^:.;.-,.*ar«; NATION*. . ,h«»»< 01 MEDICINE NLM DDlDEfl7D 1 NLM001028701 :y THE PRACTITIONER'S HANDBOOK OF TREATMENT; OR, THE PRINCIPLES OF THERAPEUTICS. J. MILXEK FOTHERGILL, M.D., PHYSICIAN TO THE CITY OF LONDON HOSPITAL TOR DISEASES OF THE CHEST, VICTORIA PARK; LATE ASSISTANT PHYSICIAN TO THE WEST LONDON HOSPITAL ; HON. M.D. RUSH COLLEGE, CHICAGO, ILL. ; FOREIGN ASSOCIATE FELLOW OF THE COLLEGE OF PHYSICIANS OF PHILADELPHIA. "The knowledge which a man can use is the only real knowledge, the only knowledge which has life and growth in it, and converts itself into practical power. The rest hangs like dust about the brain, or dries like rain-drops off the stones."—Froude. THIRD AMERICAN FROM THE THIRD ENGLISH EDITION. PHILADELPHIA: LEA BROTHERS & CO. 188 7. PHILADELPHIA : DOR NAN, PRINTER, N. W. cor. Seventh and Arch Streets. ■>?.<* TO J. M. DA COSTA, M.D., PROFESSOR OF PRACTICE OF MEDICINE IX THE JEFFERSON MEDICAL COLLEGE OF PHILADELPHIA, WHOSE REPUTATTOX EXTEXDS OVER TWO CONTIXENTS, flhts 4jjotk is Hettitaiftt BY THE AUTHOR. PREFACE TO THE FIRST EDITION. This work is not an imperfect Practice of Physic, but an attempt of original character to explain the rationale of our therapeutic measures. First the physiology of each subject is given, then the pathology is reviewed, so far as they bear upon the treatment; next the action of remedies is examined; after which their practical application in concrete prescriptions is furnished. It is not essayed to give prominence to new remedies or new therapeutic measures, so much as to analyze and elucidate the modus operandi of the measures in common use. It is designed to furnish to the practitioner reasons for the faith that is in him; and is a work on medical tactics for the bedside rather than the examination table. For nine years the writer has been laboring with the definite design of producing the present work. In consequence of its original character much difficulty has been felt from want of some guide to indicate, not so much what to insert, as what to leave out and where to stop. A certain amount of repetition has been found unavoidable; but the plan of Sections has been adopted to reduce this to a minimum. It is perhaps impos- sible to generalize broadly, and yet to be accurate in minutiae: nevertheless the writer trusts that general principles have here been demonstrated without any violence to facts. For advice and suggestions how to improve the work in future editions the writer will look to his critics, adverse as well as friendly—each alike valuable to him whose aim is strictly to advance knowledge. vi PREFACE TO THE FIRST EDITION. The writer must here express his thanks to the Journal Committee of the British Medical Association for their kind permission to reprint such portions of this work as have appeared as leaders in the British Medical Journal. He must also acknowledge his indebtedness to Dr. Lauder Brunton, F.R.S., for much friendly counsel; to Sir Joseph Fayrer, K.C.S.L, and to Surgeon-major A. R. Hall, for infor- mation on matters more especially connected with India; and lastly, to Mr. Herbert Page for revision of the manuscript, and to Mr. E. O. Bark for his cooperation in the correction of the proof-sheets. PREFACE TO THE SECOND EDITION. The comparatively brief time which has sufficed to exhaust a large edition of this work proves that it has been found acceptable by the profession. The London Medical Record said, " a work of this kind has long been urgently wanted;" and the perusal of a systematic treatise on the Principles of Thera- peutics will enable the student, all the more thoroughly and with advantage to himself, to study the works of Sidney Ringer, and H. C. Wood. Such a treatise gives him the broad lines upon which he must proceed in his therapeutic efforts; the basis upon which he can rear a superstructure that will embrace minutiae, the importance of which may not be very comprehensible without such underlying basis. The practitioner can compare his own practice with the lines here laid down, and note the points of agreement. This rapid sale further demonstrates that non-teaching hos- pitals may be made useful beyond their immediate precincts. In teaching hospitals, the energies are necessarily mainly bent toward teaching students the elements of diagnosis; where no students are present, the energies can be devoted to the study of each case from its therapeutic point of view, and the treatment of the patient be the main thing aimed at. That the experience so acquired may be made to have far-reaching consequences, the sale of this work here, and still more in the United States of America, amply testifies. Some additions have been made to the matter in this edition, as, " When not to give Iron," " The Functional Disturbances of the Liver," " The Means of acting on the Respiratory Nerve viii PREFACE TO THE SECOND EDITION. Centres," " The Reflex Consequences of Ovarian Irritation," and " Artificial Digestion," which it is hoped will add to the practical value of the work. The author begs to record his thanks to Henry Sewill, Esq., for some remarks on " The Hygiene of the Teeth ;" to Pro- fessor Austin Flint for his permission to reprint, verbatim, his remarks on " The Professional Conduct of Physicians," in his recent work on Clinical Medicine. These additions, it is hoped, will add to the practical value of the work. His best thanks are also due to Dr. H. G. Orlebar for his friendly supervision of the proof-sheets. PREFACE TO THE THIRD EDITION. The sale of a second and larger edition of this work tells of the favor it finds with its readers. The work has been carefully revised, and considerable additions have been made to it. A chapter on " The Dietary in Acute Disease and Malassiraila- tion," tells of the growing importance of dietetics in the treat- ment of disease. A second new chapter has been added on " The Management of Convalescence," which it is hoped will add to the value of the work. The Author takes this oppor- tunity to record his thanks to Dr. D. G. L. Johnson for kindly aid in the supervision of the proof-sheets. 3 Henrietta Street, Cavendish Square, W. CONTENTS. CHAPTER I. INTRODUCTION. SECT. PAGE 1. The present position of therapeutics......17 2. Medicine as a science and an art.......17 3. The transmission of knowledge . . . . . . .19 4. Man as a man ; and as an individual......22 5. Individual peculiarities.........23 6. Systemic impairment from bad environment—Imperfect organisms . 25 7. Health a balance of parts.........27 8. Sequences in medical measures—The building of a prescription . 28 9. Combined prescriptions.........30 10. Adjuncts............33 11. Hygienic arrangements (accompaniments).....33 12. Dietetic arrangements (accompaniments)......34 13. The choice of remedies ......... 34 CHAPTER II. ASSIMILATION. 14. The necessity for physiological knowledge—Forms of food; their destination...........36 15. The effects of saliva; of the gastric juice; of pancreatine—Intestinal absorption—The function of the liver..... 16. Sialagogues.......... 17. Digestion—Artificial aids—Pepsine...... 18. Stomachics—Alkalies—Bitters....... 19. Action of the pancreas—Effects of ether—Pancreatic emulsion 20. Intestinal action—Purgatives....... 21. Haematics — Lime — Iron — Combinations — Specifics in specific anaemia ........... 22. Value of water—Dilution—Tissue-Bathing—Mineral waters . 23. Tonics: mental, material—Aromatic astringent—Combinations of 24. Change of air—cold water . . •..... When not to give iron........ xn CONTENTS. CHAPTER III. EXCRETION. 25. Characters of waste matters—General excretory action of the sur- face—Specialization of parts during evolution—Community of function in excretory organs .... 26. Tissue-growth a form of excretion .... 27. Compensatory action of organs..... 28. The lungs and skin—Cutaneous respiration—Skin and kidneys- Urea in sweat—Urseinic diarrhoea .... 29. Treatment of uraemia...... 30. Effects of compensatory activity on the organs so engaged 31. Anaemia from imperfect excretion—Specific haematics 32. Compensatory excretion of bile—Lactic acid . 33. Alteratives—Mercury—Arsenic—Iodine . 34. Use of alteratives—Hydropathy .... 66 70 71 73 76 77 79 81 82 85 CHAPTER IV. BODY HEAT AND FEVER. 35. Glycogen—Heat production—Heat loss—Regulation of body tem- perature . . . . . . . . . . .90 36. Normal temperature..........93 37. Collapse temperature; its treatment—Catching cold ... 94 38. Febrile temperatures—Fever—The typhoid condition ... 97 39. Effects of high temperature on tissues......99 40. Effects of high temperature on the brain......101 41. Treatment of the typhoid condition—Apyretics—Acids—Salines— Nauseants—Baths.........104 42. Depressants—Antimony—Aconite—Veratrum—Action of alcohol as an apyretic..........107 43. Quinine and digitalis.........113 44. Cold'in various forms—Jaborandi .......115 CHAPTER V. INFLAMMATION: ITS VARIETIES. 45. What is inflammation ? as a morbid process ; as a means of cure__ Excessive nutrition ......... ;[20 46. The inflammatory process—Means of controlling it—Vascular de- pressants ..... ....._ 123 47. Treatment of the stage betwixt the inflammatory rise and convales- cence—Therapeutic and dietetic management . . . 126 CONTENTS. Xlll 48. Calomel and opium—Local applications . 49. Convalescence; its management 50. Asthenic inflammation ; its treatment 51. Specific inflammations and their management 52. Parenchymatous inflammations; their course . 53. Their treatment...... 54. Inflammatory products; their indications CHAPTER VI. ANEMIA—PLETHORA—CONGESTION. 55. Anaemia; its forms and associations . . . . 56. Indications for treatment....... 57. Specific anaemia ........ 58. Plethora; its causal associations..... 59. Therapeutic indications—Dietetic measures—Purgation 60. Congestion ; its forms and causes..... 61. (Edema; its causation in relation to treatment CHAPTER VII. GROWTH AND DECAY. 62. Disturbances of growth—Dentition .... 63. Troubles of digestion—Infantile remittent fever 64. Bronchitis in children—Colds ..... 65. Imperfect tissue growth — Oil inunctions — Struma- Syphilis—Indications for management 66. Decay. Senile decay; its oncome and pathology . 67. Indications for treatment—Diet—Alcohol—Clothes 68. Nutrition, nervous and vascular .... 69. Fatty degeneration....... 70. Rheums......... Tubercle— CHAPTER VIII. ABNORMAL GROWTHS. 71. Never truly heteromorphic—Hypertrophy, or hyperplasia—Dilata tion of the heart and hypertrophy 72. Connective tissue, normal and abnormal . 73. Pathological but perfect connective tissue 74. Degraded connective tissue—Tubercle 75. Progress of tubercle—Relations to treatment 76. Importance of fat—Food—Cod-liver oil—Climate 186 191 192 194 196 199 XIV CONTENTS. 77. Hectic fever; its treatment—Effects of rest—Preventive measures 203 78. Malignant connective tissue—Cancer; its varieties . . 211 79. Therapeutic indications.........213 CHAPTER IN. BLOOD POISONS—SPECIFIC POISONS. 80. Nature of blood poisons; effects of..... 81. Remedial agents; their action—Antiseptics . 82. Specific poisons—Malaria; its seats .... 83. Quinine; how to be given—Malarial dysentery—Ipecacuan 84. Cholera; its nature and treatment..... 85. Specific fevers; their general management 86. Special points to be attended to 87. Diphtheria ; its indications 88. Influenza; its treatment . 89. Dengue—Yellow fever 90. Pertussis—Treatment 91. Erysipelas; its forms; their management 216 219 221 223 226 227 228 230 231 231 232 232 CHAPTER X. ACUTE AND CHRONIC DISEASE. 92. Acute disease—The shock of pain—Its treatment .... 234 93. Hemorrhage; its management—Other discharges; their treatment 237 94. Syncope; its treatment—Asphyxia ; its management . . . 240 95. The theory of stimulants.........241 96. Circumstances modifying the action of stimulants—Secondary effects of excessive stimulation........245 97. Medicinal stimulation.........246 98. Alcohol as a food; its other actions; its use in convalescence . 247 99. The relations of acute and chronic disease—Acute disease becoming chronic; its indications ........ 252 100. The balance of parts in power as well as in function ; in chronic disease, and in convalescence ....... 255 101. Chronic disease becoming acute.......258 CHAPTER XI. DIABETES—RHEUMATISM—GOUT. 102. Diabetes; its origin; forms of; relation to Bright's disease 103. Treatment—hygienic, dietetic, and medicinal 104. Rheumatism; what is it? .... 260 263 265 CONTENTS. XV SECT. PAGE 105. 106. 107. Acute rheumatism—Principles of treatment.—After-management. Chronic rheumatism—Therapeutics of, general and local Gout—Lithiasis.......... 266 269 273 108. Origin and manifestations......• . 276 109. Treatment of lithiasis......... 280 110. 111. Suppressed gout; its management....... Rheumatic gout.......... 284 286 CHAPTER XII. DIATHESIS AND CACHEXIA. 112. The constitution; its outward indications—Physiognomical diag- nosis .......... 288 113. Diatheses; their influence over ailments .... 291 114. The gouty diathesis.......... 292 115. The nervous diathesis........ 293 116. The strumous diathesis ........ 294 117. The bilious diathesis........ 296 118. The lymphatic diathesis........ 298 119. The hemorrhagic diathesis—Blends..... 299 120. Cachexiae—The syphilitic cachexia; its importance in treatment 300 121. Treatment.......... 302 122. Lead poisoning ......... 305 CHAPTER XIII. ACTION AND INACTION. 123. Forms of narcotics; their action . 307 124. Opium; its action on different centres; on the vascular system; on the nervous system; in the relief of pain . . 308 125. Effect on motor and secretory actions .' 313 126. Hydrate of chloral...... . 314 127. Bromide of potassium..... . 316 128. The use of these several agents . 319 129. Astringents; their combinations with sedatives . 321 130. Inaction—Belladonna—Cannabis Indica . 323 131. Quinine and strychnine; their use . . 326 132. Combination of neurotics in practice . 329 133. Irritation and counter-irritation—External use of s edatives . 330 CHAPTER XIV. THE CIRCULATORY SYSTEM. 134. Groups of maladies..........335 135. Blood pressure; effects of agents upon......336 136. Compensatory changes in valvular lesions.....338 XVI CONTENTS. SECT. PAGE 137. Cardiac failure..........339 138. Treatment of cardiac advnamv—Rest and removal the causes of irritation ........... 341 139. Cathartics—Diaphoretics—Diuretics—Hot poultices . . . 342 140. Means of acting directly upon the heart—Digitalis; its action and its use.............344 141. Apparent objections to its use explained—The so-called " cumula- tive action"........... 347 142. Relief of consequential ailments—Dropsy—Diuretics; their ac- tion ; combinations of ........ 348 143. The dietary...........350 144. Secondary affections of the heart—Angina pectoris; imperfect forms of, treatment of ........ . 352 145. Neurosal affections of the heart—Palpitation .... 357 146. Irritable heart...........359 147. Importance of accurate diagnosis in treatment .... 360 147a. Aneurism...........362 CHAPTER XV. THE RESPIRATORY SYSTEM. 148. Respiration, in relation to disease; to mechanical irritants; to temperature—Catarrh .... 149. The treatment of catarrh .... 150. Affections of the air-tubes—The theory of expectorants—Forms of bronchitis—Its treatment 151. Bronchitis and asthma .... 152. Affections of the lung structure—Pneumonia Asthenic pneumonia .... 153. Localized pneumonia—Nutrition . 154. Treatment, general and special 155. Broncho-pneumonia .... 156. Affections of the serous coverings—Pleurisy; 157. Pleuritic effusion; its treatment 158. Cough; its varieties and their treatment 159. Dyspnoea, forms of, and treatment.......389 160. Haemoptysis.......... 39j 364 367 . 368 . 374 ; its management— . 375 . 378 . 380 . 382 its management . 382 . 384 .....385 CHAPTER XVI. THE DIGESTIVE SYSTEM. 161. Dyspepsia, how occasioned....... 393 162. The theory of emetics, direct and indirect ..... 393 163. Food in gastric affections—Medicines—Opium, in bulimia__Al- kalies—Bismuth—External applications .... 39^ CONTENTS. XVI1 SECT. PAGE 164. Points in diet—Distant irritation.......402 165. Liver affections—The action of mercury—Superfluous bile . . 405 166. Tropical biliary disturbances (Sir Joseph Fayrer's remark)—Intes- tinal acidity of Prout.........415 167. Constipation — Purgatives: gentle, cathartic; points in each— Mercury...........418 168. Purgation in intestinal stricture, in the aged, and at the menopause —Purgative waters.........421 169. Diarrhoea: its varieties and their treatment—From irritant matter —From a chill — Catarrhal — Dysenteric—Nervous—Reflex— From portal congestion—Tubercular—Uraemic diarrhoea—Colli- quative—Thermic.........423 170. Enteritis—Opium in.........431 CHAPTER XVII. THE URINARY SYSTEM. 171. Function of the kidneys—Formation of urea—Effects of sustained high functional activity........433 1*72. Water excretion..........434 173. Diuretics—Hydragogue diuretics—Simple diuretics—The use of each............436 174. Acute nephritis: its treatment.......439 175. Albuminuria: its management.......441 176. Bright's disease (chronic)........444 177. Its treatment—Action of the skin.......447 178. The diet............450 179. Fluids............452 180. Remedial measures..........453 181. In valvular disease of the heart.......454 182. Vesical maladies..........455 CHAPTER XVIII. THE REPRODUCTIVE SYSTEM. 183. Importance of the ailments of women......457 184. In relation to the nervous system.......458 185. Anaphrodisiacs..........459 186. Blenorrhagia in both sexes—Its management.....461 187. Puberty in girls—Points in practice......463 188. The menopause..........470 189. Amenorrhcea: its forms, their treatment.....472 190. Menorrhagia: its varieties and treatment......473 191. Dysmenorrhoea..........477 B xvm CONTENTS. CHAPTER XIX. THE CUTANEOUS SYSTEM. 6ECT. 192. Function of the skin —Diaphoretics and anhydrotics 193. Skin diseases: their causation and general management 194. Their relations to the stomach, uterus, liver, and kidneys 195. Syphilidae—Their treatment...... 196. Neurosal skin affections ....... 197. Injuries and parasites—Their treatment .... 198. Corns—Warts......... 199. Ulcers—Principles of treatment ..... Note.—Fetid feet. CHAPTER XX. THE LYMPHATIC SYSTEM. 200. Its distribution and function..... 201. Theory of absorbents—Iodine—Mercury—Their applications in practice............ 501 202. Inflammation of the lymphatics.......504 203. Glandular suppuration ......... 505 204. Inflammation of the lymph spaces (serous sacs)—Their treatment 506 205. Passive accumulations ......... 508 CHAPTER XXI. THE NERVOUS SYSTEM. 206. Importance of accurate diagnosis—Anatomical arrangements of the blood supply ......... 510 207. Hyperaemia—Its treatment....... 513 208. Vascular cerebral hyperaemia—Its management 515 209. Cerebral anaemia—Points in practice ..... 517 210. Local cerebral anaemia—Vasomotor arrangements . 519 211. Insomnia—Its management ....... 520 212. Delirium—Its varieties—Their treatment—Moral management- Remedial measures........ 534 213. Headache, forms of—Their treatment ..... 537 214. Cerebral paralysis—Indications in each case .... 538 215. Sunstroke—Treatment of........ 540 216. Affections of the spinal cord—Varieties of—Treatment of each 541 217. Epilepsy—Its production and treatment—Night-terrors . 542 218. Chorea—Its forms......... 546 219. Hysteria—Its varieties and their management 547 480 486 488 491 492 493 494 497 CONTENTS. XIX SECT. PAGE 220. Neuralgia—General lines of treatment......549 Electricity—its use..........551 The therapeutic instinct.........552 CHAPTER XXII. PUBLIC AND PRIVATE HYGIENE. 221. Public hygiene—Its importance.......553 222. Our houses—Ventilation.........554 223. Water—Effects of impure water.......556 224. Sewage—Sewerage—Earth closets.......557 225. Pythogenesis—Disinfection—Sewer gas—Special disinfection . 559 226. Infection—Medical men—Nurses.......563 227. Fever hospitals, cottage and other ....... 564 228. Private hygiene—The healthy and the sick.....565 229. Bathing resorts...........569 230. Mineral waters—Their varieties and uses.....570 231. Baths—Cold, warm, hot, sand, mud, peat, etc. .... 573 232. Health resorts—For the consumptive......575 233. Change of air in India (Sir Joseph Fayrer) ..... 579 234. Change of air in America—Tours.......583 CHAPTER XXIII. FOOD IN HEALTH AND ILL HEALTH. 235. Respiratory and plastic foods—Nitrogenized food .... 585 236. Hydrocarbons—Force-producing material—Effects of foods—Forms of diet............588 237. The relations of food to disease—Bantingism.....588 238. The diet in lithiasis..........596 239. In combined lithiasis and diabetes.......598 240. Drinks—Milk, beef-tea, rice-water, etc.......600 241. As stimulants...........604 242. As beverages—As water.........606 243. As a means of affecting temperature......607 244. Diet cures—Grape, strawberry, milk, whey, and koumiss cures— Substitutes for milk—Artificial digestion . . . . . 609 CHAPTER XXIV. THE DIETARY IN ACUTE DISEASE AND IN MALASSIMILATION. 245. Prepared starch..........614 246. Invalid food...........617 247. Fat.............619 XX CONTENTS. CHAPTER XXV. THE MANAGEMENT OF CONVALESCENCE. SECT. PAQK 248. Errors easy.........' • 622 249. Albuminoids for histogenesis ......•• 626 250. Forms of upset..........628 CHAPTER XXVI. CONCLUSION—THE MEDICAL MAN AT THE BEDSIDE. 251. The examination of the patient.......632 252. What to observe..........638 253. The manner of the examination.......639 254. Our social conduct.......... 642 255. The natural history of disease.......645 256. As instanced in the relation of Bright's disease to the circulation . 647 257. To be forewarned is to be forearmed......651 258. The future, and our duty.........652 THE PRACTITIONER'S HANDBOOK OF TREATMENT. CHAPTER I. INTRODUCTION. § 1. The ultimate aim of all medical research is the treatment and prevention of disease. It is eminently desirable that a medical man be generally well-informed; but what is to be still more devoutly wished for is that he shall be a skilful practitioner. It is quite possible to be the one without being the other. The combination is what we hope to see commonly accomplished. The tendency of recent teaching has been rather to produce the first, leaving the second quality to develop itself, or to remain in a condition of imperfect evolution, as might fall out. This is not an individual opinion, in which case it would have little weight, but a general comment. We constantly hear it asserted that the highly educated medical men of the present generation are not more successful in practice than their less accomplished but more practical predecessors. Even members of the profession are to be found who assert that the man under whose treatment they would place themselves, if seriously ill, is the old-fashioned general practitioner. This is a very serious reproach to all our recent advances in scientific medicine; to our modern instru- ments of precision in diagnosis; and even to our progress in rational therapeutics, with the remedies added to our armamen- tarium in late years. § 2. In order to understand how progress in one direction may exist without corresponding advances in other directions, indeed with a certain amount of retrograding in some respects, we must 2 18 INTRODUCTION. clearly distinguish betwixt medicine as an art and medicine as a science. At present, the aspect usually presented to us by medi- cine is that of it as a science. We are beginning to have precise notions about the rational consequences of valvular disease of the heart, and to see why one set of consequences results from a defect in one valve, and why a totally different series of results follows from imperfection in another valve. We are learning to distinguish the locality of disease in the brain from the vari- ous disturbances produced in it, according to the functions of the part affected. We have learnt the lesson that much of the disease of advanced life is due to imperfect elimination of nitro- genized waste. The relation of mental conditions to bodily derangements is just dawning upon us in the ordinary diseases of the sane. Physiological inquiries are moreover pointing out to us the right direction of our therapeutic measures, and light- ing up areas never to be successfully illumined by empiricism. For instance, the treatment of angina pectoris by nitrite of amyl was the logical outcome of certain physiological inquiries as to the action of this drug, together with some very exact observa- tions as to the actual condition of the circulation during: the attack. The synthesis thus erected by Dr. Lauder Brunton, and successfully applied in the wards of the Edinburgh Royal Infirmary, is an excellent illustration of the power of well-con- ducted physiological inquiry to aid us in practical medicine. The experiments of Oscar Liebreich have given us chloral hy- drate, a hypnotic of the greatest value. The observation that strychnine and atropine are direct stimulants to the respiratory centre in the medulla, promises us the means of improving the respiration when embarrassed; just as digitalis stimulates the action of the heart when failing. The stethoscope, the laryngo- scope, the ophthalmoscope, the sphygmograph, the thermometer the urinometer, and cognate diagnostic aids have done much for us in the recognition of disease. The microscope has rendered services to medicine as an art as well as a science. It has cleared up the nature of a whole class of skin diseases hitherto shrouded in mystery; while in the recognition of certain internal affections it is simply invaluable. Such are some of the important steps recently taken in that division known as the science of medicine. In the art of medicine we cannot boast of such magnificent advance. As our instruments of precision have become more INTRODUCTION. 19 numerous, as well as more exact and trustworthy, we have insensibly come to regard the information thus furnished to us as of primary importance; until the information derived from a careful collection of rational symptoms, from a cautious consider- ation of the general condition, has been awarded a subordinate position. In fact, we attach an exaggerated importance to one series of facts and underestimate the value of others. At present physical signs preponderate in the mind of the practitioner over rational symptoms, to the detriment of the patient, and possibly to the discredit of the profession. The public cannot be expected to estimate us by any other measure than that of our usefulness. It is all very well for a patient to feel that his medical man is a gentleman; that he is carefully trained in physical examination, and capable of constructing a skilful diagnosis; who has added a residence abroad, and the observation of foreign schools, to his home-acquired attainments; but the essential thing after all is confidence in his power to aid him when stricken and pros- trated by disease or accident. The latter is our actual business and occupation in life; and it is here that success is most to be desired. We can now perform the longest and most excru- ciating operations without the patient feeling one pang of suf- fering ; we can give relief by hypodermatic injections of morphia more speedily, efficiently, and perhaps with less of those unde- sirable after-effects of morphia, than we could ere this invention; to say nothing of its value in intractable vomiting. We can enable an injured heart to develop compensatory growth, and so, in many cases, preserve for years valuable lives, which, until recently, must have soon been lost to us. By our improvements in facilitating nutrition we can rear successfully myriads of children who but a generation ago would have swelled the death-rate of those who die under five years of age. By a care- fully selected diet the diabetic patient can be preserved a useful life for years. The widespread use of antiseptics and disinfectants is already working much-needed reform in relation to the arrest of the spread of disease, and in rendering our refuse less harmful. Indeed there is much to render this century memorable in the annals of medicine as an Art as well as a Science. § 3. On the minds of some, both in the profession and out of it, there is a firmly established fear that there is something 20 INTRODUCTION. dangerous and unsafe in too much understanding of the nature of things, including the nature of disease. To such it seems much better and safer to rest contented; that it is the best thing to do certain things under certain circumstances without being too inquisitive or curious as to the how and the why : in fact, they rather avoid being able to give a reason for the faith that is in them. To those who search into the nature of things they affix the term unpractical. If research has yielded positive information, and a law has been established, they call its eluci- dator a theorist. A theory, no matter how well founded, has to them something dangerous about it, and indicates unsoundness in its author. " What an insult it is to the chartered imbe- cility of industrial mediocrity, that Shakespeare, Plato, Goethe, Humboldt, Bacon, indeed any one who possesses anj'thing of inspiration, should not be a mere sense-machine for registering observations. That some should declaim against theory is no more than that an eunuch should inveigh against lechery; it is the chastity of impotence." Such leanings have done much to retard the progress of medicine and have decidedly crippled its usefulness.' The carefully acquired knowledge of one man, however useful to himself and his patients, gave little or no ad- ditions to the general stock of information, because it remained individual knowledge derived from experience, which died with its possessor because he could not formulate it—could not so arrange it as to bring it within the sphere of the cognizance of others. He could treat one complex case admirably from his previous experience of like cases; but he could not enable another to treat such, or similar cases. The knowledge existed —but not in a communicable form. It has always appeared to the writer that if such experience could only be rendered avail- able to others, a great step would be secured. Much of the advance of knowledge lies in the capacity of one generation to benefit by the experience of its predecessor, in the power to appropriate the information gathered by those who have gone before us — knowledge which we in our time should leave elaborated and enlarged to those who shall come after us. Medicine is no exception to this rule. A man should not only learn for himself, but he should gather and garner for his successors. The circumstances of having undergone an appren- ticeship, of being brought up in a surgery, of being from child- INTRODUCTION. 21 hood in the society of medical men, together with some personal fervor and a firm confidence in the future of medicine, may form some excuse for the writer's attempting a task which is felt to be difficult; though it is hoped not insurmountable. The manner in which this work has been received at home, and even still . more in the United States of America, has more than justified the hopes entertained at the time of writing the first edition. In carrying into execution the scheme as it now presents itself, no attempt will be made to gather together all the facts of ■ medicine, to collect all the information possible, nor indeed to enumerate all the members of the pharmacopoeia. Such aim would tend to make this work encyclopaedic instead of a treatise rather inciting and suggestive. The aim of the writer, if it can but be accomplished, is to supply a digest of the general prin- ciples of therapeutics, to arrange wTell-known facts of practice, together with the explanations furnished by pathological research and physiological inquiry, in such array and form, that the treatment of each individual case shall become a fairly intel- ligent and rational procedure, rather than a groping empirical guess. Failure even may indicate to some one else a line worthy of pursuit. Especially is some such work indicated for the use of those who receive a scientific education without anything like a corresponding acquaintance with actual practice; aud who pass into the ranks of the profession, and are brought face to face with the care and responsibility of grave and complex cases, without that aid and supervision from teachers or seniors to which they have hitherto been accustomed. It is a serious matter, both for patient and medical man, this abrupt introduc- tion to practical medicine, with all its difficulties and anxieties. Practice differs essentially from the examination-table. An examiner may temper the wind to the shorn lamb, and remember that a diploma only guarantees the possession of a certain minimum of knowledge; but in practice the most complicated affections are presented to the tyro. Further, too, there is this difference: in the hospital the patient is merely a case of Bright's disease, or some other disease; in actual practice the patient is to a certain extent a patron, and the management of the case may exercise a distinct and powerful influence over the professional reputation and prospects of his medical attendant. Such a consideration alone is often sufficient to produce in the 22 INTRODUCTION. young practitioner a certain disturbance of the intellectual equilibrium, and to interfere with that serenity so desirable for calm investigation and decision; to induce, in fact, perturbation of a nature militating against perfect self-possession. § 4. It is soon apparent that a patient is not merely a subject of interest as the victim of some morbid process, nor even as furnishing an opportunity for individual advancement merely; he is an elaborate and interesting organism possessing certain definite qualities. In fact, he is a Man. He is a Being who possesses the attributes of humanity collectively; together with some variations which form individual peculiarities. In relation to the first he is an organism which has possessed the power of growth, of evolution until a certain point is reached. After that point is attained growth ceases, and a condition of perfect func- tional activity is established. In time, however, the system is no longer equal to maintaining its integrity, and certain modifi- cations of nutrition are produced, which we recognize as evidence that the system is becoming old. Such changes are often prematurely induced, and are then termed degenerations. One thing especially strikes the observer in relation to disease, and that is the capacity of the organism to maintain its existence for several days without supplies of either food or drink. Yet the excretions are going on. It is also found that during this time of fasting there is a loss of body-weight. In fact it be- comes evident, as we shall see in another chapter (XXIII.), that the body possesses a reserve fund within itself; and that for some time it can exist solely upon this reserve fund. This pos- session becomes a specially valuable matter in disease. The fund takes its origin in the food we consume. After each meal so much is stored up; every day so much is withdrawn from this body bank. If each day's food had to furnish each day's supply of force, we should have a most uneven existence; and anything like a normal state would be impracticable. By this system of storage man saves up under favorable circumstances, and ekes out his daily needs under less favorable circumstances. There exists a species of capital, or physiological fund, into which he can pay, or from which he can draw according to his necessities. This store of force will keep a man alive when deprived of food, for about ten days. With slight daily sub- sidies it will maintain life for a much longer period. Thus in INTRODUCTION. 23 acute disease this reserve fund enables the system to tide over the time of trial; if this period be survived the system is left weak, enfeebled, and reduced in bulk and weight. After the active disease is over there comes a period of convalescence, when the body capital is being restored and a new fund of force accumulated. This period is not without its dangers. The treatment of the disease by stimulants is alone rendered possible by the presence of this reserve fund. Stimulants enable the system to unlock some of its reserve stores. Alcohol too is, as we shall subsequently see, a readily oxidizable form of hydro- carbon, and as such is easily converted into force by the system. Often, indeed, it is the only food practically available. But it also enables the system to borrow from itself much more than it furnishes. When the person dies exhausted, the real state of matters is this—the reserve fund has been reduced below the point compatible with survival. This is death by exhaustion. This reserve fund of force exists in every individual. In some it exists in a highly marked condition, and these persons are said to possess great "stamina." Others possess it in a less degree; they are said to have little resisting power. Systems broken by disease, or wrecked by evil habits, possess but a small reserve fund. It is a matter of vital importance in the treat- ment of disease to be able to estimate fairly and correctly the extent and amount of this reserve fund in each and every case. § 5. Then come certain other matters which gravely modify the significance of objective phenomena of a more personal or individual character, which are not to be overlooked. First among these is the diathesis. The diathesis is the form or type of constitution inherited from the parents. Five such forms are described (see Chapter XII.): the strumous, the gouty, the nervous, the bilious, and the lymphatic. Each constitution car- ries with it certain tendencies and leanings, of the greatest possi- ble practical importance. In each there is a distinct inclination to institute certain symptoms and to present certain complica- tions. The strumous are very often lacking in vital force, and are the objects of much care during convalescence from acute disease; especially if it be of a zymotic character. The gouty are very liable to ailments in advanced life, often of the most varied and even Protean character; but in each the imperfect elimination of nitrogenized waste forms the basis. In the nerv- 24 INTRODUCTION. ous there is a distinct leaning toward complicated diseases connected with the nervous system, requiring special care and watchfulness: in this class we find the patients for whom it is so difficult to prescribe, they are either excessively susceptible to all drugs which act upon the nervous system, or, less com- monly, they require very large doses. The bilious are always more or less troubled with an accumulation of bile-products in their portal circulation, and, with them, attention to the liver is indicated in the treatment of all acute, no less than of chronic affections. In those of a lymphatic diathesis there is always a feebleness of resisting power, and the unenergetic system re- quires much whipping up with stimulants, alcoholic and other, to enable it to tide over attacks of acute disease. In addition to these points of diathesis, the family history is often most in- structive. The long duration of life in one family often whispers hope under conditions of gloom. The history of the family will often put the practitioner upon his guard when there is nothing apparently in the case itself to arouse his apprehension. Amongst personal characteristics too is the possession of endurance. In one system repeated attacks of disease may have shaken it to its very foundations; and the organism is already tottering, waiting for the last and perchance minute disturbance which will result in total overthrow. In another, repeated perturbations seem but to have educated the system to seek a new equilibrium under dis- quieting circumstances, and this education enables it to recover from rude oscillations which would be utterly destructive to most systems. There is also the greatest possible difference in individual organisms as to the amount of food, wine, etc., re- quired to compass a certain effort, or to evolve a given amount of manifested energy. Locomotives apparently identical vary much in the amounts of fuel they consume in performing a cer- tain amount of work. Horses notoriously differ in the amount of food they require; the labor executed being apparently the same. All these different factors must be included in the correct appreciation of each case, and are quite as important matters as the objective facts ascertained by stethoscope and urinometer. In certain combinations, varying widely in different systems these individual characteristics just enumerated are so pro- nounced as to form what are called idiosyncrasies. Often quite unintelligible as to the why of them, these idiosyncrasies are INTRODUCTION. 25 most important matters in the treatment of disease. Thus one person cannot take milk; while others cannot eat an egg. Such peculiarities will always receive attention from the wary and far-seeing practitioner. Then others cannot take quinine, or can tolerate some forms of iron only. To one few tonics are endurable, while another seems only to be the worse for every conceivable form of neurotic. The intolerance of opium and mercury by certain persons is well known. It is often found combined in the same person, and especially in the subjects of chronic Bright's disease. In fact, such intolerance should always furnish a strong hint to investigate the condition of the kidneys. Chloral hydrate, hyoscyamus, and other neurotics are well or ill borne by different individuals in a curious and almost inexpli- cable manner. In an aged couple recently under my care, both of whom were subject to attacks of suppressed gout, chloral was simply a poison to the lady, while her husband's praise of it amounted to eulogy. § 6. There are other points, associated with individual charac- teristics, of much importance in practical medicine, directing the prognosis and guiding the line of treatment. One is the general deterioration of physique, not always giving outward visible indications, which is found in persons who have under- gone much privation, or who have lived under unfavorable circumstances for some space of time. Bad or insufficient food, impure and tainted water, and foul, polluted air, singly, but more potently when combined, in time produce a deterioration which readily reveals itself in the course of epidemics. The dif- ferent areas of individual water companies have been found to give widely varying results in the proportion of deaths occurring during epidemics. The high death-rate clings to the impure water-supply. Persons thus influenced, or unfortunately so placed, sink under disease much more speedily than others who live under more favorable circumstances. They possess little resistive force, and what they have is quickly exhausted by serious disease. In such persons it is necessary to commence a plan of stimulation combined with nutritive food, in anticipa- tion of the hour of trial. If this treatment be delayed till the indications present themselves, it will usually be found inope- rative and unsuccessful; it has been too long deferred. In such 26 INTRODUCTION. cases the medical man must learn to see his evils far ahead and prepare to meet them. On the other hand, there is a large class of people not quite coming under the head of invalids, and yet not perfectly healthy, for whom a directly opposite line of treatment is indicated. They are persons who have established an ideal of health to aim at—quite irrespective of their capacities. They do not possess a normal amount of health and strength, or age is commencing to lay upon them its enervating hand, yet they are loath to acknowledge either. They aspire to the habits and practices of perfect health, or of a by-past time, and bend all their energies to the attainment of these aspirations. Instead of reducing their self-imposed demands to the capacities of their system, they endeavor to whip themselves up to their ideal by large supplies of stimulating food and liberal draughts of alcohol. It is of no avail, however; and then a complete breakdown, followed by protracted convalescence, is the result achieved. If they can be prevailed upon by any means to moderate their aspirations, or be compelled to limit their demands upon themselves to their capacities, much better health, and even length of days, would be practicable. They form a large and important class of chronic patients; with whose peculiarities and individual necessities the prudent practitioner will do well to make himself familiar. There is another class of persons who are chronic invalids of a different description, with whom more acquaintance on the part of the profession is desirable. They usually occur in the more affluent classes; indeed, their existence is scarcely compatible with hardship and penury. They have not yet found a biographer in the ranks of medicine; and the best sketch of such a person is the brief one by George Eliot in Adam, Bfde, where she describes Miss Anne Irwine, the Eector's invalid sister. A poor wretched spinster, with a small wan face, worn and sallow; with chronic headaches, necessitating rest in bed with a darkened room; the prey of neuralgia and depression ; utterly unacquainted with the sensations of buoyant health and possessing but a minimum of energy; bare existence under the most favorable circumstances is all to which such a system is equal. Great and tender consideration, a low voice the tones of which vibrate with sympathy, and a noiseless step, are more desirable here than extensive acquaintance with remedial INTRODUCTION. 27 measures. Such cases do not furnish brilliant cures, as do the hysterical; but they furnish grateful, attached patients, suscep- tible and thankful for your consideration. It is the height of cruelty to demand manifestations of energy from such poor creatures—they are simply not equal to them. § 7. Then, again, there is still another and larger class of patients—the chronic invalid, suffering from some incurable malady. It may be chronic gastritis, cirrhosis of the liver, a tuberculous lung, a weak heart, or granular kidneys which con- stitute the weak spot of the otherwise fairly healthy organism. If the injured or defective organ could but be restored to its pristine integrity, a return to something like perfect health would be feasible. But such restoration is simply impossible. " Health consists of a balance betwixt the various parts of the organism in power as well as in function." Consequently if the disease in one part be incurable, the sooner a new balance is struck the better. A general lowering, or levelling down, is alone calculated to preserve the organism in such cases: and attempts to improve the general condition too far by arw process of levelling up is but too commonly followed by disastrous results. An improvement in the general condition is not rarely productive of a still further disturbance of balance betwixt the weak part and the rest of the body; and then usually a new accession of disease in the injured part follows as a consequence. For instance, if the kidneys are injured, a comparatively high state of general health with good assimilation and much nitro- genized waste, is not uncommonly the cause of an attack of suppressed gout, may be as bronchitis or even pneumonia, the consequence of renal inadequacy; or an attack of acute nephritis may imperil the existence of the individual—which attack might have been avoided if the general condition had not differed so remarkably from the condition of the kidneys. Or, again, a person has a weak heart or an aneurism. Here the condition of chronic invalidism is more consonant with the continuation of existence than is that of a capacity for exertion, which would test too severely these injured structures. It is a great point in practice to distinguish clearly when to cease our efforts to im- prove the injured part by measures directed toward the general condition, and when to inaugurate a line of treatment which shall bring the condition nearer to that of the incurable organ. 28 INTRODUCTION. Constantly in actual practice such modification of our therapeutic measures will be clearly indicated. Such are several of the most important variations from the norm which will present themselves in daily practice. They present problems not always easy of solution. Sometimes we are scarcely thanked for their solution; at other times they furnish us much credit. They all need careful recognition, and give much valuable material for the elaboration of a line of treatment. Practically the clear appreciation of these rational indications often outweighs the information afforded by instru- ments of diagnostic precision. Very frequently the information thus afforded will put the youthful practitioner upon his guard in seemingly trivial cases, and prompt him to leave no stone unturned in cases where the physical signs are far from alarming; at other times it will whisper hope and encouragement where all seems dark and un- toward; in either case it will exercise a most pronounced effect upon the line of treatment. In order that our therapeutics may be successful, a distinct recognition of the case in its entirety, in its subjective as well as its objective phenomena, is most necessary; and a thorough appreciation of what is to be dealt with must, or ought, to precede our measures for dealing with it, otherwise much valuable time may be lost, or opportunities have passed away never to return; and an unavailing regret be left where a more guarded attitude at first might have changed the whole aspect. The view presented to the medical man after his examination of the case should be such that it will include the past history of the case; nay, more than that, it should embrace the family history on both sides, and should also furnish useful forecasts as to the probable future. This is a genuine diagnosis, and is as widely different from the mere physical diagnosis__ now so fashionable—no matter how exact, as is a fertilized from an unfertilized ovum; the one is, too often, a mere series of barren facts, the other is pregnant with potential hvpotheses. § 8. Having decided upon the ailment and formed a careful diagnosis, having satisfied the patient's friends as to the prognosis —it is perhaps not always desirable to tell the patient what is the matter or the gravity of the position, but never leave the friends in ignorance—the practitioner must proceed to construct his plan of treatment. It is a golden rule never to prescribe in INTRODUCTION. 29 an off-hand, slipshod manner; whoever does so will sooner or later trip. It is well always to construct, as far as possible, a distinct scheme and a definite plan of treatment. No matter how slight or trivial the case, it is desirable always to act on an intelligible and intelligent plan. Always, as far as practicable, wre should prescribe with knowledge as to what we expect our remedies to do. It is certainly fortunate that the agents are not influenced in their action by any theories or hypotheses on which the}- are administered. If such were the case, our therapeutics would indeed be chaos. Nevertheless it is always agreeable to give medicines with a lively expectation as to wThat they will do. Such prescribing always gives a greater sense of satisfaction than when one is driven to prescribe secumdem artem., or according to an unilluminated empiricism. Often indeed it is necessary to sketch out a scheme which will not only include the immediate present, but which will map out a line stretching far into the future. It may be desirable to give, at first, sedative or diaphoretic reme- dies; to be followed in a day or two by mineral acids and bark, and ultimately by steel and cod-liver oil. Or a case of sup- pressed gout may require eliminant measures with alteratives and a restricted diet for a time; after which tonics, good food, and wine are desirable. These arrangements are not contradic- tory, nor even inconsistent; each has its turn of usefulness, and then gives way to another. Such alterations do not indicate changes of opinion or caprice : they demonstrate a clear-sighted view of the case. As wheat is sown, grows, and ripens ere it is cut; so complex plans of treatment have their several stages. For instance, in an acute catarrh it is well to give depressant diaphoretics, as opium, antimony and iodide of potassium, first; and then, when the skin has been roused into free action, syrup of squills and phosphoric acid follow rationally in their turn. It is desirable first to throw the skin into action and lower the temperature, measures which relieve both the catarrh and the pyrexia; and then to give well-chosen tonics, and especially tonic expectorants, when the catarrh is bronchial; if it be nasal, phosphoric acid in infusion of cascarilla would rather be indi- cated. Whatever line or plan the reader may adopt, it should be rational above all things: if there is really nothing else for it, let it be selected by or from a well-chosen empiricism, either 30 INTRODUCTION. personal or acquired. How to meet the bulk of cases encoun- tered in practice will be described in the course of this work. It is a matter of the greatest moment in grave and complex disease that the practitioner keep his head clear and his judg- ment sound. If he lose his head it is as disastrous to the case, as it is to his army when a general loses his head in a battle or a strategic movement. And nothing can or will keep a man's head clear so effectually as the consciousness that he knows his work. It is no part of the present scheme to provide a complete treatise on Practice of Physic. There are many such works of great excellence which can be profitably consulted. The attempt here is rather in the direction of enabling the reader to wield satisfactorily a great proportion of our remedial agents, and to guide him in his therapeutic evolution; teaching him how to educate himself, and how to apply remedial agents intelligently and successfully. Some learn quickly for themselves how to combine remedies, how to construct prescriptions exquisitely adapted to the case before them; but others are not so fortu- nate, and for them the combinations given in a concrete form throughout these pages may be useful. § 9. Our remedial agents form themselves into a number of classes. Several members of different classes may often be advantageously combined in one prescription. Then there are different remedial measures. They may be also united with good effect at the same time. We may briefly construct a typical prescription, and then may review combinations of dif- ferent measures. Medicinal agents comprise remedies either possessing a general action, or acting chiefly upon one system, or perhaps one excretory organ. These latter agents have been supposed to possess this property by virtue of some stimulating effect upon that organ especially. For instance, urea is a true diuretic, acting powerfully upon the kidney when administered experimentally. Aloes acts upon the bowels if applied to a blistered surface, as well as when given by the mouth. It is not quite certain how far these agents act simply as increasing the blood-supply to the different organs, and so increasing their functional activity—for these two stand in strict relation to each other; or how far they are eliminated by these organs and so stimulate them into action. Of this more anon. Agents may INTRODUCTION. 31 possess a general action like mercury or iron. It may be neces- sary to give two agents possessing different actions together— say as sulphate of magnesia and iron—in a case of anaemia with constipation. These are the two chief factors of the prescrip- tion. It is necessary, however, to give them in a vehicle which may itself possess some value. Consequently it does not follow that they need be given merely in water. There may be a certain loss of appetite which may indicate some bitter infusion, as quassia, as the best vehicle. Then it not unfrequently happens that such a dose ii3 not very perfectly borne by the stomach; it seems to be cold, or to be followed by a sense of nausea, or eructations of wind. Under these circumstances a few drops of tincture of capsicum will form a capital addition. This is termed an adjuvant. Consequently the prescription will stand ultimately in the following form: R.—Magnesias sulph. ....... Qj. Tinct. ferri perchlor........TTLvj. Tinct. capsici ........ 1Ttiv- Inf. quassiae ....... ^j. This may be taken two or three times a day, from fifteen to thirty minutes before food; either before breakfast and dinner, or before dinner and supper, or before all three. Medicines are apt to be somewhat nauseous; and the above forms a bitter and warm chalybeate. Consequently something is desirable to take away the taste. A draught of water accomplishes this best. Such draught not only removes the taste, but it often acts usefully—is, indeed, of material value. Especially is this the case with chalybeate and alkaline medicines. It is often re- marked that natural waters of these two classes effect good results when similar remedial agents given medicinally have distinctly failed ; and that, too, after long and persevering trial. The amount of water makes the difference. Alkalies and iron should be taken before food, and be washed down by copious draughts of water; and it will not often be necessary to send patients to spas for natural waters to achieve what home-treat- ment has failed to accomplish, if this rule were generally attended to. This is an important practical " wrinkle." l 1 I suppose such hints are called "wrinkles," because, like wrinkles, they indicate the presence of age, and, therefore, of long experience. A lifetime may be spent, by no means uselessly, in the gleaning of such wrinkles. 32 INTRODUCTION. It may so happen, however, that it is found convenient to modify the prescription. For instance, it may not be easy to hit upon the exact amount of purgative the patient requires in order to keep the bowels gently open. It is one of the most disturbing matters possible in prescribing to adjust the exact amount of a purgative. So commonly is this fact recognized that it is usual to ask a patient whether he, or she, is easily purged or not. This is a question that in many cases it is undesirable to omit. Consequently, then, instead of sulphate of magnesia in the mixture, a pill of aloes and myrrh at bedtime, every night or second night, may be desirable. A slight action on the bowels is almost always beneficial at the commencement of a course of iron; but it had better be within bounds, else it may be harmful, or it may disgust the patient. Sometimes, too, quinine is indicated as a tonic in addition to the iron as a haematic and tonic. The prescription would then stand thus: with R.—Quiniae sulph. Ac. hydrochlor. dil. Tinct. ferri perchlor. Tinct. capsici Inf. quassias Pil. al. et myrrh. gr-J- Mlv- gr. v p. r. n. at bedtime. There is nothing contradictory in such combination. Even more complex arrangements are sometimes needed. As, for instance, supposing the patient has piles, it would then be necessary to resort to another remedial measure: Ung. gallse co. A small quantity to be applied on the tip of the finger to the piles after each motion of the bowels; taking care to bathe them well, or rather wash them thoroughly with cold water immediately after the bowels have moved. If it happens that the patient is a female, it is more than probable that under these circumstances she will have leucorrhcea too, and then something more will have to be added, viz., another measure also of an astringent class: Aluminis sulph. Aquae . 3U- 3XVJ- to form an injection to be used twice a day, with the patient the recumbent position. in INTRODUCTION. 33 § 10. Such would form in most cases a comprehensive line of treatment; and though looking at first sight a complicated affair, is nevertheless clearly intelligible and consistent. Another therapeutic measure even might be indicated if there also existed, as there very possibly would, a certain amount of palpitation. In that case it might be well to add an external application to the skin, Emp. belladonnas, 6X4, to be applied over the region of the heart. The patient by this time would be pretty effectually drugged, and it would scarcely be quite prudent to start with all this at once. It might, how- ever, all be necessary if the patient had been long under medical care in other hands, and nothing but a thoroughly effective and comprehensive therapeutic plan will be of any avail. If the piles caused much distress and prevented sleep, it might be necessary to add one more therapeutic measure, often very serviceable: Morph. mur. ......... gr. -]-. Gallic acid.........gr. ij. Cetacei..........^j. to be inserted nightly within the anal ring; placing it upon the tip of the long finger of the right hand, in order to pass it easily through the sphincter. § 11. This would in its entirety form a fairly exhaustive treat- ment, carrying with it the elements of probable success. But it might not be wise to cease even here. It might be necessary to recommend a cold bath every morning; or if this was too severe, or not practicable, a sponge bath. Also it may be desirable to advise long hours of rest in a well-ventilated bed- room; with early hours to bed, and late ones at which to rise. A protest might be raised at this by some well-meaning friend, who has a sort of impression in his or her mind that long hours in bed are wicked. Such a notion has retarded the recovery of many a patient. If it were only necessary to count beads during waking moments, such plan of short hours of sleep might be free from mischief; but with something more to do, long hours of sleep are often imperatively necessary to insure a sense of energy when awake. They are still more necessary in the restoration of a state of health. The safest rule is to permit patients to sleep wherever, and whenever, and as long as they 3 34 INTRODUCTION. please and can, until they no longer feel sleepy. It is even desirable that the patient lie down and sleep, if possible, for a couple of hours after the midday meal; especially is this desirable if the patient be at a spa or watering-place, where all rise at an early hour. This sleep breaks the long day in two, and the evening is enjoyed. Such rest does not, except in a few cases, interfere with the night's rest; in many cases the night's sleep is all the sounder for the afternoon nap. If the practitioner have the time, and the patient craves atteution, he might substitute for the suppository mentioned above a hypo- dermic injection of a solution of morphia. This is a most efficient means of procuring sleep. It is further requisite to direct the diet. This should be at once nutritive and digestible. It is commonly most convenient to have a large portion of it in a fluid form. Milk, to which more or less of an alkali has been added, eggs lightly cooked, meat-juice, sago, arrowroot, or corn-flour or lentil-flour pud- dings, custards, blanc-mange, etc., would form the chief dietetic material. To this might be added, according to circumstances, some generous wine—sherry, burgundy, champagne, moselle, or even port. Or a little brandy and water some would prefer; whilst others are the best for some sound malt liquor in good condition, as pale ale, stout, etc., in bottle and " well up." § 12. Of course, the orders given will very much depend upon the social position and the means of the patients, as well as upon the ailments. There is, in my opinion, nothing more cruel than to order patients what they or their friends cannot procure. It matters little whether it arise from thoughtlessness or cruel indifference, it is equally heartless and useless to order patients what it is impossible for them to obtain. § 13. Having calculated, then, so far as is possible—and in the great majority of cases in general practice it is quite feasible to do this—the means of the patient as well as his needs, it behooves the practitioner to lay down his line of treatment; bearing in mind the condition of his patient, and the action of the remedies about to be prescribed. There is a something to be learned by experience in prescribing, which tells when the ammonio-citrate of iron with tincture of nux vomica will succeed—and it does—where the muriate of iron and liquor strychnise have failed, which it is impossible to transfer from INTRODUCTION. 35 one person to another. Careful perusal of the following chapters will, it is hoped, do much to enable the reader to do this for himself; but this he must do for himself—no deputy, however willing and enthusiastic, can perform this labor for him. Education is not mere information; and it is not so much any mass of mere information afforded in the following chapters which can give this work any value it may be found to possess; but rather that there is such a selection made as will best illustrate principles, and so enable the reader to peruse, with more profit and advantage to himself, the systematic treatises on Practice of Physic and on Materia Medica, which already exist in no stinted number; and the place of which this work does not aspire to usurp, rather it trusts to be auxiliary, or even ancillary, to their studj*. CHAPTER II. ASSIMILATION. § 14. The first subject which obviously calls for our attention is that of assimilation, or the means by which what is taken in as food is converted into the material by which the system is sustained. The different morbid changes which interfere with assimilation necessitate careful attention to the physiology of this process, in order that we may have an intelligent compre- hension not only of the changes themselves, but of the rationale of our therapeutic measures. We shall find that the subject, though difficult, is not by any means so insuperable as many suppose. The application of clear common sense and the deter- mination to understand the subject will enable most men to sur- mount the difficulties. The following sketch of the physiology of digestion and assimilation is not intended for teachers of that subject, but is a broad outline for readers whose physiology may not be very clear, or which may have grown rusty in practice. As said before, all force, all manifested energy, is derived from our food. This food is chiefly that form which supplies our animal heat, viz., the hydrocarbonaceous. It is furnished to us as the carbohydrates, starch, sugar, and gum, and the hydrocarbons, fat, oil, and butter. " The union of these with oxygen, or their combustion, appearing to generate the force which is rendered apparent in locomotion or manual labor." (Carpenter, 7th ed., § 58.) Such food, however, will not support life for long if altogether dissevered from nitrogenized materials. These nitrogenized principles are requisite for the formation of tissues, and for the evolution of force. Without nitrogen the force stored up in the body could not be unlocked or manifested. The leopard cannot run a race with the antelope, but it can catch the deer by a sudden rush; because its blood is hio-hly charged with nitrogen compounds, and it can generate rapid if but briefly sustained motion. The antelope can go much further but it cannot escape the rush, because it cannot discharge its ASSIMILATION. 37 force fast enough. (Haughton.) But hydrocarbons are also essential to the formation of healthy tissue; while nitrogenized materials evolve some force in their oxidation. Sufficient sup- plies of each are requisite in order to repair daily wear and tear, and to give out force. The hydrocarbons are the fuel con- vertible into force in the body as much as coal in the locomotive's tender is the driving power in a static form. The oxidation of the one drags the train from terminus to terminus; the oxidation of the other gives us all, or nearly all, our body force, intel- lectual or physical. Various salts, containing lime, chiefly in the form of phosphates, potash, soda, iron, etc., are also required to keep the body in health. We will now briefly trace the course of food. § 15. Food may be solid or liquid. If the latter, the digestive process is somewhat simpler, and mastication is not required. If solid, food is rolled over with the tongue, grouud with the teeth, and thoroughly mixed with saliva, in the mouth. Here the first change is undergone, namely, the conversion of some of the starch into sugar by the diastase of the saliva. A cer- tain amount of oxygen is worked in too, which, along with the salivary secretion, makes digestion easier and more perfect. Then the mass is swallowed.. In the stomach it is turned over and over, and the nitrogenized matters are gradually dissolved by the action of the gastric juice. This juice is an acid secretion, formed in the epithelial cells of the gastric tubules, and contains a ferment named pepsin. Pepsin is an animal ferment capable of digesting meat out of the body if in the presence of warmth and acid fluid. It is the only ferment of the body with which we are yet generally familiar; but there are other ferments in the body which serve important functions in the animal economy. In the stomach nitrogenized material is converted into peptones, in which form it is absorbed into the blood. Unlike other forms of albumen, peptone is very diffusible. " It diffuses with remarkable facility through animal membranes." (Car- penter, § 104.) During the digestive process the pyloric ring is pretty fairly contracted, and only permits of the passage of di- gested material until the termination of the digestive act, when it relaxes, and the undigested and indigestible materials pass along the intestines toward the anal orifice. After passing the pyloric ring the fat we consume is brought under its own special 38 ASSIMILATION. digestive process. It is brought in contact with the pancreatic juice, by which it is emulsionized.1 Fatty stools are almost pathognomonic of cancer of the head of the pancreas. In the intestines the different products of digestion are absorbed, either by the lacteals of the intestinal villi and so borne into the recep- taculum chyli, or by the venules of the portal circulation. The blood of the portal circulation contains during digestion a rela- tively large amount of albumen, of sugar, and of water. After long abstinence it does not differ from that of the venous system in general. A large quantity of bile is also poured into the chyme, as the digested food is termed. This bile is however usually reabsorbed, and but little bile is normally found in the lower intestine. Feces consist of the solid and indigestible con- stituents of food, chiefly; that is, with certain salts, mostly phos- phates, and certain excretions from the glands of the intestines. In connection with digestion must be included the function of the liver. The liver is a most important viscus, but the general impressions as to it and its function are very vague, and even erroneous. The prevalent idea is that it excretes bile, as a noxious product of digestion; and that biliousness indicates a sluggish liver. This view is essentially erroneous. " The ulti- mate source of sugar and of every other constituent of the body is, of course, the food we eat; and this, as we may easily see in a typical meal of beefsteak, bread, and pudding, consists of fat, albumen, starch, and cane sugar. The fat takes no part in the production of sugar within the organism, but the other three do. After they have entered the intestinal canal the starch is con- verted into grape sugar by the saliva and pancreatic juice, and the cane sugar into a mixture of glucose and another sugar, called lsevulose, by the intestinal juice. The albumen is converted into peptone by the gastric and pancreatic juices. The sugar and peptones thus formed by the intestinal canal are absorbed by the intestinal veins; but they are not all at once poured into the general circulation and carried to the brain and muscles. If this were the case, these structures would get all their nutri- ment at once, and they would have to stow it away themselves for use during the intervals of fasting. The liver acts as a store- house in which the superfluous nutriment absorbed during di- 1 Starch and albumen are also acted upon hy the pancreatic fluid. ASSIMILATION. 39 gestion is laid up, and gradually given out again into the blood during fasting. The sugar which has been absorbed from the intestines is conveyed by the portal vein into the liver; and there it is converted into glycogen, and stored up in the hepatic cells. If the portal vein be ligatured so that the blood finds its way from the intestines to the heart and body by means of the collateral circulation, without passing through the liver, glyco- suria occurs. The first great function of the liver, then, is to form glycogen from the sugar and peptones supplied to it from the intestines, and to store them up till wanted. The second great function of the liver is to give out, during fasting, the nu- triment which it has stored up during digestion. This is effected by the glycogen which has been stored up in the organ becom- ing gradually transformed into sugar again. It is then washed out of the liver by the blood, and carried with it into the general circulation." (Lauder Brunton.) The bile thrown into the in- testines is, to a large extent, superfluous matter. It probably, however, serves some useful purpose in digestion.1 Normally, it is chiefly reabsorbed. In excess in the bowels it produces diarrhoea. When its outflow is checked we have constipation, as in jaundice. The function of the liver must be remembered in our treat- ment of various forms of ailments. Mercurial purgatives do not increase the bile-secreting power of the liver, but they sweep out the bile products in the intestines and portal circulation in excess. Thus they produce bilious stools, and give relief to that condition known as biliousness. It is very important to bear this in mind. It clears up a very difficult subject, often obscured by so-called explanations. In addition to the digestion described above, a species of digestive power exists in the csecuin, especially in certain animals. This and the power of absorption possessed by the lower bowel are important matters when feeding by the rectum becomes necessary. § 16. After this brief sketch of assimilation, we may now profitably consider the different disturbances which mar or interfere with these various processes. First comes the ques- tion of the changes undergone in the mouth. Very little can 1 Bile aids in the filtration of fat through membranes. (Hermann's Physiology.) 40 ASSIMILATION. be done by drugs here, so we may dismiss them at once. But it does not necessarily follow that therefore nothing can be done. Much indigestion, and consequent imperfect assimilation, takes its origin in decayed teeth. In consequence of the condition of the teeth, the food is not well masticated. Xot only that, but as a result of the loss of power to masticate, the food is swallowed without being fairly saturated with saliva. It is thus doubly unfit for reception by the stomach. When such a condition obtains, the dentist may be of much service. So far as the medical practitioner is concerned, he can advise a suitable dietary. The food ought to undergo such culinary preparation as will, to a great extent, do away with the necessity for masti- cation. Light puddings, soups, minced collops, sausage meat, various entrees, preparations of eggs and milk, furnish a not unvaried or unpalatable dietary for the toothless. It must be impressed upon them that the rolling of the meat about by the tongue, and the mixing of it with saliva, are important matters; and the hard gums often form no very imperfect substitutes for the missing teeth. If the craving for slices from the joint be very strong, it may be indulged with a minimum of bad result by the skilful and industrious use of the knife ere the meat is conveyed to the mouth. Sialagogues.—This is a class of agents with which we are not very familiar, and little can be said about them. All sapid and acrid tasting materials cause the mouth to water by the flow of saliva so occasioned. The smell of cooking usually produces a similar result if we are hungry. If we are sated with food, the same smell causes nausea. The tasty materials which are sometimes consumed at the commencement of a long dinner, as cavaire, etc., probably act to some extent as sialagogues. The presence of food in the stomach causes a flow of saliva, as Br. Gairdner found in a case of cut throat. Here the injection of broth into the stomach caused a distinct flow of saliva. The importance of the addition of saliva to food is shown by the experiments of Spallanzani and Reamur, who found that per- forated tubes containing food placed in the stomachs of animals gave the following results. Food moistened with saliva was most quickly digested; then food moistened with water; and lastly, food not moistened at all. Mercury is a sialao-oo-ue but the excessive flow of saliva serves no useful purpose. Xeither ASSIMILATION. 41 is pellitory ever used to increase the flow of saliva for admixture with food; nor as yet jaborandi. Instead of acting upon the salivary glands, it is more con- venient in practice to give starch which is, to a large extent, predigested, either by exposure to heat or by the matting pro- cess. Such predigested starch is almost independent of the saliva. Some account of these prepared foods will be given later on. § 17. When the food is passed into the stomach, a change in the condition of that viscus is at once instituted. Ere the food is taken, the mucous lining of the stomach is pale, only slightly moist, and possessed of an alkaline reaction. On food being placed within the stomach the gastric bloodvessels dilate, the color of the lining membrane changes into a rosy hue, and the gastric juice, freely secreted by the gastric follicles, is poured out on the surface, which becomes bedewed with the secretion. At the same time there is a change in the muscular walls. No longer quiescent, they commence to contract and dilate in such a manner as to produce a rotation of the contents of the stomach en masse. By this means the whole contents are brought in contact with the digestive fluid, and are reduced to pulp. Such is the action of the stomach in perfect normal digestion. There is, however, no more common disturbance than imper- fect digestion. This may arise in various wTays, each indicating its own proper remedial measures. It not uncommonly takes its origin in either an imperfect amount of gastric juice, or in an inferior form of juice of impaired solvent properties. It is and must be a difficult matter to settle, which of these patho- logical states of the gastric secretion obtains. Consequently our treatment is rather empirical than rational, and is really educated guessing.( Two plans of treatment suggest themselves: either to increase the amount, or to improve the character, of the gastric juice. We will take the latter first. The knowledge that the stomachs of animals digest food of various kinds just as perfectly as do our own, has suggested the use of the digestive fluid of animals. The most suitable animal is the omnivorous pig. When properly prepared, pepsin is a very active agent. It can either be used fresh, or in the dried form of powder. It is given in doses of from five to fifteen grains usually, with a certain amount of 42 ASSIMILATION. dilute muriatic acid (5 to 10 drops), or it may be given on bread and butter. The use of pepsin is far from being as yet very explicit. Wood [Treatise on Therapeutics, Philadelphia, 1874) says, "Evidently one of two things is certain: cither the present practice is ridiculously absurd, or else pepsin acts upon the stomach in some way as a stimulant." He, however, admits that its utility in the treatment of imperfect digestion with diarrhcea in children is much more certain. lie thinks pepsin is much more powerful in the primae viae of children than of adults. Muriatic acid and lactic acid are also occasionally used for the purpose of aiding the gastric juice to perform its work. § 18. If we do not feel quite assured of the utility of pepsin in all cases, there exists no doubt about our capacity to increase the flow of gastric juice, and so to render digestion more perfect. The various pathological conditions of the stomach will be con- sidered in their fitting place in Chapter XVI., at present we are concerned with assimilation only, and the changes in the stomach in digestion. In fact we are here considering imperfect digestion, regardless of its causes, only in so far as the digestive act is im- perfect. As said before, the functional activity of an organ is in direct relation to its blood-supply. An increase in the blood- supply gives greater functional power: a diminution in the supply of arterial blood lessens the functional power. Many agents in- crease the vascularity of the stomach, and so improve digestion. These are called stomachics. Stomachics.—This is rather an old-fashioned appellation, but it will serve our turn well nevertheless. The list contains agents otherwise possessing widely different properties. Thus alcohol, arsenic, ipecacuan, capsicum, and others find themselves together. They all possess this property in common—they increase the vascularity of the stomach, in small doses; in large ones they act like irritant poisons, and produce inflammation of the stomach. They all are apt to produce vomiting in excess; and certainly their continuous administration in liberal quantities produces an irritable condition of the stomach. How they produce their action we do not exactly know. Ere proceeding we will just glance at the arrangements of the nervous supply of the stomach. It contains fibres of the sympa- thetic nervous system, and terminal branches of the pneumo- gastric. Speaking broadly, fibres of the sympathetic produce ASSIMILATION. 43 contraction of involuntary muscular fibre: cerebro-spinal fibres produce dilatation. Thus the brothers Weber found the vagus to inhibit the action of the cardiac ganglia, and irritation of it delayed the ventricular contractions. M. Bernard has found by various experiments that galvanism of the pneumogastric excites a flow of gastric juice; while similar irritation of the sympathetic arrests the secretion. Section of the pneumogastric nerves stops digestion, and the mucous membrane of the stomach, previously turgid, becomes pale and exsanguine after such section. Thus we see the pneumogastric fibres dilate the bloodvessels, the sym- pathetic fibres contract them. From this we can understand how any great emotion acting on the sympathetic may at once produce indigestion. Whether our stomachics act by stimulating the pneumogastric fibres, or by paralyzing the sympathetic, we do not know; there is no doubt, however, that they increase the vascularity of the stomach. In practice we find that in many persons a small quantity of alcohol improves digestion; and that by its means a meal can be digested which would otherwise be undigested, and so wasted. But it must be borne in mind that alcohol and artificial pepsin do not agree, and therefore should not be given together. Arsenic produces a vascular flow in the stomach, often very useful. In large doses it produces irritability and inflammation. It is a difference of degree. Like alcohol, a small dose increases the vascularity of the mucous lining of the stomach and a free flow of gastric juice; a poisonous dose pro- duces inflammation and total arrest of the flow. Ipecacuan produces a vascular flow in small doses; in larger doses vomiting results. Ipecacuan formed part of the best old dinner pill, which ran something like this: Pulv. ipecacuan.........gr-j- Ext. cinchon..........gr. j. Pil. al. et myrrh.........gr. rj. and as such was very useful. This pill is not so much in vogue now; but its turn may come again. Ere prescribing arsenic as a stomachic, permit me to give a quotation from Ringer about the action of alkalies. "We wish to draw attention in this place to one important property of alkalies, namely, their power to increase the, secretion of the gastric juice, itself an acid secretion. We venture to think that 44 ASSIMILATION. many facts warrant the following generalization : that alkalies applied to the orifices of glands with acid secretions increase their secreting power; while alkalies applied in a correspond- ing way to glands with alkaline secretions lessen or check this secretion." Given, then, almost immediately before food, the following prescription contains promise : Pot. bicarb..........gr. v. Fowler, solut..........TTL^J- Inf- gent..........5J. It might be given before breakfast and dinner. Next to the question of stomachics comes the question of vegetable bitters, commonly known as tonics. It is not as tonics they are described at present, but simply in their relation to the stomach and to digestion. Bitters.—Unfortunately it is not possible to give such a clear physiological explanation of the action of vegetable bitters as it is in the case of stomachics. There is, however, no better estab- lished fact in medicine than the action of vegetable bitters to increase the appetite and improve the digestion. They are in one form or other the resort of all dyspeptics, and the mainstay of herbalists. Marvellous and poetical discourses have been written as to the action and effects of these bitters, and their beneficial action has been chronicled by dyspeptics. As yet, physiology has little or nothing to say. The facts are not to be disputed, but no explanatory voice is yet audible. There are various forms of these bitters; some simply bitter, others highly aromatic and partly astringent, from the presence of tannin. Quassia is the simplest bitter. Powerful, intensely bitter, and free from tannin, it forms the vehicle when iron is indicated. It is also the chosen agent in the dyspepsia of drunkards. It is usually given with some acids, hydrochloric or nitric usually : Ac. hydrochlor. dil....... vp x Inf. quassiae...... -z- with or without a few drops of tincture of capsicum, is a capital appetizer to the stomach saturated with alcohol. Gentian is agreeable, and forms an excellent vehicle for quinine, when not combined with iron. Chiretta is a coarse gentian. Cascarilla ASSIMILATION. 45 is a very pleasant aromatic bitter, and forms an excellent vehicle for alkaline remedies when given without iron. Sp. chloroformi........Tftxx. Pot. bicarb. . . . . . . . . . gr. x. Inf. cascarillae . ........ ^j. is a capital combination in the dyspepsia of the gouty, or even where there is excessive acidity of other origin. The well-known cinchona in infusion is often much better tolerated than is quinine in solution. This fact is very apt to be overlooked; but it is well worth remembering, and its re- membrance is often very useful. We will consider these agents again in their relations as tonics. The action of these vegetable bitters upon the digestive organs is as inexplicable as it is well assured. In his Clinical Medicine Dr. King Chambers gives a very pleasant account of them, which is worth quoting, though it is quite imaginative, and utterly unsupported by any valid evidence. " Vegetable bitters brace up and harden the mucous membranes, as may easily be tried by their effect upon the mouth. Hence exosmosis is lessened and endosmosis is increased. Digestion is made more rapid and effectual, nutriment is taken up more copiously and quicker. Even in a healthy person the remains of the last meal are sooner disposed of, and the appetite for the next sharpened by a bitter. This is the pure action of a vegetable bitter. . . . When mucus is in excess, it doubtless interferes much with the taking up of nutriment by membranes, and the checking of its growth is an indirectly constructive aid. Many of the vegetable bitters contain tannin, or other astringent constituents, and are thus peculiarly suited to the leucophlegmatic (or mucogenous) diathesis." This at least gives a notion of some kind about their action, and that is not quite a useless matter in giving direction to their therapeutic aim. It fits in with the facts, and in so far is useful. But it cannot be regarded as a physiological explanation of the action of vegetable bitters. There is no doubt that these agents do increase the sensation of hunger; and these sensations depend for their expression upon the stomach. Consequently these bitters must have some action, if we only knew it. Equally 46 ASSIMILATION. certain is it that digestion is also furthered and rendered more efficient by their use. They are of avail in furthering digestion if given after a meal as well as before it. But in so doing their appetizing effect is largely lost. § 19. After the digestion of starch and nitrogenized principles we come to the digestion of fat. Fat is emulsionized mainly by the juice of the pancreas, which contains diastase like saliva, but has also a powerful action upon oleaginous matters. It is a gland about which, in disease at least, we know very little. In health, and physiologically, it has been carefully examined. M. Bernard experimentally found that ether introduced into the stomach determined soon afterward a considerable flow of pan- creatic juice. This was a very valuable observation at a very important time. The introduction of cod-liver oil by the late J. Hughes Bennett is a matter of our own times; and the im- portance of a sufficiency of fat for the building up of truly healthy tissues is a comparatively recent addition to our knowledge. The association of the formation of tubercle with a dietary too defective in fatty constituents, the repair so often instituted when fatty food was given and assimilated, pointed distinctly to an increased use of fat by the consumptive. Cod-liver oil is the most easily digested of all fats; and as such has come into almost universal use. In convalescence from acute disease, as well as in the palliative treatment of chronic disease, and especially of consumption, in supporting the system under the severe trial of surgical fever, cod-liver oil has won for itself a well-established position. One difficulty has always been felt, and it is this: Even cod-liver oil is not always digested, and therefore something else was wanting. Dr. Balthazar Foster, of Birmingham, con- ceived the idea of utilizing Bernard's hint, and so combined ether with cod-liver oil. The increased flow of pancreatic juice so induced led to assimilation of the cod-liver-oil, and thus another step forward was made in practical therapeutics. Another effect noticed by Dr. Foster was the return of a liking for fat under this plan of treatment, where previously a strong distaste to it had existed. One method is to give from ten to thirty drops of ether (sulphuric) in the dose of oil; or the ether may be given in water immediately before the oil. In private practice Dr. Foster prefers to give the following mixture: ASSIMILATION. 47 Potassae bicarb. ...... ?iss-?ij. Acidi hydrocyan. dil......1TL m xij-xvj. Spt. aetheris ....... spss-ziij. Aq. ad........£ viij.—Misce. §j. ter in die sumat.1 This method of adding to the usefulness of a course of cod- liver oil deserves wide and general attention. Since this was written, an American committee was formed to investigate this action of ether upon the pancreas. It corroborated Dr. Foster's views entirely. The adoption of a pancreatic fluid derived from animals, and rendered useful in relieving the necessities of man, has been brought forward by Dr. Horace Dobell, and is often useful. These preparations can be easily purchased, ready prepared and directed, at almost any chemist's. The changes in the pancreas of the calf, its large size and great cell-activity during the suckling period of calf-life, and its gradual diminution to a fixed size as this food is changed for a vegetable diet, point to the close relations betwixt the function of the pancreas and the assimilation of fat. When the reader arrives at Chapter XXIV. he will see what advances have been made in this matter since the appearance of the second edition. § 20. Assimilation is never very perfectly performed if the action of the intestines be sluggish and imperfect. The waste matters of food must be swept away, out of the small intestine at least, in order that the nutritive 'material of the next meal may be brought in contact w7ith the intestinal villi and absorbed. In the large bowel some secondary digestion may take place, but it is of questionable utility; and it is practically much better to keep the large bowel unloaded than to look for anything from secondary digestion. The accumulated feces are very apt to become hard and pouched in the folds of the large intestine, and so become the cause of much disturbance. The mere load, and its pressure on parts around, are often sufficient to interfere sorely with the functional activity of a susceptible and feeble stomach. In many persons digestion is never comfortable nor effective while the bowels are loaded. The enormous consump- tion of aperient pills, quack and other, in this country, to say 1 Clinical Medicine, 1874. The whole of the paper is well worth reading, as, indeed, are the other essays in this book. 48 ASSIMILATION. nothing of aperient waters, testifies to the widespread convic- tion on this head. The use of an aperient pill at bedtime and a draught of cold water first thing in the morning obtains largely; and might with advantage obtain still more largely. The purgative in such cases may well be accompanied by some nux vomica, which excites the vermicular contractions of the muscular coat of the bowels. A carminative may be profitably combined. A good pill for common use would run so; Ext. nucis vom. . . . . . . . gr. j. Pulv. piper, nig. ........ gr. j. Pil. coloc. co. ....... . gr. iiss. at bedtime every night, or every second night; or instead of this Pullna, Fredericshall, or Marienbad water may be taken; the dose apportioned to each individual and his exigencies, accord- ing to the directions given with each bottle. A certain action upon the bowels is often beneficial, especially to those who con- trol their bowels from social necessities. Such persons are all the better for occasional purgation. A slight amount of purga- tion is almost always indicated in the commencement of a course of haematics, especially chalybeates. § 21. Hjematics.—This is a very important group of agents, though its members are few. Haematics furnish to the blood matters which are defective in our dietary. They are indeed foods rather than medicines; though a haematic may of course be used in what is truly a medicinal dose. ILematics go to build up the blood, to increase blood formation, and with it the growth of every part which is fed by the blood, and that is, in fact, the whole system. One of the group is phosphate of lime. Especially useful is this agent during the period of growth. "Wherever cell-growth is active, there is phosphate of lime in excess," says Ringer. Overworked town individuals and over- suckling mothers, as well as growing infants, are benefited by this haematic. It is especially useful in rickety children. It controls morbid nutrition of the skeletou, while it supplies the lime for proper ossification. It is not needed in large doses. In fractures of bones in pregnant women lime is useful. The ad- ministration of lime during pregnancy in women whose previous children have shown tendencies to rickets is yet untried ■ but it seems to offer a good and hopeful prospect. ASSIMILATION. 49 Of all haematics, however, iron stands first—preeminently first. It is rather a food than a medicine. "Iron is a constant and necessary constituent of the body, and must be regarded as an important food." (Ringer.) Iron, though a normal constituent of the body, is chiefly pre- sent in the red blood-corpuscles, though there only to a limited extent. By its use we can increase the amount of haemoglobin, upon which the chemical interchanges conducted by the red blood-corpuscles depend. Under its use in anaemia, the cheeks grew rosy, the lips recover the usual color, the eye brightens, the tongue is less flabby, there is a general increase in body- weight, a development of muscle, and a heightened condition of nerve action. Tone is given to every part of the system. " Iron salts in anaemia possess important properties other than in- fluence over the growth of the corpuscles. They act bracingly on the relaxed mucous membrane of the digestive canal, and probably in this way tend to restore its functions. Moreover, it is highly probable that, after its entrance into the blood, the iron exerts an influence beyond that of merely increasing the quantity of red corpuscles. Hence iron preparations are useful, not simply as a food in promoting the formation of the blood- disks, but on account, likewise, of their beneficial influence on the tissues of the body. Iron, therefore, cannot be regarded merely as a food to the system; it is also an important curative agent. Large quantities of the soluble astringent preparations should be administered where we desire to benefit tonically the mucous membrane of the digestive canal and the tissues." I make this quotation from Ringer in its entirety, in order to show that, while iron may be given as a haematic, it may be usefully given in larger quantities than can be utilized in the blood. The excess acts as a tonic. When given to healthy persons for a long period, iron com- monly produces plethora, or an excess of red blood-corpuscles. When given to anaemic persons, it raises the condition of the blood to that of health. " But after a time the blood appears, as it were, to become saturated with it, and ceases to assimilate it." (Wood.) In certain chronic conditions it is very difficult to see any point of saturation; and iron may in many cases be usefully continued for years. 4 50 ASSIMILATION. What becomes of the excess of iron in the blood ? It is chiefly cast out in the feces, which become black from the union of the iron with the tannin in the feces, or the sulphuretted hydrogen it meets there. It is also eliminated in the urine. Briicke found that in rabbits, after a time, nearly all the ingested iron could be recovered from the urine. Quevenue found it as a normal constituent of urine; and Becquerel has observed the amount found in the urine to vary with the amount given. Iron in all its forms is useful. "Almost all of the prepara- tions of iron are more or less astringent, and, when in the blood, very probably they exert a direct influence upon the tissues, contracting them, not merely by increasing their tone, but also by acting on their vital contractility." (Wood.) Much difference of opinion exists as to the best forms of iron for common use. Some advocate iron in powder; others as haloid salts; while some prefer what are called the lighter preparations, as the ammonio-citrate and the potassio-tartrate. Personally, I prefer to commence, in convalescence, with the lighter preparations, and then go on to stronger forms. Much will depend upon what it is desirable to combine with it. For instance, Amm. carb. ......... gr. v. Ferri am. cit. . . . . . . . . . gr. v. Inf. quassiae ......... ^j. is a capital form in early convalescence, or in the treatment of amenorrhoea. After a time the following may be substituted for it with advantage : Cit. fer. et quiniae Liq. strychniae Inf. calumbae . This forms a beautiful tonic—effective, agreeable, and pleasing to the eye. A common form, much used in both public and private prac- tice, is the following: Quin. sulph.......... gr. i. Tinct. fer. perchlor. . . . . . , . Tfl x Ac. hydrochlor. dil. . . . . . # . Til Hi Inf. quassiae . . . . . . , t . 5i. Often the iron is felt to be heating, and then a little sulphate gr. v. miv. 3J- ASSIMILATION. 51 of magnesia is of service. The following is a typical prescrip- tion : Quin. sulph.....■.....gr. j- Mag. sulph. Liq. fer. persulph. Ac. sulph. dil. Inf. quassiae 9J- tllv. Hlv. If this lies cold on the stomach, a few drops of tincture of cap- sicum may be added. For a permanent prescription, requiring to be continued for months, a pill is the best form. It admits of a large supply of material in a small space; the nausea of the disagreeable taste daily for months is also avoided; it does not affect the teeth, and it can be taken after food without attracting the attention of others — often so trying to persons in weak health. The following is a very favorite form with me: Ac. arsenic. ......... gr. j. Fer. sulph. exsic. ........ ^j. Pulv. capsici.........gj. Pil. al. et myrrh. . . . . . . . . q. s. In pil. LX. div. 1 semel aut bis in die. Taken immediately after a meal, this is a digestive and tonic pill of the highest value. One beautiful preparation of iron should not be forgotten; it is often well borne when other forms are not tolerated, and consists of the recent addition of the tincture of iron to acetate of ammonia, Tinct. fer. perchlor.........Tfl>. Liq. am. acet..........5J- It is beautiful to the eye, palatable, and, in consequence of the decomposition produced, readily assimilated. There are many excellent preparations of iron which can only be alluded to now as occasionally furnishing a more suitable form than any here given. There is the ferrum redactum, Vallet's ferruginous pills (carbonate of iron), Griffith's mixture (mist, ferri. comp.), excellent with decoct, aloe. co. in amenor- rhcea and in low forms of gout, Blancard's iodide of iron pills, the syrup of iodide of iron, Parrish's chemical food (phosphate of iron and lime), etc. More recently a new form of iron— dialyzed iron—has been introduced from France; this is a 52 ASSIMILATION. beautiful preparation: it is readily digested, it does not affect the teeth, and its taste is not objectionable. The addition of iron to the food often produces effects little less than marvellous. It not only gives tone to the whole sys- tem, but nutrition is markedly advanced by its presence in the fluids of the body. This is often well shown in the improve- ment in a feeble heart under a course of iron. Digestion be- comes more perfect under the use of chalybeates. " Digestion cannot be normal when the blood has ceased to be so." (Stille.) Every part seems to perform its functioti more efficiently under the stimulus of iron, of blood once more rich in one of its most important constituents. One remarkable thing about the action of iron is its effect upon the dyspnoea of chlorotic girls and others. In these cases there is pallor, amounting often to waxi- ness, from absolute diminution in the number of red corpuscles, and marked shortness of breath on exertion, from lack of these oxygen carriers; there is general loss of body temperature from imperfect combustion or oxidation, while what ought to have been burnt is stored up as fat. In fattening cattle, farmers often bleed an animal which is not fattening quickly, in order artificially to produce anaemia. Under conditions of anaemia changes take place spontaneously such as the farmer induces deliberately, especially in young and not fully grown persons, chiefly girls. Iron soon induces a change, and restores matters to their normal condition. It must, however, be borne in mind that when the blood is either broken down or its formation hindered by some blood poison, iron will not cure the amemia unless combined with some specific remedy to the poison in each case. For instance, in lead-poisoning iodide of potassium is absolutely requisite to good blood formation; in syphilis, mercury; in gout, potash; in malaria, quinine should be added to the iron. It is a matter for surprise how little this fact is recognized. Often, indeed, these specifics are true haematics, by destroying the poison which is exerting so injurious an influence upon the blood. The question of the effect of im- perfect elimination and its consequences upon the blood wTill be considered in the next chapter. Iron will be alluded to again in several chapters as occasion requires, and where its action as a haematic renders it an im- portant factor in the treatment. ASSIMILATION. 53 There are other haematics, as soda, potash, etc., which require a word. Soda is a natural constituent of the blood. As chloride of sodium it forms an important addition to our food, and the - consequences of its withdrawal are so baneful, that it formed a terrible old Dutch punishment. Water and bread made without salt was one of their most exquisite tortures. The decomposition of common salt furnishes hydrochloric acid to our gastric juice, and soda to our bile-salts. African tribes will, like the buffalo, travel several hundred miles to procure this coveted addition to their food. Potash is a normal constituent of muscle, and is a valuable haematic in lithiasis. § 22. Ere leaving the subject of haematics, a few words are essential as to the value of water as an adjunct. All the haematics are soluble, and require water for their solution. Not only that, but it is a well-known fact that systems often can be brought under the influence of iron at chalybeate spas which have resisted all medicinal treatment, no matter how ingenious or varied. The difference has been found to lie in the amount of water. In all natural waters the iron exists in a state of high dilution, and a large bulk is required to furnish any material quantity of iron to the system. The late Dr. Fuller has pointed out how chalybeate remedies may be rendered much more effective by adding to them large draughts of water. From a fairly long experience, lean quite corroborate this statement; and amidst the humbler classes, where a sojourn at a spa is simply impossible, such addition is often of the highest service. Especially is this the case where chalybeate and alkaline remedies are combined, and given before food. A draught of water, varying from half a pint to a pint, after each dose, will often make all the difference betwixt no benefit and the most satisfactory treatment. The dilution has the most excellent effect, and iron so diluted is absorbed when in a concentrated form it is not assimilated. Under certain conditions, water is a true haematic. All sub- stances which are held in solution by the water of the blood must escape wherever there is a free outflow of water, whether by kidneys, skin, or bowels. In cases of lithiasis this is especially noticeable, and furnishes an explanation of the excellent effects often derived from a stay at hydropathic establishments. Not 54 ASSIMILATION. only does water wash away the waste matters which have accumulated, but in doing so it paves the way for the growth of new material. Ringer says, with much force, " If water drinking exerted only a disintegrating influence, it would merely lead to loss of weight; but simultaneously with this rapid dis- integration, a corresponding increase of assimilation takes place in the same tissues; whence it happens that water, taken under certain precautions, may increase both construction and destruc- tion of tissue, and so act as a true tonic, improving the vigor of body and mind." This view I quite endorse. Further, there is every reason to believe that too little water is drunk by most persons, especially in the upper classes. The thirst produced by labor compels the drinking of water. Those who are not compelled to labor are very apt to diminish their bulk of water to an injurious minimum. Doubtless its effect upon the bladder is occasionally inconvenient, especially in certain places of common resort, and especially to ladies. Also its tendency to appear through the skin as perspiration is at times inconvenient. Nevertheless the consumption of a fair amount of fluids per diem is an excellent measure, and ill-health is commonly the penalty for the abstinence so practised. A draught of cold water every morning is an excellent hygienic measure; it stimulates the action of the bowels; it is a tonic to the digestive organs; and it is a true haematic, by its removal of waste matters which hinder histogenesis. This effect is very much increased when the water used is from some natural spring. Apollinaris water is a delicious beverage alone, while it mixes well with most things, notably red wine. Other waters, as Nassau Seltzer, are very good indeed. Some can only be made pleasant by adding them to wine or spirits. The use of mineral waters as beverages is much on the increase. This is good in several ways. These mineral waters are often pleasant medicines. But more than that, these palatable and trustworthy waters will lead to more water drinking—to the ingestion of more fluids. § 23. The next class of remedies which claims our attention is scarcely inferior in value to that just considered. This class is that termed tonics. A tonic (from reivu, I stretch) is an agent which has a systemic action. The ruling idea is that it gives tone, just as the tia-ht- ening of a cord or wire causes it to give out a better tone. A ASSIMILATION. 55 tonic differs from a stimulant in that its action is not merely temporary and exhaustive, leading to reaction. The effect is more permanent and lastingly beneficial. Neither does the action depend upon astringency. Doubtless tannic acid is often a tonic, and that too by its astringency; but quassia contains no tannin, and quinine is as tonic as cinchona bark. Nor, again, does the tonic action depend on any aromatic qualities, for many tonics are decidedly not aromatic. They do not merely act on the muscular system, though that develops under their use. They act upon mucous membranes in restoring them to a nor- mal condition, and very frequently tonics add very much to the efficacy of astringents. What their action upon the mucous lining of the intestinal canal is, we do not know. But we know well enough that under their use the appetite returns and digestion improves. "The effects of tonics upon the general system are never rapidly displayed; but after they have been taken for some time, their influence is obvious by the increased force of the circulation, the greater energy of the digestive organs, the improvement of the secretions, the abatement of nervous susceptibility, and the augmented power in particular which is communicated to the muscular system. The effect of a tonic, when administered under proper circumstances, and when it operates favorably, is, in fact, to place the system in that state which characterizes health; and from the mode by which it produces this effect, the description of diseases in which tonics are indicated is sufficiently obvious; they are evidently those of depressed power." (A. Todd Thomson.) Such is the brief but vivid sketch by one of the past masters of therapeutics. There is no more recent sketch which in my opinion is so good. Tonics, indeed, have been but little lighted up by modern physiological investigation. All we know of them is derived almost solely from empiricism. But our knowledge is not stinted, and tonics form one of the most important therapeutic benefits obtained from empirical observations. Not only has- empiricism given us tonics, but it has also furnished us with many little hints as to the best means of securing their action, and of the different circumstances which should guide us in their use and selection. In the first place, tonics are both mental and material. Hope is a capital tonic. Depressing mental conditions will often 56 ASSIMILATION. neutralize the best plans for administering tonics and thwart our desires. Nextly, the prospect of recovery will often bring about satisfactory results almost in the absence of material tonics, and certainly often helps out wonderfully a lame line of treatment. Mental tonics can usually be advantageously combined with material tonics. Material tonics are usually bitter, often aromatic. The aromatic principle is commonly stimulant, and consequently aromatic tonics, as cusparia, cascarilla, etc., are often given in early convalescence. Man}' are also astringent, and this astrin- gency often is a useful property. Astringent tonics are indicated when there exists any tendency to excessive secretion, as undue perspiration or looseness in the bowels. Sometimes, if given too early, they produce disturbances in the bowels. "It is also well known that if their dose is not proportioned to the suscepti- bility of the digestive organs, they may not only cease to pro- duce a tonic effect, but absolutely destroy the appetite and give rise either to diarrhoea or constipation. It is, moreover, a familiar fact, that a febrile state of the system altogether contra- indicates their use, because they then immediately derange the stomach and augment the vascular excitement. (Stille.) There is much truth in what Stille states, and all writers have held similar views about the undesirability of giving tonics during conditions of febrile excitement up to a recent period. Of late, however, both in France and Germany, the plan of giving large doses of quinine—an unquestioned tonic—to lower the tempera- ture in pyretic affections has obtained with many competent authorities. Nevertheless, the rule not to give tonics during conditions of febrile excitement is a good one. During the presence of a pyretic condition, especially in connection with acute disease, it is well to stick to mineral acids. When the temperature has fallen somewhat, and the fever is defervescino- in its other symptoms, then an aromatic bitter may be given with advantage. The prescription of dilute phosphoric acid nixv and cascarilla 5J is a good and suitable one, or a certain amount of a stimulant may still be necessary, and then some- thing like the following prescription is indicated: Sp. chloroformi . . . . . _ TM* xx Acid, hydrochlor. dil. ...... \r> x Inf. cusparia?, or Inf. cinchona? .... -: si- ASSIMILATION. 57 It is often a good plan to act gently on the bowels at the com- mencement of a course of tonics after acute disease. A dose of aloes is very suitable either as pil. al. et myrrh., or decoct, aloe. co. Aloes, indeed, itself possesses a bitter principle of no mean properties as a tonic. Often, especially after the violence of an attack of bronchitis is over, carbonate of ammonia is a good stimulant to combine with tonics. It goes specially well with ammonia, citrate of iron, and quassia (§ 20). Quinine may often be given with advantage along with some acid in an aromatic tonic: Quinise sulph. ........ gr. j. Sp. chloroformi ........ ttlxx. Ac. hydrochlor. dil........TTLv. Inf. cascarilla? ........ gj. forms a pleasant and efficient tonic. When tonics disagree with the stomach several measures may be indicated. A change in the form of the tonic is one; the addition of a carminative is another. At other times a slight action on the bowels is de- sirable, and a little sulphate of magnesia removes the heating sensation complained of. Very often a mineral acid is indicated; if a small quantity be already added, it is well to increase the dose of it. Tonics are especially useful when given with iron, and this well-known association has made the expression "iron and bark" one as well known in the household as in the lecture- room. There also exists in the minds of many a strong im- pression that the lighter forms of iron, as the ammonio-citrate and the potassio-tartrate given in quassia or calumba are better agents to commence with than the more powerful and astrin- gent preparations. Two cases will point this well. A patient recovering from an acute ailment was ordered quinine and the muriate of iron. This disagreed with her, and the ammonio- citrate in calumba was substituted for it. This agreed perfectly, and at the end of a week the former mixture was resumed, and then was taken without discomfort. Another and even more striking case occurred lately. A patient suffered much from anaemia and debility. I ordered her the ammonio-citrate of iron with tincture of nux vomica in quassia. She improved forthwith most satisfactorily. One day, when nearly well, she brought me her old prescription to look at. She had taken it 58 ASSIMILATION. for six months, not only without benefit, but absolutely she had lost ground under it. To my amazement, it consisted of the muriate of iron and liquor strychniae. What the difference was it is not easy to say, but the result was widely different. The only possible source of fallacy in the matter, to call in question the difference in the form of the medicine in producing the result, was that she was told to go into a larger bedroom. The combination of hydrobromic acid with quinine will usu- ally relieve cinchonism in those persons where this is readily provoked by medicinal doses of quinine. (De Witt C. Wade.) Quinine is the type of tonics, yet it does not agree with every one. Many East Indians volunteer the information that they either cannot take quinine, or it does not do them any good. There is one matter of some importance about quinine not suffi- ciently well known, and that is its tendency to produce irrita- bility of the bladder, especially in elderly people. In fact, it is not so well suited to elderly persons, as a rule, as to the young, the adult, and the mature. Stille says—" The elimination of the salts of cinchona with the urine exposes these organs to irritation. If the urinary tract be anywhere the seat of disease, it is apt to be aggravated by these medicines. This effect is fre- quently observed in gonorrhoea. Sometimes, independently of such a cause, the patient is affected with irritation about the neck of the bladder, with haematuria, or with retention of urine." This is well worth remembering. Experto crede. There is a large amount of acquired skill in the right selection and combination of tonic remedies which cannot be transmitted at once to another. But by careful observation the young medi- cal reader will learn for himself what it is impossible to commu- nicate by writing. The very fact that there is something to be learnt that cannot be so conveyed will certainly stimulate many to find out what that something is. Those who succeed will find in their knowledge the reward of their labor, while those who decline to observe their experience intelligently will have to go without the benefits they would otherwise receive. That some- thing is the power to see a relationship betwixt a certain case and one previously encountered, which indicates that the plan necessitated in the previous case will be the one best suited to the present one. This is a knowledge which cannot be con- ASSIMILATION". 59 veyed, but close observation will enable a man to learn it for himself. § 24. "In addition to the tonics described above, there are the common tonics of pure air and water. That persons who breathe pure, fresh air, and drink pure and uncontaminated water, are in a better state of health, have more tone about them, is demon- strated by the effects of epidemics. When the air is foul and the water filthy, their systems succumb to the onslaught of zymotic affections more extensively than do systems existing under better hygienic arrangements. The establishment of con- valescent homes in the country, in connection with metropolitan hospitals, is a proof of the tonic effects of good air and water. In private practice it is the rule to send patients away to health resorts, if the conditions of life are such that their home sur- roundings are not quite what they might be. The change of air annually indulged in is a famous tonic. Then there is also the effect of cold water upon the skin—no mean tonic. The bracing effect of the sudden chill, the sense of energy it srives, the glow which follows, all tell of the tonic effects of cold bathing. Experience has decided that the good effects of cold water are increased by its being salt. Consequently it is very common for convalescents to prefer the seaside, where they can have sea-bathing combined with fresh air and pure water. For children, the addition of Tidman's sea-salt to the water in which they are bathed is often beneficial; and a substitute for a sea dip is thus furnished, not altogether without value. Still, it is a substitute, and nothing more. Assimilation is an important part of nutrition; and the best energies of the medical man are often bent earnestly toward securing it by the various methods that have been just described. The necessity for good and perfect excretion, in order to permit of healthy tissue growth, will become apparent in the course of the next chapter. How the body waste may check nutrition will be shown; and the proper combination of agents aiding in excretion, with those conducing to better assimilation, will be pointed out. Before leaving this chapter, however, there is one point on which some stress must be laid; and that is the peculiarities of some individuals: There are some organisms which seem to perform a maximum of work with a minimum of waste. There GO ASSIMILATION. are others, again, which consume a large quantity of fuel, while they leave a huge quantity of ashes, etc., and perform only a small amount of work. If these latter are to be so 'fed that there shall be but little ash and waste, they will simply perform no work at all, they will die out. It is not only in animal organisms, so varied and diversified, that this occurs. It is to be seen in furnaces, engines, and flues. Some work with very little waste, their combustion is perfect; while others always need to have their refuse removed, else they cannot get on at all. So it is in certain systems. If we attempt to reduce their supplies to what they can perfectly consume, we simply starve them. Their supplies must be liberal, and the removal of their waste constant. There are many people who consume a large amount of food—indeed, without it they could not work at all— who are all the better for occasional, almost, in some cases, per- sistent purgation. They are always having too much bile in their intestines, and they seem to get on better with having it swept away than when it is reabsorbed and an attempt made to consume it. It would seem that they do better when their bile is always freshly made than when it is taken up from the chyme. Limited quantities of food do not prevent these people being bilious. Wiiat they want is to have their spare bile got rid of. Regular action of the bowels, especially by alkaline purgatives, good food, and a tonic occasionally, enable these individuals to reach a much higher standard of health than they usually attain. They are wasteful organisms, it is true; but it is no good destroying them in attempting to make them more economical. They require that plan which enables them to work best. At this point it may be well to insert some remarks on the subject of " When not to give Iron," which were well received by the profession when they appeared in the Practitioner, in Sep- tember, 1877. They are as follows : The conditions which call for the administration of iron are par excellence those where debility is combined with anaemia. In these conditions iron acts as a general tonic as well as increasing the number of the red blood-corpuscles. But there are certain circumstances which contraindicate the use of iron and which are deserving of note and remembrance. It is not enough to say that in conditions of plethora and vascular fulness ASSIMILATION. 61 iron should not be given. There are other conditions in which it is well to resort to other tonics, and even to other remedial agents altogether. Pereira says that the contraindications are "great strength and activity of organs, excessive tonicity (char- acterized by a firm and tense condition of the solids), and re- dundancy of the red corpuscles of the blood—as in general excess of the blood (plethora), in fever, in acute inflammation, and in the sanguine temperament. To these may be added, congestion, or a tendency thereto of important organs, especially of the brain and lungs, and intestinal irritation." Again he says, "Administered in large quantities, or when the alimentary canal is in an irritable condition, all the compounds of iron are liable to excite heat, weight, and uneasiness at the precordia, nausea, and even vomiting, and sometimes purging." From the well-known action of iron in increasing the red blood-corpuscles, no one would now think of giving iron in states of vascular fulness. It is unnecessary to say anything further on this subject. Then again conditions of vascular excitement are unsuited for the exhibition of iron. As long as there is rapidity of pulse combined with rise of temperature, so long must iron be withheld in the treatment of acute disease. When the convalescence is well established, when the pulse may be fast and small, but is without excitement; when the temperature is perfectly normal or below it; when the skin is cool, the face pale, and the tongue clean, then, and not till then, should the administration of iron be commenced. If it produce any gastric disturbance, or headache or feverishness, it should either be totally abandoned for a time, or the dose be much reduced. Vegetable tonics, as quinine or strychnine, together with mineral acids, the hydrochloric, the phosphoric, or the hydrobromic even in some cases, should be given instead; and then the iron, in small doses at first—to be taken after meals, especially dinner. So administered iron can often be tolerated, when it disagrees given in the usual way in combination with vegetable tonics. The same rule holds good of the resort to iron when the py- rexial stage of ordinary phthisis has passed away. The tonics and acids must be given before food, and the iron after, either as the tincture of the muriate in acetate of ammonia, the car- bonate, or Niemeyer's pill of sulphate of iron with carbonate of potash in a drop of syrup. But as long as the tongue is thickly 62 ASSIMILATION. coated, or red and irritable, it is well to withhold chalybeates altogether. This is very true of phthisis. However much the general pallor, the lack of tone and loss of power seem to call for iron, it is useless, and sometimes worse than useless, to give it unless the tongue be clean, without irritability. If the tongue be red and irritable, bitters with bismuth are to be adhered to, until all intestinal irritability has passed away, of which the condition of the tongue is the best index; if the tongue is loaded with fur, bitters and acids are to be preferred with a little sulphate of magnesia, or a vegetable pill at bedtime; or both if necessary. The gastro-intestinal canal must be got into a normal condition, neither too irritable, nor sheathed with a layer of epithelium, as indicated by the fur upon the tongue, before either chaly- beates or cod-liver oil can be satisfactorily prescribed. About this my experience at the Victoria Park Chest Hospital con- stantly makes me more and more positive. In ordinary convalescence from acute conditions it is well to commence with the lighter preparations, the ammonio-citrate, the tartrate, or the citrate of iron and quinine; afterward the muriate or the sulphate will be tolerated equally well. But these latter forms often disagree during the early stages of con- valescence. At times too the mixture of the sulphate of iron with quinine, and a few drops of dilute sulphuric acid, is found to be heating, and each dose to make the patient uncomfortable, especially in warm weather; here the addition of a little sulphate of magnesia, not necessarily to the extent of producing purgation, will at once remedy the uncomfortableness so induced. In atonic gout also iron is commonly of no service, and makes the patient uncomfortable. In the sanguine and plethoric forms of gout iron is never indicated. But when there is evidence of chronic renal disease with anaemia, and even with albuminuria, then it commonly seems desirable to administer iron in some form. Very often, however, it distinctly disagrees. It is well to see that there is no acute action going on anywhere, that the joints are cool, even if still enlarged, before commencing with chalybeates. The bicarbonate of potash, or the potassio-tartrate of soda, with a little nux vomica, in infusion of buchu, with a liberal draught of water after each dose, are the medicinal agents to be adhered to until all is perfectly quiet. When the ASSIMILATION. 63 tongue is clean, the skin cool, and there is no evidence of much acidity, then small doses of iron may be commenced with. But for some time the iron and the potash should be taken together; if the potash is left oft', the iron disagrees. Especially is this the case with elderly persons. It may be laid down as a broad rule that the toleration of iron diminishes as the age increases. With old persons iron comparatively rarely agrees, and then only in very small doses; while young children take iron well, and it often is well borne by them in conditions which in the adult distinctly forbid its use. But as age advances the system seems to growT less tolerant of the drug in any form; and the dose must be much diminished. In advanced life, in convalescence after acute disease, or paroxysms of gout in any of its forms, chalybeates have often to be abandoned, and alkalies, as potash or ammonia, with vegetable tonics and bitters, substituted in their stead. It would seem that the power of the digestive organs to assimilate iron is strongest in infancy—except it be very young children and babies—and that it diminishes, until in advanced life the blood manufacture often appears to be inter- fered with rather than assisted by chalybeates. Consequently with old people it is often better to give them tonics with alkalies and easily digestible food, than to give iron, when it becomes desirable to give a fillip to their nutritive processes. There is one condition where iron is absolutely forbidden, and that is the condition known as biliousness. As long as there is a foul tongue, a bad taste in the mouth, and fulness of the liver, with disturbance of the alimentary canal, iron is to be prohibited; it is not only that it is of no service, it positively does harm. It aggravates all the symptoms and intensifies the condition. Iron undoubtedly increases the oxidizing processes, but somehow or other in biliary disorders it does not suit. Defective oxida- tion is at the root of these states, and yet iron does not agree with such patients. As long as any of the symptoms remain, and there is any fur whatever on the tongue, iron must be withheld. The patient may be anaemic and iron seems to be urgently indicated, but it will do no good until the system is in the proper condition to receive it. Sir Joseph Fayrer's Indian experience is in full accord with this expression of opinion. (See § 16^.) The liver must be thoroughly unloaded by alka- line salines first; then some strychnia and nitro-muriatic acid 64 ASSIMILATION. may be taken in the day, the salines being only taken first thing in the morning; and ultimately, when the liver is once more working efficiently, chatybeates may be prescribed. But it seems that the oxidizing power of iron embarrasses rather than aids the liver when working inefficiently; and when iron is given, the morning purgation of salines, mineral waters, or other means, should still be maintained. By attention to these points much may be done for bilious patients; aye ! and much discredit avoided. Whenever, indeed, there is disturbance of the gastro-intestinal canal, bilious or other, chalybeates are contraindicated, and if given, cause discomfort, nausea, and not uncommonly a pyretic condition. The digestive organs must be got into good working order before iron is administered if it is to be properly assimilated. When given in large doses iron alwaj's blackens the stools, but if given in moderate doses and well assimilated this blackening of the stools is not so marked. The color of the stools, then, may be utilized as an indication as to how far chalybeates are assimilated and are likely to be useful. There are two different states found in women where iron is either totally contraindicated or to be given with great caution. The first is the condition of amenorrhcea in florid, plethoric persons. In such cases, especially if the patient be of tense fibre, depletory measures are to be resorted to, as local bleeding and free purgation. The other is the opposite condition of menorrhagia in certain females. Of course, no one would think of resorting to any form of iron, however astringent, in those cases of menorrhagia which are due to a state of general plethora. But there are cases of menorrhagia associated with pallor and debility, where the usual compound of iron and extract of ergot is not so useful as is a non-chalybeate treatment. In these cases it is not any imperfection in the processes of blood manufacture which is to be remedied, for the blood is made rapidly and quickly, only to be lost at each menstrual period. An irregular process of rapid blood-making with still more rapid blood-loss is established, and requires its appropriate treatment. It is undesirable to stimulate blood formation by chalybeates here, for the greater the increase in the bulk of the blood, the more excessive the catamenial loss; and to "ive iron is but to aggravate the condition. It is here desirable rather to limit the rapidity of the blood formation, so that when ASSIMILATION. 65 the general vascular turgescence of the menstrual period comes, it will not find the bloodvessels too distended with blood. This will lead to diminished catamenial loss, and so the blood-waste will be economized. For in these cases it is the proper practice to lessen the loss rather than to stimulate blood-formation. During the interval a little sulphate of magnesia, with dilute sulphuric acid, in some infusion of a vegetable astringent, forms an appropriate medicinal agent, and should be given along with a restricted dietary. At the periods, the dose might be increased and the patient kept quiet, while all aliment should be cold. By such a plan the irregular condition of rapid blood-formation and blood-loss will be converted into a steady state of slower blood-formation with diminished loss. The same rule holds good of other periodical hemorrhages, and especially of some forms of haemoptysis. Even in cases of menorrhagia, where it is necessary to en- courage blood-formation during the interval, it is often well to cut off the chalybeates a day or so before the menstrual moli- men, and to substitute for it the mixture just mentioned above. By such plan the blood-waste by the catamenia is economized, and the necessity for great blood-formation minimized. Finally, the consideration of iron here is confined to its use as a haematic, its use in pyrexial affections, as erysipelas or scarlatina, not being included. When used as a haematic, it is clear that certain points must be kept in view. First, that the digestive organs be in fair working order; and, second, that certain precautions be taken as to its administration when it is necessary to resort to it. Since writing the above, Dr. Ilughlings Jackson tells me that at one time he did not acquiesce in Brown-Sequard's idea, that iron does not suit epileptics, but that a more extended expe- rience has convinced him that it is so. When iron is given to epileptics who are anaemic, it may improve the condition of the blood; but while doing so, it increases the tendency to fits. It may improve the general condition, but it aggravates the epilepsy. When iron is given as a haematic or tonic, it is well for it to be taken after food. This should be made a broad rule in practice. It is, however, convenient at times—as when iron is given along with potash or bitters—to depart from this rule. 5 CHAPTER III. EXCRETION. § 25. Having just seen the importance of a healthy assimila- tion in the production of normal nutrition, we now come to the question of excretion. This is a much more important subject than is usually supposed. We have for long been familiar with the gravity of imperfect nutrition; but are not equally intimate with the still graver subject of defective excretion, and the evil effects of imperfect elimination. It is not merely that life soon becomes extinct if the different excretory actions of the body are not carried out—a method of destroying life much more rapid in its action than the withholding of ingesta—but it is also the more chronic action of imperfect elimination which is fraught with grave issues. The importance of the functions of egestion as compared to those of ingestion, was insisted upon by Marshall Hall in 1842. The system is soon poisoned if it cannot get rid of its own carbonic acid. The excreta of the urine are powerful neurotic poisons, causing coma and convul- sions; and bile is equally destructive to life in large quantities. It would appear indeed that the assimilation of food is accom- panied, or. followed, by the production of principles of a pre- eminently destructive character, either as injurious products of the food taken when split up, or as waste matters—the result of histolysis. Very grave, indeed, are the questions relating to retrograde metamorphosis within the organism. Especially is this the case with nitrogenized principles. These nitrogenized matters do not merely go toward tissue formation, and then, by a process of oxidation, pass from one form of histolytic pro- duct to another. They do not break up in tissue destruction into creatine, creatinine, tyrosine, and other early products of tissue decay, and then pass on into uric acid and urea merely; each form being in large amounts a dangerous poison. They also form within the animal organism ferments which exercise no unimportant function. Pepsin, so powerful a ferment in the EXCRETION. 67 production of the digestion of albuminous matter, is a secretion, and in so far an excretion of the stomach by means of its folli- cles. Ptyalin is the ferment of saliva, very effective in the con- version of starch into sugar. Pancreatine is another albuminous ferment, formed in the pancreas, also possessing marked power as a digestive agent. These different products are in so far excre- mentitious that they are thrown out of one part of the system, and yet they are most effective in promoting digestion by their action upon the material which is furnished as food. These ex- cretions are valuable digestives and ferments. Carpenter, in his article, "Secretion," in the Cyclopaedia of Anatomy and Physiology —a most valuable paper, to- which frequent reference will be made in this chapter—says: " Thus the salivary, the gastric, and the pancreatic fluids all contain an animal principle nearly allied to albumen; but this principle seems to be in a state of change, or of incipient decomposition; and it would not seem improba- ble that whilst this very condition renders the albuminous matter useful in promoting the solution of the aliment, it renders it unfit to be retained within the circulating current." This is a suggestive paragraph. It throws a ray of light over the subject of the relations of excretion to nutrition. There are also albuminous ferments scattered through the body, which cause, it is believed, the changes which give us our body heat. The glycogen stored up in our livers, and there re- converted into sugar, is broken up into lactic acid; and this acid, uniting with the soda of the blood, is gradually oxidized, and the oxidation of lactic acid, as lactate of soda, causes our body heat. (Headland.) The production of waste matters in excess, by the action of these ferments when overactive, is a matter just coming within the range of our physiological vision. There are already indications enough to give us grounds for good ex- pectations from it. Before we go further with excretion by the different organs, we must first look at excretion in its entirety. Thus, in the lowest forms of life, we find the surface generally excretory, as it is also generally tactile. But as certain portions in time mani- fest greater activity in certain directions, and form the rudiments of special senses; so apparently there are certain areas which are more active than others in the excretion of waste products; and so we get the rudiments, the first shadowings out, of special 68 EXCRETION. excretory organs. As these develop, they come to possess cer- tain specialties; yet nevertheless they do not lose altogether their primitive characteristics as part of a general excretory surface. " In all instances, then, the excretory organ essentially con- sists of a limitary membrane, which forms part of the integu- ment of the body, or of its involutions, and of cells covering the free surface of that membrane, and, consequently, in direct relation with the external surface. Thus we have the limitary membrane of the true skin, and of the mucous membrane of the alimentary canal, which is directly continuous with it, sunk into follicular depressions; and the free surfaces of these are lined with cells, the layers of which are continuous with those of the epidermis and of the gastro-intestinal epithelium respectively. We trace inward another extension of the same membrane along the genito-urinary passages up to the kidneys, where it forms the wall of the tubuli uriniferi; and there, too, its free surface is covered with an epithelial layer of cells, which is the efficient instrument of the selection of the constituents of the urinary fluid, and which, when exuviated, is conveyed along the urinary passages to the exterior of the body. So, too, the hepatic cells, by which the biliary matter is eliminated from the blood, are brought into direct continuity with those of the external surface, through the hepatic ducts and gastro-intestinal mucous mem- branes. The case is not different, in any essential respect, with regard to the organs by which the recrementitious secretions are formed. Thus the lachrymal, salivary, pancreatic, and mam- mary glands are in like manner composed of a continuation of the limitary membrane of the true skin, or of the mucous membrane lining the alimentary canal, involuted into tubes and follicles, the free surfaces of which are covered with epithelial cells. These cells, drawing into themselves certain constituents of the blood, are cast off" when they have completed their full development, and their contents, set free by the disintegration of the cell-walls, are carried off by the ducts, which collect them from different portions of the glandular structure, and deposit them in the situation where the purposes of the secreted product are to be answered." (Carpenter.) This gives us a clear view of the community of origin of the different excretory organs. We can see how, gradually, the function of each has become more and more specialized until EXCRETION. 69 we have the different systems distinctly established. The air- tubes are nothing more than involutions of the general tegument, by meaus of which the respiratory changes are carried on. They also furnish the means by which oxygen is brought within the system, to perform its combined action of the production of force, by the oxidation of material within the body, and of the removal of waste. While permitting of the chemical inter- changes which furnish oxygen, and also of the removal of carbonic acid, these air-tubes resemble the skin, in that they provide a large surface from which water may exhale. The air-tubes, with their alveolar pouches in the lungs themselves, are an involution of the general tegument, preserving many of its primitive characteristics. The lungs and skin give off the water of combustion within the body. The kidneys represent the ingested water rather, and their secretion varies with the amounts of fluid imbibed. There is a general play, backward and forward, betwixt these excretory organs in the elimination of water from the system, occasionally interfered with, or aug- mented, by the action of the gastro-intestinal canal. The skin and kidneys play backward and forward very much according to the temperature; in hot weather the skin is most active, in winter the kidneys. Agents like potash act as diuretics or diaphoretics very much according to the temperature surround- ing the organism. It is not in the elimination of water merely that the mutual action and reaction of the skin and kidneys are demonstrated. They each excrete, along with water, waste products and salts. Long ago Nysten observed that urinous products were given off by various emunctories when their passage by the kidney was interfered with. " The passage of a urinous fluid from the skin has been frequently observed in cases where the renal secretion was scanty; and the critical sweats by which attacks of gout sometimes terminate, contain urates and phosphates in such abundance as to form a powdery deposit on the surface. It has lately been ascertained that in warm climates urea is an element of the perspiration even of healthy persons." (Landerer, quoted by Carpenter.) At other times a urinous fluid is cast out by the gastro-intestinal canal, which possesses an excretory as well as an absorbent action. As ex- cretory organs these involutions of skin, and their primitive form the tegument, possess much in common. 70 EXCRETION. § 26. Along1 the gastro-intestinal canal there are established a series of excrementitious actions, resulting in the production of numerous albuminous products which are also recrementitious, and are very useful in the elaboration of our food. Though varied, they possess much action in common. That is, along the digestive tract the primitive tegument has undergone such modifications as to excrete, or secrete, a series of products which fulfil no unimportant function in assimilation. And yet these excretory organs give off other products when the system is charged with them; products too far advanced to possess any nutritive power, and simply active poisons. From the times of Chirac and Helvetius, who noticed that a urinous fluid was passed off from the stomach after ligature of the ureters, down to the time of William Roberts, this power on the part of the gastro-intestinal canal to supplement the action of the other excretory organs has been observed and acknowledged. In the same way, the biliary excretion is removed by different parts of the body (not usually eliminating bile) when the system is charged with it. The skin, the serous membranes, the mucous membranes, are often penetrated with the coloring matter of bile, which they have withdrawn from the blood. The urine is often so charged with bile as not only to give bile reactions in testing, but even to stain the linen; while bile- stained tube-casts are among the most striking objects revealed to us by the microscope. The elimination of the catamenial flow by other organs than the lining membrane of the uterus, furnishing what is called vicarious menstruation, is a phenom- enon to which portentious importance is attached by many savage tribes. Even milk has been found to procure an exit by other channels than the mammary gland-ducts. The relations of excretion to nutrition are very much involved. We have seen how a great many products are excreted, and yet not cast out, but fulfil an important functional end. Unexcreted, they might have been injurious; excreted, they are useful and beneficial. But there is something more than this in their rela- tions. "As was first pointed out by Treviranus, 'each single part of the body, in respect of its nutrition, stands to the whole body in the relation of an excreted substance;' in other words every part of the body, by taking from the blood the peculiar substances which it needs for its own nutrition, does thereby act EXCRETION. 71 as an excretory organ; inasmuch as it removes from the blood that which, if retained in it, would be injurious to the rest of the body. Thus the phosphates which are deposited in our bones are as effectually excreted from the blood, and prevented from acting injuriously on the other tissues, as are those which are discharged in the urine." The effect of each act of tissue- formation is to remove that which if unremoved would, or at least might, have exercised an injurious influence; and which, if accumulated, certainly would exert a prejudicial action. What is requisite for one part is injurious to another. It is somewhat difficult to realize this fact fully, in an organism so complex and so interpenetrated as the body is by bloodvessels and lymphatics. At first sight, it would seem that every form of pabulum must be carried to every tissue; just as small organisms are seen to melt in the jelly-speck—the amoeba—a simple solution of the tiny creatures being set up; and a centrifugal distribution of the solution throughout the mass of sarcode carries it at last, as waste, to the external excretory surface. But nutrition has become a complex matter as evolution has progressed; and the development of the different specialized areas, with their varied functions, is not more compound than is the general nutrition, which gives to one tissue as food, what would but be a poison to other tissues if not removed. § 27. And yet, through all this, there remains, in each and every excretory organ, a sufficient amount of its primitive character to render one organ a compensatory excretory agent for the elimination of what is more distinctly the province of another organ. Consequently we get compensatory over- actions, which are often mistaken for disease. Indeed, until physiological research came to illuminate our practice, such a thing as uraemic diarrhoea was unthought of; and, as a conse- quence, its proper treatment remained undevised. We had simply no conceptions of any augmented secretions or excre- tions, other than as morbid actions. In this respect we have made great advances; and now we commonly recognize the secondary character of what is truly a compensatory action, and not a morbid process. Especially have we learnt this lesson in regard to the recurring ailments of advanced life. In early life, most ailments take their origin in imperfect nutrition—in failure in the nutritive processes; in advanced 72 EXCRETION. life, ailments usually arise from impaired elimination of waste products. Of course, zymotic and accidentally acquired diseases act alike in both extremes of life. Many valuable lessons in practice are to be learnt solely from physiology, and it is only now becoming possible to learn them. It is only at the present time that we are in a position to admit of an intelligent and rational comprehension of much of the ill-health of matured existence. Ere proceeding to go practically into this question, it is desir- able to make one more quotation from Carpenter's suggestive monograph. It relates to the power of one excretory organ to supplement the action of another, when defective. He calls it "Metastasis of Secretion," and writes: "Although the number and variety of secretions become greater in proportion to the increased complexity of the nutritive processes in the higher classes, and although each appears as if it could be formed by its own organ alone, yet we may observe, even in the highest animals, some traces of the community of function which char- acterizes the general surface of the lowest. It has been shown that, although the products of secretion are so different, the elementary structure of all glands is the same; that wherever there is a free excreting surface it may be regarded as an exten- sion of the general envelope of the body, or of the reflexion of it which lines the digestive cavity; that its epithelium is continuous with the epidermis of the integument, or with the epithelium of the mucous membrane from which it is prolonged; and that the peculiar principles of the secreted products pre- exist in the blood in a form at least closely allied to that which they assume after their separation. Now it may be stated as a general law in physiology, that in cases where the different func- tions are highly specialized (that is, where every one has its special and distinct organ for its own purpose alone) the general structure retains, more or less, the primitive community of function which char- acterized it in the lowest grade of development. Thus, although the functions of absorption and respiration have special organs pro- vided for them in the higher animals, they are not altogether restricted to these, but may be performed in part by the general surface, which (although the special organ for exhalation) per- mits the passage of fluid into the interior of the system, and allows the interchange of gases between the blood and the air. EXCRETION. 73 In the same manner we find that the functions of secretion are equally performed in the lowest animals by the whole surface, whilst in the highest there is a complicated apparatus of glandular organs, to each of which some special division of the function is assigned; either the general mucocutaneous surface, or some one of its subdivisions or prolongations, is able to take on in some degree the function of another gland the functions of which may be suspended. This truth was well known to Haller, who asserted that almost all secretions may, under the influence of disease, be formed by each and every organ. This state- ment, however, needs to be received with some limitation, and it would probably be safest to restrict it to the excretions the elements of which preexist in the blood, and accumulate there, when the elimination of them by their natural channel is sus- pended." This introduction to the physiology of excretion will enable us, all the better, to take up the subject of its abnormalities, and to see more clearly the indications for a rational treatment. § 28. Thus, for instance, we see how water is eliminated from the system by the different emunctories, the skin, kidneys, lungs, and bowels. When the skin is very active the bulk of urine is small: and a similar decrease in the amount of water excreted by the kidneys follows a sharp diarrhoea with watery motions. Sometimes when the action of the skin is checked while the kidneys are acutely congested, a condition often produced by exposure, we see a general oedema induced, a storage of the water in the areolar tissue, only to be removed by sweating and purging. Carbonic acid is chiefly exhaled by the lungs, but a portion also escapes by the skin. Under certain circumstances of arrest in the action of the lungs, the amount passed off by the skin be- comes notably increased. Holding the breath in summer quickly induces perspiration in many persons. In fact, when the exha- lation of carbonic acid by the lungs is interfered with the skin passes it off. " Moreover, it has been observed not uufrequently that the livid tint of the skin which supervenes in asphyxia, owing to the non-arterialization of the blood in the lungs, has given place after death to the fresh hue of health, owing to the reddening of the blood in the cutaneous capillaries by the action of the atmosphere upon them; and it does not seem improbable that, in cases of obstruction to the due action of the lungs, the 74 EXCRETION. exhalation of carbonic acid through the skin may undergo a considerable increase; for we find a similar disposition to vica- rious action in other parts of the excreting apparatus. There is also evidence that the interchange of gases between the air and the blood through the skin has an important share in keeping up the temperature of the body (Chapter XII.); and we find the temperature of the surface much elevated in many cases of pneu- monia, phthisis, etc., in which the lungs seem to perform their function very insufficiently." (Carpenter, Human Physiology, § 309.) Every observant practitioner will agree with this last, as he must have had opportunities of noting this fact about the consumptive patient when far on his journey. About 5 or 6 a. M. the patient will usually do one of two things: either waken up and beg for air, sitting gasping, from the diminished lung space, and throwing into play all the auxiliary muscles of respi- ration—breathing for dear life indeed; or he falls into a deep comatose sleep, and becomes drenched with perspiration. Some- times one happens, sometimes the other. In each case there is a desperate effort made to get rid of the carbonic acid of the system. In some of the lower animals the cutaneous respiration is an important matter. Even still more important, and withal interesting, is the subject of the elimination of nitrogen. It is usually taken for granted that nitrogenized waste passes off by the kidneys onl}\ Few practitioners think of the other means of its exit, in their practice and treatment, The importance of renal inadequacy is being now very generally comprehended, and a short review of the matter may be profitable. Prevost and Dumas were the first to find that when urea was not cast out by the kidneys it accumulated in the system. Since then we know that urea, uric acid, and the earlier products of histolysis, creatine and creatin- ine, are all to be found in the blood after ligature of the renal artery. Such being the case, these waste matters pass out by different emunctories. A quotation from H. C. Wood will show the attention paid to this subject. "In 1851 Dr. Schottin discovered urea in the sweat of patients suffering from the collapse of cholera. Not only has the dis- covery of Schottin been confirmed by the researches of G. 0. Rees, of Fiedler and Jiirgensen, of Leube, and of G. Deinino-er, but it has also been abundantly proven that the skin excretes EXCRETION. 75 urea freely during the advanced stages of Bright's disease, and also during the partial suppression of urine of scarlatinal des- quamation and nephritis. The urea in renal disease may even form a distinct crystalline powder on the skin; but it is most abundant about the mouths of the sweat-glands. I believe Landerer was the first to announce that urea was present in the sweat of healthy persons; and although chemists of excellence have been unable to detect it, yet its presence at times can no longer be denied, since it has been found not only by Landerer, but also by Funke, in 1858, by Meissner, and by Leube; Four- croy has found it in the sweat of horses. By a series of elabo- rate experiments Leube has rendered it probable, if he has not actually proven, that in health there is such a relation between the skin and the kidneys that when the former is very active the latter excrete less than the normal amount of urea." (Loc. cit., p. 435.1) From this it would appear that suppressed gout may arise from defective action of the skin as well as from renal inade- quacy. Richardson found that ammonia was given off by the breath in uraemic coma (Asclepiad), and experience has made it a common observation. Zalesky found in serpents, after ligature of the ureters, that all the organs and tissues were strongly infiltrated with urates, which formed thick white crusts and patches on all the mucous and serous membranes, in the joints, in and upon the kidneys, liver, heart, and spleen. By chemical analysis uric acid was also abundantly found in the lungs, muscles, and throughout the body. (Roberts on Penal Diseases.) The same authority says, " When the vomiting is really uraemic it takes place with- out reference to the nature of the contents of the stomach, and is oft repeated or uncontrollable; the vomited matter is a watery fluid, either distinctly ammoniacal to the smell, or (if acid) evolving ammonia when caustic potash is added thereto. The alvine dejections are similarly characterized when due to the same cause." (Part III. Chapter IV.) We are all familiar with the inflammations of serous membranes so commonly found in chronic Bright's disease. 1 I have omitted the references to these authorities given in the text. Any reader wishing to go further into the matter will find them given in "Wood's Treatise on Therapeutics, at p. 435. 76 EXCRETION. Thus we can see how a whole array of so-called ailments may arise in consequence of imperfect elimination of nitrogenized waste; and that such, of course, will most commonly occur where the kidneys are no longer in their integrity. But these affections are not the disease itself. They are forms of natural cure. They are better obviated, if possible. If this is not feasible, they may be aided by proper treatment. A large series of the affections of advanced life find their origin in impaired elimination of nitrogenized waste. They are compensatory actions rather than diseases per se. % 29. It is, from the foregoing, very obvious that in the treat- ment of affections originating in the imperfect elimination of nitrogenized waste there are several points to be attended to: 1. To reduce the amount of nitrogen consumed. This needs no explanation. 2. To give large quantities of fluids, in order to bathe the tissues, and wash away the sparingly soluble salts. 3. On no account to attempt to stop the compensator}7 excretory action, until the normal excretion is restored. 4. To act upon the different compensating organs, and set up vicarious elimina- tion through other channels. For this last purpose, action upon the skin is at once the most physiologically rational, and at the same time practically feasible. In all cases, then, the skin may be kept in action with advantage. Warm baths, Sir James Simpson's bath, the hot-air bath, etc., all may be resorted to beneficially. Especially are they useful when there is obstinate vomiting. When the stomach is unaffected, large draughts of water, pure or alkaline, are indicated. Such draughts may advantageously be used to wash down the following dose: Pot. iod. . . . . . . . gr. v. Pot. bicarb.........gr. x. Inf. buchu........gj om. 4ta hora. At the same time, if there be evidence of congestion of the kidneys, hot sinapisms may be applied over the loins, or dry cupping resorted to. The bowels may be smartly acted upon by drachm doses of compound jalap powder, or the following: Pulv. cambogiae ....... gr. v. Pot bitart.........^ij. Pulv. pip. nig........gr. x. EXCRETION-. 77 , daily, followed by action on the skin and draughts of water. Such a plan of treatment must be pursued intelligently and courageously; and if so followed out will often give very satis- factory results. When the plan of treatment is decided upon, it is not well to interfere with it to allow for some intercurrent trouble, unless the new trouble imperatively demand attention. Affections demanding such a plan of treatment are much more common among elderly people than is ordinarily supposed. Even after the violence of the outburst is quelled, it is very important to remember the pathology of the morbid condition, and to avoid vegetable astringents, and still more opium. This last is often a desperate poison in conditions of impaired elimi- nation, and must be scrupulously avoided. If the diarrhoea persists after the action of the kidneys is fairly reestablished, the skin must be kept in action, and the following mixture may be prescribed: Liq. fer. pernit........T)lxv. Pot. nit. ........ gr. v. Inf. buchu........Jjj ter in die, until matters have once more become normal. It is a matter of much importance in the treatment of such cases to put the patient on a slop diet, which contains a mini- mum of nitrogen. The error made by our predecessors, in their adoption of a slop diet, was, that they applied it too exclusively; and did not, with sufficient care, discriminate betwixt the cases where such a diet was indicated, and those where a more liberal dietary was desirable, and even imperatively necessary. For some time, indeed, after any outburst associated with im- paired elimination, the patient must live very carefully. The diet must be largely farinaceous, the skin be kept well clad in flannel, and the bowels regulated with alkaline purgatives. The pathology of the ailment shadows out the true and rational treatment. § 30. It not unfrequently happens that organs actively en- gaged in compensatory action, or vicarious elimination, become themselves affected from this functional activity. Thus in chronic renal changes it is very common for the skin to become chronically diseased; and the skin affections so induced are 78 EXCRETION. very intractable if their origin be not remembered. Numerous chronic skin affections, eczematous and scaly, are cured, for the time being, by a course of Buxton or other waters. The elimi- nation of the waste products, by the action of the alkalies dis- solving them, and so permitting of their washing out through the different water-channels of the body, is followed by the cure or relief of the affections induced by the vicarious functional activity of the skin. But they return again, usually in a brief period, unless the drinking of some alkaline water is continued. A very illustrative instance of the effect of a well-directed treatment is furnished by the following case: Some years ago a friend of mine asked me about a case of very obstinate irritable ulcer in a lady patient, who had been troubled with it for eighteen years, and during that time had consulted many leading sur- geons at home and abroad. It had resisted all and every form of treatment hitherto devised. Remembering the instructions of my excellent surgical teacher, Joseph Bell, of Edinburgh, that irritable ulcers were commonly found in gouty persons, I asked if there was a possibility of the lady being gouty. He thought it probable, though she had never suffered from regular gout. The ordinary mixture— Pot. iod. . . . . . . . . . gr. v. Pot. bicarb. Tinct. sem. colch Inf. buchu was given three times a day, with copious draughts of water. Simple water dressing was applied to the ulcer. In three weeks the ulcer had healed, to the patient's immense satisfaction. Not only the skin, but the bronchial membrane, is exceedingly apt to become chronically deranged from vicarious action; and in these cases iodide of potassium, etc., is extremely useful. Indeed, these are the cases of bronchitis which yield to this remedial agent only. In many cases the stomach seems to suffer continually from the irritant effects of the uric acid present in the gastric juice. It maybe merely a coincidence, but it has occurred to me several times to see cancer of the stomach developed after a long history of gouty dvspepsia. It is quite possible that the irritation so caused ultimately leads to EXCRETION. 79 a development of pathological connective tissue of a grave char- acter, viz., scirrhus. Dr. C. J. B. Williams has drawn attention to the relations of localized inflammations with general conditions of imperfectly depurated blood. He says: "Irritation and inflammation are sometimes caused by excrementitious matter retained in the blood, where the functions of the excernent organs are im- paired." And again he writes: "The natural excretions of the body become most acrid irritants when brought into contact with serous membranes; thus urine, feces, and bile, effused in serous membranes, even in the smallest quantities, produce intense irritation and inflammation." Such being the case, it is quite possible that long-continued irritation, by trifling quantities of these substances, may result in tissue changes of a chronic character; and, in those advanced in life, such change may assume the direction of malignant connective tissue. § 31. Another important effect of impaired excretion is the action of retained excreta upon the blood-formation. These poisons—for they are identical in their effects with blood poi- sons—so produced within the system itself, act in the most prejudicial manner upon the formation of the blood, or, if not that, they break the blood down when made. In the London Hospital it is quite common to see what they there denominate "fecal anaemia"—that is, anaemia caused by the action of the excretions of the intestinal canal being again absorbed, during persistent constipation, and exercising a destructive action over the blood-corpuscles. Purgation at once improves this state of matters, and the condition of anaemia is relieved ere chalybeates are resorted to. In the same way Ave find the anaemia so common in the course of kidney disease to be produced. The presence of renal derivatives in excess affects the red blood- corpuscles in reducing their number. Anaemia follows, and iron, alone, will not relieve the condition. As in fecal anaemia, iron will not increase blood-formation unless a specific be added to it. Purgatives in all cases aid the action of iron, and this is the explanation of much of the benefit derived from such com- bination. In gouty anaemia, potash added to iron, and the dose washed down by large draughts of water, produces at once a pleasant change in the state of matters. Such combination is 80 EXCRETION. furnished by the mist, ferri co. It is perhaps better to combine iron with potash thus : Pot. bicarb. . . . . . . . gr. x. Ferri am. cit. ....... gr. v. Inf. quassia?.......^j ter in die. gradually decreasing the potash and increasing the iron, until a good state of health is produced. It has fallen to my lot to see gouty anaemia pass away, and the hue of health come back to the lips and cheeks, simply under the use of potash and diure- tics, before a single grain of iron had been administered. In this respect anaemiae, the result of systemic poisons, resemble the anaemiae of syphilis, of lead-poisoning, and of malarial disr ease. In each case the specific, mercury, iodide of potassium, or quinine, must be added to the chalybeate, ere good blood con- struction can be induced. Promoting the action of the skin is often useful in bringing the system under the influence of iron in these cases. This is brought about by its eliminant action. AVarm baths and purgatives are very serviceable as adjuncts to the haematic remedies in such cases. Thus mercury, iodide of potassium, or quiuine are true haematics in these cases, because they directly aid in inducing healthy blood-formation. (§ 21.) In many cases of anaemia the ordinary methods of giving good food and iron totally fail. The treatment is persevered with, but is of no avail. The blood-formation is prevented by some poisonous material in the blood, and all our efforts are futile. When the specific remedy is administered then progress is made, and the case goes forward. When anaemia is a con- sequence of impaired elimination of nitrogenized waste a spare diet, but poorly supplied with nitrogen, will often produce excellent effects, and procure an improved blood-formation. Such a plan of treatment would never suggest itself except under two sets of circumstances. 1. A good comprehension of the physiology and pathology of assimilation. 2. A close and observant experience, which can guide the treatment of one case from its remembrance of the course of events in another. Few are equal to the latter; the former is easily possible. Such a plan of restricted diet must always precede any restorative treatment, in cases of inadequate excretion. However the patient may dislike it—and some do rebel in earnest__it is the EXCRETION. 81 only plan. We might wish to reap our corn as soon as the ear is shot—and the folly of that is clearly apparent—without satisfactory results; so sometimes patients wish to hasten pro- cesses, instead of allowing them their proper order; and the folly becomes apparent iti time. The old trainer's plan of clear- ing out the system, ere commencing to build it up, was sound and sensible. § 32. There is another product which in its waste or excess is certainly an excretion, and that is bile. Though the creation of the liver essentially, when the flow through the gall-duct is obstructed, there is a general saturation of the body with bile products. The different involutions of the general primitive tegument are specially involved, as vicarious and compensat- ing eliminants. Bile may either not be secreted originally, if indeed this occurs at all, or it may be reabsorbed; the latter being infinitely more common. Biliousness usually springs from the reabsorption of spare bile going round and round in the portal circulation. " In either case, the urinary apparatus is the principal channel through which the biliary matter is eliminated, the urine becomes tinged with the coloring principle of bile, being sometimes of a yellowish or orange hue, and sometimes of a brown color with a considerable sediment; and the presence of the most characteristic constituents of the bile has been determined in the urine. The same result presents itself when the biliary duct has been artificially obstructed by ligature. Other secretions have been found tinged with the coloring matter of bile: thus the pancreatic fluid has been seen of a yellow color in jaundice; and the milk has presented not merely the hue, but the characteristic bitterness of the biliary secre- tion. The cutaneous transpiration is not unfrequently so much impregnated with biliary matter as to communicate the tinge to thelinen covering the skin; and even the sputa of patients affected with bilious fevers have been observed to be similarly colored, and have been found to contain biliary matter. The secretions of serous membranes, also, have frequently been seen to present the characteristic hue of bile; and biliary matter has been detected, by analysis, in the fluid of the pleural and peri- toneal cavities." (Carpenter, Art. "Secretion.") This quotation demonstrates the excretion of bile by various organs, when its escape from the liver is interfered with. 6 82 EXCRETION. In practice, however, we do not treat functional disturbances of the liver by acting on other emunctories, so much as by measures which will be detailed in Chapter XVI. (§§ 165, KID). We are also familiar with disturbances wrought in the system by the excess of a normal product, viz., lactic acid. It is a normal recrementitious excretion in the gastric juice, and it normally exists "in the parenchymatous juices, and especially in that of muscle." It is apt to be found in excess in those whose diet is too exclusively farinaceous. It is formed in great excess by the organism in acute rheumatism, or rheumatic fever. Indeed, rheumatic fever has been induced by doses of lactic acid given medicinally.1 In acute rheumatism the skin is bathed in a sour perspiration, the saliva is usually sour, the intestinal canal pours out sour and offensive feces, and the urine is acid and charged with lithates. As the patient recovers the secre- tions become normal. This again shows how under certain cir- cumstances general excretory activity is induced, with the effect of cleansing the sj'stem from a normal product when in excess. We act upon the excretions in the treatment of rheumatism, as we shall see when we come to take up the question of rheu- matism. (Chapter XL) § 33. Alteratives.—" These are employed by practitioners of medicine to affect certain diseases most intimately connected with the processes of nutrition, various substances which do not, at least in the doses commonly employed, produce any very obvious symptoms. These drugs may perhaps neither stimulate nor depress, so far as can be perceived, any function of the body; their action may be silent and imperceptible, their mode of influence may be unknown, but their therapeutic effects are among the most assured of clinical facts. It is to medicines of this character that the name of Alteratives has been applied, because when administered they seem simply to alter morbid processes." (Wood.) Our inability, as yet, to explain the action of alteratives by exact physiological experiment, is the less unfortunate that the clinical facts so well support what empiricism has tauo-ht us. It must not for one moment be supposed that all empirical facts which physiology or pathology cannot yet explain, are to be 1 See Balthazar Foster's Clinical Lectures. EXCRETION. 83 rejected accordingly. What will become of all which we trust to learn, if we are to cast away everything not yet illumined? We should be cutting ourselves off from some most valuable knowledge if we were to abandon the teachings of empiricism. It is certainly much more satisfactory to be able, by the light of physiological research, to elucidate what empiricism has demon- strated to be a fact. But where this cannot, as yet, be done, we must acknowledge the facts, and in doing so perhaps pave the way for forthcoming investigations, which may tend to clear up our imperfect knowledge. " To den}*, as has been done, the existence or value of medicines of this class because we cannot tell why mercury relieves syphilis, or why iodide of potassium cures rheumatism, is as absurd as to deny the existence of the syphilitic or rheumatic dyscrasia, because we do not know their ultimate nature." (Wood.) Arsenic is a powerful alterative. We have seen before that it was a stomachic. The union of these two qualities renders it an excellent adjuvant to haematics. As an alterative it is found to be eliminated by the kidneys chiefly, then by the intestinal canal, by the skin, and even by the saliva and tears. Thus we see that it is eliminated by the principal excretory organs, and can understand its efficacy in procuring more perfect elimination of waste, and so more perfect nutrition of the body. The im- proved elimination leads to a more thoroughly healthy state of the secretions and excretions. Consequently we find that arsenic is used in some countries, especially Styria, to give robust health. This it does, and endows the arsenic-eater with ruddy cheeks, the bloom of health, long wind, and a good physique generally. It has been used in other countries for its famous alterative qualities, as a cosmetique, for both human beings and horses. It can be added to haematic and tonic remedies with advantage. Fowler's sol........Vf[v. Pot. bicarb........gr- v. Fer. pot. tart........gr. v. [nf. quassiae.......5J ter in die, before food is often a capital combination. Sometimes it is desirable to give arsenic in an acid solution with iron, as Valangin's sol. (liq. ars. hyd. chlor.) . TTL'ij- Tinct. fer. perchlor......nt* ter in die, 81 EXCRETION. in water, or other vehicle, after food. This is the best fluid form of arsenic to be given with haematics, when wishing to build up the blood and system generally. Or it may be administered in the pill given in § 20. It is often very convenient to use the terms "Fowler's solution" and "Valangin's solution" when nervous patients would be alarmed to see arsenic in their pre- scription. Mercury is a notable alterative. It is found in all excretions. It acts upon the flow of bile, it is found in the urine, in the serum of ulcers, in the saliva, feces, and even in the seminal fluid. It has a marked action on the skin. Its value is generally recognized, not merely as an antisyphilitic and antipyretic, but as an alterative. When the tongue is foul, the skin dry, the bowels loaded, and there is a bitter taste in the mouth in the morning, calomel will almost at once make a difference in the effects of purgation. Purgatives may have been resorted to in vain, but mercury produces a decided difference. As an occasional purga- tive it is most useful, but its severe after-effects render its lono; continuance undesirable except in syphilitic cases. The soluble preparations, as the bichloride and the iodide, are most'powerful poisons, and must be given in small doses. Headland has given somewhat lengthy explanations of the difference betwixt the soluble and the insoluble preparations, which may be profitably perused in his Action of Remedies. He thinks calomel, blue pill, and others are rendered soluble—without which they would be physiologically inert—in the gastric juice, or the alkaline chlo- rides of bile. Mercury may be given in powder, pill, mixture, or by a plaister. It can often be combined with iron with advantage, especially in the anaemia of syphilis, whether acquired or congenital, where it is most useful. (Chapter XII. § 120.) It is unnecessary to write out any form for the administration of mercury, every one knows them! Some special combinations will be given from time to time as we proceed. Iodine is a powerful alterative. It passes off chiefly by the kidneys, but is found in the secretions of all mucous membranes. I have tasted it in the mouth on waking after its local applica- tion to the knees. R. W. Taylor thinks he has found evidences of its free escape by the skin. As iodide of potassium it is one of our commonest and most valued remedies. Its absorbent EXCRETION. 85 power will be considered hereafter. (Chapter XX. § 201.) Its alterative action on the different emunctories, and especially in getting uric acid out of the system as well as the poison of syphilis, renders its use very common. Various combinations can be made, several of which have been already given. As a haematic it is given with iron, in the well-known syrup of the iodide of iron, or Blancard's unchangeable iodide of iron pills. The most powerful alterative known is the combination of iodine, mercury, and arsenic, called Donovan's solution. In all cases where the excretory organs, at large, need acting upon, this is a capital agent to employ: Donovan's solut. ...... TTf xx. Inf. cascarilla? . . . . . . g ss ter in die, is a famous alterative, especially in tertiary or congenital syphilis. Alteratives are commonly and advantageously combined with purgatives; and often a liberal dietary becomes necessary at the same time that they are continued, especially if there be much wasting. Colchicum, sarsaparilla, and guaiac are vegetable alteratives often used along with iodide of potassium. Guaiac is a better vehicle and adjuvant than sarsaparilla in most cases, especially in the rheumatic. § 34. In actual practice the well-directed use of alteratives will often give the most gratifying results. Indeed they are a class of agents too little understood by the merely well-taught hospital student; but with which he will do well to make himself more familiar, if he desires success in private practice. Their effect not being explicable or demonstrable by actual experiment, they are too often neglected, to the injury both of medical man and patient. They were much more used by the practitioners of the last generation than they are now; but we are not quite certain that we are better practitioners than our predecessors. Their neglect is one of the surest pieces of evidence that while our profession as a science has distinctly improved, in some respects it has retrograded as an art. There really is no room for doubt that the brief mercurial course—not to the extent of salivation, but a few grains of Plummer's pill every night for four or five nights—so commonly resorted to by the practitioners of the past, was often very salutary. Such means threw into action the different emunctories of the body, and so restored the 86 EXCRETION. blood to a normal condition, or in homelier phrase " cleansed the blood." In the treatment of affections of the skin, so notoriously associated with imperfect elimination, or the formation of crude matters by imperfect assimilation, these alteratives are chiefly relied upon for the cure of many of the most obstinate of these decidedly intractable diseases. Of old it was quite common to fall back on a course of alteratives when any affection was more than ordinarily rebellious; and now we resort to the same thing whenever there exists a suspicion of syphilis. But it is some- what irrational to assume that the poison of syphilis—be it what it may—is the only one eliminated by agents acting generally upon the excretory organs. There are symptoms, about which experience alone can give much information, where alteratives are distinctly indicated; people with muddy complexions, unctuous skins, a disagreeable odor in the breath, and generally constipated bowels. Such persons are all the better of a course of alteratives and purgatives, from time to time, when out of sorts. It was a practice among the practitioners of the past to give a dose of calomel and James's powder at bedtime, with a Seidlitz powder in the morning, to patients who presented themselves with severe colds. Here the tongue was usually foul and the skin dry, with some thirst. After the bowels had been freely opened, acetate of ammonia with ipecacuan wine, as diaphoretics, were given for a day or two. Excellent effects were thereby produced, as my experience in my father's surgery taught me. Nevertheless, when at last a graduate, in the fulness of my knowl- edge, and after a hospital training, I took the reins of practice, it seemed quite proper to discard alteratives as impostors, whose claims could not be substantiated. Consequently, and logically, they were put aside. But, as time went on, one case after another turned up where the administration of the powder and purgative produced better results than the diaphoretic treatment, without such preliminary preparation; until, at last, a silent recantation was brought about, and the powder and Seidlitz resumed their place as of yore—after their temporary seclusion. All this may seem to some readers as simple twaddle; that the results were coincidences; and that the patients would have done just as well without the alterative. Of course, there exists the right of private judgment in matters therapeutic, as in EXCRETION. 87 matters theological; and such persons have a right to their own opinion. I thought at one time as they may think now; but at present my opinions have changed, without making me a worse practitioner, I trust; and the right and skilful use of alteratives is, to my mind, one of the best evidences of an observant expe- rience and of thoughtful practice. No doubt habits of cleanliness, better ventilated bedrooms, more regulation of the bowels, and a systematic attention to the general health, have altered matters much; and that the appeal to the general excretory organs, once so necessary, is not now so strictly indicated among the more affluent classes; but among the humbler classes the old plan of commencing treatment is a sound one. So, too, in convalescence, the occasional use of alteratives is proper and beneficial. It often happens that a steadily progress- ing recovery is suddenly clouded by a state of feverishness, a foul tongue, loss of appetite, and general malaise. Under these circumstances it is a good plan to give some pil. cal. et colocynth co. at bedtime, and some citrate of magnesia in the morning; or to give a few grains of calomel with jalap or scammony in the morning, if the patient be seen in the forenoon. A gentle action on the bowels generally restores the condition to what is to be desired. But it must not thence be conjectured that it is the mere purgative action which is the whole matter; like results will not happen if the mercurial be omitted. The alterative action of arsenic is well illustrated in the excellent effects produced by its combination with iron. In many cases of impaired health, where the hair has lost its gloss, the skin is dry and harsh, the tongue always furred, and the assimilative process is imperfect, a course of arsenic and iron restores the lost lustre to the hair, the skin recovers its pliability and softness, the tongue cleans, digestion and assimilation pro- gress, the system gathers weight, and the person possesses once more the characteristics of health. In cases where there has been mischief in the lung, as for instance where an acute attack of pneumonia has degenerated into tubercle, or incipient tuber- culosis exists, then the combination of arsenic with iron, and a liberal dietary, seem specially valuable, and give most gratify- ing results.1 1 It is of service even in spreading caseous pneumonia. 88 EXCRETION. The combination of iodine with iron, as in the syrup, has been found most useful in the treatment of the strumous, and espe- cially strumous children. Whether it is in the convalescence after some exanthem, or in imperfect growth with defective assimilation, the union of iodine with the chalybeate is usually adopted as a matter of course—as a consequence of experience merely, without any investigation into the rationale of the matter. In fact it is done as a matter of habit, as a consequence of what has been observed and silently registered—the outcome, indeed, of experience. Neither is it difficult, after the physiological introduction to this chapter, to comprehend why a generally improved excretion should exercise such a beneficial action upon assimilation. Waste must be removed ere new material can be deposited in a tissue; and waste products must be efficiently eliminated, if the assimila- tive processes are to be carried on with normal efficiency. This truth has found an expression in the wonderful growth of a system of treatment now becoming fashionable and common. It is only about a century since Vincent Priessnitz, a peasant in Austrian Silesia, evolved the idea of modern hydropathy. In spite of obvious folly in some of its practices, in spite of the neglect and disdain of the profession, in the face of the fact that it has not yet succeeded in attracting the best men into its ranks^ that it is indeed tabooed by most orthodox members of the pro- fession; hydropathy is establishing itself and making good its claims, not only to our attention, but to our respect. In the treatment indeed of the ailments of mature life, especially of the man who has kept himself up to his work by large supplies of rich food and a liberal amount of alcohol, and in whom the system is saturated with the products of waste, this plan of liberal draughts of water is excellent. The wTaste products of the body are soluble, if but sparingly soluble in water; and the bathing of the tissues with water, and the washing out of the system, are applications of sound physiology, even if arrived at by an uncultured empiricism. By this means, by the powerful alterative action of water in unstinted quantities, the aim of purifying the organism, by exciting its different emunctories into high functional activity, is achieved. To this is conjoined an almost total abstinence from alcohol—the beverage is water. The food is simple, and not specially inviting, there is nothing EXCRETION. 89 in it to tempt too free indulgence; there is a total absence of the entrees and various wines that have led to repletion, as the consequence of pleasant viands rather than of systematic wants. There is good food for the needs of the organism; there is plenty of fresh air, with its waste-removing oxygen ; many hours every day out of doors in bracing air; and, finally, there are early hours to bed, and an early hour to rise in the morning. In fact, there are aggregated all the conditions under which a jaded and over- taxed system may recover itself; where it may get thoroughly rid of its waste, and inaugurate a course of healthy tissue- formation : a process of which it stands much in need. Indeed in hydropathy we see empirically achieved what a scientific physiology would ere long have indicated as the logical and rational plan of treatment of numerous affections of mature and advanced life, which take their origin in the imperfect elimina- tion of waste; either the products of tissue change, of histolysis, or the results of protein compounds imperfectly assimilated or furnished to the system in excess of its needs. We are rapidly coming round to a point when the importance of proper, sufficient, and healthy excretion, in the maintenance of health and the treatment of disease, can be established by scientific evidence, as well as by the accumulated but undigested facts of simple empiricism. As a logical sequence, then, altera- tives are again being included in our armamentarium with benefit to our patients. CHAPTEE IY. BODY-HEAT AND FEVER. § 35. Whether under the burning sun of the Sahara, or on an iceberg in Davis's Straits, the body-temperature of man is practically the same. There may be sometimes a slight differ- ence, but it is only to be measured by tenths of a degree Fahrenheit, or little more. To a certain extent this result is due to clothes; and without warm clothing, by which the body- heat may be conserved, man could not maintain a temperature compatible with life in the Arctic regions. But admitting that clothes are an indispensable auxiliary in cold climates, this body-heat is maintained in the one case, and regulated in the other by most important processes going on within the organism. All our heat is the result of combustion, of oxidation of the material consumed as food. At one time it was thought this combustion was carried on in the lungs solely—that they were the furnaces of the body. We now know that oxidation goes on in all the minute capillaries of the body. But the combustion is much more active in some parts than in others. The chief combustion goes on in the muscles. The actual combustion is said to consist chiefly of the oxidation of lactic acid in union with soda. The hydrocarbons are stored up, for the time being, in the liver as glycogen, which, when liberated, becomes sugar, and is then split up into lactic acid and as such is oxidized. The muscles have each a little store of glycogen, but the great storehouse is the liver. The more permanent storage is in the form of fat; and on these stores of fuel the body lives when deprived of food. As the reserves of glycogen become exhausted the fat is utilized to sustain the body-temperature. This tem- perature is almost entirely maintained by the union of oxygen with the carbon and hydrogen of our food. To a small extent nitrogenized matters are oxidizable, and so furnish a small quota of heat. A certain combustion goes on in the viscera, and the venous blood of the kidneys and liver is warmer than the BODY-HEAT AND FEVER. 91 arterial blood supplied to these organs. The blood of the in- ferior vena cava is warmer than that of the superior vena cava, and even than arterial blood itself. A greater amount of heat is produced during the action of muscles than when the same muscles are inactive. It makes a decided difference, however, whether the muscular action is doing so much work, or whether it is not so employed, as to the amount of heat produced. In tetanus very high temperatures are reached. In ordinary mus- cular action a certain amount of what would otherwise be heat goes to produce mechanical results; and there are good grounds for holding " that the products of muscular contraction—i. e., the heat and the mechanical results—are conjointly the expres- sion or equivalent of the chemical action which goes on in the muscle." (Wunderlich.) Heat is also furnished by mental exertion; this is more marked in tropical climates than in cold ones. Very active mental exertion produces a rise of tempera- ture of from one-half to a degree Fahrenheit. A large supply of good food also occasions a temporary rise of temperature, probably from the increased heat produced by the active changes of digestion and assimilation. On the other hand, heat is lost chiefly by the skin; and to a less extent by the respiratory tract. The blood circulating through the skin is cooled by heat-loss, by the radiation away of the heat in the surrounding cooler air. The larger the amount of blood circulating through the cutaneous vessels the greater the heat-loss. Consequently, in cold weather, the skin is cold and marbly; it is also white and anaemic. The vessels are con- tracted, and the heat-loss reduced to a minimum. On the con- trary, when there is an excessive heat-production, the vessels of the skin dilate; the skin is high-colored and glowing; it is in a highly vascular condition. We have seen that a free blood supply leads to a functional activity, and if the heat production be maintained, we get the sudoriparous glands thrown into action, and perspiration ensues. The consequence is that the cooling effects of evaporation are called into play, and still further heat-loss is occasioned.1 By such means the tempera- ture is kept at or near the normal. In tetanus, and in rheu- matic fever, there is free perspiration often found along with 1 The evaporation of water produces much coolness, from the amount of heat rendered latent, as water assumes a gaseous form. 92 BODY-HEAT AND FEVER. very high temperatures; but all that this proves is that the evaporation and heat-loss are unequal to neutralizing the exces- sive heat-production. (The body temperature often rises after death, and continues high for some hours. This is due to the fact that the heat production is no longer met by heat-loss, by radiation of heat away by a blood-current through the skin.) The play backward and forward betwixt the production of heat and its loss is not only very interesting, but is of the highest practical importance. Rosenthal has divided the body into an internal, or heat-pro- ducing area, and an external, or heat-losing area, with a mixed, or intermediate plane betwixt them. In the internal area heat is being produced by combustion; in the outer area it is being lost, or got rid of. Now it is obvious that a great effect must be produced by the amount of blood circulating in these two opposite areas. If the vessels of the skin be contracted by the action of external cold, then the amount of blood circulating in the cutaneous vessels will be small, and the heat-loss will also be small. Further, if there be but little blood circulating through the outer-area, there must be more circulating in the internal or heat-producing area, and consequently greater heat- production. The combined effect of this is increased heat-pro- duction and diminished heat-loss in cold climates; and so the body preserves its normal temperature in the coldest regions— aided, as we have before said, by the action of clothes. In hot countries this process is reversed. There is in a sur- rounding medium of high temperature, a fulness or dilatation of the vessels of the skin. By this means the heat-loss is brought to a maximum, and heat-production to a minimum. The less the amount of blood in the internal, or heat-produc- ing area, the less heat is evolved. Consequently, there is a lessened heat-production, and very little oxidation or wasting. Under these circumstances life can be maintained on a very small amount of food, as evidenced by the long fast of the crew of the Arracan in the Indian Ocean, from which all recovered.1 In a cold climate they would have been burnt out in a very few days. In the high temperature by which they were surrounded, their reserve stores of fuel were scarcely drawn upon to main' tain their body-heat, and so remained available for mechanical 1 Fifteen days of short commons, and then seventeen of almost absolute fast. BODY-HEAT AND FEVER. 93 results. In order to be well and healthy in tropical regions but a small quantity of food is absolutely necessary. That people should not lose their gustatory tastes in hot climates, and, as a consequence, eat a great deal more rich food than is either necessary or good for them, does not bear on the real question. The ill health which follows systematic overindulgence, suffi- ciently proves the desirability of maintaining a strict modera- tion in the matter of diet. It is unnecessary and undesirable to furnish to the system in excess the material for combustion. Where there is such indulgence there follow discharges of waste fuel from the liver, and the cooling effects of purgation. § 36. For the maintenance of health it is necessary that the temperature of the body be near the norm. According to Wunderlich, the mean normal temperature is 98.6° Fahr. (37.5° Centigrade), and the range of normal temperature in the axilla is from 97.25° Fahr. (36.25° Centigrade) to 99.5° Fahr. (37,5° Centigrade). There is a constant oscillation, back and forward, betwixt the two antagonistic areas of Rosenthal—keeping the heat-production and loss in equilibrium. Speculations have been indulged in as to whether or not there is a " heat-centre" which regulates the heat supply, like the governing balls of an engine; or the steersman of a craft, who by gentle movements of the wheel keeps the vessel's head steady. Its existence can- not yet be regarded as proven. Certainly there are good reasons for holding that there are two sets of nerve fibrils running along the walls of the bloodvessels—at least of the arteries—by which their calibre is maintained. The one, the vaso-motor nerves of the sympathetic, tend to contract the calibre of the vessels; the other, the vaso-inhibitory nerves, derived from the cerebro-spinal system, are antagonistic to the vaso-motor nerves, and produce dilatation. Betwixt these two sets of nerve fibrils the calibre of the vessels is maintained in constant equilibrium, by perpetual oscillations, however; and similarly the body-heat is kept at a norm by constant back and forward play betwixt the antagonistic heat- producing and heat-losing areas; but here also there is probably some oscillation on each side of the straight line. By the resort to clothes man voluntarily aids in the mainte- nance of the line of normal temperature. At night, when the surrounding temperature is cooler, he covers himself freely with 94 BODY-HEAT AND FEVER. non-conducting materials, and so retains his heat. This is the more necessary in that the cutaneous vessels are dilated in sleep —to permit of the requisite cerebral anaemia—and so there would be greater heat-loss if not so restrained.1 In warmer climes the clothes are lighter, and of less perfect non-conducting materials, so as to interfere but little with the dispersion of heat. If man is careless about protecting himself warily in the daily changes of temperature, where there are burning noons and chilly nights, disease, the result of temperature-disturbance, will certainly result. In addition to his clothes man has the aid derived from fire, and the protection from external influences furnished by build- ings. Further, he can, when exposed to cold, derive much aid from fluids artificially heated. He draws from the fire, by the heated drink, so much warmth, and so saves his own consump- tion in heat-production. When too much hot drink is indulged in perspiration follows. By reversing this process, and by the inhibition of cold fluids in warm climates, or when surrounded hy a heated atmosphere, man cools himself down, or neutralizes the effects of heat accumulated from insufficient heat-loss. The use of iced fluids is greatly on the increase, and the terrors of a chilled draught, when heated, are being dissipated. By such various means, and especially by skilful combination of them, man aids his heat-regulating processes to maintain his tempera- ture at or about the norm. § 37. The variations from the normal temperature are of the greatest moment to us. High temperatures, with which we all are so familiar, will engage our attention at considerable length, but, before entering upon that side of the question, we will first examine the subject of low^, abnormally low, temperatures. A lowering of temperature may be variously induced; in less degrees it is the consequence of exposure, especially without effort (heat-production), or of hemorrhages, or of free discharges. When more pronounced the fall is called collapse. Slight lower- ings of temperature, down to 96° or 95° Fahr., are not in them- selves dangerous to life. Further lowering from 95° to 93.5° Fahr. indicates danger, and needs active measures. The lower 1 When exposed, unprepared, to severe cold it is well known that the man that sleeps—dies. Wakefulness alone can preserve life. BODY-HEAT AND FEVER. 95 the temperature the more active the measures required to main- tain life. If the limit 93.5° is reached, the danger is great; and if the temperature falls below 92° there is a deep algide collapse, from which the patient rarely, if ever, recovers—except in cases of acute alcohol poisoning, where a temperature of 90° is not incompatible with recovery (Bathurst Woodman). Below 92° survival for a brief period is possible, but recovery can scarcely be looked for. Too low a temperature is as incompatible with the continuation of existence as is too high a temperature. States of collapse are more readily induced in children than in adults; in women than in men; in the sick than in the healthy. The measures to be pursued or adopted for the treatment of low temperatures are various. The first thing to be done is to conserve the body-heat to the utmost, and to economize it by the use of non-conducting materials. In addition to this, external heat can be utilized to lessen the heat-loss, and even to give heat to the body. Consequently, it is desirable to see that the patient is surrounded by blankets, or other woollen material; to have bottles of hot water placed around him, taking care not to burn the skin; and, further, to furnish to the organism heat artificially, by the administration of hot fluids. These fluids may contain alcohol with advantage; its presence makes them more palatable, while it acts upon the heart, increasing its con- tractions in frequency and in power (Binz). The heat-loss, how- ever, must be obviated, else the alcohol will act mischievously. We shall shortly see that alcohol is a potent means of lowering temperature. As to any medicinal means of increasing heat- production, it is very questionable whether we possess them in any practically useful form ; and it is more questionable whether we can avail ourselves of them in practice. Such an agent is belladonna, in moderate doses, which notably raises the tem- perature. Very frequently there occur sudden, passing lowerings of temperature known as "catching cold." The essential starting- point here is the quick abstraction of heat in excess of heat- production. Thus colds are commonly caught by the sudden removal of the body from a persisting high temperature into a cold surrounding medium. The vessels of the skin are dilated and partially paralyzed by the warm surroundings, and when 96 BODY-HEAT AND FEVER. suddenly exposed to the cold environment they, instead of con- tracting, become still further paralyzed by the cold; and then an immense current of warm blood is brought into contact with the cool air. Great heat-loss follows: but there is not a corre- sponding sensation of cold, because the current of warm arterial blood prevents the cutaneous nerves from feeling cold, as is illustrated by the hands of the snow-baller, which glow in spite of the contact of the frozen mass. There is, however, much greater heat-loss with these dilated cutaneous vessels than when the vessels are contracted; when the cutaneous nerves are not bathed in a warm current of blood, and so register the sensation of cold. The feeling of cold and the amount of heat-loss are, consequently, often in inverse proportion to each other. Habit endows the system with a certain power of regulating the heat- balance, and of giving off heat when required to meet great heat-loss. This is well illustrated in the case of those much exposed to great variations of temperature: they become inured to such changes—we say. The system is educated to look after itself, and by habit the vessels of the skin are taught to contract on contact with cold, and so to lessen the amount of blood in the cooling area and to increase the bulk in the internal or heat- producing area. This is the effect of the constant use of the cold bath; viz., to educate the system to develop its heat-regu- lating actions. When the cutaneous vessels are paralyzed a large mass of blood is in the cooling area, and the heat-loss is great. Further, too, there is a correspondingly small amount of blood in the internal heat-producing area; and the evolution of heat is proportionately small. Consequently, in the combina- tion of the two we find that loss of temperature known as "catching cold." The secondary fever, often amounting to no more than feverishness, is the consequence of delay in the heat- regulating processes, and an excessive heat-production comes on when too late—too long deferred to be useful. It forms, however, a pyrexia, often calling for our aid to dissipate, or rather to aid in dissipating the excessive heat. The pathology of taking cold is at once simple and highly interesting, while it clearly points out two things. First, how to conduct mat- ters so as to lessen the primitive depression of the body-tem- perature; for usually the secondary reaction is in direct pro- portion to this original depression. To avoid cold, then, it is BODY-HEAT AND FEVER. 97 necessary to keep the skin in good tonic action; then it must be borne in mind that if the exposure to cold after being long at a high temperature, as at a ball, for instance, be but brief, the excessive heat merely may be got rid of; but if the exposure be prolonged, then great heat-loss is experienced. The less, too, the system is inured the greater the risk. The second indication furnished is —to get rid of the superfluous heat, occasioned by the delayed heat-production, the pyrexia, or secondary reaction, by measures to be described a little further on, §§ 41-44. § 38. An increase in the body-heat forms the condition known as fever. A pyretic condition may extend from a mere condition of feverish ness, with a temperature of from 99.5° Fahr. to 101.5°, states often found in children without any sinister meaning whatever; up to a high febrile state of from 107° to 108.5° Fahr., beyond which existence is possible for only a brief period, and recovery impossible; though there are some isolated cases to the contrary, this statement of Wunderlich is almost universally true. A temperature of 113° Fahr. has been found ere actual death; wThile a sharp rise of temperature is a common'precursor of death in febrile states. In the notorious Scarborough high- temperature case, where the thermometer rose to 122° Fahr., the explanation now largely accepted is, that the thermometer was twirled in a portion of the night-dress; and the friction so pro- duced caused the very high reading. The different conditions under which pyretic states are found are so numerous, and these pyretic states are so common, that fever, in some form, is one of the most familiar morbid conditions we are called upon to treat. Not only in the ravages of fever known as epidemics, or in its local persistence as an endemic affection, as on the Gold Coast; but in isolated cases, specific fever has for us, as practitioners, a deep interest and a powerful attraction. As typhus it follows overcrowding; as typhoid, or enteric fever, it forms the nemesis of sanitary negligence; as relapsing fever it hangs around periods of famine; while in the form of the exanthemata it is the plague of our youth; as ague it is the scourge of undrained marshes; while as malarial or climatic fever it strews the shores of the Gold Coast, of Guiana, and of the Mexican Gulf with the remains of the natives as well as of the white man. It is commonly found in the form of 7 98 BODY-HEAT AND FEVER. well-marked specific disease; but it is not essential that it should be connected with anything specific. A prolonged high tempera- ture—no matter how produced—will occasion that state known as "the typhoid condition." We see it produced by hectic in the consumptive; by surgical fever and pyaemia in other cases. Wherever met, it forms a characteristic and a terrible condition; and this consequence of a persistent high temperature is the chief clanger of all fevers. The typhoid condition is thus graphically described by Tweeclie, whose experience of fever enabled him to picture it well: "It is announced by the decline of the previous more acute symptoms; by the pulse becoming more rapid and soft; the tongue dry and brown, tremulous, and protruded with diffi- culty ; by the incrustation of the teeth with sordes; by the in- creasing intellectual disorder, indicated by the constant low muttering delirium, and the greater insensibility and deafness; and by the condition of the muscular system, evinced by mus- cular tremor and subsultus tendinum, and in some cases by irregularity or intermission of the pulse; by the patient lying sunk on his back, or sliding to the foot of the bed, the muscles being unable to support the body even in the horizontal posture." With this condition all medical men of any experience are unfortunately but too familiar. It is a condition which, to a greater or less extent, obtains in every well-marked attack of typhus, and is common in severe cases of enteric fever. From its frequent occurrence in specific fever it has acqpired the name of the typhoid condition, and was once supposed to be found solely in specific fever. Consequently, when this condition showed itself in the course of any other affection, the practi- tioners of old said, "The disease has turned to typhus;" because they recognized a condition, as they thought, pathognomonic of typhus fever. In this they were distinctly mistaken. It is true that such a state is associated with a sustained high temperature —a condition most commonly supplied by specific fever—but it is not causally associated with the specific fever per se, but with the sustained high temperature. They were, then, in error in supposing that the ailment had turned to typhus when they observed a typhoid condition coming on; but, ere the day of the clinical thermometer, the recognition of the association of this state with a persistent high temperature was simply impossible. BODY-HEAT AND FEVER. 99 Even yet the well-worn formula, that such a person's disease turned to typhus, which killed him, is heard from time to time. Still are patients suffering under different maladies sent into fever hospitals because they have passed into a typhoid condition. In his very able work on medical diagnosis, the well-known physician, Da Costa, writes, "No blunder is more common than to misconstrue into typhoid fever a typhoid condition of the system." § 39. The pathology of the typhoid condition is a matter so important that a section may well be devoted to its special con- sideration. Such examination of its pathology will both clear up its origin, and point the direction of the therapeutic agents to be employed. To commence with, it is necessary to point out this fact, viz., that at the ordinary temperature of the body the nitrogenized tissues wear away but slowly, and their oxida- tion is a trivial affair. But as soon as the body-temperature rises the nitrogenized tissues begin to melt down by oxidation; and there is found a corresponding excess of histolytic products in the blood. The higher the temperature the greater the waste of the nitrogenized tissues, especially the muscles. After a fever, the fat of the body is left comparatively untouched, but the muscles are shrunken and wasted. A microscopic examina- tion of the muscles after death from fever demonstrates that they are the subjects of extensive structural changes. Zenker has pointed out these changes, and his observations have been- corroborated by others. The changes are not so marked where death has taken place in the earlier stages of the pyrexia, but if it has been delayed till the later period, they are very distinct. " There are two forms of degeneration, the granular and the waxy. The granular form consists in the deposition of minute, highly refracting granules in the contractile tissue, giving to the fibres a dark appearance by transmitted light, and obscuring the striee. This muscular deposit is not wholly composed of fat. The degenerated fibres are very friable. The waxy form con- sists in the transformation of the sarcous tissue into a homo- geneous, colorless mass, glittering like wax, and causing a complete obliteration of the striae and nuclei of the fibres, the sarcolemma remaining intact. The waxy cylinders thus formed crack up into numerous fragments, which crumble down into a finely granular detritus, and this is gradually absorbed." (J. 100 BODY-HEAT AND FEVER. Ilarley.) Rindfleisch gives a plate of these changes in the muscular structure of the heart after relapsing fever. Such changes are not only found in the dead, but, by a process known as " harpooning the muscles," identical changes have been found in fever patients alive, and who have ultimately recovered. They are not, then, post-mortem changes; they are the changes wrought in the muscle by a sustained high temperature. They are not confined to febrile conditions of a specific nature; they are found also in the hearts of women who have died from puerperal septicaemia. Such being the actual condition of the muscular structures of the body, we can feel no surprise at the sense of prostration which is so marked in the typhoid condition. Muscular weari- ness is an initial symptom of fever; muscular prostration marks its height. " If you could place your fever-patient at the bottom of a mine twice the depth of the deepest mine in Cornwall, and compel the wretched sufferer to climb its ladders into open day, you would subject him to less torture from muscular exertion than that which he undergoes at the hand of nature as he lies before you, helpless, tossing, and delirious, on his fever couch." (Haughton.) Murchison says, " There is found too, on the whole, a direct relation between the temperature and the amount of urea.....According to Brattler, there is a close correspondence between the amount of urea and the tempera- ture : the greater the amount of urea, the greater the tempera- ture." The normal excretion of urea per diem is about 400 grains, but as much as 1065, and even 1235 grains have been ex- creted in one day in pyrexia. Some of this might be due to the albuminoid matters given to the patient as food, or there may have been imperfect action of the kidneys for some time before; still, admitting all this, there is a large quantity of urea remain- ing, which is, in all probability, the result of tissue-waste. In cases of preexisting kidney disease, the elimination of urea in fever is impeded, and consequently the waste products of his- tolysis accumulate, so that Murchison says: " The gouty diathesis, from its being so often associated with disease of the kidneys, is a very serious complication. I have never known a gouty person attacked with typhus recover." Urea not being found in excess in the urine may, then, point to a still more perilous condition than its presence in excess would indicate. These are BODY-HEAT AND FEVER. 101 important points to be considered; not only in the estimation of the patient's danger in a typhoid state, but they also bear directty on the remedial measures to be employed. A still more important matter to recognize is this: The excessive waste of the nitrogenized tissues in febrile states, proportioned, we have been told, to the rise of temperature, is not solely connected with specific fever. Thus Unruh found an excess of nitrogen in the urine in twenty-eight cases of febrile temperatures, of which sixteen only were specific fevers. In all of them, however, the amount of nitrogen was high, amounting to half as much again as is the average in health; while in some cases it was twice as much. Naunyn found, by experi- ment, that an increased body temperature was produced by the simplest of all methods of raising it, viz., by confinement in a heated atmosphere saturated with moisture; and along with this rise there was found an increase in the amount of urea. These experiments corroborate the views of Traube, Vogel, and others, that the excess of urea is the measure of high tempera- ture, pur et simple, without relation to its cause. The associa- tion of the excess of waste products with the typhoid condition, where, we have seen, the muscles undergo degeneration in life, and their production, in undue quantities, in the simplest forms of high temperature, close the circuit in this direction; and point to the conclusion that these changes in the muscular structures, accompanied by the formation of urea in excess, are the consequences of a sustained high temperature, without reference to its causation. It is a matter, then, of the greatest practical importance, that we should clearly recognize these facts, as to the manner of the production of the typhoid condition—which is essentially the same in specific and non-specific pyrexia. Its treatment— speaking broadly—is the same, whatever the form of disease with which it is causally associated, or coexistent. Its oncome is of deep import, and indicates a condition of peril whenever and wherever met. Everywhere and ever, a typhoid condition is a condition of grave seriousness. § 40. We have seen that the typhoid condition is associated with a high temperature, no matter how produced. We will now see how far this pathological review will explain the con- dition of the patient, and the peculiar symptoms of this state. 102 BODY-HEAT AND FEVER. It is probable that the temperature of the blood going to the brain has somewhat to do with the production of that abnormal condition—the delirium. There is much evidence tending to show this, viz., its association with high temperatures, and its removal by lowering the temperature by means of the application of cold. With the fall in the temperature the reason returns and resumes its wonted sway. This, too, is quite irrespective of ultimate recovery or death. Delirium is extremely common in children during febrile attacks, and sharp high temperatures are common also; the two commonly go together. Of course, too, an excitable brain is much more easily thrown off its equilibrium than is a less mobile one. The functional disturbances of the nervous system are—nevertheless and admitting all this—in the typhoid condition, chiefly produced by the waste products in excess in the blood. Murchison says: "The observations which have been made in relapsing and pythogenic fevers also support the opinion that the head symptoms of typhus are due, not to inflammation, as was once believed, nor to the presence of the original fever-poison in the blood, but to the circulation through the brain of urea, carbonate of ammonia, or other products of disintegrated tissue. ... As in other febrile conditions, the increased formation of urea, notwithstanding the diminished supply of food, is evidently the result of an exaggerated disin- tegration of the muscular and other nitrogenized tissues. As long as the urea continues to be eliminated by the kidneys, its effects are comparatively trifling; but if the quantity be excessive, and, still more, if from any morbid condition of the kidneys, either antecedent to or resulting from the febrile attack, its elimination be interfered with, it accumulates in the blood and gives rise to uraemic (typhoid) symptoms. If the urine be com- pletely suppressed, as sometimes happens, death speedily ensues, under symptoms of coma, and sometimes with uraemic convul- sions; but if the suppression be less complete, it may still give rise to delirium, stupor, and coma." In fact the brain is poisoned by the waste products in excess in the blood, there being direct evidence to show that the blood does contain urea, etc., in this condition; and the congeries of symptoms, so produced, is per- fectly characteristic, especially when read in connection with the peculiar muscular symptoms. The oncome of the symptoms of the typhoid condition ever indicates the presence of the BODY-HEAT AND FEVER. 103 products of histolysis in the blood in excess; the lighting up of the intelligence marks the cleansing of the blood, and an im- provement in the condition of the patient generally. Under certain circumstances this grave typhoid condition is compara- tively free from danger, as in the course of specific fevers in the young;- but when found in the elderly, and associated with chronic renal disease, it is ever fraught with peril, and is com- monly fatal. As the direct consequence of a sustained high temperature, the typhoid condition indicates what measures should be em- ployed for the arrest of its oncome, viz., means calculated to keep down the temperature; it shows the dangers which accompany a sustained high temperature, and the importance of apyretic measures. At the same time its own production, or genesis, is very instructive in pointing out to us what measures we should adopt in the treatment of the condition itself. By careful and repeated examination of the urine, along with similar temperature observations, and a general summing up of the various symptoms, it is possible to calculate fairly well what the exact position of the patient is; and whether the kidneys are equal to their work or not. As the condition progresses—as if unrelieved it certainly will—the general indications show that the system is becoming more and more poisoned by the products of histolysis. There is the persistence of the posture in bed, viz., on the back, with the tendency to slip to the foot of the bed, indicating the muscular prostration; there is the starting of the tendons, due to the clonic spasms of the muscles in connection with them, which differ but in degree from general convulsions; there is inertness of the sphincters; there are also disturbances of vision, indicated by the picking of the bedclothes, and the graver indications, disturbances of hearing, as imaginary ringing of bells, etc., showing how deeply the nervous system is affected; there is also a brown, chapped tongue, well retracted, the brown fur consisting of an accumulation of dead epithelial scales—signi- ficant of the condition of the whole intestinal canal; with brown sordes on the teeth of similar origin, accompanied by the forma- tion of crusts upon the lips; there is the hissing respiration, so characteristic of this condition, and contrasting with the stertorous breathing of apoplexy; and very often an urinous odor of the breath, due to ammoniacal matters, which form crystals of muriate 104 BODY-HEAT AND FEVER. of ammonia when a glass slide moistened with hydrochloric acid is held under the nostrils. Everything goes to show how deeply the system is under the influence of products formed from dis- integrating tissue, by the effect of a sustained high temperature. There is much to demonstrate the importance of preventing a high temperature being reached; or if that be impossible, or we do not see the case till a high temperature is already inaugurated, of lowering it as speedily and effectually as may be. § 41. Antipyretics.—For the purpose of lowering the bo