alcohol are by the encephalic centres. So, too, we know, that me- chanical irritation of the spinal marrow or of its nerves will cause con- vulsive motions; this is exemplified in the effect of tumors 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 irritation here begins in a distant nervous branch, and is propa- (grand mal) comprehends not merely suspension of sensorial and voluntary power, the function of the cerebral lobes and ganglia, but also excitement of the involuntary excito- motory functions of the cerebellum and medulla. But this diversion of the cerebral cir- culation may be produced by other means besides pressure; there are various distur- bances of the quantity and motion of the encephalic blood that are capable of effecting it: thus convulsions with insensibility—i. e. medullary excitement with cerebral syncope —occur in consequence of extreme loss of blood, as well as in consequence of fulness— in consequence of depraved quality, as well as of disordered quantity. It would far exceed the limits of a note to enter upon a detailed statement of cases illustrative of these views, but there is one natural provision concerned in the results that may be pointed out, namely, the greater proximity of the medulla and cerebellum to the source of arterial supply (especially through the vertebral arteries, which are least liable to derangement) so that under most circumstances of irregular flow of blood these organs get the first and best share, often at the expense of the cerebral hemispheres. This doubtless is a salutary arrangement to secure the maintenance of those functions that are most imme- diately important to life. Life may go on for some hours without the aid of the brain, but not even for a few minutes without the influence of the medulla, as this sustains the respi- ration. Sleep is a natural and prolonged condition like the petit mal of epilepsy; the cere- bral power is impaired, whilst the energy of the medulla is enforced and augmented during its continuance. The close affinity between sleep and epilepsy is further shown by the way in which somnolency commonly follows the occurrence of epileptic attacks, and these frequently supervene during sleep. The following remarks comprise certain practical bearings of this subject, which my own experience has suggested :— In a majority of instances convulsive fits of the epileptic or epileptoid character, have been immediately preceded by symptoms of disturbed circulation, such as palpitation or strong action of the heart, throbbing in the carotids, sudden change of color and cold- ness of the extremities; these signs being sometimes obvious to others, when unobserved by the patient. The fits may sometimes be prevented or arrested by the adoption of measures which tend to subdue disturbances in the circulation; as by making firm pressure on the ca- rotids (Dr. Parry), dashing cold water on the face and neck, and plunging the hands and feet into hot water. The frequency of the fit%is often reduced by remedies which equalize the circulation, either by reducing it where there is excitement or occasional palpitation (hydrocyanic acid, digitalis, and aconite act in this way), or by raising its power when in a depressed state and irregular (iron, quinine, zinc, silver, and other tonics do this), or by purifying the blood when it is depraved (iodine and other eliminants possess this power.) _ The undue susceptibility of the nervous system itself in many such cases'is of high importance; many of the remedial means alluded to above act mainly upon it, as also do others which tend to improve the nutrition of the nervous structures. The more rational treatment of convulsive paroxysms (whether of the decidedly epi- leptic or mere hysterical class,) based upon these views, proves at least more successful than the too prevalent empirical plan of using first one remedy, and then another re- puted to be specific, and in doses increased to a hazardous extent. DEFECTIVE REFLEX ACTIONS—REMEDIES. 125 gated 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. Tetanus may be defined to be dependent on an undue excitability of the entire series of the spinal ganglia. Slight impressions then pro- duce violent reflex actions; when these are once established, they are kept up by the irritation present in the spinal ganglia. Then the re- moval of any cause of nervous irritation fails to be of any service. In hydrophobia the irritation seems to be transmitted from the sensory ganglia or from the cerebrum—while in tetanus it issues directly from the spinal cord. Another cause which may be fairly assigned as sometimes increasing the involuntary excitomotory function, is accumulation by rest. The augmentation in narcotism from opium is of this nature, and also in injuries of the spine (§ 149,) which suspend the exhausting influence of volition on the whole or part of the marrow, so that the nervous energy accumulates therein, and becomes unusually abundant. There is a natural increase of excitomotory power in sleep, which by suspending the sensorial functions, augments the energy of those of the medulla : but this accession of power, which then maintains the movements of respiration, also disposes to the occurrence of spasmodic attacks ; hence the fits of epilepsy and asthma commonly come on during sleep. So likewise sedentary habits, and too much indulgence in sleep, may cause an accumulation and morbid excess of involuntary nervous power, and develop convulsive and spasmodic symptoms, which are the result of its overflow. True coma differs from sleep mainly by the functions of the sensory ganglia being suspended or destroyed. In the slightest forms, as in hysterical coma, the cerebral functions are not abolished, but only much impaired. 154. Deficiency of the reflex, or involuntary excitomotory function, is exemplified in forms of paralysis which affect the sphincters, the eye- lids, the muscles of respiration, and other parts whose normal action is sustained by these means (§ 148.) When this function is generally and considerably impaired, the result is fatal, because respiration, deg- lutition, and other actions essential to life, are arrested. It is by interfering with these actions that apoplectic coma and narcotism de- stroy life ; and the state of sinking in excessive weakness or great de- pression, when the urine and feces are voided involuntarily, and the breathing is irregular and gasping, being forced by voluntary effort, further illustrates failure of the reflex power. From the same cause coughing and expectoration become inefficient in clearing the air pas- sages of mucus; hence the bronchial and tracheal rattles which precede death. As these movements are the last to fail, so, in recovery from asphyxia, syncope, and other similar states of partially suspended ani- mation, the actions connected with the reflex function are the first to return with the restoration of life; vomiting, coughing, and sneezing are among the early signs of reaction, under such circumstances. The steady tonicity of the muscles by which they are kept in their places when at rest is much under the influence of the spinal function ; hence when it fails an unsteady tremor affects the various muscles, which in- 126 REFLECTED AND SYMPATHETIC NERVOUS INFLUENCE. .creases as strength declines. So also in the decline of life from age or extreme debility, the sphincters act imperfectly ; incontinence of urine and feces, drivelling, lachrymation, and a sighing, moaning, or gasping breathing, betoken the failure of the nervous powers most intimately connected with the processes of life. A failure of the medullary function, similar in kind, but less in de- gree, is exhibited in all states of extreme debility, whether from exces- sive fatigue or excitement (§ 64, 65,) or from directly depressing or sedative influences, as in adynamic fevers (§ 105.) A person in this state is too weak to sleep; for the medulla, partaking of the general exhaustion, cannot maintain the respiration without assistance from voluntary efforts. Hence a feeling of oppression and frequent sighing banish all repose ; or if sleep do occur, it is disturbed by the startings and fearful dreams occasioned by the painful sensations of imperfect breathing and the distressing efforts which they excite. 155. Remedial measures.—As with other instances of exalted ner- vous function, so with excessive reflex action, when it depends on in- flammation, or determination or congestion of blood in the medulla, the most suitable remedies are such as are directed towards these states ; the same measures in less active degrees are also often useful in hys- terical affections, when these are accompanied by fulness of habit and spinal tenderness. But in my own experience cases of pure inflamma- tion of the medulla and its membranes, requiring active antiphlogistic treatment, are rare. Instances of a rheumatic kind where vascular excitement of the medulla is kept up by the irritation of morbid mat- ter in the blood, are far more common. Under such circumstances the most effectual remedies are agents which promote elimination, as for instance colchicum, iodide of potassium, guaiacum, and turpentine. In simple irritation of the nervous centres (as in tetanus, hydrophobia, poisoning with strychnia, &c.,) a narcotic or sedative which is able to lower the exalted function, is the influence that would seem to promise the best results. We possess some agents which efficiently reduce the energies of the spinal system, and cause general relaxation of the mus- cles ; such are hydrocyanic acid, woorara, resinous extract of Indian hemp, codeia, belladonna, and conium: these drugs may themselves de- stroy life by arresting the function of the medulla oblongata, and through it respiration ; but this very action renders the remedies almost as dangerous as the disease. One of them, hydrocyanic acid, is also farther hazardous on account of the sedative influence which it exerts over the heart. Perhaps the least dangerous, and in this sense there- fore the safest medicines where full doses are required, are the extracts of belladonna and Indian hemp ; and these remedies have recently been successfully exhibited in cases of tetanus. The inhalation of chloro- form is also a powerful means for subduing this, as well as other forms of excited nervous functions, and although it can only be viewed in the light of a palliative in tetanus and hydrophobia, it has been of direct service in some of the less intense kinds of convulsive disorder. In the slighter irritations of the medulla, neuro-sedative medicines, given in moderate doses, often prove beneficial. Thus hydrocyanic acid is a'very efficacious remedy in vomiting, nervous palpitation, and DEFECTIVE REFLEX ACTIONS—REMEDIES. 127 hiccup; it is likewise useful in convulsive cough, in which, however, as well as in spasmodic asthma, the extracts of belladonna and stramonium are still more effectual. The same medicines, and opium, are often beneficial in relieving the spasms of colic, dysentery, dysuria, and dysmenorrhcea. Some medicines, which act as stimulants to the heart and vessels, and to the cerebral functions, seem to operate as sedatives to the me- dullary system: such are the stimulant antispasmodics, ether, ammonia, musk, sumbul, essential oils, gum resins, creasote, chloroform, and al- cohol ; these are useful remedies in spasmodic and convulsive affections in weak subjects without inflammation ; they probably operate by giving vigor and equable diffusion to the circulation, and by preventing undue local determination and congestion of blood in the nervous cen- tres. External heat and counter-irritation act in a similar way. There is another class of remedies which have some power in re- ducing 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, iodide, valerianate, and other preparations of iron are efficacious in chorea, and perhaps in the more chronic forms of tetanus. Nitrate and oxide of silver, valerianate, sulphate and oxide of zinc, sulphate and ammoniuret of copper, and trisnitrate of bismuth, have been found to diminish the attacks of epilepsy, hysterical convulsions, spas- modic asthma and cough, gastralgia, dysentery, and other like affec- tions. The chief operation of these medicines is obviously on the vas- cular system, to which they prove astringent and tonic, but it is uncertain whether their beneficial action in nervous diseases is of this kind only, or whether they exercise any more direct influence on the nervous system besides equalizing the circulation. The same question is open with regard to certain regiminal means which are efficient in reducing nervous excitability, such as cold bathing, country air, change of air, and exercise. The latter, however, no doubt may prove useful by exhausting the superfluous nervous power (§ 153) through another channel, that namely of voluntary motion. The best remedies for defective or failing medullary function are stimulants, narcotics, and various strengthening measures. Fatal states of sinking have sometimes been removed by the free administration of ammonia, ether, brandy, and other stimulants; the best proof of the beneficial operation of such agents is afforded when they procure re- freshing sleep, which in itself is a source of renewed power. Narco- tics also seem to be indicated, but in extreme conditions of weakness their indiscriminate employment is hazardous, as they may paralyze the little remaining power, and lull the patient into the sleep of death (§ 56, Note.) When given they should be preceded by, or combined with, stimulants; and those narcotics should be selected which have the least depressing action, such as opium, ether, and henbane. Other means must, however, then be adopted to sustain the power restored by the stimulants, especially the administration of nourishment fre- quently in a liquid form; complete rest in a horizontal posture, and the exclusion of all exciting and exhausting influences; such as light and noise. 128 REFLECTED AND SYMPATHETIC NERVOUS INFLUENCE. REFLECTED AND SYMPATHETIC SENSATIONS. 156. Clinical observation teaches us that not merely motory impres- sions, but those also which cause sensations, may be reflected, so that when the impression is made on one part, the sensation 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 im- pressions 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 ex- ternal auditory meatus causes a tickling sensation in the glottis. A calculus in the kidney sometimes gives rise to pain and numbness in the testicle and thigh; one in the bladder produces pain referred to the extremity of the penis. Congestion of the ovaries and uterus pauses pain in the back, loins, and thighs. Ascarides in the rectum induce itching of the anus, and of the pudenda in females. Congestion of the liver is sometimes accompanied by pain in the right shoulder- blade, and a disordered state of the stomach, occasionally with pain in the left shoulder-blade. In angina and gastrodynia the pain often extends to the whole chest; and in the former especially, it radiates to the left arm. Severe frontal headache is almost instantly caused in some persons by acid ingesta, in others by eating ice. Irritation of the intestines, such as is experienced in cholera and colic, (especially painter's colic,) frequently causes pain and tenderness in the legs and feet, even when there has been no cramp or other excitomotory pheno- mena. Temporary neuralgic affections, generally described as spinal irritation and excessive cutaneous sensibility, seem to be due to similar causes. Instances of excessive sensibility often amounting to consi- derable pain, are very common, particularly in the female sex, and are occasionally very puzzling to the practitioner from their resemblance to inflammatory affections. They occur chiefly in nervous individuals (§ 126;) but not uncommonly in others not constitutionally nervous they form part of a temporary nervous susceptibility connected with weakness and inanition, after losses of blood and other exhausting in- fluences (§ 63, 64.) An example or two will suffice to show that they belong to the phenomena of reflex nervous action. A young female has an attack of tonsillitis—of pleurisy, of hepatic congestion, of gas- tric derangement, or of uterine irritation,—and after the symptoms of these affections have subsided, suffers pains of more or less intensity near the seat of the primary disorder, so as to give the appearance of a relapse. The wary physician remarks, however, that the pain is of a sharper and more shifting character; that there is a complete absence of such febrile and functional disturbance as real relapse would cause, and that there are peculiar nervous symptoms, especially extreme sensi- }™y.of ^kin traceable to a corresponding part of the spinal column behind, where on pressure there is tenderness, and sometimes radiation of pain to the seat of suffering in front of the body. The real truth is that the spinal irritability has been exalted by the primary disease, particularly in that portion which corresponds in position with the af- fected organ, and that this irritation is propagated to the sensory cen- SPINAL IRRITATION—CHOREA. 129 tres, and then reflected on the cutaneous and other nerves, occasioning in their extremities the abnormal sensations. Thus after tonsillitis, the morbid sensibility and tenderness is experienced close to the spines of the cervical vertebrae on the same side. After pleurisy, it is near the spines of the dorsal vertebrae: after hepatic and gastric disorder, at those of the lower dorsal vertebras; and after uterine and gastric dis- order, along the lumbar and sacral portions of the spine, the pain then being very apt to be intense and to be extended over the loins, pelvis, and thighs. These are all so many several examples of what is com- monly called spinal irritation. In these and other analogous instances, the morbid sensations can- not be referred to direct nervous impressions, but to an influence pro- pagated from the spinal centre to the sensory ganglia, and then re- flected thence. Involuntary reflex actions issue from all the great centres of the nervous system—the spinal, the sensory, and the cerebral ganglia. The reflex actions determined by the sensory ganglia are instinctive, and in man these are masked by the superior cerebral influence and will; but they are seen in full operation in morbid states where there is complete exhaustion and abeyance of cerebral power, as after re- peated attacks of mania or epilepsy, and also in instances of congenital idiocy, where the cerebral influence has never been established. Cho- rea is something of this nature; its seat is in the summit of the cranio- spinal axis. The fact that the symptoms cease during sleep is incon- sistent with the notion that it is the spinal centres that are solely or mainly involved. In chorea there is augmented activity of the sensory- motor centres, and diminution of the power of will. The sympathies subsisting between some organs are very remarkable; this is especially the case with the breasts and the uterus. Applying the infant to the breast commonly induces uterine pains in women re- cently delivered; the catamenial discharge has been induced in some instances by stimulating applications to the breasts. 157. The remedies most effectual for the relief of reflected morbid sensations are—1st, such as remove the irritating cause; and 2nd, such as deaden sensibility (§ 137.) The peculiar efficacy of trisnitrate of bismuth and hydrocyanic acid in relieving gastrodynia and some kinds of angina, is, however, not explicable through any narcotic quality; but is probably due to an influence exercised over the power of the nerves to transmit sympathetic irritations. These morbid sym- pathetic susceptibilities are often exalted, in common with other ner- vous functions (§ 126, 148) by weakness or irregularity of the circula- tion (§ 153;) and are generally diminished under a tonic plan of treatment, especially when the metallic tonics, preparations of iron, nitrate and oxide of silver, sulphate of copper, arsenic, &c, are used. The peculiar affection, alluded to above as spinal irritation, is no exception to the applicability of this mode of treatment. In a few instances leeches or blisters to the tender part of the spine prove serviceable, but such means are rarely necessary^ and prolonged or excessive depletion and counter-irritation are positively injurious and tend to aggravate the evil. Anodyne applications to the spine, as of 9 130 DISEASES OF SECRETION. chloroform, belladonna, aconite, arnica, and morphia, alternated by sponging with tepid or cold vinegar, or spirits and water, a tepid or cold douche, or dry cupping in the vicinity of the part, are more ef- fectual than weakening measures, and the permanent cure is most likely to be completed by a plan for invigorating and equalizing the circula- tion and nervous functions. SECTION VI. DISEASES OF SECRETION. 158. The power of secretion appears to be a vital endowment of the ultimate cells or vesicles of secreting structures.1 It is uncertain whether the process consists in the formation of the peculiar matter of the secretion, or merely in its separation from the blood. In the case of the urine and bile, these principles seem really to be formed in the blood without the aid of the secreting organs; for urea has been found in the blood of animals whose kidneys have been prevented from acting by ligature of their blood-vessels, or by extirpation; and both urea and some of the principles of the bile (coloring matter and cholesterine) are found in the blood and in various parts of the body when the kid- neys and the liver respectively have been disabled by disease. But whether the secreting structures assist in the formation of the secre- tions, or only effect their separation, their elective power is equally a peculiar attribute of life, and inexplicable at present by any physical or chemical law. Thirty years ago2 I advocated the opinion more re- cently advanced by Dumas and Liebig, that the formation of the prin- ciples of the chief secretions takes place through chemical affinities, (especially those of the absorbed oxygen and the constituents of the blood,) controlled by vital agencies; still in this view the power by which the liver separates bile; the kidneys, urine ; mucous membranes, mucus, &c, is to be regarded as a vital property. We are then led to consider secretion as a peculiar property of the secernent structures, just as much as we do irritability, of muscular fibre (§ 110;) and as such, disorder of secreting power constitutes a primary element of disease. In doing this we avoid the hypothesis of some physiologists, who ascribe secretion to nervous influence, which is a notion by no means in accordance with numerous ascertained facts. 159. In reviewing the other disorders of vital structures, we have found that many are plainly referable to changes in the supply of blood to the respective textures (113, 127, 131, 133, &c.) The same in- fluence operates still more decidedly in producing variations in the process of secretion. The blood being the material from which secreted matter is supplied, modifications in its quantity or quality surely af- • Muller, De Glandularum penitiori structura. Henle, Allgemeine Anatomie. Goodsir, Trans. Royal Society of Edinburgh, 1842. Bowman, Phil. Trans. 1842. 2 In a thesis, De sanguine ejusque mutationibus, Edin. 1824. See also Med. Gaz. Sep- tember and October, 1835. "* EXCESSIVE SECRETION OF BILE. 131 feet the quantity or quality of this product. Thus when an increased flow of blood takes place to a mucous membrane, its secretion is in- creased, and sometimes rendered more acrid than usual; but a con- gested state of the same membrane rather impairs the secretion. The most common causes of altered secretion are such as operate on and through the sanguiferous system. 160. But affections of the nervous system, and of the mind which acts through that system, also influence the secreting process; this is shown by the mouth watering at the sight, or thought, of a good meal; by the bilious diarrhoea that mental agitation causes in some persons; the large flow of limpid urine after nervous agitation ; the tears excited by grief or other strong emotion; and the unwholesome quality of a nurse's milk when she is in a state of anxiety or apprehension. We do not however know whether these influences act by altering the flow of blood (§ 159,) or, in a more direct way, by modifying the vital pro- perties of the secreting organ (§ 158.) 161. The importance of this element of disease may be estimated by the universality of the process of secretion, which includes both the formation of excrementitious products (only to be voided out of the system) and recrementitious products, (concerned in effecting digestion, assimilation, and nutrition,) and also by the extent of its effects, in re- lation both to the destination of the secretion, and to the condition of the blood from which it is separated. The several processes of secre- tion may be influential in producing diseases through being either ex- cessive, deficient, or of a perverted kind. 162. Excessive secretion of any kind, whether of bile, urine, mu- cus, or anything else, may weaken by the drain which it causes from the'mass of blood (§ 28, 71;) and the debilitating effect is in proportion to the quantity of the loss, and to the amount of the animal matter which is contained in the secretion. Thus an excessive secretion of bile weakens more than that of thin mucus. But each secretion has also peculiar effects which are connected with its office and composition ; and these effects may tell forwards, on .the parts to which the secretion goes, and backwards, on the secreting organ and on the blood from which the secretion is formed. m 163. The forward effects of an excessive secretion of bile depend on its stimulating properties. It irritates the intestinal tube, causing bilious diarrhoea or cholera. The symptoms of this disorder consist in an exaggeration of such properties of the alimentary canal as have already been spoken of as elements of disease. Thus the irritating bile causes increased irritability (§ 113,) and more rapid motion of the contained matter through the intestinal tube : pain from exalted sensi- bility (§ 134, 135;) vomiting, straining, and cramps, from exalted ex- citomotory function (§ 119, 151;) and profuse mucous secretion from excited secernent function (§ 162.) An excessive secretion of mucus into the intestines may cause only simple diarrhoea; but if it be into the bronchi it may occasion dyspnoea and cough, and, if not expecto- rated even suffocation. Excessive secretion may in the stomach cause pyrosis or water-brash, the liquid being sometimes acrid, and also nausea and vomiting, as well as eructation. The excessive discharges from secreting organs generally constitute fluxes or profluvia ; and 132 DISEASES OF SECRETION. those from internal enclosed serous surfaces, or cellular texture, con- stitute dropsies. The effects produced vary according to the situation. 164. But excessive secretion also acts backwards, on the secreting organs, and on the blood from which it proceeds. It often weakens the vital powers of the organ, so that it subsequently becomes torpid so far as its proper function is concerned. Thus after diarrhoea the bowels often become confined, with defective secretion. So, too, in cases where an excessive secretion continues for a long time, it gene- rally becomes impaired in its quality, because the secerning organ is weakened and rendered unable to perform its proper office. 165. Excessive secretions, if rich in animal matter, not only reduce the mass of the blood, but often also affect its composition. Thus bile and urine, which differ much in composition from the blood, if separated in unusual amounts, must leave that fluid changed. Urine contains a large proportion of azote ; its excessive separation from the blood therefore leaves a comparative predominance of hydrogen and carbon in this fluid. The bile, again, abounds in hydrocarbon, and its copious removal accordingly leaves a superfluity of azote. It may be objected to this statement, that some chemists are of opinion that the urine and the bile are not formed from the constant elements of the blood, but from materials derived directly from the food, and from the decay or transformation of the tissues. To this it may be replied, that this opinion is not at present more than hypothetical; and should it ulti- mately prove to be true, it would hardly affect the question, with the undoubted fact before us that the secretions of the liver and of the kidneys are balanced one against another, and also adjusted to the removal of carbon by the lungs; whether the materials by which these eliminating processes are supplied by the principles of the blood itself, or the decayed constituents of tissues, or matters derived from the food, the co-operation of all is equally required to maintain uniformity in the composition of the circulating fluid; if one of these processes is more active than the others, the blood must suffer from the excess of such matters as the less active processes allow to accumulate in it (§ 68, 69.) A practical illustration of this position is offered in the case of bilious diarrhoea or cholera. These fluxes of bile are either accompa- nied 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 com- position of the blood: so long as the kidneys rectify this disorder by separating in greater abundance the solid contents of the urine, no fever results; but if the kidneys fail in their task, fever ensues, and continues until they resume it; then a free secretion from them and copious uninary deposit becomes symptomatic of the decline of the fever.1 i Note by Dr. Mann.—In order to estimate the influence which disordered secretion may have in the constitution and aggravation of disease, it may be useful to glance at Borne of the more recent conclusions of physiologists respecting the chief secretions. The entire action of the liver in the animal economy has not been yet satisfactorily determined, but all physiologists now seem to be pretty well agreed that at any rate it removes from the blood those hydro-carbonaceous products of the destruction of tissues EXCESSIVE SECRETION—REMEDIES. 133 166. The remedial measures that are serviceable in cases of exces- sive secretion well illustrate the view that has just been given of the balancing office the secretions are designed to fulfil. In so far as ex- cessive secretion is dependent on the quantity and quality of the blood (§ 159,) the treatment should be addressed to this fluid: it may be attacked by depletion, derivation, and evacuation, in cases of conges- tion or determination of blood; and in such cases the excessive secre- tion itself should not be hastily checked, as it may be a natural means of relief; nay, in some cases, it may even 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 connected with an engorged liver, which astringents fail to check. But where the excessive secretion proceeds more from nervous and other sources of irri- tation (§ 160,) and causes weakness and disturbance of the functions, it is more important to check it at once. Secretions are diminished by influences which act as general tonics or astringents (§ 124,) and by others which operate only on particular organs. Of the former class of agents are, cold applied to the part, common astringents, such as alum, superacetate of lead, sulphates of zinc and copper, gallic and tannic acids, and substances which contain them, as nutgalls, oak bark, that cannot be converted into simple sugar and fat, and that it does this by changing them into glyco-cholic and tauro-cholic acids, which perform a certain definite office in the digestive process, and are then carried off from the lungs as carbonic acid and water, their sulphur and alkaline bases being thrown into the urine. But it is also now clear, that both the liver and kidneys eliminate superfluous alimentary matters, as well as the products of disintegration of the organs. The liver turns all forms of saccharine matter contributed by the food into liver-sugar, and all kinds of fat from the same into liver-fat; and also makes the same substances out of protein compounds. Liver-sugar and liver-fat seem to be in a peculiarly favorable state for undergoing the process of further oxidation and decomposition. M. Bernard's experiments seem to point out that the liver also exercises a subsidiary assimilative action, beyond its excernent one, by rendering albumen more fit to be carried through the channels of the circulation and even by forming fibrin out of its material. The principal purpose performed by the urine is unques- tionably the removal from the blood of worn-out azotized matters that have done their work. The urine of children contains a larger proportional amount of urea compounds than that of adults, because the processes of disintegration are going on very actively in their bodies. The quantity of urea and sulphates in the urine is augmented by muscular exertion. But on the other hand the amount of alkaline phosphate is increased by mental exercise, the phosphorus proceeding from the disintegration of nervous substance. In inflammatory disorders of the brain, where the disintegration of its texture is accelerated, the phosphates of the urine always become abundant. The kidneys, however, not only carry off the effete azotized matters, phosphates, and superfluous water, but they also receive many other foreign matters that may be introduced from without in hurtful quantities, and it is remarkable that these are removed more readily whenever the kid- neys are stimulated to increased action. Wohler has shown that those soluble salts are most readily got rid of out of the system that most easily determine the blood towards the kidney. The effete organic matters, on the other hand, cannot be removed by the same means as readily, for Professor Krahmer has shown that when they are in excess in the blood, diuretics rather produce irritation and congestion of the kidneys, with sus- pended action,1 than increased action. The alkalies, their carbonates and vegetable acid salts, however, seem to augment the quantity of organic matter in the urine, as well as of inorganic salts.2 Recent researches have further proved that common salt increases the amount of urea (Bischoff,) and liquor potassee has the same effect, and further remarkably augments the excretion of sulphuric acid in the urine (Parkes.) ' Heller's Archiv. Dec, 1847. « Golding Bird in Med. Gazette, 1848. Vol. xlii., p. 230. 134 DISEASES OF SECRETION. rhatany root, catechu, matico, and mineral acids, &c. These act most surely when directly applied, as instanced by their use in diarrhoea and leucorrhcea; but they seem to have some effect also through the medium of the circulation, for when taken internally they reduce the secretions of the air passages and skin. Of the agents which more specifically diminish the secretion of particular organs, without exer- cising any general astringent effect, may be mentioned opium, which remarkably lessens the secretions of the liver and intestines, and some- times that of the kidneys too. If an excessive secretion have already caused febrile disturbance, great advantage will be found to result from the use of measures which increase other secretions, and in this way the balance of the normal condition of the blood is restored, as before explained (§ 165.) It is thus that saline diuretics and diaphoretics are highly serviceable in bilious cholera. In renal irritation with copious secretion of lithic acid, blue pill, which augments the secretion 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 augment the secretions of particular organs (mercury that of the liver and salivary glands, colchicum that of the kidneys, &c.,) but there is a limit to the operation of these agents; the limit may how- ever be extended by simultaneously acting on other organs which maintain the balance. Hence in any disturbance of the secretions, especially if it continue long, combinations of medicines are much more useful than the administration of such as fulfil one indication only: thus experience has sanctioned the practice of conjoining mer- curials with diuretics, and antimonials with salines, &c. 167. Secretions may become deficient in consequence of a weakened state of the whole circulation, or of that of the secreting organ, as in the case of exhaustion from previous excitement (§ 164.) They may be diminished by depressing influences which paralyze generally the vital powers, as seen in the operation of zymotic and narcotic poisons (§ 56, 1)4, 65.) Or they may be checked by agents like cold and astringents, which increase the tonic contraction of the vessels of the part (§ 77,) or by those which influence the whole sanguiferous system, as in the case in the hot stage of fevers (§ 85, 421.) Deficient secretion of any natural or habitual discharge (§ 70) may cause a fulness of the blood-vessels; general, if the secretion be na- turally copious ; local, if it be trifling in quantity. Thus deficient se- cretion of urine or bile may lead to general plethora, or to extensive local congestions, which may end in dropsical effusions, fluxes, hemor- rhages, or inflammations. Diminished secretion of tears or saliva merely causes fulness and dryness of the parts immediately concerned. The morbid effects of deficiency of secretion may be excited both forwards, that is on the parts for which the secretion is destined, and DEFICIENT SECRETION—EFFECTS. 135 backwards, that is on the organ by which, and on the blood from which, it should be eliminated (§ 162.) 168. Deficient secretion of bile causes disorder in the latter stages of digestion. The neutralization of the acid in the chyme, and the sepa- ration of the chyle, to which the bile seems to contribute, are imperfectly performed, and sometimes colic and diarrhoea, sometimes costiveness, result. Deficient secretion of mucus in the intestinal canal and bladder exposes their lining membranes to suffer more irritation from the mat- ters that are habitually in contact with them. Deficient secretion of mucus on the respiratory membrane, may lessen the facility with which the air and blood act on each other. Insufficient secretion of cerumen in the ear, or of saliva in the mouth, impairs respectively the faculty of hearing, and the process of mastication. A want of synovia in the joints has been supposed to be the cause of imperfect motion and sub- sequent inflammation of their structures. 169. The effect of deficient secretion in causing congestion ot the organ concerned, has been already noticed: the concomitance of con- gestion and defective secretion, in the case of the liver, the kidneys, and mucous membranes, is well known : but either may stand in the position of cause or effect, for circumstances which increase the secre- tion diminish the congestion, and influences which reduce the conges- tion tend to restore the secretion. - , * • 4 170 The most remarkable of the backward effects of deficient se- cretion are instanced in cases of the excretions (§ 70.) The materials of urine and bile appear to be positively noxious, and to poison the system if not separated from the blood. Hence the sudden suppres- sion of urine or bile causes typhoid symptoms, extreme depression and coma, which may speedily end in death; and in such cases, urea or the coloring matter of the bile, has been found in the blood and in various organs. Where the suppression is incomplete, the poison- ing process more tardy, various functional and visceral derangements are produced, such as delirium or lethargy, convulsions dyspnoea pal- pitation vomiting, diarrhoea, dropsical effusions, and structural de- generations. But the amount of these effects will depend on the extent, and especially on the suddenness, of the diminution of the excretion; and it is very remarkable, when it is very gradual, how little disturb- ance it may for some time induce. In these gradual cases, excre- mentitious matters may be detected in the blood and in other fluids and solids of the body, more certainly and decidedly than when the suppression is sudden. Thus in some structural diseases of the liver, the color of the bile becomes manifest first in a yellow, and then from accumulation, in a deep greenish color in all the textures, consti- tuting the yellow and the black jaundice. In cases of extensive granu- lar degeneration of the kidneys, in which scarcely any urea is excreted bv these glands, this principle is found in the blood and various fluids J the body In the case of a patient of mine affected with ascites from disease of the heart, liver, and kidneys, Dr. Garrod obtained nparlv four grains of nitrate of urea from an ounce of the peritoneal fluid and a considerable quantity of bright yellow solid matter, pro- hnblv bilious. In other cases I have known the fluid of ascites and anasarca induced by diseased kidneys, to emit a decidedly urinous 136 DISEASES OF SECRETION. smell, and to exhibit on analysis easily appreciable quantities of urea. One of my pupils, Mr. Edward Palmer, detected urea in the serum contained in the ventricles of the brain, in a case of fatal apoplexy connected with granular kidneys and diseased heart. The inequality observed in different cases with regard to the pro- duction of symptoms from ureemia (urea in the blood) has led many to question the power of urea to cause the symptoms ascribed to it (coma, convulsions, &c. ;) and it is said that urea has been artificially intro- duced into the blood of living animals without any morbid effects en- suing. Professor Frerichs, of Kiel, suggests the hypothesis that the poisonous properties of urea in the blood depend on its conversion into carbonate of ammonia through the agency of some ferment. If the urea be abundant, and the conversion into carbonate of ammonia be sudden, coma or apoplexy is the result: if more slow, the symptoms are those of stupor, prostration, and convulsions. In support of this notion, Dr. Frerichs states that he has detected carbonate of ammonia in the breath during uraemic intoxication ; and he has succeeded in causing similar symptoms by injecting a solution of carbonate of am- monia into the blood-vessels. The clinical history of disease abundantly illustrates the resources which nature brings into play to relieve herself from the mischief de- pendent upon failure of any of the great eliminating organs. Other portions of the excretory apparatus then throw off the offending mat- ters. Thus when the action of the liver is obstructed, the urine mani- fests at first an increase of its ordinary pigmentary principle, and afterwards the presence of a new matter of the nature of purpurine or purpurate of ammonia, a highly carbonized body. If the elimination of the bile be farther impeded, the true bile pigment presents itself in the urine, this secretion then becoming of a dark orange, or olive green color. Such vicarious action of the kidneys must be viewed in the light of relief designed for the service of the general system. ^ I have known cases of jaundice in which the redundancy of bile material was thus disposed of during several months without such rapid failure of health being induced as might have been anticipated under the cir- cumstances. In cases of Bright's disease, where there have been ur- gent symptoms of poisoned blood at first, these are alleviated under the operation of purgative medicines ; a portion of the urea, and other urinary constituents being removed through the intestinal surface; these principles indeed may be detected in the secretions of the intestines. These facts serve, not only to explain why the diminution of an excre- tion is less injurious when it takes place so gradually that there is time for a compensatory operation to be established, but also to point out an important therapeutical means whereby such a result may be hastened or brought about. The glandular apparatus of the intestines are important excretory organs whose main specific function seems to be the removal of putrid and otherwise offensive matters from the system. Hence, when from extreme weakness and failure of the vital powers, from imperfect nu- trition, or from the presence of a septic and poisonous ferment in the body, the normal process of decay and decomposition is quickened, DEFICIENT SECRETION—REMEDIES. 137 the alvine excretions become excessively fetid, and the worst results may follow if they are locked in or suppressed under such circumstances. In low or typhoid fevers, great relief often ensues upon the occurrence of fetid diarrhoea. Suppression of the catamenia also induces disorder not only through the production of a state of plethora, but also by rendering the blood depraved; this follows as a natural consequence from the fact that the catamenial discharge contains matter of an ex- crementitious nature. 171. The excretions are deficient in most idiopathic and symptoma- tic fevers ; and there can be little doubt that many of the constitutional effects of such fevers are in a great measure due to this important fact. 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, and perversion of functions, which fevers so generally pre- sent. The morbid conditions of the blood, manifested in some such cases in its fluidity and in petechial appearances of the skin, may also be in part referred to defective elimination of effete matter;' 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 very* probable that severe mechanical injuries or shocks (§ 52,) and animal and other poisons (§ 85, 105, 57, &c.,) sometimes operate by thus injuring the vital powers through which the blood is continually purified from its own noxious products ; and that this is one of their modes of action seems almost certain from their effect in sup- pressing or impairing the natural excretions. Accordingly, in such cases, urea has sometimes been detected in the blood. There can be little doubt that a morbid element, which in its ex- tremes acts so injuriously as to cause serious disorder, and even speedy death, must in slighter degrees be still an important cause and con- stituent 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. It is a com- mon observation of "gouty patients that their urine is either more scanty or paler than usual before a paroxysm, and they hail the appearance of a red deposit in the secretion as an indication of the departure of the enemy. Dr. Garrod remarks that before the gouty fit, and at^ its commencement, there is a disappearance of lithic acid from the urine, and an increase of it in the blood; and that the converse takes place as the attack declines. 172. Remedial measures.—Deficient secretion may be caused by deficient or excessive supply of blood to the part, as in various cases of anaemia, congestion, and inflammation (§ 159.) It must therefore be treated by the remedies adapted to the precise condition present: thus stimulants restore secretions that are scanty in consequence of a defective supply of blood; but depletion and derivation may be the best remedial measures, when they are stopped by inflammation and congestion. i Purpura I have found to be often connected with hepatic congestion and imperfect excretion of bile : it is most effectually removed by remedies which promote the restora- tion of the proper secretion. 138 DISEASES OF SECRETION. 173. But sometimes the first disorder is in the secreting structure itself (§ 158,) and may best be removed by agents which specially in- crease the respective secretions, as common stimulants will not do. Thus mercury increases the secretion of the liver; colchicum, nitre, and other salts, with other diuretics, that of the kidneys ; croton oil, jalap, sulphate of magnesia, and other purgatives, that of the intes- tines; and this they do, however introduced into the system, whether by the mouth, through the skin, or by injection into the vessels or textures. These are important practical facts, however difficult they may be to explain ; and their application to the restoration of defective secretions is sufficiently 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 may exhaust even the vital powers which they first excite (§ 159:) and the result may be either a diminution 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, the im- perfect action of the bowels ; of diuretics, scanty, albuminous, or watery urine, defective in urea. These facts point out the expediency of in- termitting the use of such agents, and of alternating them with others calculated to improve the vital properties of the textures generally, or of employing the two classes of remedies conjointly. Tonic medicines, and such regiminal means as improve and equalize the state of the cir- culation (§ 124,) and keep the digestive and assimilative functions in the best order, so improving the condition of the blood, are well cal- culated for this purpose. In illustration of the position, I may refer to the acknowledged advantage of giving bitters with or after mercu- rial courses; chalybeates with or after saline aperients and diuretics, when these are long used: such tonics, if used alone, or at first, check the secretion ^ desired to be increased, but when subsequently added, they sustain it and render it permanent. Some medicines which are generally of inferior efficacy to those already named, are nevertheless better suited to improve deficient secretion in some chronic cases, be- cause they are less exhausting, and combine some measure of tonic in- fluence with the power of increasing the secretions. Taraxacum, pre- parations of iodine, sarsaparilla, and the nitric and nitro-muriatic acids may be named as illustrations of such agents. Courses of these medi- cines are sometimes very efficacious in keeping free the secretions after they have been restored by more powerful means (§ 173 ;) and they likewise often improve the functions of digestion and nutrition. The salutary operation of many kinds of mineral water is dependent upon a similar principle. Saline chalybeates exercise the two-fold function of increasing the secretions, and conferring tone upon the general sys- tem ; and they do this with the production of less disturbance than most medicines which act in the same way. 175. WThere deficient secretions are not readily restored, the forward disorder (§ 168) arising from their deficiency may be sometimes tem- porarily obviated by artificial substitutes. Thus in defective secretion of bile, the action of the intestines may be promoted by the exhibition of ox gall. A combination of aloes and soap has been thought to sup- PERVERTED SECRETION—EXAMPLES. 139 ply the place of bile in some cases. Toasted bacon at breakfast benrs a similar reputation : but it is probable that it really excites the liver to increased secretion, as other fat matters do ; cod-liver oil seems to act upon the bowels by means of'the bile which it contains. Imperfect lubrication of the throat and larynx, and other mucous membranes, in consequence of deficiency of mucus, may be remedied by mucilaginous and demulcent matters. A dry state of the skin may be relieved by direct applications of oil, honey, or glycerine. 176. Perversion of secretion often accompanies excess and de- ficiency of the process. In febrile diseases, the secretions of the kid- neys and alimentary canal are altered as well as diminished. Inflam- mation and determination of blood, change, as well as increase the secretion from mucous membranes, rendering it more saline, and some- times albuminous. The urine exhibits remarkable illustrations of mo- dified quality under various circumstances: full living, stimulating beverages, and irritations of the digestive organs or kidneys, render it unusually strong and acid ; low diet, and other causes of weakness, generally make it pale and alkaline. Excessive anxiety, fatigue, and mental and bodily exertion often increase the proportional amount of urea in urine ; sometimes causing the deposition of the phosphates ; a result of the increased decay of the tissues. Out of these morbid con- ditions may arise various further decompositions, leading to the de- posit of sediments and calculous concretions of different kinds (§ 51, 53.) In febrile diseases there is commonly an augmented quantity of uric acid in the urine. This is probably because there is then increased decomposition of tissue, but at the same time incapacity to perform the ordinary processes of oxidation by which uric acid is converted into urea. There is therefore then comparative deficiency of urea, and ex- cess of uric acid. Oxalic acid is sometimes present in the urine on account of the morbid performance of the ordinary retrograde transfor- mation of the tissues; especially in low febrile or cachectic states in which it replaces lithic acid, but its strong affinity for lime makes it alwavs appear in combination with that base. Oxalate of lime some- times appears in the urine after an abundant deposit of lithic acid. The disappearance of the chlorides from the urine in pneumonia is an interesting fact, well established by the observations of Redtenbacher and Dr. L. Beale. It takes place especially during the progress of the inflammation, and seems to be clearly traced to the retention of this saline matter in the inflamed part (Med.-Chir. Trans., 1852, p. 325.) Concretions sometimes result from an altered state of the bile. The alvine secretions are greatly modified by various febrile and the ca- chectic diseases, being altered in color, and becoming unusually of- fensive in odor. The perspiration is also sometimes modified ; thus, it is very acid in rheumatism, and fetid in some fevers, and in delirium tremens. 177. Secretions which serve particular purposes, become unfit for their offices when they are altered, and thus cause disorder ; 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 140 DISEASES OF THE CONSTITUENTS OF THE BLOOD. obstructs tubes which it was intended to lubricate ; altered gastric juice causes indigestion ; sebaceous matter of the skin accumulates in the follicles when thickened, and thus causes irritation, inflammation, &c. 178. The appropriate remedies for perverted secretions (§ 176) are usually such agents as likewise increase secretion (172, 173.) Thus, depraved secretions of the intestinal canal are often satisfactorily al- tered by continued purging ; a turbid state of the urine is sometimes removed by diuretics ; too thick a state of the mucus of the air-passages is modified by expectorants, &c. But when the change depends on al- tered circulation in the part, the remedies must be chosen accordingly. In some cases, tonics restore a healthy state of the secretions ; and in most instances of long-continued perversion, tonics may be advantage- ously combined with medicines which increase secretion (§ 174.) Such a combination is presented in most of those remedial agents which have obtained the appellation of alteratives, and which therefore would be especially suited to correct the diseased condition under consideration, if they really possess the properties that are ascribed to them. An accurate knowledge of the nature of an altered secretion often guides to the selection of the appropriate remedy for the disorder. Thus diarrhoea with a very sour state of the evacuations may be in some degree corrected by the administration of magnesia and other antacids, combined with purgatives. But as bile is commonly deficient in these cases, mercurials may be usefully added to the treatment. An- tiseptics, such as chlorine, nitro-muriatic acid, and creasote, are ser- viceable where there is extreme foetor of the dejections; but as in these cases there is usually some cause of quickened decay and decomposition acting on the system (§ 171,) this should be looked for and removed or counteracted. Urine turbid from the presence of the lithates is most readily cleared by the alkaline diuretics ; that cloudy with phosphates, by acids such as the nitric and benzoic. The viscid mucus of bronchial congestion is often connected with a gouty diathesis, and yields to al- kalies combined with iodide of potassium, squill, or colchicum. An inspissated condition of bile, leading to the frequent recurrence of jaun- dice, is in some cases removed by the use of hydrochlorate of ammonia, taraxacum, or guaiacum, and in other cases by cod-liver oil. Nutrition is effected by means of a species of secretion (§ 158 ;) but inasmuch as its operations cannot be understood without a previous knowledge of the blood and its constituents, and inasmuch as they in- volve the complex subject of structural disease, their consideration is best deferred. SECTION VII. DISEASES OF THE CONSTITUENTS OF THE BLOOD. 179. The pathological elements (§ 107) hitherto considered are al- terations in the vital properties of the elementary solids. We now proceed to examine the morbid changes of the blood. These (as in the ELEMENTARY DISEASES OF THE BLOOD. 141 case of the solids,) may often be traced to the component elements of the blood, and they are properly included in the present division, as they must be viewed in the light of ultimate elements of disease. But as the blood also operates as a" whole, compound in itself, although simple in its influence on vital functions and structures, it forms a pro- per connecting link between ultimate and proximate elements of dis- ease. So, also, inasmuch as it is, in some respects, an organized com- pound, whose materials are changed, together with its functions, and which itself contributes to the production of alteration of structure in the solids of the body, the consideration of its changes will be a proper introduction to that of modifications in the circulation, which in their turn induce changes of structure, and thus lead to structural diseases themselves. 180. We have found that blood is the support of all thevital proper- ties ; 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.) We have now to examine the properties of the blood itself, and, first, those which are most elementary, or referable to its respective constituents. 181. The circulating blood consists of red and colorless corpuscles, and of the liquor sanguinis, in the proportion of about 512 parts, by volume, of moist corpuscles, to 488 parts of liquor ; a variation to the extent of 40 parts on either side of the 512, being, however, perfectly compatible with the state of health. But the liquor sanguinis is itself compound, both as regards its constitution and its function. Hence several of its ingredients need to be separately specified. The average proportions of the chief constituents of the blood are by weight, ac- cording to Lehmann, and the views adopted by Dr. Carpenter—cor- puscles (consisting of hgematin, globulin, and cell membrane) 149| parts, fibrin 2 parts, albumen 89J parts, fatty matters 2 parts, salts and mineral substances (exclusive of iron) 8J parts, extractive matters 3 parts, and water 795J parts. Hence the following blood ingredients have to be brought separately under consideration, as agents in the production of disease. 1. Red corpuscles, 2. Colourless corpuscles and fibrin, | ;n excess 3. Albumen, ! ;n defect,' 4. Fatty and other combustive matters, | or in aitere<3 state. 5. Saline and mineral matters, I 6. Water, J RED CORPUSCLES. 182. The red corpuscles seem to constitute that portion of the blood which possesses calorific and vivifying power, for Prevost and Dumas found that animals bled almost to death could be restored by injecting into their veins a mixture of red corpuscles and serum, even when the fibrin was absent; but the serum alone failed to produce a like effect. Hence it is inferred that it is the red corpuscles that are mainly of service when transfusion is performed in cases of hemorrhage. Andral, Gavarret, and Delafond remarked that the vigor and beauty of do- mestic animals are in proportion to the quantity of red corpuscles con- 142 DISEASES OF THE CONSTITUENTS OF THE BLOOD. tained in the blood, rather than to that of any of its other elements, and that when the characters of any breed are improved by crossing, the proportional amount of red corpuscles is increased. Liebig believes that the red corpuscles serve to carry oxygen through the system, and to bring it to act on all the various textures. There is no doubt that the red corpuscles do contain a large proportion of the gases present in the blood. Van Maack and Scherer have proved that their fluid contents possess a peculiar absorbent power over oxygen. 183. The red corpuscles of the blood are formed of delicate hollow films of a fixed albuminous substance, containing in the interior cavity a liquid composed of two peculiar azotized principles mingled together. These principles are known to the chemist as globulin and hsematin. The globulin is seventeen times more abundant than the hsematin, and is merely albumen very slightly changed by the influence of the cell film as it passes through. The hsematin is a more highly animalized principle of a red color, and contains a remarkably large amount (7 per cent.) of iron. It is now generally considered to be the material especially prepared by the blood cells for the nutrition of the muscular and nervous tissues of the frame. Globulin and haematin seem to hold the same position in blood corpuscles that albumen and fibrin do in the blood liquid. The red corpuscles appear to contain the principal part of the phosphorus, fat, and potash salts that are employed so largely in the construction of the nervous and muscular fabrics. Their pro- portion to the other constituents of the blood varies in different cases, even in health. According to Andral and Gavarret the variation ex- tends, either way, from 110 to 152 parts in the thousand. The pro- portion is generally from 1 to 2 per cent, less in healthy females than in healthy males. It is greater in early adult age than it is at still earlier, or at later, periods of life. More red corpuscles are present in foetal than in the maternal blood (according to Denis, in the ratio of 222 to 140,) and this preponderance is retained for some weeks after birth, until, in fact, the blood becomes more watery. 184. Excess of the red particles might therefore be expected to cause a general excitement of the vital properties of the body (§ 183,) and this is found really to be the case. Lecanu observed that the red corpuscles exist in larger proportion in persons of sanguine tempera- ment, especially in vigorous constitutions, than in others. Andral and Gavarret detected a slight increase of them in the early stage of in- flammation and fever, in some cases, especially in eruptive disorders, , such as measles and scarlatina. In sanguineous plethora and in he- morrhagic diseases before much blood was lost, they were in excess, in some instances rising to 185 parts in 1000 of blood. The obvious sign of the abundance of red particles is the florid color apparent in the lips, cheeks, gums, and other vascular parts; the deep blue color of the superficial veins ; and the fine deep crimson which a thin film of blood gives when spread on a white plate. The bodily functions, ani- mal heat, and muscular irritability are in an exalted state, bordering on or passing into febrile excitement. Judging by.these indications we may often infer the existence of an excess of red corpuscles in those accustomed to good living, and such an amount of exercise in RED CORPUSCLES—EXCESS. 143 the open air as suffices to keep the digestive and assimilative functions in an active state. 185. The red corpuscles are deficient in persons of the lymphatic or leucophlegmatic temperament (§ 40;) after great losses of blood (arti- ficial or from disease;) in chlorosis, and in other anaemic states, such as those connected with advanced stages of cancer, diabetes, scurvy, and other cachectic diseases ; in scrofulous and tuberculous diseases ; in the latter periods of fevers, and after severe inflammations ; in granu- lar degeneration of the kidney, and other organic diseases, especially when attended with dropsy; in diseases of the spleen, and others of malarious origin (§ 85 ;) in cases of slow poisoning with lead; and in persons inhabiting dark and ill-ventilated abodes. In an extreme case of chlorosis, the proportion of the red particles was found by Andral reduced to 27 in 1000 of blood. The signs of the defect are, paleness of parts naturally colored with blood, pallid or sallow hue of the skin, pink color of superficial veins, and a pinkish or light purplish hue of a film of blood spread on a white plate. The symptoms of such a condition will be more fully described under the head of anaemia; they pertain chiefly to a weak state of the functions generally, comprising those of circulation, calorification, di- gestion, and nutrition. 186. Alterations in the condition of the red corpuscles are evinced by changes in the color of the blood, and in the form of the individual corpuscles as seen by the microscope. The coloring matter is evi- dently altered in some diseases, 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 color; in the Walcheren and other malignant fevers it has been described as pitchy black. In the worst forms of cachexia (or rather cachaemia,) from malarious influence, ge- nerally found in conjunction with disease of the spleen, the blood is not only very poor, but also perverted in constitution, exhibiting vari- ous shades of purple, brown, and even greenish colors. Some change seems to occur in congestive typhoid fevers, in which the blood-vessels become stained or dyed of a deep claret color: for this staining im- plies a breaking up and unnatural solution of the red corpuscles. Probably 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 scorbutus, in jaundice and albu- minuria, and in secondary syphilis, seems to indicate an altered state in the coloring matter of the blood; inflammations and ecchymoses in the skin are commonly followed by livid, purple, or copper-colored stains. The yellow tinge of the skin in yellow fever, occurring chiefly along the course of the large blood-vessels, the peculiar sallowness connected with diseased spleen and in chlorosis, and the dark discolo- ration around the eyes in the same diseases, apparently proceed from a change in the coloring matter of the blood, which causes it to escape from the vessels and tinge the skin, as in a part discolored by a bruise. The black matter of melanosis seems to be the coloring part of the blood in an altered state, constituting a peculiar pigmentary matter: it is likewise so in the spurious melanosis of the intestines. 144 DISEASES OF THE CONSTITUENTS OF THE BLOOD. 187. Besides changes effected in the color of the blood, the red corpuscles are subject to alterations in their form, size, and other pro- perties effected through the influence of 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 exosmosis: the saline matter drawing the water into or out of the little cell, which with its contained coloring matter, constitutes the red corpuscle. It is highly probable that similar changes may take place in the living body, when circumstances greatly alter the proportion of saline matter and water in the blood. Such changes may possibly contribute to produce the serious symptoms, and even the sudden death, which have ensued on drinking a large quantity of water after great exertion. Has it also aught to do with the reaction and irregular excitement that sometimes occur after excessive losses of blood? Or with the symp- toms of suffering which animals manifest on the instant when water is injected into their veins ? Dr. Owen Rees has suggested that the re- markable diminution of the blood discs in cases of albuminuria may be due to their destruction in consequence of the draining away of albu- men from the blood, and its subsequent reduction to a very watery state ; the same circumstance may also prevent their redevelopment from the chyle and lymph both in these cases and in chlorosis. In several cases of Bright's disease of the kidney I have observed, the blood discs to be jagged or crenate at their margins, and otherwise imperfect; and the same remark has been made by Simon of Berlin and others, and by Andral in a case of chlorosis. In one fearfully rapid example of albuminuria, which proved fatal in six days, with effusion of pus in the joints the day before death, I found the coloring matter dissolved in the blood-liquor after death, and scarcely any red discs remaining. There were also numerous pus globules in the blood. A similar total destruction of the blood discs was observed in Univer- sity College Hospital in the blood of a person who died of malignant scarlet fever with purpura. I have met with similar proofs of break- ing up of the red particles, but to a much smaller extent, in acute purpura connected with jaundice, and in cases of disturbed function of the liver without jaundice. Is this due to the remarkable solvent power which small proportions of bile exert over the red particles, as noticed by Simon and others? 188. The change of the blood from dark to florid, on the addition of saline matter, appears to depend on the increased density and white opacity then given to the corpuscles, whereby they are rendered less transparent and more abundantly reflective of light.1 Probably the action of oxygen in reddening venous blood is of a similar character, for it also renders the blood less transparent. This explanation of the color of arterial blood was suggested to me by some experiments which I made in 1835, and in some measure corresponds with the opinion of Dr. Wells,2 that the brighter color is due to fine mechanical division. i Medical Gazette, Sept., 1835. 2 Phil. Trans., 1795. RED CORPUSCLES—ALTERATIONS. 145 Dr. J. Davy, in 1838, expressed a like conclusion. Mulder's notion, more recently advanced, that the florid color of the arterial blood is caused by the formation of a film of deutoxide of protein on each cor- puscle, is in accordance with this explanation as regards the influence of oxygen, but it hardly meets the case of the more rapid and complete brightening of blood by saline matter. Dr. Carpenter suggests that the brightening of blood may be due to the corpuscles becoming more empty and therefore assuming the biconcave form, whilst the darken- ing depends on their swelling to a more globular shape. Still it is the change in density rather than change in shape that would alter the reflective power. I have noticed that the dark fluid blood found in the body during malignant scarlatina, and other bad congestive fevers, does not redden so soon as usual on exposure to the air. The same remark applies in some of the other cases of alteration of the red cor- puscles mentioned above (§ 187.) 189. The red corpuscles are distinct structures, living cells, isolated and floating in a lifeless fluid. Like other living cells, they appear to possess the power of secretion. They certainly form the red coloring principle and the globulin which they contain. It has been conjectured that they have yet other vital properties, such as spontaneous motion, and the power of attraction and repulsion ; but there are no unequi- vocal facts that can support such notions. The motions described by Treviranus, Schultz, and others may be accounted for on purely phy- sical principles. It is said, that a systolic and diastolic movement in blood particles has been observed by Dr. Martin Barry in the Fallopian tube of a recently impregnated rabbit; but this seems to have been effected by the cilia of the membrane. 190. Hewson, Prevost, Dumas, and others, observed that the red corpuscles of new-drawn blood cohere together in piles or rouleaus. This cohesion in healthy blood is of very short duration : for it may be seen, as first remarked by Dr. Hermann Nasse and Mr. Wharton Jones, that in a few seconds the adherent discs float about loosely among each other again ; but in blood drawn from a person affected with inflamma- tion, this cohesion takes place more readily, is more firm, and lasts for a longer time; it has been considered that this is the chief cause of the separation of the red particles from the fibrin, which then consti- tutes the buffy coat. WTe shall notice the relation of this phenomenon to the formation of the buffy coat under the head of fibrin; but for the present we would remark of it that it is not certain that the cohesion of the red corpuscles is more than a case of mechanical aggregation modified by changes in the relative dilution of the liquor sanguinis, and the contents of the blood corpuscles. The momentary exposure of a thin film of blood to the air causes evaporation from the serum without affecting the contents of the blood corpuscles as instantaneously; these then cohere ; but the exosmosis of fluid from their interiors soon again detaches them from each other.1 Without however dwelling on this, ' Hence, as it has been remarked by Mr. Gulliver, the addition of a little salt prevents the cohesion of blood discs. I do not assert that there is nothing vital in these properties exhibited by the organized parts of the circulating fluid, but I must protest against the hasty assumption made by some physiologists, that the motions and alterations revealed 10 146 DISEASES OF THE CONSTITUENTS OF THE BLOOD. or the equally hypothetical notion that the cohesion is due to a vital attraction, we may remark that it is important to bear in mind what has been stated to occur where inflammatory disease is present. In- deed it has been supposed that a similar aggregation of the blood cor- puscles then takes place within the capillaries, and is the cause of the obstruction there. But although the blood corpuscles are sometimes seen to aggregate in masses within the larger vessels of a frog's web, when the motion of the blood is arrested by pressure on a vein, this aggregation is speedily broken up when the obstruction is removed; and the more permanent accumulations in the vessels of an inflamed part will be hereafter shown to be, sometimes at least, due to obstruction set up by the colorless particles, and their adhesion to the sides of the ves- sels. (See Inflammation.) 191. There is still much doubt concerning the manner in which the red corpuscles originate. During early embryo life they unquestion- ably multiply by a process of subdivision. Each then contains a nu- cleus cell, which parts into two, a new corpuscular vesicle being then developed round either half. In more mature life this process of mul- tiplication by division does not seem to be continued. There is no nucleus whatever in the completed adult red corpuscle of the human blood. The red corpuscles appear to be then formed out of the chyle and lymph globules, through some unknown course of transmutation. Mr. Paget believes that he has seen colorless corpuscles change into colored ones; but there is a higher probability in the notion that the colored and the pale corpuscles are independent formations, designed for distinct offices, but both originating in a common source, the chyle and lymph globule. The development, growth, and decay of the red corpuscles go on simultaneously and indiscriminately in all parts of the circulation, but are in a great degree dependent on the active state of the organs of nutrition, as well as on that of the great depurative organs (the lungs, liver, and other glands,) and on a due supply of the ferruginous element that enters so largely into their composition.— {Dr. Mann.) The influences which promote the decay and retard the formation of the red particles (§ 185, 186,) are chiefly circumstances which im- pair the nutrition of the body; but there are some of these which affect the red particles much more than they do other components of the frame. Two of the most remarkable are a diseased state of the spleen, and disordered uterine function. The striking pallidity, or pale sallow in animal and vegetable fluids by the microscope are all dependent on a mysterious vi- tality. If any microscopical observer will take the trouble to watch the behavior of a light flaky precipitate recently thrown down from a solution in water and spirit, he will see motions and aggregations as remarkable as those of the recently effused blood discs although less regular from the unequal size and shape of the particles. The close and orderly arrangement of the blood discs is favored by their mobility and flatness which facilitate the operation of the aggregate force; and in this respect they contrast with the white globules, whose globular shape and larger mass render them less apt to coalesce; these however often form centres, around which rolls of discs cluster in circles or rays It is remarked by Mr. Gulliver, that the elliptical blood corpuscles of reptiles and camels cohere together in irregular heaps, devoid of the rouleau arrangement seen where round discs are concerned; it is therefore highly probable that the cohesion is due to some me- chanical influence. RED CORPUSCLES—FORMATION AND DECAY. 147 hue, of persons who have been long suffering from malarious influence, particularly in warm climates, has often attracted attention ; it is now generally considered that these are cases in which the spleen has be- come diseased, an acknowledged result of the continued operation of malaria. The general state of the blood in these affections has been already noticed (§ 186 ;) and it may now be farther explained that a diseased spleen operates by not only withdrawing from the circulation an undue proportion of blood, but also by keeping it in a stagnant state, unrenewed and unpurified through circulation and excretion: it spoils the blood itself, and renders it unfit for farther use. Hence, when in lapse of time portions of this spoilt blood are again returned into active circulation, they corrupt and contaminate the whole mass, and induce the various kinds of cachaemia or cachexia which form the sequels of malarious diseases. This view accounts for the fact, often considered unintelligible, that such morbid effects result only from enlargements of the spleen, and not from its entire obliteration, which last has been repeatedly noticed to occur without the production of any peculiar ef- fect on the blood. Other instances of a similar character will be men- tioned under the head of congestion. The mode in which amenorrhcea tends to impair the quality and quantity of the blood corpuscles may also derive some light from the foregoing remarks. A young female, during or before menstruation, is exposed to continued cold, or to sudden mental excitement; the dis- charge is checked ; and if no serious illness immediately ensues, she begins to fail in strength, and in a few weeks or months becomes chlo- rotic. The uterine system remains congested after the repression of the discharge ; and the blood in the system suffers, not only from the interruption of the process of excretion (M. Gay Lussac and Andral have proved menstruation to be such, for during the flow the quantity of carbonic acid exhaled by the lungs is much diminished) (§ 170,) but also from the influence of a reservoir of the impure blood which tends gradually to derange and contaminate the whole mass. 192. Remedial measures.—Excess of the red corpuscles may be speedily removed by blood-letting, for they are diminished in quantity by the employment of such means much more rapidly than the other constituents of the blood. Low or vegetable diet, and the antiphlogis- tic regimen generally, including the avoidance of all stimulating or exciting agents, produce a similar effect, although more tardily. It is not certain whether any medicines produce the same result by direct influence; but cholagogue purgatives, and the continued use of mer- cury, colchicum, and other medicines which largely increase the excre- tions (§ 173,) ultimately reduce the proportional amount of the red corpuscles. The dark green evacuations produced from the bowels by the continued action of calomel, and other preparations of mercury, appear, from the observations of Dr. Golding Bird, to consist of altered hsematin. This operation of calomel may therefore be well considered as closely allied to blood-letting. Mineral saline waters, and saline medicines taken copiously and in a state of much dilution, sometimes diminish extreme rubicundity of the surface in so remarkable a degree as to suggest the notion that when absorbed into the mass of the blood 148 DISEASES OF THE CONSTITUENTS OF THE BLOOD. they may directly destroy some of the red corpuscles ; they are there- fore useful cooling agents where these are in excess. The remarkable pallidity which accompanies the occurrence of extensive suppuration would also point to the formation of pus as a means for diminishing the red corpuscles; and this formation may be artificially effected by the employment of setons and suppurative counter-irritants. 193. As regards the increase of the red corpuscles, when in deficient quantity, it might be expected that nourishing food, and especially the free use of brown meats, exposure to invigorating air and light, and the employment of tonics generally, would be the proper means to promote it. But without the teaching of experience we could never have antici- pated that medicines containing iron should possess such remarkable effi- cacy as we find to be the case 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. In the choice of the preparation of iron best suited to accomplish this purpose we must be guided by the state of the stomach and other considerations; but the most soluble preparations are the most effectual when they can be borne ; and this is of more importance than the particular combinations in which they are administered: thus the iodide, sesqui-chloride, sulphate, citrate, acetate, and acid phos- phate, are all severally eligible. This subject will again come under consideration in connexion with anaemia. It has been supposed by Dr. Stevens that saline medicines have great power in restoring to their healthy state the red corpuscles which are changed in typhoid and malignant fevers (§ 186 ;) but if these remedies are beneficial in such maladies, it is very doubtful whether much is to be ascribed to this mode of action. It is more probable that the good results from the removal of the diseased corpuscles out of the system through increased excretion (§ 192,) at the same time that fresh corpus- cles are produced by the influences suggested above. Thus in malarious and anasmic cachaemia, the best effects result from the combined use of purgatives, diuretics, and chalybeate tonics. Hence the advantage ac- cruing from the operation of saline chalybeate waters, which promote the elimination of decayed blood, at the same time that they promote the formation of more of a better quality. The disposition of the red corpuscles to coalesce, which is augmented as we have seen in inflammation, is diminished by the addition of saline matter to the blood ; and Mr. Gulliver has surmised that a part of the useful operation of saline medicines in inflammation may be due to this cause. SECTION VIII. FIBRIN AND WHITE CORPUSCLES. 194. Fibrin and albumen cannot be distinguished from each other by difference of chemical composition. Liebig maintains that they are chemically identical; but Dumas considers that fibrin has rather more FIBRIN—NATURE AND OFFICES. 149 nitrogen in it than albumen. Fibrin is, however, characterized by one peculiar property, of the utmost importance in its physiological and pa- thological bearing—its readiness to become organized. For a long time it has been considered to be the organizable material of all the tissues in its final stage of preparation, and just about to become organized. Now, however, it is known that it is only the fibro-gelatinous textures of low vitality that it forms. Its own high organizable power peculiarly fits it to become the material of structures that have little formative strength in themselves. But besides furnishing the substances out of which the fibro-gelatinous tissues are made, fibrin serves the highly important office of conferring certain physical properties upon the blood, that are necessary to it as circulating fluid. A slightly viscid fluid moves more readily in narrow tubes than water itself, but at the same time it is less prone to escape through the minute pores in the walls of the containing tubes. The fibrin present in the blood guards against the occurrence of too ready transudation and hemorrhage, and leads to their limitation within safe bounds when accidental openings of escape are made. Being the constituent then which confers coagulability on the blood, in all the varieties which that process exhibits, and which furnishes coagulable lymph, it becomes a very important agent in the mainte- nance of health or the production of disease. Although probably not so immediately concerned as the red corpuscles in sustaining the vital processes of respiration, circulation, and innervation, its presence is nevertheless essential to the active state of these processes, as well as to that of the nutritive and reparative function; and it therefore exists in larger proportion and higher perfection in arterial than in venous blood. Although, as above stated, it is distinguished from albumen less by chemical differences than by its ready organizability and suscepti- bility of life, yet there are certain conditions, chemical as well as phy- sical, which are favorable to its formation, and by knowing these we are able to influence its production at will. Fibrin, as presented to us in washed clot, coagulable lymph, or the buffy coat of inflamed blood, consists of a mass of extremely fine fibres, containing scattered among them transparent granular bodies, some separate, and others in round encysted clusters. In fluid blood we see the same granular bodies or pale corpuscles, but none of the fibres. The capability of forming these^6res seems to be the great characteristic of fibrin, and its power to assume this fibrous state distinguishes it from albumen, which solidifies in a granular mass. So long as fibrin re- mains dissolved, as in the blood liquid, it is in no way distinguished from the albumen with which it is combined, but it even then has the inherent capacity to solidify in a peculiar manner. This capacity, from the time of J. Hunter to the present, has been generally consi- dered to be an attribute of indwelling life; undoubtedly it is connect- ed with vital activity in the sanguiferous functions; but various facts, particularly some pointed out by Dr. Buchanan of Glasgow, and Mr. Gulliver, show that the fibrillation of fibrin, like the crystallization of a salt is promoted by, and sometimes even dependent on, the presence of fibrin already solidified, of the pale corpuscles, or of some other 150 DISEASES OF THE CONSTITUENTS OF THE BLOOD. kindred matter. Exposure to the air, and dilution with water, also favor the consolidation of fibrin. The former is probably essential to the result; for the circumstances which promote the formation of fibrin in the blood, generally include a certain degree of increased oxygenation. In fact, according to Mulder, fibrin is chemically an oxyprotein, or more definitely, the deutoxide of protein, and that its formation is in part at least dependent on the process of oxydation, is probable from the fact that arterial blood contains more fibrin than venous, and of a more perfectly fibrillating and contractile quality. But while fibrin is thus viewed with regard to its mere mechanical and physical nature, we must not lose sight of the peculiar relation in which it stands to vital properties, which attach themselves to it more than to any other constituent of the blood. Its fibres and granules are the rudiments of new living textures ; and while observing its me- chanical construction and its chemical constitution, we are only noting the conditions which render a highly animalized material fit for the peculiar offices of life. The average proportion of fibrin in the blood of a healthy adult is between two and three parts in every thousand. Within the limits of health it may vary from two to three and a half parts, being most abundant in well fed persons with active circulation during advancing growth ; and least in early infancy, and in persons of weakly consti- tution and advanced age. It has been frequently observed that a greater number of colorless corpuscles are present whenever the fibrin of the blood is in marked excess. This has led some physiolo- gists to adopt the view that fibrin is formed through the agency of these bodies; that indeed the main office of the colorless corpuscles is to transmute crude albumen into plastic fibrin. By others it is deemed more probable that the colorless corpuscles do for the other albuminous textures what the red corpuscles do for muscle and nerve, that is, prepare the material especially suited for their nutrition. Practically it is quite impossible to separate the fibrin and the color- less globules, and hence all estimates of the quantity of fibrin include the colorless corpuscles present, whatever the amount may be. Dr. Carpenter remarks that in a general way the colorless corpuscles may be deemed to be superabundant in comparison with the fibrin, when a bulky clot is of loose consistence and easily broken between the fingers, and the converse when it is very tenacious and firm. I have found the corpuscles always abundant in the fibrin and coagulable lymph of scrofulous subjects. 195. An excess of fibrin, and of colorless corpuscles (hyperplasma, or hyperinosis,) exists in all true inflammatory diseases, especially those of a sthenic character, and in young subjects, and in acute rheumatism. In some cases of pneumonia and rheumatism, MM. An- dral and Gavarret found the proportion as high as 13.3 parts in a thousand. It is stated by them that inflammation never occurs unless the fibrinous constituent of the blood amounts to five parts in a thou- sand. So likewise whenever an inflammation supervenes in the course of another disease, there is always an augmentation in the quantity EXCESS OF FIBRIN AND WHITE CORPUSCLES. 151 of fibrin in the blood. The proportion of fibrin is also increased du- ring the latter months of pregnancy.1 MM. Andral and Gavarret observed an increase of fibrin in tuberculous diseases, in which we have noticed that there is a deficiency of red particles (§ 185.) In one case of phthisis, Popp found the proportion of fibrin to amount to 10.7 parts in a thousand. This result is now generally attributed to the inflammatory action that is induced around tubercular deposits. Mr. Gulliver has observed the increased quantity of white globules in blood drawn in inflammation, and I have noticed this as occurring within the vessels. (See Inflammation.) It has been supposed that the increase of fibrin in inflammation may be due to the accelerated movements of circulation and respiration, which might augment the changes of the blood in the lungs; and in some experiments by Dr. Gairdner, an increase of fibrin was produced in the blood of rabbits by making them breathe pure oxygen, or by exciting the respiration by galvanism. But it must be remarked that the amount of fibrin in inflamed blood is by no means in proportion to the frequency either of the pulse or of the respiration. There are other diseases, chlorosis for instance, in which blood drawn exhibits a fibrinous or buffy coat, without there being any absolute increase of the fibrin: this will be noticed presently. This is observed in various states of atrophy and cachexia, whether connected with deficiency of blood, defective powers of digestion and assimilation, or excessive expenditure of the nutrient fluid. An excess of fibrin, and still more so of the white corpuscles, has been noticed to exist in certain cases of anaemia, generally in con- nection with enlargement of the spleen, liver, and lymphatic glands. The predominance of the pale corpuscles has led Professor J. Hughes Bennett2 to coin the word leucocythcemia to designate this affection: its true pathology remains in obscurity; but it is probably a disease of the cell formation of the blood, in which, instead of normal red corpuscles, cells are produced without coloring matter, and advance no further. Three cases of this kind, which have recently fallen under my observation, derived no advantage from the use of ferrugi- nous medicines. 196. Deficiency of fibrin (hypinosis) is of frequent occurrence in many diseases, and temporary conditions bordering on disease. Its sign is fluidity, or imperfect coagulation of the blood after it is drawn. As venous blood contains less fibrin and of a less perfect quality than arterial, so the quantity is absolutely diminished when the blood is more venous than is usual, as in cases of asphyxia or impeded breathing ; and in those of cyanosis, in which the venous blood becomes mixed with the arterial in consequence of the existence of an unnatural opening. Excessive bodily fatigue more or less expends the fibrin; hence the blood often remains fluid in animals hunted to death (§ 65.) It was stated by John Hunter that the same thing may be observed in animals killed by lightning; but Mr. Gulliver has shown that this is not generally the case. In many instances the blood is found fluid ' In domestic animals the proportional amount of fibrin is diminished before, and in- creased after, parturition. (Ann. de Chim. 1842.) 2 Edinburgh Monthly Journal. 1851. 152 DISEASES OF THE CONSTITUENTS OF THE BLOOD. in cases of death from poisoning and other suddenly acting influences. In some of these the deficiency of fibrin may be attributed to im- peded respiration, which is the immediate cause of death. This is the case when poisonous doses of hydrocyanic acid, opium, and strychnia are taken, when apoplexy occurs, and when "the pneumogastric nerves are divided. (Dupuy.) There is, however, some uncertainty about these facts. (See Mr. Blake's experiments mentioned further on.) In other instances,—as in poisoning with arsenic, sulphuretted hydro- gen, 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 adynamic fevers, which arise from the presence of a pe- culiar poison in the blood, its fluidity or imperfect coagulability is one of the most remarkable conditions, and seems to be a chief cause of the hemorrhages, petechiae, and vibices, which sometimes then occur. In a case of very low typhoid fever, Andral found that there was less than one part of fibrin in each thousand of blood, and he states that the proportion never rises above 3.7 parts in the 1000 in ordinary continued fevers. In one instance of abdominal typhus, Simon could find no trace whatever of fibrin in the blood. The arti- ficial imitation of this kind of fever, produced in dogs inoculated with various morbid or putrid matters, or confined over their exhala- tions, in the experiments of Gaspard, Magendie, Gendrin, Leuret, and Hamon, exhibited the result of a similar deficiency of fibrin in the blood (§ 194.) In one case of putrid fever, Scherer observed that the deficiency was accompanied by the presence of carbonate of am- monia in the blood, doubtless the result of incipient decomposition. In the eruptive fevers the proportional amount of fibrin is not so much diminished, but neither, on the other hand, is it so much increased as in other inflammatory disorders. The febrile and the inflammatory condition seem to modify and antagonize each other's influence to a certain extent as regards the composition of the circulating fluid. In epidemic cholera the fibrin is invariably deficient in the blood. M. Andral also found a diminution of fibrin in cases of cerebral conges- tion, with headache, vertigo, and tendency to epistaxis. In apoplexy the diminution was even more remarkable, and in one case was as low as 1.9 in 1000 during the state of unconsciousness; but on the third day, when the apoplectic symptoms were subsiding, it rose to 3.5. This rapid change seems to suggest that the oppressed state of the functions, especially of the breathing, may have reduced the proportion of fibrin. When some neutral and alkaline salts are added to the blood out of the body, its coagulating property is lessened, and it has been stated that subsisting on salted, food will produce a thin or hypoplastic 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,) and that the blood does not coagulate in this disease, both of which are erroneous. (See Lib. of Prac. Med., Art. Scurvy, by Dr. G. Budd.) 197. Besides the state already mentioned,—permanent fluidity or little coagulation of the blood when drawn,—a defect of fibrin in the blood DEFICIENCY OF FIBRIN. 153 causes a tendency to various kinds of hemorrhage, generally of the asthenic kind, and to an unmanageable oozing of blood from any ac- cidental wound or breach of texture. In a case of purpura hemor- rhagica, Routier found the fibrin reduced to less than one per thousand. Under the same circumstances, too, wounds do not readily heal, nor fractures unite. In fact, the plastic or reparative process is at fault for want of its material (§ 194;) and for a similar reason, the nutrition of textures which are allied to fibrin, such as the fibro-gelatinous tissues, is then imperfectly maintained. 198. Magendie found that when the fibrin was abstracted from the blood of animals, they were affected with congestions and effusions in the lungs, brain, and other organs. This he ascribed to a cause sup- posed by M. Poisseuille to be the expression of a general physical fact; namely, that very thin fluids pass through capillary tubes less readily than fluids of somewhat greater consistence. His experiments were, however, too rude, and his deductions too hasty, to merit confidence ; the obstructions and congestions alluded to might have been due to the cohesion of colorless or red corpuscles, or even to the deposits of little clots of fibrin left by the processes employed. There can, however, be no doubt that a certain spissitude in the blood is favorable to its transit through the hydraulic apparatus of the circulation; and that when this is deficient, various irregularities in the distribution of the fluid may occur. Some of these will be mentioned under the head of anaemia : but I may mention here that preternaturally thin blood is easily thrown into sonorous vibration, and that various unusual sounds or murmurs in the heart, arteries, and veins, may be thus produced. As these sounds are sometimes met with in cases in which the com- plexion does not indicate a deficiency of red corpuscles in the blood, and as they are sometimes absent in the most pallid subjects, I am in- clined to connect them as much with deficiency of fibrin and albumen as with that of the red corpuscles of the circulating fluid.1 199. The consideration of 'alterations in the quality of the fibrin brings under our notice certain important morbid appearances that the buffy coat and the blood-clot occasionally present. As the consolidation of the fibrin is the cause of the coagulation of the blood, so differences in the proportions and properties of the fibrin affect the state and appearance of the coagulum. 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 be- tokens an abundant proportion of fibrin with some deficiency of red particles; but the smallness of the clot points to excess in another pro- perty of the fibrin, that of contraction during and after its consolida- tion. The upper part of the clot is commonly more contracted than the lower portion; it is also firmer and contains more fibrin, whilst the lower abounds more in red particles. Here there is evidently a ten- dency to a separation of the red particles from the fibrin. In some 1 This inference has been confirmed by the subsequent observations of MM. Becquerel and Rodier, who found that in the pallid cachexia produced by the poisonous influence of lead, the'albumen is not diminished, and the vascular murmurs are not present. 154 DISEASES OF THE CONSTITUENTS OF THE BLOOD. cases, the separation is, to a certain extent, complete, the red particles subsiding, whilst the fibrin rises to the surface, and forms at the top of the clot a layer of a light yellow or buff color, commonly known by the name of the buffy coat. It may be inferred, then, that besides coagulation (§ 194,) fibrin possesses a property of contraction, and another of separation from the red particles. These properties are severally presented in different degrees of activity in different states of the system. Let us then consider their influence, first separately, and afterwards in mutual re- lation. 201. Coagulation is generally retarded in inflammatory diseases, and in other cases in which the fibrin is abundant (§ 195 ;) the amount of fibrin present is indicated by the firmness and size of the clot. The coagulation is tardy also in the opposite condition ; where the fibrin is scanty ; but then the clot is very loose, and where the fibrin is very deficient, there may be no coagulation at all. Other circumstances may make the coagulation slow, as warmth and seclusion from the air; whereas rapid cooling, and exposure to the air (as when the blood trickles from the vein, or is drawn into a shallow vessel,) hasten the coagulation. A temperature of 150° totally destroys the coagulability of the blood. The addition of some saline matters, such as common salt, nitre, or carbonate or sulphate of soda, retards the coagulation of the blood. Mr. Gulliver found that the blood of a horse to which nitre had been added, remained fluid for fifty-seven weeks, yet even then coagulated, on the addition of water. Contact with dead organic matter promotes coagulation, and most especially when that matter is at the time undergoing degradation. Mr. H. Lee1 found that when putrescent pus was injected into the ju- gular vein of an ass, the vein instantaneously became like a rigid cord, in consequence of the deposit of fibrin within it. It is probable that pus is often shut up in the channels of the circulation, and rendered harmless, by an investment of fibrin being thrown around it. MM. Du- puy and De Blainville found that the injection of cerebral substance into the veins of a living animal caused instant death by the sudden forma- tion of clots in the heart and large vessels. The coagulum of the blood is dense in proportion to the elaboration the fibrin has undergone. But the specific gravity of the blood is not by any means a test of its coagulability; the heaviest blood is often that which has most corpuscles and least fibrin : the length of time that ensues before coagulation takes place, and the degree of solidification that ensues, are often in inverse proportion to each other. The last part of a stream of blood generally coagulates the most rapidly and the least firmly. Contact with the lining coats of a living vein seems to retard coagu- lation, unless the vessel be in a state of inflammation. Dr. Carpenter represents the liquid condition of fibrin, while in the circulating blood, as being the consequence of a sort of balance of forces, the living tis- sues with which it is in contact tending to keep it fluid and its own plastic nature to render it solid.2 It seems evident that all causes 1 On the Origin of Inflammation of the Veins and on Purulent Deposits. 1 Principles of Human Physiology, 1853, p. 184. FIBRIN—SEPARATION—BUFFY COAT—CAUSES. 155 which impair the elaboration of fibrin also diminish the plastic property of the blood. 202. The contraction of the clot evidently depends on the attraction 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 pressed together, whilst a portion of the serum is squeezed out. The more slow the coagulation is, generally the greater will be the contraction. Hence as the upper surface of the clot is often formed more quickly than the lower, it is also larger; but the central portions of the large upper layer are drawn downwards by the stronger con- traction of the mass below, and in this way is caused the concave or cupped appearance in the clot, so commonly seen in buffed blood (§ 200.) When the blood is drawn from a vein slowly, or received into a shallow vessel, the coagulum is speedily formed in all parts, adheres to the sides of the vessel, and is not cupped. As the contraction and cup- ping of the clot are due to the fibrin, it might be expected, d priori, that these results would be marked or otherwise in proportion to the amount of fibrin present. This is the case in inflammatory diseases. But there is also great contraction, and often cupping, in chlorosis and some analogous states, where the fibrin is not absolutely increased ; here the red corpuscles are so deficient, that they do not offer the usual resistance to the contractile influence of the fibrin. For a similar reason the contraction is greatest where the fibrin is 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 plethora (§ 184,) or where the aggregation of the fibrin is impaired by the addition of saline matter (§ 196 ) In a boy suffer- ing from purpura, under my care, Dr. Garrod found the fibrin in the blood to be quite as abundant as usual, amounting to 3 in 1000 parts, but it was remarkably defective in the usual contractile property, and the salts of the fluid were in excess. 203. The separation of the fibrin from the red particles (§ 200,) ex- hibited in the formation of 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 corpuscles as constantly sink, it is obvious that one chief reason for the separation is the greater weight of the latter. They subside entirely from the upper layer of fibrin before it has time to coagulate. Consequently this result may be favored by four different circumstances :—1, tardy coagulation of the fibrin giving more time for the subsidence; 2, increased specific gravity of the red corpuscles; 3, diminished specific gravity of the fibrin ; 4, diminished thickness of the liquor sanguinis. Now two of these conditions may be produced by adding a little salt to healthy blood as it flows from the vein; and this addition really does produce a separation of the fibrin; but the fibrin then rising to the surface has neither the con- tractile power (§ 203) nor the firmness of the inflammatory buff; it is gelatinous like size,- and resembles the sizy film sometimes exhibited in scurvy and diabetes. Farther: 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 156 DISEASES OF THE CONSTITUENTS OF THE BLOOD. speedy, and, according to Schroeder Van der Kolk, is seen in patches and thin films in places where gravitation could not have been opera- tive in promoting the separation.1 There must therefore be some other cause for the formation of the buffy coat, besides the one above named. The great firmness and contraction of the surface in the clot of inflamed blood may be ascribed to the increased proportion of fibrin, which is then constantly present. 204. Dr. Alison considers the separation of the fibrin in inflamma- tion to be due to a vital repulsion acting between the fibrin and the coloring matter. Dr. Hermann Nasse and Mr. Wharton Jones think that it may be entirely accounted for by the increased aggregation (before noticed, § 190,) then observed in the red corpuscles (Brit, and For. Med. Rev., Oct. 1842, p. 592.) The cohesion of the red corpus- cles into connected piles or rouleaux may facilitate the separation, not only by the direct influence of the separative aggregation, but also because the connected mass sinks 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 if in the state of fine powder. Mr. Gulliver has observed that the red cor- puscles sink rapidly in proportion to the amount of this aggregation. Another circumstance most probably favoring the separation of the buffy coat, is an increase in its own lightness, due to an augmented proportion of fat globules mixed up with the pale corpuscles diffused through it. 205. In order that the true characters of the clot may be exhibited, the blood should be drawn by a full stream into a deep or globe-shaped basin or cup, previously warmed, and should be kept covered over until the coagulation is complete. These precautions serve to retard the coagulation, and to favor 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 if the receiving vessel is shallow and cold, the blood congeals at once, and the appear- ance of the buffy coat is prevented (§ 202.) This is one reason why blood drawn at a single blood-letting often exhibits a different appear- ance on being received in different vessels.2 206. The fact that fibrin exists in larger proportion in arterial than in venous blood, and that its proportional amount is diminished when respiration is seriously impeded, seems to point out that it is ex- pended in the nourishment of certain of the textures, and that it is renewed through the agency of respiration. It might be supposed that inflammation increases its quantity by accelerating the circula- tion and respiratory movements without adequate expenditure of blood ; but although this may be the case to a certain extent, particularly in acute rheumatism, it is not a sufficient explanation of the fact, for the quantity of fibrin in the blood is not proportioned to the frequency of the pulse or of respiration ; it is often much increased before these are 1 Alison's Outlines of Physiology, p. 89. * For much interesting information on the coagulation of the blood, the reader is re- ferred to the edition of Hewson's works published by the Sydenham Society, with the valuable notes of Mr. Gulliver. FIBRIN—NATURE AND ORIGIN—VARIETIES. 157 materially 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 in- crease of fibrin during inflammation has its origin in the vessels of the inflamed part. 207. The coagulation of fibrin in the blood is favored by two cir- cumstances, the presence of the pale corpuscles (§ 194,) and the for- mation of the deutoxide of protein by some oxygenating process ope- rating on the albumen: the same circumstances also appear to be mainly instrumental in the production of fibrin. Thus, as Dr. Carpenter has pointed out, this principle appears in the chyle of the lacteals after their passage through the mesenteric glands : it increases in the thoracic duct, and becomes still more abundant in the blood of the lungs, where there is a free supply of oxygen. It is quite uncertain how much in the process is due to vital influence, but there is good ground for the belief that some of the change is of a chemical nature. The molecular base of the chyle (Gulliver) supplies a congeries of mi- nute fat globules which have a tendency to attract around them thin films of coagulated albumen (Ascherson,) probably identical with^wi or deutoxide of protein ; and this process takes place in proportion as oxygen is supplied from the adjoining red blood discs; thus the mole- cular base is converted into single and aggregated granules or pale corpuscles of the chyle and blood. The oxygenating process extends also to the serum, and converts a small portion of albumen into an oxyprotein, still liquid, but ready to take the form of a finely fibril- lated solid (fibrin,) under various circumstances already adverted to (§ 194.) The perfection of this material, and its susceptibility of farther organization, constitute additional characters of fibrin, which appear to belong to the class of vital rather than of mere physical properties. These will be noticed in the succeeding paragraph ; but we may observe here that they are in some degree dependent on the quality of the chemical materials, oil and protein, which the chyle and blood contain, and the activity of the processes of circulation and res- piration, by which these fluids are constantly influenced. _ A farther evidence of the existence of an oxidating process in connection with an abundant production of fibrin may be found in the fact that the buffy coat of inflamed blood contains the tritoxide of protein, a soluble mat- ter approaching in nature to gelatine, and which exists also in pus, being identical with the principle to which Giiterbock gave the term pyin. 208. Fibrin, identical with the buffy coat of the blood, is the ma- terial of which new membranes and cicatrices are formed; it is the coagulable lymph, indeed, which is the plasma or basis of the constric- tive and reparative process. In its capacity for these processes fibrin exhibits some modifications of condition constituting degrees of plasti- city. Thus in a healthy state (euplastic) it forms a fine congeries of minute fibrils, which, having a high capacity for life, may become or- ganized in a high degree, as in the case of false membranes resulting from acute inflammation in a healthy subject. But in many instances 158 DISEASES OF THE CONSTITUENTS OF THE BLOOD. this high capacity is degraded, and the nutritive material is caco-plastic, with fewer and less perfect fibres, and with more corpuscles, giving the exudation more opacity, and is susceptible of only a low degree of or- ganization, as in the indurations resulting from low or chronic inflam- mation, in cirrhosis, gray tubercle, &c; or it is aplastic, not organizable at all, abounding in degenerating corpuscles with few or no fibrils, as in pus, curdy matter, yellow tubercle, &C.1 It is a fact 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 sub- jects, although in such the products of the inflammation, as well as of nutrition, are commonly caco-plastic or aplastic. The fibrin of the blood or coagulable lymph in these cases is more opaque and less elastic than in healthy subjects, and under the microscope presents a predominance of corpuscular and granular matter and fat globules, and less of the finely defined fibres and regular nuclei, as if it were imperfectly elaborated; and it therefore has a tendency to farther de- generation. Even the more perfect forms of fibrin or lymph, if in a position in which their vitality is not sustained by the completion of organization, tend to degenerate, and become disintegrated into an amorphous or opaque aplastic substance (Gulliver,) which appears to be of the nature of spontaneous fatty degeneration and disintegration, and which eventually may undergo a farther change into fatty and cal- careous matter, like other aplastic deposits. It is interesting to ob- serve that in many of these cases the red corpuscles also are defective in quantity (§ 185;) and this suggests a probable reason for the imper- fection of the plasma. 209. The coagulation of fibrin is promoted by the contact and mo- tion of a rough solid: thus by stirring fresh-drawn blood with a stick, the fibrin is caused to adhere in shreds to the stick. The same result is exhibited within the body by the deposition of lymph on rough sur- faces within the heart and great vessels (" vegetations,") and it is pro- bable that the fibrinous concretions called polypi, which are found after death in the heart, are formed on its irregular surfaces, when its fail- ing motions cause agitation rather than propulsion of the blood. The cohesive property of fibrin especially characterizes it, and determines its aggregation in patches and films on the surface of membranes ; where it is most plastic, it may be drawn into threads or bands. 210. Remedial measures.—Hyperinosis or excess of fibrin in the blood (§ 195,) is less rapidly reduced by blood-letting and low diet, than is excess of the red corpuscles; yet these are the chief means employed for effecting the object. It would probably be found that purgatives, 1 The varieties of lymph here described in some measure correspond with those desig- nated by Mr. Paget as fibrinous and corpuscular. (Lectures on Surgical Pathology. 1853, Vol. L, p. 332.) Mr. Paget lays more stress on the fibrillated texture of the fibrinous kind, and the great predominance of the corpuscles in the other; but it seems to me very important to keep in view the intermediate variety, which I term caco-plastic, and which contains both corpuscles and fibres. This has its difference in its subsequent his- tory, and comprehends the three varieties of croupous exudation-matter described by Rokitansky. FIBRIN—EXCESS—REMEDIES. 159 and other agents which much increase the more solid secretions, dimi- nish the fibrin. A similar power has been ascribed to mercury, to alkaline salts, to iodine, and to antimony; there is a want of experi- mental proof in support of the notion; yet it is favored by some analo- gies, and seems well worthy of farther investigation.' The effect of salts and alkalies in doing the same thing was probably suggested by their property of dissolving fibrin out of the body.2 211. According to the views of Dumas and Liebig, subsisting chiefly on saccharine, amylaceous, or gelatinous articles of food, must diminish the fibrin and albumen of the blood; and such food is found by experi- ence 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 quantity of fibrin, and may be advantageously employed with this view in sthenic plethora and in scrofulous hyperinosis, but is not admissible in inflammatory diseases. Neither can we suggest any practicable mode of lessening the fibrin through 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 condition, makes this matter deserving of some research. Simon mentions one case of phthisis long treated with cod-liver oil, in which the fibrin in the blood was reduced in a remarkable degree. 212. Hypinosis, or deficiency of fibrin (§ 196,) is to be remedied by assisting the functions on which the supply of the plastic principle de- pends,—particularly those of digestion, circulation, respiration, and assimilation,—and by avoiding its expenditure through too much exer- cise or other exhausting processes. If the digestive organs will bear them, meat, eggs, bread, and other articles of diet abounding in pro- tein 'compounds, should be taken. The digestive and assimilative functions may be roused by stimulants, bitters, quinine, and the mine- ral acids; which, from their power in stopping passive hemorrhage, in ' Dr Karl Popp who has made elaborate researches on the composition of the blood, infers that tartar emetic and nitre, and (in a less degree) calomel, diminish the amount of fibrin. Dr. Day in Ranking's Abstract, June, 1846. z Mr James Blake made many experiments by injecting various saline and other fluids into the veins, and he has furnished me with a summary of the results found in the b.ood after death. . . The blood was found to be coagulated after the injection of the following matters: — Liquor potassse (firmly;) carbonate of potass (firmly:) nitrate of potass (firmly; blood scarlet-} nitrate of soda; nitrate of ammonia; nitrate of lime; nitrate of baryta; chlo- ride of calcium; chloride of barium; chloride of strontium; sulphate of magnesia; sul- phate of copper; acetate of lead; arsenite of potass; nitric acid (strongly;) narcotin (firmly;) tobacco; strychnia (moderately;) conium; hydrocyanic acid; euphorbium; and water in large quantity. . . The blood was not coagulated, or imperfectly so, after injection of caustic soda, car- bonate of soda, sulphate of soda, ammonia, nitrate of silver, sulphate of zinc, sulphate of iron, phosphoric acid, arsenic acid, arsenious acid, oxalic acid, infusion of galls, infusion of digitalis, alloxan. . . Some of these results are different from what might have been expected; for instance the decided coagulation with potass and its salts, especially nitre, and the fluidity with nitrate of silver, sulphate of zinc, infusion of nutgalls, which have been commonly sup- posed to possess a coagulating property. 160 DISEASES OF THE CONSTITUENTS OF THE BLOOD. augmenting the muscular substance and strength, and in causing the healing of phagedenic and flabby ulcers, seem to have some more direct means of promoting the formation of the plasma of the blood, than by their mere operation on the digestive organs. To improve the function of respiration, besides attempting to remove or diminish any disease from which the respiratory organs may be suffering, 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 induces in con- tinued fever, where defect of fibrin in the blood is a constant condition. Fatigue of every kind, and wakefulness, should be carefully avoided, and sleep should be obtained by narcotics, if it do not come naturally. In case of deficiency of fibrin from the presence of a febriferous or pu- trescent poison in the system, it is not to be expected that azotized 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^ other 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 improvement in the symptoms, than the quan- tity of fibrin increases; and this faster than could be explained by any increase of nourishment taken. (Andral and Gavarret.) It would seem that the immediate effect of the presence of these poisons is to accelerate the decay of the more animalized matters of the blood, which thus speedily become resolved into urea or carbonate of ammonia (§ 196,) and as we find that such septic changes are retarded by certain agents, such as nitre (chlorate of potass, strong bitters, alcohol, &c.,) out of the body, it does not seem irrational to suppose that similar agents may be effectual in counteracting the septic influence within the body. The beneficial operation of wine and other alcoholic stimulants, of quinine in large doses, and of medicines containing a large amount of oxygen, as nitric and nitro-muriatic acids, and chlorate of potass, in typhus fevers and other adynamic diseases, is probably connected with their antiseptic as well as with their stimulating power. The oxyge- nating agents might, perhaps, be more efficacious could they be more readily conveyed into the blood without irritating the alimentary canal. The administration of oxygen or nitrous oxide by inhalation suggests itself as worthy of trial for the same object. 213. Very little is known of the power of remedies to correct changes in the quality of the fibrin of the blood. The increased properties of separation (§ 204) and contraction (§ 203) manifested by the fibrin of blood in inflammation, are diminished by blood letting and other anti- phlogistic remedies, even more constantly than the excessive proportion of fibrin is by the same means ; but they seem to be soon re conferred if the inflammation continues. Thus, although the last cup drawn of blood-letting may exhibit none of the buffed and cupped appearance pre- sented by the first, yet blood drawn a few hours after often shows it as much again. Knowing that this speedy recurrence of morbid proper- ties in the blood depends on the influence of the local inflammation, we see the necessity of fully using local remedial means, together with those that are calculated to operate on the system. The beneficial influence of saline medicines in inflammatory-diseases FIBRIN—DEFECTIVE AND ALTERED—REMEDIES. 161 is supposed by Mr. Gulliver to depend on their power to prevent the cohesion of the blood corpuscles, and he has hence suggested the free application of salt lotions to an inflamed part. The application of salt to a recent wound is a well-known popular remedy. 214. Blood-letting and other general antiphlogistic remedies, if they do not remove local inflammation, may render its products more inju- rious through lowering their plasticity (§ 211,) thus approximating them to tuberculous and other aplastic deposits. Thus, chronic inflammation continuing after the full employment of the antiphlogistic treatment, almost surely tends to produce degenerated changes of structure, over which remedial art has little power. Hence, therefore, we see how desirable it is that inflammations should be removed before they be- come chronic; and when there is a risk of their becoming so, it is an indication that we should try to improve the condition of the blood by a tonic and nutritive plan of treatment, at the same time that local antiphlogistic measures are addressed to the lingering inflammation. 215. A similar course of tonic treatment is yet more forcibly called for in scrofulous, chlorotic, and other cachectic states, in which the fibrin, although less abundant than in inflammation, is yet copious in proportion to the scanty red corpuscles (§ 212.) Here there is a ten- dency to the deposit of imperfect fibrin and granular matter (§ 211,) even independently of inflammation ; and, besides means calculated to improve the nutrient functions and to raise the character of their pro- duct, it may be necessary to use remedies that tend to keep the fibrin dissolved, and to prevent its consolidation in aplastic forms. Alkalies and iodide of potassium have been supposed to have some claim to the power of doing this; but more efficacy seems to attach to regiminal and dietetic influences, such as the exclusion of all food containing solid fat and protein matters of the lower class (like casein ;) the freshest and most sustaining but easily assimilated nutriment should alone be allowed, and every available step should be adopted to promote the functions of digestion, respiration, capillary circulation, and excretion, through due supply of healthy air, and through the employment of ex- ercise and frictions of the surface. SECTION IX. ALBUMEN. 216. Albumen is an important constituent of the blood, amounting in health on an average to about thirty-nine parts in every thousand. It was generally supposed to be chiefly useful in affording the material from which the plasma (fibrin) is elaborated ; but it was suggested in the former edition of this work that some textures may be formed at once from the albumen of the serum. This opinion seems now to be the prevailing one ; that the more solid tissues as well as the globulin and hsematin, are formed from the albumen, whilst the fibro-gelatinous textures alone are constructed of fibrin. The albumen is farther useful 11 162 DISEASES OF THE CONSTITUENTS OF THE BLOOD. in giving to the serum a consistency favorable to the process of circu- lation : it also fits it for the suspension and preservation of the red corpuscles, and for blandly sheathing the acrimony of the saline con- stituents. The quantity of solid principles in serum amounts to from seventy-two to eighty-eight parts in every thousand during health, and of these four-fifths are albumen. It may be generally inferred from the specific gravity of the serum, how much albumen it contains: this in healthy subjects averages about 1030, but sometimes in disease falls as low as 1013. 217. Excess of albumen exists in most cases of inflammation and fever, especially during the more active stages. Its increase is not, however, in the same proportion as that of the fibrin. Its relative amount is much augmented in epidemic cholera; but this is mainly due to the removal of the water of the blood. Albumen is the principle of the blood that is least affected in its proportions by disease. Very poor living, long-continued or copious hemorrhages, and other drains on the system, will pretty surely reduce it in common with the other animal principles; but good living has less power in raising it above the natural standard. In the pallid cachaemia of persons who have suffered long under paraplegia, it has been ascertained by MM. Bec- querel and Rodier that the albumen is not diminished, but is actually in excess, as compared with other solid constituents of the blood: in fact it is not the albumen that is absolutely increased, but the red cor- puscles diminished, the albumen remaining the same. 218. The means of reducing an excess of albumen in the blood are similar to those capable of diminishing the other animal constituents (§ 192, 210,) including depletion, purgatives (especially mercurial,) diu- retics, (especially alkalies and colchicum,) and low diet, with a sparing supply of azotized food. 219. 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 corpuscles, which takes place in the advanced stages of this disorder. Dr. Bright found the specific gravity of the serum as low as 1013 in a patient with albuminuria. (Bright's Reports, vol. i., p. 85.) Dr. Babington noticed the specific gravity of the serum, in a case of diabetes, as low as 1024, and in another as 1027, although that of the blood was higher than usual, being 1061. In this case the serum was milky. (Cycl. of Anat., &c, Art. " Blood.") Andral observed that the deficiency of albumen in the serum of the blood is in exact proportion to its ex- cess in the urine. In their later researches, MM. Andral, Gavarret, and Delafond discovered a remarkable diminution of the albumen in dropsical sheep affected with the rot (a watery state of the blood, with distomata in the liver.) Sheep in a cachectic state, with deficiency of red corpuscles in the blood, but without entozoa, or dropsy, had the albumen undiminished. It is therefore most probable that the cases of cachexia, or anaemia, attended with 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 FATTY AND OTHER COMBUSTIVE MATTERS. 163 along the vessels, and prevents it from transuding through their walls. This deficiency of albumen, therefore, seems to be a chief condition of the dropsical diathesis. 220. We are not acquainted with any other means of increasing al- bumen in the blood, where it is deficient, than the adoption of such measures as tend to restrain wasting discharges, and to improve the general nutrition. The excessive loss of albumen through diseased kidneys may be in some cases checked by what may be termed astrin- gent diuretics, which are also effectual in arresting hemorrhage from the urinary organs. Among these may be mentioned gallic acid, tinc- ture of the sesquichloride of iron, benzoate of ammonia, and in some cases tincture of cantharides, and oil of turpentine in small doses. In various instances, I have used each of these with the result of increasing the specific gravity of the urine, yet diminishing the albumen. To counterbalance the waste by a liberal supply of nutritious food is another obvious indication; and, in addition to the ordinary albuminous articles of solid food, a sustaining beverage may be made of raw whites of eggs and water, flavored with sugar and lemon juice. A case is mentioned by Simon (Animal Chemistry, by Day, vol. i. p. 280,) illus- trative of the extraordinary nutritive properties of cod-liver oil in phthisis; the solid constituents of the blood after its use amounted to 25 per cent.; the albumen being above 13 of this: the fibrin, usually high in phthisis, was below the normal proportion. SECTION X. FATTY, AND OTHER COMBUSTIVE MATTERS. 221. The blood in a state of health, contains three distinct kinds of fatty matters:—1. Saponifiable fats composed of the spermaceti- like substance called margarine, dissolved in olein, an oily liquid: 2. Phosphorized fats, contained principally in the red corpuscles: and 3. Cholesterine, a hydro-carbon combined with a minute proportion of oxygen, and formed in the liver. The saponifiable fats appear to be nutritious principles introduced into the blood by the chyle. The phos- phorized fats are probably formed by the blood corpuscles for the especial support of the nervous substance. Both these kinds of fatty matter are necessary to the early stage of cell production. The cho- lesterine seems to be, on the other hand, merely a fuel furnished out of excrementitious matter for calorific purposes. It is now known that, besides these true fats, the blood also ordinarily contains sugar. This principle may always be detected in venous blood, between the liver and the lungs, but is destroyed in the lungs by the influence of the air, being in these organs converted into water, lactic acid, and finally car- bonic acid. No sugar can be found in the blood of the left ventricle. Bernard has shown that it is formed by the liver, alike out of azotized and unazotized matters. Division of the pneumo-gastric nerve, and diseases that exhaust the nervous energy, arrest its production. It is 164 DISEASES OF THE CONSTITUENTS OF THE BLOOD. highly probable that it is destroyed in the lungs for the support of animal heat, and that like cholesterine it is a true fuel. Carnivorous creatures seem to make most sugar, and the herbivorous most fat, for the purposes of combustion. 222. The oily or fatty matter in the blood is sometimes so much in- creased as to give a milky appearance to the serum; and this increase may arise under different circumstances, and from various causes. The most common cause is that originally suggested by Haller, and lately proved to exist by Dr. Buchanan, the presence of unassimilated chyle (§ 211.) The latter physician has ascertained that the serum is generally milky in blood drawn four or five hours after a full meal. In other instances, this appearance has been observed during illness after long fasting, and doubtless then proceeds from the absorption of fat from the textures, as supposed by Hewson. In some cases a tur- bidity in the serum has been found to depend on the presence of an increased number of minute granules of albumen or fibrin, soluble in acetic acid, and not affected by ether. (Vogel's Path. Anat. by Dr. Day, p. 64. Notes to Hewson's works by Gulliver, p. 85.) Dr. Ba- bington met with an extreme degree of milky serum in a case of ad- vanced diabetes. This physician states that he has repeatedly found milky serum to have a low specific gravity, indicating a deficiency of albumen; and he suggests that the fat might originate in a change in the albumen. A similar idea has frequently occurred to myself, when considering the remarkable instances of fatty transformation exhibited in degenerating textures and deposits, and even in slowly decaying animal matter, as in the instance of the production of adipocire. This notion has been fully confirmed by the researches of Dr. R. Qunin, which will be noticed further under the head of Degenerations. The fat of the blood seems to vary in nature as well as in proportion; cho- lesterine and margarine are often found on the increase in old and cachectic persons, as they also abound in the degenerated tissues and cacoplastic deposits of such subjects. 223. The increase of healthy fat or adipose tissue in the body is probably preceded and accompanied by its presence in excess in the blood; and the circumstances which promote obesity must operate through the composition of this fluid. Of these may be .mentioned fatty, sweet, and farinaceous food in excess, yet where obvious disorder of the digestive organs is not caused ; full living with sedentary habits, and especially if combined with the free use of malt liquors ; imperfect assimilation, often connected with want of exercise of the respiratory organs, either from disease or disuse ; insufficient excretion of bile. Exercise tends especially to reduce the fat of the body, probably by increasing its combustion in respiration ; the nutrition of muscular tex- tures being then augmented by the same influence. Thus fat com- monly increases at the expense of strength, and is reduced in propor- tion as muscular power is restored. Besides the use of as much exercise as the strength will bear, exposure to the invigorating influence of pure air, and the avoidance of fat and similar articles of food abounding in hydro-carbon, some further advantage may be secured for corpulent persons by the employment of food and medicines, in which oxygen FATTY MATTER—IN EXCESS. 165 and azote predominate, as, for instance, nitric acid, chlorate of potass, benzoate of ammonia, and some vegetable acids. But there is sometimes an increase of fat in the blood without any remarkable obesity; when the fatty matter is formed at the expense of albumen and fibrin by a process of degeneration, which affects not the blood only, but also the tissues under various circumstances of de- graded nutrition and circulation. This fatty cachaemia may slowly result from age, debility, or various chronic cachectic diseases which impede respiration and excretion; but I have observed an acute affec- tion of the kind to ensue in persons, young and middle-aged, who, with very intemperate habits, have endured such privations as to destroy all constitutional vigor; in cases after death, from delirium tremens, erysipelas, or some acute attack which proved rapidly fatal, the blood and all the textures have been found so abounding in fat as almost to countenance the notion that a little more of such a change might ren- der the body spontaneously combustible. But in case of disease of the liver, the fat in the blood has been found to increase to two or three times its ordinary proportion, and it is then chiefly cholesterine. In cases of peritonitis and pneumonia also, an excess of fat has frequently been found in the blood. A remarkable case of peritonitis is de- scribed by Helder, in which the fat attained the extraordinary propor- tion of 50 in 1000 of serum: the red corpuscles were much below the usual standard (Dr. Day's Note to Simon's Animal Chemistry, vol. i., p. 271.) It is probable that in many of these instances the excess of fat is the- result of its rapid absorption from the adipose tissue during the disturbance of the acute attack; but others are the result of an undue formation of fat, or of its insufficient combustion by the respi- ratory process. 224. Defect of fat in the blood occurs in connection with continued inanition and emaciation, especially in typhoid fevers and malignant diseases. In scrofulous emaciation the fat in the blood is not always lessened; sometimes it is increased ; apparently in connection with the fatty transformations which take place in the deposits, and sometimes in organs, as in the liver. It would be interesting to know the state of the blood in those cases in which large quantities of fatty matter are discharged from the intestinal canal. Deficiency of fat in the blood is to be obviated by the administration of such oleaginous articles as the stomach will bear (such as cod-liver oil, cream, bacon, mutton suet diffused in milk, &c.,) and also by oily inunction and frictions of the surface. This subject will come under our notice in connection with atrophy. But it may be mentioned here that a knowledge of the condition in which the fatty principle best assists in nutrition in health may be useful in guiding us in the selec- tion of the oleaginous articles of food or medicine best suited to supply the deficiency. Thus the more fluid fats are preferable to the solid, from their being more easily absorbed and as supplying finer molecules for the chyle. Again, some oils are more readily saponified than others; in this respect there is an advantage in cod-liver oil, which, like the fat of-bacon, readily saponifies or forms an emulsion with carbonated alkalies, which is not the case with oils or fat in general. In case of 166 CONSTITUENTS OF THE BLOOD. paralysis or great depression of the nervous power, it may be useful to give phosphorated oil, with the object of supplying the materials by which the nervous function is sustained. From ^th to sVth of a grain of phosphorus may be given in a teaspoonful of almond or cod liver oil. A diet abounding in milk and cream is also .calculated to supply both oil and phosphate of lime to the blood, and has often proved be- neficial in cases of atrophy; but it is remarkable how readily in some cases it arrests the secretion of bile. SECTION XI. SALINE AND MINERAL MATTERS. 225. Healthy blood contains, upon an average, 8 parts in 1000 of mineral substances (exclusive of the iron of the red corpuscles ;) these are principally in the condition of salts,—chlorides, carbonates, phos- phates and sulphates of soda, potash, magnesia, and lime. The chlo- ride of sodium is singularly constant in its proportions,—the phos- phates in larger amount in carnivorous animals, and the carbonates in herbivora. Rose thinks that the phosphates are only formed at the instance of the destructive oxidation of the phosphorized fats, the phos- phoric acid then taking the alkaline bases from carbonic, and the or- ganic, acids. He holds a similar view with regard to sulphur, iron, sodium, potassium, &c, which, existing in the blood and in other ani- mal constituents in an unoxidized state, take an important part in their metamorphoses. The saline matter dissolved in the blood tends to preserve the form of the red particles and the fluidity of the fibrin. The phosphate of soda dissolved in the serum enables that fluid to take up twice its volume of carbonic acid (as much again as water can absorb.) Phosphate of pot- ash is devoid of this important property. It is most probable that the phosphate of potash and chloride of sodium in the blood are constantly effecting each other's decomposition, phosphate of soda being found to render the serum powerfully absorbent of carbonic acid, and the potash being employed in the construction of muscular substance. Potash is as essential to the composition of muscular tissues as phosphorus is to that of nervous matter. The earthy salts supply inorganic ingredients to the various tissues; and especially the phosphate of lime, which appears to be essential to the formation of rudimentary cells. Vogel states that the salts of the blood are in excess in scurvy, and cause the hemorrhagic disposition in that disease; but this does not accord with what has been observed in this country (§ 196.) He also thinks that the same influence renders the red corpuscles granular or puckered at their margin by withdrawing some of their fluid contents. Such a condition of the red corpuscles, as well as an excess of saline matter, was present in the blood of a boy suffering from purpura, who was under my care a few years since. There can be little doubt that the thirst induced by the use of salt SALINE MATTER—DEFICIENT. 167 food is connected with the excess of saline matter then thrown into the blood, which causes a shrinking in the red corpuscles, and makes them attract, by endosmose, fluid from the textures and surfaces, wherever they come ; this constantly setting up fresh demands for liquid, pro- duces the sensation that prompts drinking as the natural means of fur- nishing the supply. 226. Diminution of the ordinary quantity of saline matter in the blood has been said by Dr. Stevens to take place in yellow fever and in other pestilential diseases, and to cause then so dark and grumous a state of the blood, that free exposure to air will not render it florid, as it generally does. This has been distinctly ascertained to be the case with regard to malignant cholera, by Dr. O'Shaughnessy; and the defect of saline matter and water seems to be the immediate cause of the obstructed circulation, lividity, and collapse, so remarkable in the advanced stage of that terrible disease. Dr. Mackintosh found in some extreme cases that the blood was extensively coagulated in the heart and large vessels. There can be no doubt, therefore, that in these circumstances the blood coagulates in the vessels for want of sa- line matter, and that the red corpuscles become partially dissolved and altered. Hence the temporary efficacy of injection of saline solutions into the veins of cholera patients; it seems at once to renew circulation, respiration, warmth, and other vital functions, as if the saline solution were the only thing needed. But the defect in the blood is a result of the excessive evacuations of serum from the stomach and bowels which are the effect of the action of the poison; and if these go on, the good influence of saline injections is soon exhausted.1 227. The researches of Andral scarcely support the notion enter- tained by Dr. Stevens, that the salts of the blood are deficient in typhus fever. If saline medicines are useful in common continued fevers, it is a question whether it is in consequence of their supplying what is deficient, 1 It has been stated that in many cases of malignant cholera there is little or no dis- charge from the stomach and bowels, and yet the symptoms of collapse proceed as usual; but so far as my limited experience has permitted me to judge, it appears to me that there is a relation between these symptoms and the loss of serum from the intestinal surface. In the worst cases, where the prostration is most complete, this serum is not evacuated, but distends the intestines, and on palpation may be felt, giving the feeling of liquid weight in the abdomen, which is remarkably dull on percussion. Doubtless the forcible and speedy discharge of this secretion is an evidence of a strong reaction endeavoring to rid the system of the poison; and I quite agree with those who objeot to the practice of beginning the treatment with astringents and opium. To aid and equalize the expul- sory effort by remedies which promote the biliary and renal, as well as the intestinal se- cretions, seems to be the first indication. But it may soon be necessary to moderate the excessive discharge, and allay severe pain and irritation, sometimes by moderate but fre- quent doses of astringents and narcotics, but always by ice and cold beverages internally, and by heat, stimulants and frictions very freely and assiduously applied to the surface and extremities. Whether this treatment shall prove successful or not, will depend on the intensity of the poison and the power of the constitution to resist its influence. At the outbreak of the epidemic the poison is usually so strong that the larger proportion die in spite of all treatment; as the epidemic declines, the treatment proves more success- ful -md the plurality of cases recover. It is during the balance between the contending forces that saline injections into the veins may save life—not by curing the disease, but by counteracting its fatal effects on the blood, so that longer time is gained. This mea- Bure therefore, should not supersede others, which are indicated by the symptoms of the 168 CONSTITUENTS OF THE BLOOD. or whether it may not rather be through the augmentation of torpid secretion (§ 171,) and the removal or counteraction of septic influences present in the system (§ 98, 105.) Certain it is that not only in feverish affections, but in that very numerous class in which the urine is scanty, high colored, highly acid, and often depositing a sediment of lithates or oxalates, and frequently the coated tongue, thirst, disturbed appe- tite, and depraved secretions, show the unhealthy condition of the ali- mentary canal. Saline solutions, especially in the effervescing state, are most beneficial and grateful, and often correct what is disordered in the secretions. In prescribing these salines, however, it is right to bear in mind the influence which they may have on the composition of the blood, and so to combine the alkalies that neither shall have a dis- turbing preponderance. With this view soda and potass should both be given, with the addition of ammonia if the dryness of the skin or the weak state of the circulation should indicate it. This method of com- bining the alkalies much increases the utility of saline medicines ; but if exhibited long they have a tendency to weaken the digestive powers and to cause flatulence and distention of the abdomen. This may often be counteracted by the addition of a minute proportion of a salt of iron, which endows the medicine with a tonic property. It is stated by Henle that a diminution of saline matter takes place in the blood of inflamed blood-vessels, but this statement seems to be no more than an assumption made in aid of his favorite explanation of the obstruction in inflammation. SECTION XII. WATER. 228. The average proportion of water in healthy blood may be stated at about 79 per cent. It is obvious from what has been already said, that this proportion increases as that of the organic constituents de- creases. Thus, after excessive hemorrhage, 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 a tendency to dropsical effusions and fluxes, besides the consequences which result directly from the relative deficiency of the other constituents of the blood. 229. I have before suggested (§ 187) the question for consideration, whether the serious functional disturbance sometimes following the ingestion of very large quantities of liquid, particularly after exertion when absorption is active, may not in some degree arise from the too copious and sudden addition of water to the blood. Certainly tempo- rary plethora, with palpitation, and feeling of oppression or dyspnoea, often results from the too free ingurgitation of liquid, and is not removed until perspiration, or a free flow of urine, relieves the overloaded vessels. These effects are most distinctly observed when some structural disease of the-organs of circulation or respiration incapacitates them for meet- ing the increased task. Hence the aggravation that occurs in the WATER—DEFICIENCY—WATER CURE—EXCESS—DRY CURE. 169 symptoms of disease of the heart and lungs, when too much drink is taken. The colliquative sweats in phthisis seem to arise from a similar cause, and may often be relieved by a judicious reduction in the quan- tity of liquid food. 230. Deficiency of water in the blood is exemplified in epidemic cho- lera, in which the specific gravity of the serum has been found as high as 1045(Lecanu;) this implies a reduction of the ordinary quantity of water to the extent of nearly one-half. 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 undistended state of the vessels, indicate the di- minished bulk of the circulating fluid; and thirst pretty constantly points out the mode which nature suggests as a remedy for the defect. Ex- posure to heat, especially if long continued, and prolonged violent ex- ercise, expend the water of the blood, and cause the feeling of thirst which prompts to its restoration. Long-continued abstinence from drink has a similar effect. It has been already mentioned, that the extraordinary decrease ot the water of the blood in malignant cholera renders that liquid so thick that it cannot circulate freely, and that this change is the chief cause of the cessation of the pulse, lividity, and other signs of obstructed cir- culation. No such effect is, however, known to accompany any of the other states where water is deficient, The influence of heat and pro- longed exertion is complex, and therefore not referable to this princi- ple only. Abstinence from drink for two or three days induces languor, small and easily accelerated pulse, a somewhat dry and pasty state of the mouth, and scantiness and turbidity of the urine, but little derange- ment of other functions. The digestive process, which might be ex- pected to suffer, in some cases at least, shows no symptoms of disorder. 231. We thus have the power of increasing or diminishing the quan- tity of water in the blood by increasing or diminishing the quantity of liquid drunk; and these expedients may be usefully employed in cases such as are mentioned above. But these expedients also furnish us with therapeutic agents of more extensive power when they are em- ployed in extremes. Drinking large quantities of water may excite the whole vascular system and its connected secreting organs, and may, in a salutary manner, wash out of the blood various effete or noxious matters; it is in this way that the "water cure" sometimes produces its beneficial effects. The free use of liquid ingesta is supposed by Prout to prevent the formation of lithic acid, or, according to Liebig s views' it facilitates the conversion of lithic acid into urea. From the experiments of Dr. Bocker (Brit, and For. Med Rev Oct, 1854 p. 393 ) it is proved that large draughts of water reduce the weight ot the bodv by accelerating the metamorphosis of tissue and in increasing its elimination through the kidneys and bowels. On the other hand a total abstinence from drink for two or three days is an effectual mode of stopping fluxes, and of relieving catarrhal inflammations and con- eestions Either plan exerts an alterative operation on the circulation and secretions, which, if more studied, may perhaps be turned to good 170 ELEMENTARY CHANGES IN THE BLOOD. account in the treatment of many diseases. But their injurious effects should be held in mind: thus the " water cure" is known to produce an eruption of boils on different parts of the body ; and these, although considered by the advocates of this system as symptoms of a salutary crisis, are a serious and sometimes dangerous evil; and most probably proceed from an injury done to the blood and the nutritive function by an excess of water, which tends to injure the red corpuscles, and thus to spoil the blood, and to increase the waste of the textures. Again, the "dry-cure," by abstinence from liquids, may cause faintness and exhaustion in weakly persons, and might be hurtful in those subject to urinary gravel. SECTION XIII. CHANGES IN THE BLOOD BY RESPIRATION. 232. The process by which venous blood is made arterial, and ren- dered fit for its purpose of maintaining the life and functions of the several parts of the body, is liable to be variously modified; and the differences in the state of the blood thence resulting form important elements of disease. The conversion of venous into arterial blood is effected by the ab- sorption of oxygen, and the removal of some carbonic acid and water; and a slight increase in the proportional amount of fibrin is the constant accompaniment of these changes. Each of these several parts of the process is probably concerned in giving to arterial 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, superfluous fat and other combustible matters consumed, and heat evolved; the re- moval of the carbonic acid being the excretion of a noxious matter; and the renewal of the fibrin supplying the loss of that plasma occa- sioned by the waste of the fibrous and membranous structures. 233. It is doubtful whether the respiratory changes are ever carried on in excess ; for, by an admirable adaptation, the activity of respira- tion is proportioned to the rapidity of the circulation and the corre- sponding need of alteration in the blood.1 Thus exercise accelerates 1 It seems to me that Professor Liebig has given too mechanical a view of the change of the blood in respiration. He appears to consider the increased arterialization, during exercise and on exposure to cold, to be a necessary consequence of the greater amount of air inhaled, in one case in consequence of accelerated movements of the chest, in the other in consequence of 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 re- ceived into the lungs, how easy would it be to increase them (and thereby animal heat also) by voluntarily augmenting the respiratory movements. I cannot but think that the proportion of oxygen absorbed, and of carbonic acid expired, depends more on the condition of the blood brought to the lungs, and that the respiratory movements are re- gulated by this. Thus the increased oxygenation of the blood is a consequence of greater changes previously wrought in the blood itself, and not a mere result of a fuller access of air. In confirmation of this view I may mention an experiment which any one can repeat; if a succession of moderately deep and quick respirations be performed during several minutes at a pretty low temperature, the effect is to cause feelings of chilliness CHANGES BY RESPIRATION—INCREASED. 171 the circulation and changes of the blood, and also augments the breath- ing movements. In fevers 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 operations is augmented in the same 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 be a correct observation, the hyper-arterialization of the blood may per- haps account for the unusual quantity of fibrin which is present in the disease. I must, however, remark that I have found the excess of fibrin in cases in which there had been no remarkable acceleration of the pulse or respiration. We shall see hereafter that the increase of fibrin is connected rather with the local inflammation than with the fever. 234. From the experiments of the late Mr. Broughton, it appears that when animals are confined in oxygen gas, they die comatose in the course of a few hours : the respiration first ceases, whilst the heart continues to beat with vigor, and the blood even in the veins is quite florid: the blood 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 through previous excitement, or by the increased coagulability of the blood, or by the excessive production of carbonic acid, has not been decided. The last named mode of explanation 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 exclu- sion of oxygen, appears from an experiment by Rolando: he found that the air-tube of one lung of the land tortoise may be tied without ma- terially injuring the animal, but that 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. 542.) 235. Defect of change in the blood by respiration is a common and important cause of disease, and constitutes a chief feature in affections of the respiratory apparatus. Being the essence of the special disease asphyxia or apncea, its minute consideration belongs to special patho- logy, and we shall here only describe 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 evil. An acute attack of disorder in the organs of respiration may prove distressing, and even fatal, although the impediment to the breathing is much smaller than that caused in some chronic diseases, where nevertheless, in consequence of the gradual nature of the in- fringement, the mischief is scarcely perceived. Thus, too, patients and faintness rather than of increased warmth and energy ; it is like extinguishing a fire by overblowing it. It appears certain, however, that moderate cold to the surface of the body, as by cold bathing, increases the respiratory process; for it not only renders the respiration more frequent, but it causes more urea to pass off in the urine, which is an evidence of accelerated oxidation. 172 ELEMENTARY CHANGES IN THE BLOOD affected with extensive emphysema of the lungs are habituated to an imperfect state of respiration, which is shown by a constant lividity of the lips and cheek; such an appearance would be a sign of approach- ing death in other persons. The cause of this difference is not merely the general fact that sudden changes produce more effect than slow changes ; it lies chiefly in this ;—that the importance of the respiratory function varies under different circumstances. When the several parts of the body, especially the muscular organs, are in a state of full ac- tivity, more breath is needed to remove from the blood the noxious ef- fete matter which is always produced by functional exercise. Hence in such a condition (which is that of healthy action) the respiratory process cannot be abridged without serious disorder. This disorder is first obvious in the increasing sense of oppression and suffocation which the want of breath causes, and which excites forcible exertions to breathe. If these exertions still fail to duly aerate the blood, it partly is arrested in the lungs, right compartments of the heart, and veins, and partly passes in an imperfectly arterial state to the left side of the heart, and to the arteries. 236. The phenomena of asphyxia are thus compounded of—1, accu- mulation of blood in the venous system; 2, diminution of blood in the arterial system; and 3, deficiency of oxygen and excess 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 last is injurious,—negatively through want of oxygen, the proper exciting agent, and positively from excess of carbonic acid and other excrementitious matters, which are sedative influences. The symptoms induced are also of two classes—1, those implying failure of function, such as muscular debility, feeble action of the heart, pallor and coldness of the surface and extremities, and loss of the sensory and mental faculties; and 2, those arising from con- gestion and the noxious influence of the black blood, such as palpita- tion, flashes in the eyes, noises in the ears, delirium, muscular spasms, stupor, &c. Either of these sets of symptoms may predominate in different cases, and hence a variety in the phenomena of asphyxia which has not been sufficiently noticed by writers on the subject. 237. But we have also to notice the other mode in which the changes in the blood effected by respiration may become defective, that occur- ring gradually, or when the vital functions are in a languid state. It is well known that hybernating animals scarcely breathe at all, and yet live; this is obviously because their vital functions are reduced to an extremely torpid state. So, too, animals newly born will bear the privation of air for a much longer period than those which are older; 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.) Although a man cannot be reduced to the torpidity of hybernation, yet it is certain that he may be brought to bear a defect in the respiratory blood-changes, which would be fatal in a few minutes under common circumstances. This is seen when the defect is congenital, as in those affected with malfor- mations of the heart causing cyanosis; and it is also seen where the defect is very gradually induced, as in emphysema of the lungs. BY RESPIRATION—DEFECTIVE—APNCEA—HYBERNATION. 173 238. In cases of cyanosis, (the blue disease, in which, from malfor- mation 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 processes of nutrition 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 is 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 circumstances that tax their activity. In the few that reach mature age, there is no sexual pas- sion, which seems to be a happy provision against the chance of per- petuating a race of imperfect beings—human reptiles. The subjects of cyanosis are said to be very liable to hemorrhages, and when these occur spontaneously, or from accident, it is very difficult to stop them. This must be ascribed to the deficiency of fibrin which we already stated to occur where the changes of the blood by respiration are im- perfect (§ 196.) The same peculiarity occurs in the foetus. 239. In connection with the scantiness of fibrin in the blood, when the respiratory changes are defective, we must notice that the exces- sive deposition of fat, which often occurs, agrees very well with Lie- big's idea that respiration directly consumes the oily parts of the blood; the respiration being defective, the fat accumulates (§ 224.) Liebig appears to suppose that the poisonous action of hydrocyanic acid and sulphuretted hydrogen is due to their rendering the iron of the red corpuscles of the blood incapable of absorbing 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 hydrocyanic acid exhibits the usual changes on exposure to the air. Sulphuretted hydrogen does seem permanently to injure the composition of the blood, but it does not affect the red corpuscles merely; for it renders the blood fluid, as well as of a dirty red color. It does not seem possible now to deny the fibrin and al- bumen a share in the absorption of oxygen, as well as the chief place in furnishing the material on which that oxygen afterwards acts.1 240. Remedial measures.—Besides the obvious measure of endea- voring to restore the respiratory function where it is defective, the view taken above of the mode in which the defect is hurtful (§ 236) suggests means by which its injurious effect may be diminished. What- ever lowers the activity of the vital functions will often give relief. Complete rest of body and mind; warmth to the surface and extremi- ties, whilst air is supplied cool and fresh to the face and air-passages ; and the employment of various sedatives, which reduce the circulation and other vital functions to a lower standard, (or, in the language of 1 The opinion thus expressed in the former edition corresponds with the views of Mulder, Scherer, and others, subsequently published; but these chemists seem to me to go to the opposite extreme in assigning to the protein the chief share in the process of absorbing oxygen. Many facts (g 183, 188,) combine to prove that the red corpuscles are pre-eminent in their power to absorb and convey oxygen, although it is by no means certain by what chemical property they do so. 174 ELEMENTARY CHANGES IN THE BLOOD Laennec, diminish the want of breath,) such as digitalis, conium, hyos- cyamus, &c, should all be adopted. Other medicines, such as ether, belladonna, stramonium, lobelia, &c, sometimes relieve dyspnoea, but they probably act in another way by removing spasm or other me- chanical impediments to respiration. 241. In extreme cases bordering on asphyxia, the enfeebled circula- tion may require stimulants (§ 235,) and the engorgement of the venous system may call for depletion at the same time ; in different instances one or the other of these conditions may most need attention ; some- times both must be attended to in the same case. It appears from the researches of Chossat, Erichsen, and others, that no stimulant is so generally useful as that of heat to the whole body; and in the ex- perience of the officers of the Royal Humane Society, the warm bath has been found the most useful remedy in restoring animation sus- pended by submersion. Warm frictions and stimulating applications are likewise very serviceable in exciting the failing circulation. 242. Experience has not yet furnished us with any other means of arterializing the blood than the process of respiration. This process may in some cases be carried on artificially, either by mechanical means, such as the inflation of the lungs, or by electricity applied to the mus- cles of respiration, (the diaphragm and abdominal muscles alternately ;) or it may be helped by bronchotomy; or by chemical means, such as the supply of pure oxygen or nitrous oxide. Whether the internal ad- ministration, or the injection into the veins, of saline and other mat- ters containing much oxygen in loose combination, such as the chlorates, nitrates, and some peroxides, may not be made to aid in some degree in compensating for defective respiration, is worthy of consideration and more extensive trial than it has yet received. If these matters could furnish oxygen to the blood, they would yet leave unaccomplished 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 potassae combined with chlorate of potash. Possibly warm baths containing these ingredients might be made serviceable, as well as friction of the surface of the body with these solutions and those of similar matters. 243. The congested state of most organs, which occurs when the respiratory process is imperfect, necessitates the employment of re- medies suitable to the removal of this condition ; it is from a disregard of this consequence of imperfect breathing that many fall victims to the secondary effects of apnoea. The lungs, the brain, and the liver suffer from it most. The best remedies in these cases are mercurial, and other medicines which act freely on the secretions (§ 173.) Pro- bably these act in part by making the liver assist the lungs in their office of decarbonizing the blood. Tlhe speedy relief afforded to dys- pnoea by a bilious diarrhoea has several times seemed to me to coun- tenance this notion. 244. When the respiratory changes of the blood are reduced by dis- ease within a narrower sphere, it becomes an object not to increase the BY SECRETION—URINE—DEFECTIVE. 175 hydrocarbon of the blood by the use of food with much fat or by the employment of spirituous liquors ; lean meat and other fibrinous arti- cles, with farinacea and fruit abounding in vegetable acids, should form the chief sustenance. SECTION XIV. CHANGES IN THE BLOOD BY SECRETION. 245. Having already noticed this subject under the head of diseased secretion (§ 158,) it will be unnecessary to dwell long on it here; but it will be useful to glance at the changes which result from the re- tention in the blood of matter which ought to be excreted, and which gives rise to various important disorders. The most remarkable instance of disorder arising in this manner is exhibited in defective secretion of urine (§ 70, 170.) The extreme power of this as a cause of disease was shown in experiments first per- formed by Prevost and Dumas, in which the kidneys of animals were extirpated. On the third day after the operation, there came on vo- miting, diarrhoea of a copious brown liquid ;' fever, with heat sometimes as high as 110°, and at other times as low as 92°; pulse very small and frequent; breathing labored: death ensued from the fifth to the ninth day. After death there were found effusions of serum in the brain, copious mucus in the bronchi, and bilious fluid and feces in the intestines. The liver appeared inflamed (?) and the urinary bladder much contracted. The blood was more watery than is natural (§ 222,) and was found to contain urea to a large amount: thus five ounces of blood of a dog yield twenty grains of urea; and two ounces of cat's blood, ten grains. 246. The symptoms induced in defective secretion of urine resulting from degenerative disease of the kidneys are very similar to those just mentioned, but more diversified, partly from the defect taking place in different degrees as to amount and time. Thus, in acute cases of albuminuria, or acute aggravation of old ones, there may be epileptic convulsions, low delirium, and other typhoid symptoms passing into coma (§ 129,) suffocative catarrh, obstinate vomiting, diarrhoea, or in- flammatory effusions in the serous cavities, any of which may end in death. In slower cases, cachexia and dropsy may ensue more gradu- ally, as the blood and solid structures become altered. _ All these effects may be traced to excrementitious matters being retained in the blood, and especially urea, which has in very many instances been detected in considerable quantities: when in the greatest amount, acting on the nervous system as a narcotic poison (§ 129 ;) when in smaller, operating as an irritant, and inducing low inflammation in various « From the researches of Bernard and Barreswil it appears that the matter excreted from the intestines contains a quantity of ammoniacal salt which results from the elimi- nation of urea from the surface.—Dr. Day's Lectures on Animal Chemistry, Med Gaz., Sept., 1847. 176 ELEMENTARY CHANGES IN THE BLOOD membranes and viscera ; and in still lower degree, causing sundry func- tional disorders, fluxes, and dropsies, impoverishing the blood, and in- ducing degeneration of certain textures (§ 212.) It has been before mentioned (§ 170) that Professor Frerichs ascribes the worst effects of urea in the blood (coma, convulsions, &c.) to its being converted into carbonate of ammonia by a further fermentative process; and this notion is rendered more probable by the fact that urea is sometimes present to a considerable amount in the blood without any serious symptoms. But the tendency to local inflammations and effusions, and gradual degeneration of the blood and textures probably depend on the imperfect elimination of urinous matter from the circulating fluid.1 It has been already mentioned that the blood in albuminuria loses its proper amount of red corpuscles (§ 185) and 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 different cases, and the treatment should be varied accordingly. 247. The effects of a defective secretion of bile have not been so accurately determined. The presence of bile in the blood is often ob- vious in the yellow color of the serum and fibrin, which changes to the characteristic green on the addition of nitric acid ; in such cases, analysis has discovered, besides the bilin and the biliphaBin, an increase of fatty matter to double or treble the ordinary proportion. In several cases of fatal jaundice connected with structural disease of the liver, I have observed extensive ecchymoses on the legs, which were probably due to the destructive influence exerted by bile on.the red corpuscles (§ 187 ;) 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, the most effectual treatment being accordingly by the use of me- dicines which this circumstance suggested. The presence of bile in the blood, although sometimes causing tingling, pruritus, and cutaneous eruptions, does not appear to produce so much local irritation and in- flammations, or change of the blood constituents and general dropsy, as that of urea does. Bile seems to be effete and noxious matter rendered comparatively harmless that it may be again absorbed into the blood and employed as a fuel in support of the animal temperature, before it is finally expelled from the system. Still it appears from very pro- longed cases of diseases of the liver with or without jaundice, in which the dropsy is not local merely (ascites,) but general (anasarca and hydrothorax,) that the blood at last is impoverished, and that the whole body becomes cachectic. Andral found that in dropsical sheep,with flukes in the liver, the albumen, as well as the red corpuscles of blood, was diminished. Symptoms of giddiness, faintness, drowsiness, and nausea often occur in connection with imperfect action of the liver, together constituting what is commonly designated by the term bilious attack, and these are relieved by medicines which promote a free flow of bile ; but whether all this is caused by retention of the excrementitious mat- 1 The diminution of the salts in the urine, particularly the chlorides, noticed by seve- ral observers to occur in various inflammatory diseases, is probably connected with a corresponding increase in the diseased parts. BY SECRETION—DEFECTIVE—UREMIA—REMEDIES. 177 ter in the blood, or by the sympathy (§ 152) of the brain and heart with the stomach and liver, is uncertain ; but in severe cases the symp- toms are sometimes alarming from the depression of the heart's action, feeling of death-like oppression, and overwhelming vertigo ; a very acid fluid is often vomited, and subsequently bile in quantities ; and not unfrequently a very dark-colored bile passes downward with great relief to all the symptoms. 248. The remedial means to be directed against an accumulation of the urinous constituents in the blood comprise chiefly medicines which increase the secretions (eliminants,) and those which counteract the pernicious influence of the excrementitious matter on the various func- tions including that of nutrition. Of eliminant remedies, doubtless, diuretics, which may restore the function of the failing secretory organ, are most called for; but it often happens that the kidneys are diseased, and will not answer to their usual stimuli, as it occurs in inflammation, extensive congestion, and degeneration of these glands. Under these circumstances, purgatives, especially those that excite a copious watery discharge, and diaphoretics, may give relief, by effecting the purifica- tion of the blood by other emunctories ; and in case of coma, convul- sions, or extensive dropsy from uraemia, these remedies, if freely and promptly used, often succeed in averting a fatal result. In this way a dose or two of calomel, followed by repeated saline purgatives, may give seasonable relief. Saline purgatives and diuretics are generally safer and more efficacious than others ; but croton oil, jalap, gamboge, and elaterium are sometimes required where great promptitude and energy of action are wanted. In more chronic cases, saline purgatives and diuretics are commonly more useful than others, as they seem more surely to act as eliminants where the blood is diseased : but they may be advantageously combined with other remedies, such as the prepara- tions of dandelion, broom, foxglove, &c. To promote diaphoresis, ex- ternal warmth, applied by the vapor-bath or hot-bath, is more effectual than internal medicines; but sudorifics, according to my experience, are much inferior in utility, as eliminants, to purgatives and diuretics. 249. As the effects of uraemia are various in different cases, and even in different parts and functions, the means to counteract them must be varied so far as they have any efficiency. It is uncertain that we have any means of counteracting the narcotic influence of uraemia; but if this depends, according to the notion of Frerichs, on a fermentative conversion into carbonate of ammonia, some good might be expected from antiseptics and perhaps from the mineral acids. In a conversa- tion with Dr. Simpson on this subject, he suggested that part of the beneficial influence of chloroform in cases of infantile and puerperal convulsions (which are generally connected with uraemia) might be due to the chlorine preventing the injurious development of carbonate of ammonia in the blood. In more chronic cases of uraemia, I think I have seen good results from the free use of chlorate of potass and nitric acid, whilst the depression of the muscular power (including the respi- ration,) is combated by diffusible stimulants. But the local action of the urinary constituents in the blood is irritant; hence arise irritation 12 178 ELEMENTARY CHANGES IN THE BLOOD and inflammation of serous and mucous membranes, requiring local antiphlogistic remedies, the most efficient of which are blisters. The tendency of excrementitious matter to impoverish the blood and to pro- mote degeneration of tissues is to be opposed by nourishing diet and by tonics, especially those containing iron ; but these are rarely borne well, unless in very small doses, and they may be advantageously com- bined with iodine, bromine, and salines, as in certain mineral waters, which act as eliminants as well as tonics. 250. The indications of treatment in cholsemia are similar to those in uraemia, with this difference, that cholagogue purgatives take the precedence of other eliminant remedies. The most potent of these are the preparations of mercury; but their weakening operation forms an objection to their being used too largely or too long. They may be combined and followed by saline aperients and diuretics, especially the sulphates of soda, potass, and magnesia, the hydrochlorate and phos- phate of ammonia, together with suitable additions of senna, aloes, and taraxacum, all of which have a distinct influence on the biliary secretion. The nitro-muriatic acid has been reputed to promote the biliary secretion, especially when used in a bath or as a lotion over a large surface of the body. Nux vomica, in the form of extract, and its active principle, strychnia, have also been supposed to exercise some influence on the secretion of the liver, whilst they certainly pos- sess valuable properties as a tonic to the alimentary canal.1 What are called bilious attacks are usually connected rather with an excessive than a defective secretion of bile; but probably the chief symptoms depend on its imperfect elimination from the liver and its ducts, as well as its presence, sometimes in a decomposed state, in the stomach and intestines. An emetic and diluents will give the speediest relief where vomiting is unavoidable, but it should be followed in due time by a mercurial purgative ; and where the sickness is less urgent, the latter, with effervescing salines, is generally sufficient. For the prevention of these attacks, it is important to avoid all fat and highly- sweetened articles of diet ; to be very moderate in the use of fermented liquors ; to use regular exercise, especially on horseback ; and carefully to attend to the action of the bowels. 251. The perspiratory secretion contains lactic acid and lactates of soda and ammonia, which probably proceed from the transformation or decay of the textures, particularly the muscular, which the researches of Liebig have shown to contain a large preponderance of this acid (Chemistry of Food, &c, 1847.) Hence these products abound during great muscular exertion; and when perspiration is checked by external cold (§ 77,) they are accumulated in the blood, thus often causing rheu- 1 In cases of prolonged jaundice, after mercury has been used as long as is prudent, and the feces are still without bile whilst the urine is deeply tinged and loaded with lithates, the most generally useful combination of remedies that 1 have tried has been that of an effervescing draught comprising the three alkaline carbonates, with strychnia in doses of one-fortieth to one-twentieth of a grain, dissolved in the citric acid used for the saline, whilst the surface of the body is sponged twice daily with a nitro-muriatic acid lotion. The extract of nux vomica in doses of one-sixth to one-third of a grain, twice or thrice daily, is a useful addition to a pill of rhubarb, aloes, or taraxacum, in cases of torpidity of the liver and bowels, when it is desirable to avoid the frequent use of mercury. BY SECRETION—PERSPIRATION—DEFECTIVE. 179 matism, urinary disorders, or cutaneous diseases. The very serious effects that sometimes result when cold is suddenly applied to the per- spiring body may be partly referred to the same cause, as well as to the disorder produced in the circulation.1 Rheumatism is especially liable to occur as an effect of cold and wet, when the body is fatigued by much muscular exertion (§ 30;) and I have sometimes observed that the rheumatism chiefly affects the limbs which have been most exercised. When the skin fails to excrete, increased work is thrown on the kidneys, and hence may result various diseases of these organs: if these organs fail in the performance of their task, the lactic acid accumulates in the blood, and, probably acting as a ferment (§ 56,) causes the formation of more and of kindred products : these, in inflammatory subjects, ex- cite rheumatic fever ; that is, fever, with inflammation of more or fewer of the joints, and often of the membranes of the heart. In cachectic persons the same acid matters cause miliary fever, erysipelas, or pem- phigus; and in more torpid frames, various local rheumatic or gouty affections. All these cases are frequently remarkable for the acid cha- racter of the cutaneous and renal excretions,2 and in a few instances the blood has been said to possess acid qualities, or to be deficient in its usual alkaline reaction. (Dr. Day's Vogel, p. 80.) I have never detected any approach to an acid reaction in the serum of the blood in any dis- eases, but repeatedly I have found the effusions in serous membranes decidedly acid. In one case of peritonitis, in which the peritoneal fluid caused smarting of the hands of the operator, it was found to redden litmus paper most strongly. Dr. Garrod, in rheumatic cases, always found the blood alkaline.3 He could not discover any lithic acid in the blood of patients with rheumatism, whilst it was always present in that of the subjects of gout. In low forms of rheumatism, especially the neuralgic, the materies morbi is probably oxalic acid, as was originally suggested by Dr. Prout; for I have in numerous in- stances found an abundance of the octohedral crystals of oxalate of lime in the urine, especially when the patients began to convalesce. The only instance in which oxalic acid has ever been detected in the blood was that of a patient suffering from chronic gout, who was for some time under my care at University College Hospital. In this case Dr. * Garrod detected a very appreciable amount of crystals of oxalate of lime in the blood. The man died dropsical with albuminous urine; the uriniferous tubes were found obstructed with lithate of soda. (Med.- Chir. Trans, 1850.) 252. The treatment in rheumatism, and other diseases arising from defective excretion, therefore, should not be merely antiphlogistic, but also of a kind calculated to eliminate the morbid matter from the blood. > Dr. R. Willis has suggested that checked perspiration may prove hurtful by rendering the skin dry, and therefore unfavorable 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 also pernicious effects should always result from a dry state of the skin. In neither case is this consistent with facts. 2 In patients with acute rheumatism, I have frequently found the perspiration of the affected joints more strongly acid than on other parts. The vesicles of miliary eruption contain a fluid which also strongly reddens litmus paper. * Med.-Chir. Trans., 1854. 180 ELEMENTARY CHANGES IN THE BLOOD. In slight cases, topical heat, stimulant frictions, and sudorifics may suffice for the cure ; but in most instances, the kidneys and liver should be excited to assist in the process of elimination ; and various combina- tions of colchicum and alkaline carbonates and other salines, with mer- cury, opium, and iodide of potassium, generally effect this purpose very satisfactorily, and speedily and permanently remove the disease. Where the disease is more decidedly asthenic, and the urine exhibits a deposition of oxalate of lime with, or instead of, lithates, or acid phosphates, great advantage may be often derived from the employ- ment of measures calculated to raise the tone and vital energies of the circulating and secreting organs, such as the administration of bark, quinine, arsenic, and iron; and these remedies are the more eligible in cases of neuralgic rheumatism, because the attacks are then periodic, with intervals of depression that are highly favorable to the influence of the medicines. Within the last few years two new remedies for rheumatism have been much extolled, as effecting a cure more surely and rapidly than any mode of treatment previously in use. One is nitrate of potass in large doses (from 3ss to Jiij per diem) much diluted with barley-water, ptisan, or other diluent. This treatment was strongly recommended by several English physicians of the last century, and has recently been introduced in France by M. Martin Solon, and here by Dr. Ba- sham. The other is lemon-juice, also given in large quantities, as first advised by Dr. Owen Rees. There is good testimony in favor of each of these remedies, and the trials which I have made of them have con- vinced me of their utility; but for certainty and speed in curing rheu- matism, they do not appear to me to equal the combination of colchi- cum with alkalies, which I have been in the constant habit of using during the last twenty years. Both nitre and lemon-juice have more action on the kidneys than on any other secretion, and this is the ef- fectual mode in which colchicum with alkalies operates; but it is not improbable that the former remedies may have a more direct alterative action on the composition of the blood, promoting the destruction of the acid morbific matter by combustion or some process of decomposi- tion. The acid of lemon-juice is itself certainly decomposed in the system; and it may in its own destruction involve that of the kindred lactic or other acid which causes the rheumatism. In this way the alkaline lactates are certainly decomposed in the healthy body, the lactic acid being converted into carbonic acid and water in the course of the circulation.1 Neither the lemon-juice nor the nitre treatment has so depressing an effect as that with colchicum, and therefore they may be more eligi- ble for cases unattended with much inflammatory excitement; but, it may be added, that they are inferior to colchicum in the severer forms of the disease, where many joints are affected, and especially those ' Dr. Bence Jones has found that the large exhibition of lemon-juice causes the appear- ance of lithic acid crystals in the urine ; and he justly remarks that this might lead to the formation of red sand or calculus (Med. Times and Gazette, Oct., 1854.) This re- sult may be prevented by adding a little carbonated alkali to the lemon-juice, an expe- ' dient which I have generally adopted. TREATMENT OF RHEUMATISM. 181 complicated with inflammation of the membranes of the heart; in which case, also blood-letting, mercurials, and other antiphlogistic remedies are required in addition. My own experience would lead me to assign to colchicum with carbonated alkalies the highest place in the list of remedies for rheumatism, this being the one most efficacious in subduing the specific or rheumatic element of the disease ; but it is insufficient where inflammatory excitement runs very high, or involves the heart in inflammations which are not merely rheumatic in nature; under these circumstances, blood-letting, local and general, calomel and opium, and at a later period, blisters, are required in addition to the colchicum and alkali. Opium or morphia also affords most valuable aid in the treat- ment of cases of extreme pain or nervous excitement; and also where the bowels are irritable and are disposed to diarrhoea under the influ- ence of the colchicum. The proper curative action of the latter medi- cine is through the kidneys; and its beneficial operation is generally accompanied by an increase in the solid constituents of the urine, as in- dicated by its quantity and specific gravity. The diarrhoea produced by colchicum and other purgatives often reduces rheumatic swellings for a time; but the improvement is not lasting, and there is usually a relapse of the disease so soon as the purging ceases. The eliminating process which colchicum establishes through the kid- neys should be kept up for some time after pain and other local symptoms have been relieved; but this may usually be effected by reduced doses, and its weakening operation may sometimes be counteracted by combi- nation with bitters or mild tonics. In cases where the stomach and bowels do not tolerate the colchicum, a substitute may be found in iodide of potassium, but it is by no means of equal efficacy. Both the disease itself and the chief remedies used to subdue acute rheumatism, cause an expenditure of the blood and tissue material, and therefore a tonic and nutrient treatment is required to re-establish the health; and for this purpose, quinine, iron, the mineral acids, and cod- liver oil, deserves especial mention as the most suitable aids to nourish- ing diet.1 . „ ,. It is well to bear in mind that independently of the action of medi- cines, Nature has her own methods of purifying the blood from the ' The treatment for acute and sub-acute rheumatism generally adopted during my charge at the hospital of University College was as follows: after one mercurial purge, colchicum wine was given to all, in doses varying from twenty to sixty minims with the same num- ber of Safns of carbonate of soda or potash in peppermint water, every four, six, or eight hours, according to the severity of the symptoms. In case of disposition to diarrhoea, a few drops of laudanum were added. In very acute cases with high fever, and many joints implicated, one venesection to twelve or sixteen ounces was sometimes practised; and in cTse of complication with cardiac inflammation, blood was drawn from the region of the heart by cupping or leeches, generally followed by blisters. Under the same circumstances, calomel and opium or morphia, with ipecacuanha, was generally given once or twice daily until the severe symptoms were relieved. The general result of this treatment was that on an average of 300 cases, convalescence fthat is freedom from fixed pain, tenderness, and swelling) was established in five days ; but to secure the patient against relapse, the remedies were continued to from one to thLa weeks after-during the latter half of which period the colchicum was combined lith or replaced by a tonic, and the patients allowed full diet. That the colchicum was • the most efficient anti-rheumatic remedy employed in this treatment was proved by the muc^more tedious process of a few cases in which, on account of irritability of stomach or bowels the colchicum was omitted, and the alkalies and mercurials alone continued. 182 CHANGES IN THE BLOOD BY TRANSFORMATION. materials of rheumatic and kindred diseases; and these methods are the more adequate and efficient in proportion to the vigor of the con- stitutional powers and the moderate amount of the disease. Thus not only by throwing off the acid matter by the kidneys, bowels, and skin, but also by its decomposition by the action of the oxygen absorbed in respiration, may the blood rid itself of the morbid material ; and it is by promoting all these processes that active or athletic exercises gra- dually increased, combined with baths or other water cure, have been sometimes found a very efficient remedy for chronic rheumatic affec- tions.1 SECTION XV. CHANGES OF THE BLOOD FROM THE TRANSFORMATION OF CHYLE AND OF THE TEXTURES OF THE BODY. 253. The changes of the blood resulting from the transformation of chyle and of the textures, involving the processes of nutrition, repara- tion and decay, have been too little examined to supply the pathologist with a complete view of the subject. It seems quite warrantable, how- ever, to connect with these changes some remarkable states of disease, on the pathology of which chemistry has thrown much light, gout, for instance, and other lithic acid diseases (§ 176,) diabetes, both saccharine and ureal, and obesity. 254. Gout, and the commonest kinds of urinary gravel, are now ge- nerally considered to depend on the production in the system of an excess of lithic acid.2 This acid, being a highly azotized compound, is abundantly generated in those who take a large proportion of ani- mal food, and in whom the digestive and assimilative processes are im- paired ; the more these processes are weakened, and the less digestible and assimilable the food supplied, the more surely will be found this acid, with ammonia, the product of degenerating decomposition. Hence the disease is engendered not only as a consequence of general full living and sedentary habits, but especially from the use of highly-sea- soned and over-cooked meats, cheese, pastry, and strong acid wines : the avoidance of such articles is a more effectual safeguard against 1 It appears from the experiments of Dr. S. Lehmann and others (Brit, and For. Med. Chir. Rev., July, 1855,) that the cold sitz-bath distinctly increases the quantity of urea in the urine, probably by augmenting the activity of the respiration, which is rendered more frequent, although the pulse is slower. 2 This view, although generally admitted on inferential evidence, was for the first time proved in the case of a gouty patient of mine at the University College Hospital, in whose blood Dr Garrod readily detected the presence of lithic acid. The case was one of chronic gout, and strikingly illustrated the pathology of the disease by presenting a total absence of lithic acid in the urine, until colchicum had been exhibited for some time, when its characteristic crystals appeared under the microscope. Dr. Garrod has since succeeded in detecting lithic acid in the blood of a large number of persons affected with gout in different forms. It is remarkable that before and during a fit of gout, the lithic acid disappears from the urine; and Dr. Garrod could not detect it in the blood taken from a joint affected with gouty inflammation. It would seem as if the inflammatory process in some way decomposed .the lithic acid. LITHIC ACID—GRAVEL—GOUT. 183 gout, than more general abstinence, which in many cases would be absolutely hurtful. Lithic acid, like urea, is one of the lower forms into which the higher animal principles, fibrin, albumen, and gelatin, tend to pass in their progress towards resolution. Hence it is pro- duced in excess where there is more azotized matter than is wanted for the reparation of the textures, or than the vital assimilating powers can appropriate for such a purpose. It results also from the decay of the textures after much exertion, and especially during febrile or inflammatory irritation, when copious deposits of the lithates appear in the urine. The morbid effects of an excess of lithic acid vary considerably, according to the amount of the excess and to other circumstances. The kidneys 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 l may occur; or the water and the al- kali secreted with it in the urine may be insufficient to hold it in solu- tion, and it may be deposited in the form of crystallized sand or gravel, or calculus, in the kidneys or bladder ; various irritations and obstruc- tions in the urinary apparatus are thus induced. But sometimes the kidneys may fail in their power of elimination (§ 170;) in fact, before a fit of gout, the lithic acid does disappear from the urine; it then, with its compounds, accumulates in the blood, and may cause various forms of irritation and functional derangement (irregular gout, which is extremely common, and of infinitely varied kind and seat:) until at length some circumstances may fix the mischief in a limb, when a fit of regular gout is the result. In this fit, if per- fect, inflammation is excited, and more or less of febrile disturbance, which ends with a copious deposit in the urine, effecting the removal of the morbid matter (§ 165.) The more acute and fixed the inflam- mation, and the smarter the fever, the more abundant is the deposit after it, and the more free is the patient from subsequent disease. 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 re- lieved. It is when gout thus lasts long, or frequently recurs, that 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.3) This chronic form of the disorder is connected with a more or less permanent derangement of the digestive or assimilative functions, and this renders the treatment more difficult, or less suc- cessful, than is that of the more acute forms. In such chronic cases, lithic acid seems to be engendered in great abundance, and although ' I have in several instances found in the cortical and tubular structure of the kidney, clustered crystals of lithic acid, which, under the microscope, exhibited such sharpangles and dagger-shaped projections as would afford an easy explanation of the pain, inflam- mation, and hemorrhage often attendant on an attack of renal gravel, even when none is obvious in the urine , * A case of chronic gout that was under my care in June, 1847, afforded me an oppor- tunity of verifying this observation: the matter obtained by puncturing the white tumors of the patient's fingers was of a consistence of thick cream, and consisted of very fine acicular crystals of lithate of soda, with a trace of lime. Dr Garrod has found little deposits of this kind frequently in the lobe of the ear, and more rarely in the lower eyelid. Their most usual seat is in the small joints of the hands and feet. 184 CHANGES IN THE BLOOD BY TRANSFORMATION. it is thrown off in large quantities in the urine for an indefinite period, yet it never leaves the body free. Such cases are commonly either hereditary, or they have been rendered inveterate by intemperate ha- bits, or neglect of proper treatment. 255. In saccharine diabetes, the morbid matter is of a nature that is quite contrasted with that of gout and gravel, being grape sugar, a wholly unazotized principle; yet this is also probably produced by de- rangement in the processes of digestion and assimilation—the condi- tion of the urine being only a consequence of such disorder. The ana- lyses of Ambrosiani, Maitland, and others, have proved the abundant existence of sugar in the blood of diabetic patients, the specific gravity of whose serum occasionally rises to 1060 from its presence: Macgre- gor has also established the fact of its unusual production during the process of digestion. The facility with which starch and gum can be converted into sugar in the laboratory, especially under the action of acids, throws light on the possible origin of sugar in diabetes; and the actual presence of a very large amount of acid in the stomach in dia- betic patients tends to support this mode of explanation. The appear- ance of sugar in the urine can scarcely be considered otherwise than as a result of its presence in the blood. But sugar is probably formed not only from isomeric principles in the food, such as starch, and gum, but in confirmed cases of diabetes may be also derived from a decay of the textures, especially the gelatinous, through a modification of the process by which urea is naturally evolved; for it has been found prac- ticable to convert gelatin partially into glucocol, which has saccharine properties, and probably consists of sugar and urea. Further, it now appears, from the researches of Bernard, that the liver has the power of forming sugar out of azotized matter; and that sugar thus formed is continually passing through the portal and hepatic veins into the vena cava to the right side of the heart; but it usually disappears in the passage of the blood through the lungs. But in case of the re- spiratory functions being impaired, as from injury to the floor of the fourth ventricle or to the medulla oblongata, the sugar then is not con- sumed in the lungs, but passes into the general circulation and appears in the urine. It is possible then that the sugar of diabetes may arise either from an excess formed by the digestive organs and liver, or by an interruption to the process by which the sugar so formed is usually consumed in the lungs. Even in healthy subjects, an excessive amount of sugar in the food may sometimes cause its presence in the blood and in the urine shortly after a meal; and in aged persons, and in those whose respiration is habitually impaired, as with pulmonary em- physema, the presence of sugar in the urine is by no means uncommon. The trophy and cachexia accompanying diabetes probably 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 often increased considerably be- yond their natural amount. 256. There is a parallel between the indications of treatment in gout and in diabetes, although in the fulfilment of these indications SUGAR—DIABETES CONTRASTED WITH GOUT. 185 the means to be employed are most opposite. In both cases, we must withhold those articles of diet from which the morbific matter can be most readily generated. Thus it is important to withhold animal food and stimulating condiments and beverages in cases of gout, and to use these very articles, excluding all saccharine or amylaceous substances, in cases of diabetes. In both disorders it is advisable that those pro- cesses of digestion and assimilation, from a perversion of which the morbid matter is probably generated, should be invigorated. But, un- fortunately we know too little of the processes, and of the circumstances which influence them, to be able to fulfil the indication with any cer- tainty. A gouty constitution, in the absence of the febrile paroxysms, is often much improved by the use of bitters and other mild tonics; and in diabetes, amendment occasionally takes place during the exhi- bition of opium and some of the stronger astringents and tonics, such as preparations of iron and copper. As in both gout and diabetes the mal-assimilation seems to be connected with an unusual development of acidity in the system, alkalies have been found to be alike useful; for reasons, however, presently to be mentioned, soda and potass are more suited to gout, whilst ammonia and magnesia, or the alkaline phosphate of soda, succeed best in diabetes. To insure their full ef- fect, alkalies must be given largely in the form of carbonates. In the effect which each exerts on the economy, there is a great dif- ference between the morbid matter of gout and that of diabetes. The sugar of the latter has no tendency to accumulate in the system and produce local derangements; but, acting as a powerful diuretic, it passes rapidly away, carrying with it a great quantity of water and of the other constituents of ordinary urine (§ 165 ;) the thirst, dry skin, and emaciation of diabetes, seem to be chiefly due to this cause. The common complication of diabetes with pulmonary consumption shows also that the plastic process of assimilation is therein degraded (§ 211.) Diabetes often terminates in death by coma, from failure of the power of the kidneys to secrete urine (§ 249,) anasarca usually preceding the fatal event.1 i Diabetes is one of those diseases which we may fairly hope to cure when our know- ledge of animal chemistry shall be more advanced. The fact that febrile and inflammatory diseases suspend it for a time, that is, cause the sugar to disappear from the urine is a proof that the morbid production of sugar is not necessarily permanent, and we may there- fore anticipate that it may be prevented by artificial means. Experience has not, however, as vet discovered any agent capable of effecting this in the greater number of cases. Opium, alkalies, permanganate of potass, and rennet, have severally been said to be successful in a few instances, but they have proved of no avail in general experience. Carbonate ot ammonia (gr. x. ter die) has seemed to me the most useful medicine for counteracting the prevailing acidity, which it does without increasing diuresis or general depression. Cod- liver oil is of real service in sustaining the nourishment of the body and removing the craving appetite which is commonly present. The diet is of primary importance in the treatment of diabetes, as the strict exclusion of all saccharine and amylaceous articles constitutes the only sure means of controlling the disease This must be done most rigidly in all decided cases; otherwise little ad- vantage wiil result, from restriction. Dr. Prout permitted patients to eat brown bread and to drink porter; but in my -experience a very small quantity of either of these arti- cles has wonderfully increased the saccharine quality of the urine: neither have I found cluten bread answer; it is difficult to make well, and it is not relished by patients. The best substitute for bread is a biscuit made of fine bran with egg and a little lard, lhe bran must be well washed to remove the flour from it; then dried, and ground fine in a 186 CHANGES IN THE BLOOD BY TRANSFORMATION. The lithic acid of gout and gravel, unlike the sugar of diabetes, has a tendency to accumulate in the body, and to cause the local and general irritations already mentioned (§ 254.) Hence it becomes of great importance 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 vege- table salts, combined with colchicum, or iodide of potassium, saline mineral waters, and alterative aperients. These all increase the action of the kidneys and intestinal canal, and drain off the offending matter from the system; but the operation of colchicum is far more certain than that of the others; and its permanent efficacy depends especially on its continued action on the kidneys more than on any other ex- creting organ. The impropriety of using active antiphlogistic treatment in gout has long been acknowledged; and it is a general opinion that a regular fit of the disease tends to relieve the system from the mor- bific matter, and therefore ought not to be checked or too rapidly cured. Two facts, first ascertained by Dr. Garrod, and confirmed by others, are worthy of note in connection with this subject. One is the disappearance of lithic acid from the urine just before and during an attack of gout, and its reappearance on its decline ; the other fact is the presence of lithic acid in the blood of gouty subjects, and its absence in the blood of the inflamed part. It appears probable, therefore, that the gouty inflammation, when acute and sthenic, tends to get rid of the lithic acid both by its decomposition in the vessels of the inflamed part, and by its elimination through the critical discharges which it promotes at its decline. Instead, therefore, of attempting to subdue gouty inflammation by leeches, cold applications, and reducing measures, it is expedient to promote it by warm coverings of French wadding and oil silk, whilst the pain is allayed by occasional applica- tions of a little spirit, chloroform, or opium, and the critical discharges are encouraged by moderate doses of colchicum with alkalies.1 steel mill (made for the purpose by Mr. White, Holborn ;) and then mixed with the other ingredients and baked into a kind of cake, which is by no means unpalatable, and is very much prized by patients who are deprived of bread. Watercress, greens, and cab- bage may also be allowed with meat; and a little cream instead of milk with tea or coffee. Sound claret, or weak pale brandy-and-water may be used as a stimulating beverage. Although it is doubtful how far a cure can be effected by strict exclusion of saccharine and starchy food, yet it is quite certain that the disease is suspended by it, and patients regain flesh and strength, and may enjoy life for many years. I know several persons who were found to be diabetic from five to fifteen years ago, and who are now in the en- joyment of very tolerable health, although the urine stilf contains sugar. It is very difficult to estimate the efficacy of medicines supposed to have a direct influ- ence in restraining the production of sugar in the system, because the examples in their favor are so few. Instances have occurred within my own knowledge in which the urine lost all trace of sugar when the patients were taking severally, ammoniuret of copper, hydrosulphate of ammonia, tincture of sesquichloride of iron, and liquor arsenicalis. Further experience alone can determine whether in any case these medicines were really instrumental in producing the change. The permanganate of potass (chamseleon mine- ral) was recommended as a remedy for diabetes on account of its remarkable oxidizing property by which it rapidly decomposes sugar and other hydrocarbonaceous elements. ■ The treatment of an attack of simple gout is usually an easy affair; in fact, there often is such a spontaneous disposition to cure, that it may be wise to interfere as little as possible with the process of nature. But it is otherwise with the gouty constitution, which causes a tendency to repeated and prolonged attacks, often of an irregular kind, involving the disorder of various functions and derangement of the general health, without INCREASED FORMATION OF UREA—REMEDIES. 187 257. It is supposed by most chemists, that the urea excreted by the kidneys is chiefly derived from the transformation or decay of the azotized textures of the body (§ 254,) most of their carbonaceous matter being abstracted by the affinity of the oxygen in the blood, and thrown off from the lungs in the form of carbonic acid gas (§ 232.) According to Liebig, whatever excites the activity of the function of respiration, which supplies the consuming oxygen, increases the pro- duction of urea; active bodily exercise acts in this way. Under some circumstances, however, the formation and excretion of urea is much augmented, 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 free production of the matter which seems to be properly a kind of debris of the body, indicates organic debility, or exhaustion of the vital powers, and has been observed to occur in young persons who have grown rapidly, and in those weakened by great mental exertion and want of sleep, or by venereal excesses. An excessive excretion of urea (or of carbonate of ammonia, which is of kindred composition,) sometimes takes place in typhoid fevers, and is attended with great loss of flesh and strength. A great and sudden increase of urea in the urine was ascertained to have taken place, in some patients with acute rheumatism, and in others with delirium tremens, in University College Hospital, at the decline of the fever and other acute symptoms. This perhaps ought to be viewed as arising from the removal of the urea which had accumulated, rather than from an increased formation of it; and this fact may be connected with another ascertained by Professor Chelius and Dr. Lewins, namely, that colchicum causes an augmented discharge of urea and the other organic principles of the urine (§ 252, 173.) The operation of diuretics, especially those con- any disposition to a spontaneous termination. Now this gouty constitution is also depen- dent on the production of an excess of lithic acid in the system; and although generally more amenable to the action of the eliminant remedies, especially colchicum with alkalies, than to any other treatment, yet the weakness of stomach and other organs, occasionally predominant, may much interfere with the use of these remedies and may call for others of a different class. Thus where the circulation is very weak, bitters, tonics, and even stimulants may be necessary to enable the excretory organs to throw off the morbid matter; and any weakening influence which the eliminatory medicines may have, may be more or less counteracted by these means. But there is a seat which the gouty disorder some- times occupies, which entirely interrupts the usual course of treatment, and may render the case unusually grave. This is when it attacks the stomach, causing more or less pain nausea, and obstinate vomiting. Here colchicum and iodide of potassium are quite out of the question; and except small effervescing draughts with an excess of alkali and a little hydrocyanic acid, and a few grains of simple calomel, medicines of any kind are rarely tolerated. Small bits of ice slowly swallowed, should take the place of drink; and the only nourishment likely to be retained is in spoonfuls of milk and soda-water, chicken tea, or thin arrowroot flavored with brandy. In some instances the vomiting has been checked by sinapism to the epigastrium, or by minute doses of strychnia (from one-fortieth to one-twentieth of a grain;) in others opium or strong stimulants have been According to my experience, gout in the stomach is the most formidable variety of the •disease and therefore it is the more important to be guarded against. The occurrence of any nausea, or pain in the stomach, should be taken as a warning against the con- tinuance of colchicum or any other medicine of a sickening tendency; and in the in- tervals between attacks the tone of the stomach should be strengthened by bitters, with a due attention to the diet and regimen. 188 CHANGES IN THE BLOOD BY TRANSFORMATION. taining alkaline and saline matter, is also eliminative, promoting the removal from the blood of the products of decay; but it is very pro- bable that both these and saline mineral waters, and even plain water when taken in excess, tend to increase the waste of the blood and of the tissues nourished by it (§ 231.) In cases of excessive formation of urea, all circumstances which depress or exhaust the organic life should be avoided, as for instance great excitement of body or mind; waste should be compensated for by a generous diet, and the nutritive function should be sustained by tonics. Opium and other narcotics are found to be useful in reducing the quantity of urine in the diabetes ureosus; and they probably operate by calming exhausting nervous excitement, and by procuring sleep. The researches of Dr. Bocker show that alcoholic liquors, tea, and coffee, also restrain the waste of the tissues, and thus become the means of giving strength to the frame (§ 56:) in this respect they are contrasted with simple water and mere diluents which have a tendency to promote waste, as these augment the solid contents of the excretions. 258. The eduction, or production, of fat from food takes place with remarkable activity in some persons ; and whenever it obstructs or supersedes the proper formation of fibrin and other protein princi- ples more immediately concerned in giving strength to the bodily frame, it amounts to disease. The circumstances in the diet which tend to this result have been already noticed (§ 59, 60,) and we have had occasion to mention that sedentary habits and a lowered condition of the respiratory function have sometimes a similar effect (§. 239, 65.) But in connection with our present subject we may remark that there are many reasons for supposing that an excessive production of fat sometimes occurs as an error in assimilation, and may interfere with the sufficient production of other animal principles and with the nourishment of the textures of kindred composition, whilst it not only accumulates in its proper tissue, but invades other textures, lowering their vitality and cohesion, and thus constituting a cause of gradual degeneration. Thus Mr. Gulliver has shown that the atheromatous patches in the coats of arteries, which appear to be a mark of de- clining age, (natural or premature,) are of the nature of fatty degenera- tion. The same pathologist has discovered a predominance of fatty matter (chiefly olein, margarin, and cholesterin) in the lungs, the kidneys, and testicles, in various chronic diseases. (Med. Gazette, June, 1843.) A similar abundance of fat has been frequently observed by myself (first in conjunction with Dr. R. Quain, in May, 1845) in the kidneys, liver, and other structures of persons whose habits of excessive intemperance proved fatal, with the production of general cachexia and failure of many functions. This subject will be noticed again under the head of perverted nutrition; when the remedies to be opposed to the morbid element, fatty transformation, will be considered. CHANGES IN THE BLOOD BY FOREIGN MATTERS. 189 SECTION XVI. TOXEMIA—CHANGES IN THE BLOOD FROM THE PRESENCE OF FOREIGN MATTERS. 259. The blood is probably the chief seat of the morbid poisons which excite various contagious (§ 93,) epidemic (§ 88,) and endemic diseases (§ 81;) and where these act most intensely it is much changed in its physical characters, being rendered darker, indisposed from defect of fibrin to coagulate, with breaking up of many red corpuscles. Probably, too, the blood is the hot-bed in which morbid poisons are propagated, whether by seeds, ova, cell-germs, or parasites (§ 99 ;) and it is through changes in its composition that many of the destructive effects of these poisons are produced (§ 186, 196.) We have already noticed some of these changes under former heads of our subject. 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 a putrid fever, attended with an eruption of sloughing pustules. Some blood taken from this man was injected into the cellular texture of the groin of a cat; the animal was soon affected with vomiting of bile, dyspnoea, frequent small irregular pulse, dry brown tongue, with slight convulsions, and died seven hours after the injection. The same pathologist produced in animals various severe symptoms, speedily ending in death, by in- jecting into their veins blood taken from a person laboring under confluent smallpox. MM. Dupuy and Leuret communicated to a healthy horse the malignant pustular disease called "charbon," by in- jecting into its veins some of the blood of a diseased animal; and M. Renault propagated glanders from one horse to another in a similar way. Andral quotes from Duhamel an extraordinary case, in which blistering, pustules, malignant fever, and death, followed the mere con- tact of the diseased blood of an animal with the lips. Other instances are on record of sickness, faintness, and serious illness being caused by the odor of blood; and Dr. Copland quotes from Zacutus a mar- vellous story of three persons being struck dead by the smell of the blood of a patient in the plague. The mutual influence exerted between various morbid poisons and the blood may be traced in numerous facts in the clinical history of toxgemic diseases; and a few examples may serve as illustrations of the subject in relation to its practical bearings. It has been already stated that the disposition to suffer from zymotic diseases (Sect. III., Div. II.) is connected with a weakness of the func- tions generally (§ 23,) but it is more particularly favored by the 190 CHANGES IN THE BLOOD BY FOREIGN MATTERS. presence in the blood of an easily decomposed azotized matter result- ing from the retrograde transformation or decay of tissues (§ 105.) Thus after great bodily fatigue ; after severe wounds or other injuries ; and after delivery of women, where there is more than usual of an effete matter in the blood, there is great susceptibility to zymotic diseases and a liability to them in an aggravated form. So also in the deve- lopment and progress of these diseases, we have many proofs that their essential seat is in the blood, though their action may be exerted on various tissues or organs. Thus the earliest symptoms are those of general weakness and uneasiness, with disturbance of the circulation more constantly than of any other function ; and not unfrequently, as before mentioned, with an obviously altered condition of the blood. In the worst cases of zymotic disease, where the poison is most viru- lent, the change approaches to putrescence; and the excretions first, and eventually the whole body, exhale offensive odors, a'nd give evi- dence of the prevalence of a decomposing force opposed to the conser- vative powers of life ; and this corrupting influence may triumph in a few days or even in a few hours before any secondary or local changes can take place. This has been observed to happen in the plague and in the worst forms of putrid or pestilential fevers, in which the blood seems to be so rapidly corrupted that it no longer sustains the func- tions of life. In like manner the poison of the most venomous serpents appears to exert its deadly influence on the blood, which it renders the medium of death to the whole body. But the more usual operation of zymotic poisons is of a more mixed character, comprising much local irritation as well as constitutional disturbance and depression. Thus the poisons of the exanthemata produce various specific forms of cutaneous inflammation ; and that of scarlatina also affects the throat and frequently the uriniferous tubes, and measles the air-passages,—with inflammatory or congestive dis- orders. The follicular intestinal lesions in typhoid fever, and the more intense phlogoses and ulcerations of epidemic dysentery, are farther ex- amples of local irritation resulting from the presence of a morbid poi- son in the blood. Now although these local inflammations are proofs of the activity of the respective poisons, and are, in fact, the foci of their multiplication, yet they truly appear to be parts of a process by which the poison is brought to a surface from which it may be elimi- nated from the system and the blood freed from its contaminating in- fluence; for they all involve more or less of a process of effusion and discharge, and the more simply and superficially this takes place, without spreading deeply and disorganizing the textures, the more favorable will be the result. Thus scarlatina, the eruption of which is vivid and soon ending in desquamation, the throat-inflammation superficial and attended with free secretion;—measles with full florid eruption, and the catarrhal affection ending early in defluxion and ex- pectoration ;—smallpox with distinct pustules circumscribed by a firm phlegmonous base, which protects the system whilst the pustule matu- rates, and then soon dries into a hard inert scab ; typhoid fever,—in which an early moderate diarrhoea indicates the activity of the intes- tinal follicles in throwing off the morbid matter;—these are examples ZYMOTIC POISONS—OPERATION. 191 of the favorable operation of the vis medicatrix naturse in the removal of a noxious influence. On the other hand, in scarlatina,—where the eruption is not persistent or is livid, and the throat inflammation is deep-seated, with much swelling, sanious and fetid discharges, and sloughy patches ; in measles,—with a dusky and imperfect rash, and the inflammation of the air-passages assuming the form of croup, ex- tensive bronchitis, or even of pneumonia; in smallpox,—a very co- pious eruption of confluent, flattened pustules, with little or no indu- ration at their base, but much dark red diffuse swelling of the integu- ments and cellular tissue, sometimes with purple ecchymosed spots or petechise, and sanguinolent discharges from various mucous membranes; in typhoid fever,—a torpor of the bowels and other excreting organs, with tympanitis, dark sordes on the teeth and tongue, petechiae on the skin and general oppression of all the functions;—in such forms of disease we see evidence of a prevalence of the operation of the poison in depressing the vital powers, in injuring the condition of the blood, and in depressing the local processes intended for the protection of the system. Various combinations and complications of these two op- posing influences,—the poison, and the reaction against it,—constitute the infinite diversity in type and form that toxgemic diseases present. There is good reason to suppose that purulent matter, the germs (§ 90) of carcinoma, and other forms of malignant disease, are spread through the system by the medium of the blood. Pus has been fre- quently detected in the blood by the aid of the microscope, first by Mr. Gulliver, and by many subsequent observers. The pus globule is to be distinguished from the pale or lymph corpuscle by its larger size, more marked and often granular cell-wall, by its contained granules or nuclei being more distinct, and sometimes loose in its interior, and lastly by its exhibiting exosmotic and endosmotic propertiee much more actively. The different effects of pus in the blood will be noticed under the head of results of inflammation. The tendency to symmetrical arrangement which cutaneous eruptions, nodosities of the joints, para- lysis from lead, and some other local affections exhibit, has been ad- duced, by Dr. W. Budd and Mr. Paget, as an instance of effects pro- duced through the medium of the blood—the symmetrical distribution of this fluid on the opposite halves of the body leading to like results in corresponding parts. 260.' It is very evident from the phenomena and results of toxgemic diseases, that the blood itself and the organs connected with it possess a certain preservative and correcting power, by the operation of which efforts are made to counteract or throw off any noxious matters which may be present in the circulating fluid. The success of these efforts will depend much on the vital vigor of the blood itself and of the or- gans of circulation and depuration, as opposed to the quantity and vi- rulence of the invading poison. When the latter operates with the greatest energy, as in the bite of the most venomous serpents, or in the most malignant forms of pestilential fever and cholera, the poison seems to overwhelm all resistance, and destroys life in a few hours, apparently by its direct deadly action on the blood and living tissues. The blood after death commonly remains fluid, or imperfectly coagu- 192 DISEASES OF THE BLOOD. lated, and often it is extravasated in parts, and deeply tinges the tis- sues in contact with it. Even where the poison is less rapidly and directly destructive, the resisting and eliminating processes, although brought into operation, may be insufficient to prevent a fatal result; and where the struggle is more prolonged, its marks are usually seen not in the blood only, but also in the mucous surfaces, skin, glands, and other organs, which become irritated, congested, inflamed, and even disorganized in the ineffectual processes of resistance and elimi- nation. In this way arise the specific inflammations of the skin in ex- anthematous fevers, of the throat in scarlatina, of the nose and bron- chial membrane in measles, of the follicles of the intestines in typhoid fever, and the irritative discharges of epidemic cholera, dysentery, and yellow fever. In these several instances, the direct operation of the poison and that of the reaction against it, appear to be equally destruc- tive, and together constitute the features of these respective diseases in their ordinary severer forms. On the other hand, the milder varie- ties of these maladies show the influence of a moderate operation of the morbid poison, disguised in various degrees by the several processes of irritation or reaction peculiar to each disease. The preceding view of toxasmic diseases may be extended to com- prise the most useful facts ascertained with regard to their treatment. With the most energetic kinds and degrees of poison in the blood, re- medies are of little or no avail; chemical antidotes capable of destroy- ing the poison would be equally injurious to the blood which contains it; and if aid is to be derived from any agents, it is chiefly to be looked for from stimulants and antiseptics, or those which excite the vital functions, and those which resist the tendency to decomposition in the animal fluids and solids. And if the influence of the poison is not of the most rapid and overwhelming kind, such means may so far coun- teract it as to give time for the processes of oxidation and elimination, which are the natural means by which the system is freed from noxious matters. In the treatment of cases of toxaemia we have, then, to hold in view these indications :—1. To counteract as far as possible their injurious influence, both general and local; 2. To promote their decomposition and expulsion from the system; and 3. To regulate the functions and sustain the nutrition of the body, during the struggle which may last some time between the disease and the bodily powers. A few examples may serve to illustrate the fulfilment of these several indications. In the treatment of persons under the influence of sedative poisons, such as digitalis, hydrocyanic acid, aconite, &c, which act through the blood, we endeavor to counteract their depressing influence by diffu- sible stimulants, such as ammonia, alcohol, ether, and artificial heat. In case of poisoning by narcotics, such as opium, alcohol and dele- terious fungi, we endeavor to excite the torpid sensibility and main- tain the respiratory movements by cold affusion, sternutatories, sina- pisms mechanical irritation, electric shocks, &c, and by strong coffee and tea, which counteract the soporific tendency. If these means are successful in countervailing the operation of the poison for a certain length of time, the danger is removed; for the poison in that period is ZYMOTIC POISONS—COUNTERACTION AND ELIMINATION. 193 so far decomposed or eliminated, that the system is relieved from its effects. In like manner the poisons of typhous and other adynamic fevers have their depressing operation, which is to be counteracted by the judicious administration of wine, ammonia, and other stimulants ; but these morbid poisons are more persistent than vegetable sedatives and narcotics, and remaining longer in the blood, require a continued use of not only stimulants, but also of eliminant remedies, which aid the secretions in expelling them from the system. Further, it has been mentioned that these morbid poisons show more or less of a septic tendency, sometimes in their direct action on the blood, and always in their increasing the putrefactive properties of the excremen- titious matter, which by their peculiarly offensive odor give evidence of the advance of decay. To limit this process of decomposition, and to deprive its products of their injurious properties, antiseptic remedies become useful; and for this purpose, chlorinated liquids, nitromuriatic acid, chlorate of potass, chloric ether, creasote, and powdered charcoal, have been employed both externally and internally for various toxeemic diseases. Bark and quinine may be considered to possess some title to the same property, but they appear also to have important relations to the vital property of tonicity (§ 124,) which give them an antagonis- tic power against the poison of fevers in general, but more especially of intermittent and remittent fevers. The power of quinine in large doses to cut short the course of continued fever is still a matter of question ; and although the experience of a few practitioners testifies in its favor, there is not that concurrence which would be required to es- tablish the efficacy of a great remedy, like that of the same medicine in intermittent diseases. But this last example of remedial action, that, namely, of bark, quinine, and arsenic in intermittent diseases, is also one of antidotal or antagonistic kind, opposed to the operation of a poison or noxious principle in the blood; and in farther illustra- tion of this position may be adduced the important fact, accredited by several experienced observers, that several doses of quinine (a grain twice daily) are protective against malarious poisons in persons exposed to their influence. Another instance of counteractive treatment of blood poison in a more limited degree is in the exhibition of opium and other narcotics to soothe pain or nervous irritation (§ 149—53) caused by the operation of the poison. In ataxic or nervous forms of fever, in delirium tremens and other toxaemic affections attended with nervous excitement, the operation of narcotics is salutary, not counteracting altogether the morbid poison, but in controlling one of its most mischievous effects, which tends to wear down the vital powers by exhausting excitement. It is very probable that part of the salutary operation of wine and other stimulants, especially chloroform and chloric ether, may be due to their tranquillizing influence on the nervous system, whilst at the same time they sustain the power of the muscular. But it is by promoting their elimination that nature and remedial art more constantly and successfully operate against noxious matters in the blood. Orfila found that even energetic mineral poisons, such as arsenic, could be given to animals in small repeated doses without 13 194 DISEASES OF THE BLOOD—TOXEMIA. any injurious effect so long as a diuretic was exhibited at the same time ; and it is well known that the poisonous action of lead, in those whose occupations expose them to it, may be prevented by keeping the bowels constantly free. Fevers and other toxaemic affections are some- times carried off by a spontaneous diarrhoea, a diuresis, or a copious sweat: and the artificial treatment which most seems to promote a fa- vorable termination of these disorders is that which moderately ex- cites these secretions. Thus mild do&es of mercury, antimony, salines comprising all the alkalies combined with citric, acetic, or tartaric acid, and increasing the proportion of ammonia and adding stimulants as the weakness requires,—are the most generally useful medicines in these diseases ; and an indication of their successful operation is the free flow of the several secretions, often offensive at first, and giving proof of their containing much decaying animal matter, but gradually becoming more natural as the disease yields. On the other hand, in unfavor- able cases, the eliminatory process fails, the discharges being either scanty, or so depraved and offensive as to injure the function and structure of the excreting organs, and the body loses all chance of being freed from the deleterious operation of the morbid poison. With these facts may be connected that of the peculiar liability to infec- tious diseases (§ 17, 26, 32,) shown by persons affected with lesions of the kidney, which impair its excernent function ; and when such are attacked, they rarely recover. Similar observations may be made re- specting various pharmaceutic poisons which operate through the blood, such as opium, arsenic, and mercury, which act with uncommon, and therefore with dangerous energy on those whose excreting functions are much impaired, either by structural disease, or by extreme weak- ness or exhaustion. In all toxaemic diseases of a severe kind there is a remarkable ex- penditure of flesh and strength. The changes which the poison induces in the blood tend to spoil it for the purpose of nutrition, the function of which is therefore suspended for the time, and emaciation proceeds with the accelerated decay of the materials of the blood and textures. Hence the importance of affording fresh supplies of nutritious food in such forms and as frequently as the digestive organs will allow. Ani- mal broths and jellies, and farinaceous liquids are commonly the most eligible forms during the continuance of the febrile process ; but they may be often advantageously administered in small quantities every hour or every two hours, with wine or brandy, according to the state of depression. The utility of alcoholic liquors in checking the waste of the body, when judiciously administered, may be better understood by a reference to what has before been mentioned with regard to their action in this respect (§ 56.) In many fevers the gastrointestinal mucous membrane is so much irritated that even during convalescence solid food is not borne for a long time, and the restoration of flesh and strength is proportionately slow. In such cases, as well as in others in which alimentation is difficult, I have found great benefit from the use of the cod-liver oil in small doses after each meal, which commonly agrees well even in cases in which the irritable state of the alimentary canal will bear neither strong animal food nor tonics. 195 CHAPTER III. SECONDARY OR PROXIMATE ELEMENTS OF DISEASE, CONSISTING OF TWO OR MORE PRIMARY ELEMENTS (