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ON 

DISOEDEES OF DIGESTION 



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DISOKDEES OF DIGESTION 



THEIR 



CONSEQUENCES AND TKEATMENT 



BY 



T. LAUDER BRUNTON, M.D, D.Sc, F.R.S. 

FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS ; ASSISTANT PHYSICIAN AND 
LECTUEEE ON MATEBIA MEDICA AT ST. BARTHOLOMEW'S HOSPITAL 



MACMILLAN AND CO, 

AND NEW YORK 
1893 

\The Mght of Translmtion is Reserved] 






First Edition Printed June 1886. 
RErRiXTED July 1886, 18S7, 1888, 1893. 






TO 

ARTHUR GAMGEE, M.D., F.R.S. 

IN ADMIRATION OF HIS SCIENTIFIC ABILITY AND CLINICAL SKILL, 

AND 
IN GRATEFUL REMEMBRANCE OF THE LESSONS 

IN EXPERIMENTAL PHARMACOLOGY AND PHYSIOLOGICAL CHEMISTRY 

FIRST RECEIVED AT HIS HANDS, AS WELL AS OF MANY KINDNESSES 

DURING A FRIENDSHIP OF TWENTY YEARS, 

BY HIS ATTACHED FRIEND 

THE AUTHOR. 



Digitized by the Internet Archive 

in 2010 with funding from 

Open Knowledge Commons 



http://www.archive.org/details/ondisordersofdiOObrun 



PREFACE. 

"When I was requested by the Medical Society to publisli the 
Lettsomian Lectures which I had the honour to deliver before it, 
I intended to print them alone. But on looking over them I 
found that in many places I had referred for fuller particulars to 
papers which I had formerly published, and it occurred to me that 
some who might wish to consult these papers would be unable 
to obtain them, and others might like to be spared the trouble of 
hunting them up. I therefore decided to reprint some of them 
along with the Lettsomian Lectures. These papers were chiefly 
read at different times and before different audiences, and contain 
the same ideas repeated again and again, sometimes in nearly the 
same words, almost acl nauseam. Indeed, if any one should attempt 
to read this book straight through he "svill probably throw it aside 
in utter disgust. But if he will only take the book up now and 
then at a spare moment, and read a single paper at a time, he may 
perhaps excuse the repetition, as it malies each paper more com- 
plete in itself Moreover, the reason why certain ideas are repeated 
again and again is, that they seem to me very important, and I 
have decided to let the papers remain as they were originally 
published, 'vvdthout attempting to lessen the repetition, because I 
hope that the constant recurrence of certain ideas may obtain for 
them in the mind of the reader the same importance which they 
have in that of the writer. 



viii PREFACE. 

The order followed in the arrangement of the papers which follow 
the Lettsomian Lectures correspond generally to the course taken 
by food in the body from the mouth to the stomach and intestine, 
thence into the circulation and tissues, and finally to the excreting 
organs. 

The Lettsomian Lectures were written after all the other papers 
with one exception, viz. " On poisons formed from food," etc. ; they 
may therefore be considered fairly to represent our present know- 
ledge of the subject of digestion, while the other papers represent 
our knowledge of a few years back. The ideas which are fully 
developed in the Lettsomian Lectures are in some cases at least to 
be found only in their germs in the earlier papers ; especially is this 
the case with the idea of the poisonous action upon the organism 
of substances formed in the intestine or in the tissues themselves. 
It may be interesting to some readers to follow the development 
of these ideas, and therefore a chronological list of the papers has 
been added to the table of contents. 



TABLE OF CONTENTS. 



LETTSOMIAN LECTURES. 

LECTUEE I. 

Slan a cooking animal — Exceptions to definition — Methods of cooking — "WTioleness 
and health — Strong and weak health — Inside and outside of the body — Solution 
and absorption — Strong and weak digestion — Physiological fuel — Mixed foods — 
Mechanical disintegration — Molecular disintegration — Size of molecules — Mem- 
branes as molecular sieves — Primary and secondaiy digestion — Mastication — 
Its effects upon the mouth — Upon the stomach — Upon the brain — Effect of 
suction on the brain — Effect of swallowing upon the heart — "Why children suck 
their thumbs — Products of gastric digestion — Poisons formed by digestion — 
Peptotoxine — Piclaxation of pylorus — Action of pancreatic juice — Antiseptic 
action of bile — Foimation of poisons by putrefaction in the intestine — Action of 
the intestinal juice — Absorption — Destruction of peptones — Formation of globulin 
■ — Formation of glycogen — Action of the liver as a gate-keeper — Action of 
tongue and palate as porters — Education of special senses — Cooking as a fine art 
— Artistic City dinner — A City dinner as a moral agent — ^A City dinner as a 
physical restorative — Courses in ordinary diuners — Physiological reason for the 
order usually adopted — Digestibility of different kinds of meat — Uses of wine — 
Moderation for one and excess for another — Effects of excess ... ... p. 1 

LECTUEE n. 

Nature of biliousness — Portal obstruction and intestinal congestion — Sponginess of 
the liver — Contractile power of the capillaries in the liver — Indigestion and 
biliousness as seen in Alexis St. Martin — Gastric origta of indigestion — Possible 
hejiatic origin of indigestion — Symptoms of indigestion — Flatulence — Acidity — 
Oppression — Intestinal gases — Sensitiveness of the CEsophagus — Hepatic con- 
gestion — Piles — Uses of slow circulation in the liver — Glycosuria and diabetes — 
Functional albuminuria — Peptonuria — Oxaluria — Shortness of breath — Asthma 
— Stomach cough — Intennittent pulse — Sudden death — Its possible causation 
by intestinal poisons — Similarity between symptoms of indigestion and curara 
poisoning — Non-bittemess of bile — Connection of hyxx»chondriasis and melancholy 
with hepatic derangement — Intestinal sewage poisoning — Oxaluria — Headaches 
— Giddiuess ... ... ... ... ... ... ... p. 23 



CONTENTS. 



LECTURE III. 

Imperfect mastication — Man a low-pressure engine — Bolting food — Eeading during 
meals — Imperfect teeth — Hot rolls and buttered toast — Buttered muffins and 
suet dumplings — How to eat mutton fat — How to make a sandwicli — Cause of 
toughness and tenderness in butcher's meat — "High" meat — Papaw — Bad 
cooking — Usefulness of pleasant taste in food — Unappetising service — Cookery 
as a moral agent — Drunkenness and thirst — Dentistry as a moral agent — Water as 
a stimulant — Nervous dyspepsia — Eegulation of diet — Dr. Austin Flint's opinion 
— "Grabbing" food — Uses of a table d'hote — The appetite as a regulator — Over- 
eating — Advantages of a weak stomach — Wrong interpretation of the dictates of 
the palate — Salt herrings — Oldest diet tables of the world — Adam's diet table — 
Noah's diet table — Diet table of Moses — Diet tables for dyspeptics — General 
rules for dyspeptics — Avoid things hard to disintegrate — Avoid things hard to 
digest — Indigestible substances — Prehistoric strawberries — Acid fruits — Sour 
wines — Hypersesthesia of gullet — Afternoon tea — Effect of tea on digestion — Tea 
at breakfast — Long infusion of tea — Very hot tea — Effect of coffee on the intestinal 
and hjEmorrhoidal veins — Cocoa — Effect of fatigue upon digestion — Co-ordination 
of the digestive functions — Digestive stumbling — Use of rest — Abuse of exercise 
— Business men's dinners — Effect of depressing emotions — Consumption from 
crossed love — Emotional dyspepsia — Use of bromides — Uterine dyspepsia — Con- 
nection of digestion with other functions — Gastric tonics — Carminatives — Stimu- 
lants ; their place and power — Dirt — Alcohol in dyspepsia — St. Paul's advice to 
Timothy — Purgatives — Regularity (?) of the bowels — Constipation — Dinner pills 
— Fashions in purgatives — Carlsbad water at home and in Carlsbad — Pathology 
of biliousness — Action of aromatic compounds upon the bile — Toluylendiamine 
— Salicylate of soda — Possible effects of intestinal poisons — Epidemic jaundice — 
Blue pill and black draught — Horse exercise — Alteratives — Action of ammonia 
upon the formation of glycogen — Diuretics — Hot water — Treatment of asthma — 
Intermittent pulse — Giddiness and headache — Action of atropine in megiim — 
Weir-Mitchell treatment ... ... ... ... ... p. 49 



MISCELLANEOUS ESSAYS. 

ON HEADACHE, NEURALGIA, AND OTHER NERVOUS DISEASES 
CONNECTED WITH THE TEETH. 

Headache and toothache — Pathology of megrim — Caries and neuralgia — Laryngeal 
pain from bad teeth — Teething cough — Dental caries and blindness — Magendie's 
experiments — Twitching of the eyelid — Paralysis of the eyelid — Spasmodic 
closure of the jaws — Teething as a cause of paralysis in children — Pathology of 
infantile paralysis — Dental irritation in chorea — Epilepsy — Dental irritation in 
dyspepsia — Diarrhoea — Connection between the teeth and heart — Dental irritation 
and insanity ... ... ... ... ... ... ... p. 83 



CONTENTS. xi 



ON THE PATHOLOGY AND TREATMENT OF SOME FORMS 
OF HEADACHE. 

Seat of sensation — Hysterical pain — Neuralgia— Toothaclie and headaclie — Patliology 
of megi'im — Action of heat and cold on tlie circulation — Transference of pain 
from temple to occiput — Occipital headache from decayed teeth — Enlarged tonsils 
and headache — Strain of the eyes as a cause of headache — Presbyopia and giddiness 
— Diseases of the nose as a cause of headache — Disease of the ear as a cause of 
headache — General causes of headache — Seat of headache — Treatment of frontal 
headache — Occipital headache — Vertical headache — Anaemic headaclie — P»,heu- 
matic headache — Gouty headache — Albuminuric headache — Syphilitic headache 
— General diagnosis and treatment of headache ... ... ... p. 98 



ON DYSPEPSIA. 

Functions of the body in health — Effect of exhaustion — Physiology of digestion — 
Historical summary — Observations on Alexis St. Martin — Appearance of the 
healthy stomach — Appetite — Condition of the stomach with craving appetite 
— Condition of the stomach in biliousness — Causes of indigestion — Treatment 
of temporary indigestion — Removal of iiiitants — Medicinal treatment of tem- 
porary indigestion — Chronic indigestion — Its" symptoms and treatment — Atonic 
dyspepsia ... ... ... ... ... ... ... p. 113 



ON THE USES AND ADMINISTRATION OF FAT. 

Attempts to swim the Channel — Causes of failure and success — Fat as a protective 
against external cold — Fat as a store-house of energy — Different amount of fat 
in tissues — Different kinds of fat — Formation of fat — Exclusively meat diet as 
a cause of weakness and muscular fatigue — Pastrycooks and consumption — How 
to eat fat — How to give cod-liver oil — Uses of cod-liver oil — Sick-room cookery 
Gruel for bronchitis — Bantingism and nervous derangement — Gouty glycosuria 
— Pathology of fatty degeneration — Treatment of fatty degeneration of the 
heart ... ... ... ... ... ... ... p. 128 

ON THE PHYSIOLOGICAL ACTION OF ALCOHOL. 

Is alc(A.ol a food or poison ? — Answers to this q^uestion — Local action of alcohol — On 
the skin and mucous membranes — Astringent action of alcohol — Action of alcohol 
on the mouth — On the stomach — Lobster and brandy — Alcohol as a gastric 
stimulant — Injurious effects of excess — Adaptation of the stomach to a stimulus 
— Reflex action of alcohol upon the circulation — General action of alcohol after 
absorption — Effect on the blood — Effect on the skin — Use in fevers — Alcohol as 
a food — Action of alcohol on the circulation — Indirect action of alcohol through 
the circulation on the nervous system — Effect of posture on the circulation in 
the brain — Action of alcohol as a stimulant — Results of the Ashanti campaign — 
Action of alcohol on temperature — Danger of alcohol during exposure to great 
cold — Usefulness of alcohol after exposure is over — Intoxication — Drunk in the 
head and drunk in the legs — Immunity from shock in drunkards — Paralysing 
action of alcohol ... ... ... ^ ... ... ... p. 110 



xii CONTENTS. 

ON THE PHYSIOLOGY OF VOMITING AND THE ACTION OF 
ANTI-EMETICS AND EMETICS. 

Nature of vomiting — The role of the stomach in vomiting — The role of the diaphragm 
and abdominal muscles — Phenomena in vomiting — Inability of certain animals 
to vomit — Nervous centre for vomiting — Connection with the respiratory centre 
• — Reflex vomiting — Nerves producing it — Cerebral vomiting — Treatment of 
vomiting — Removal of ii-ritant — Diminution of sensibility — Position and vomit- 
ing — Vomiting in phthisis — Congestion of the stomach and vomiting from 
cough — Emetics — Local emetics and general emetics — Secretion of emetics into 
the stomach after injection into the blood — Action of apomorphia and tartar 
emetic — Uses of emetics in poisoning — In indigestion — In croup and bronchitis 
— In gall-stones — In ague — In epilepsy ... ... ... ... p. 165 

ACTION OF MERCURY ON THE LIVER. 

Christmas dinners — Blue pill and black draught — Secretion and excretion of bile — 
Circulation of the bile between the intestine and liver — Cholagogues and 
hepatic stimulants ... ... ... ... ... ... p. 184 

ON THE ACTION OF PURGATIVE MEDICINES. 

How do purgatives act ? — Action on intestinal movement — Action on intestinal 
secretion — Experiments on purgatives — Dinner pills versus temperance — Intes- 
tinal irritation and cerebral circulation — Constipation and headache — Intestinal 
irritation and pain in the ear — Constipation and pains in the loins or groin — 
Action of purgatives on digestive secretions — Entero-hepatie circulation — Re- 
moval of poisons from the body by purgatives — Removal of bile by purgatives 
— Fasting in biliousness — Mercury rs a cholagogue — Reabsorption of ferments — • 
Possible continuous use of ferments — Ferments and fever — Action of purgatives 
on arterial tension — Summary ... ... ... ... ... p. 188 

HOW TO MAKE A POULTICE, 

Action of heat and cold on the circulation — Poultice to superficial parts — Poultice to 
deep-seated parts — Importance of proper method of making poultices for the 
relief of pain ... ... ... ... ... ... ... p. 210 

ON THE ACTION OF TONICS. 

"Want of tone " — Functional activity of the body and its parts — Modes of increasing 
functional activity — Gastric tonics — Cardiac tonics — Sewer gas in the intes- 
tines — Action of charcoal — Vascular tonics — Spinal tonics — Removal of waste 
products — Pathology of oedema — Action of digitalis on absorption — Action of 
strychnine — Action of iron ... ... ... ... ... p. 213 

ON THE ACTION OF ALTERATIVES. 

Gregory's powder as a moral agent — Meaning of the term "alterative" — How do 
alteratives act ? — Resemblance between alteratives and nutrients — Excretion of 
salt — Changes in foods — Action of ferments — Excretion of ferments — Slight 
combustibility of albumen — Possible action of alteratives upon ferments — 
Depressing action of purgatives — Oxa'uria — Treatment of gout — Common salt 
in epilepsy — General summary ... ... ... ... ... p. 223 



CONTENTS. xiii 



INDIGESTION AS A CAUSE OF NERVOUS DEPRESSION. 

Need for a holiday — Condition after a holiday — *' Running down " — IiMtability and 
depression — Melancholy and sleeplessness — "Nips" — "Keeping up the strength" 
— Fire and life — Choking by ashes — Use of water — Removal of waste — Suscep- 
tibility of nerve centres — Unaccountable sensations — Unexpected poisoning — 
Sulphuretted hydrogen — Toxic headache — Absorption of digestive juices — 
Zymogens — Urates and disordered liver — Disagreeable smells and poisonous 
gases — " As bitter as gall " — Black bile and melancholy — Beef tea and albu- 
minoids in the urine — Peptones as poisons — Action of intestinal juices — Limita- 
tion of digestive processes — Action of the liver upon peptones — Circulation of 
lymph in the extremities and trunk — Circulation of cerebro-spinal fluid — 
Poisoning of nerve-centres — Catarrhal jaundice — Hsemorrhoids — Stimulants 
and purgatives — Clearing out the liver — Effect of sipping upon the secretion 
of bile — Carara-lQce poisoning — Use of hot water — Order at meals — Horse 
exercise ... ... ... ... ... ... ... p. 233 

ATROPIA AS AN ANTIDOTE TO POISONOUS MUSHROOMS. 

Poisonoiis mushrooms — Active principle in them — ^Action of muscarine on the heart — ■ 
Its action on the pulmonary vessels — Effect of atropine as an antidote ... p. 259 

PHYSIOLOGICAL RESEARCHES ON THE NATURE OF CHOLERA. 

Causes of cholera — Effects of cholera poison on the body — Symptoms of cholera — ■ 
Search for a remedy — Pathology of cholera — Resemblance between symptoms of 
cholera and of poisoning by muscarine — Action of atropine as an antidote to 
muscarine — Its possible use as a remedy in cholera — Action of nitrite of amyl 
in cholera — Venous circulation in cholera — Possible use of digitalis in cholera — 
Use of atropine in cholera — Moreau's experiments — Paralytic secretion from the 
intestine — Action of drugs upon this — Paralytic secretion in cholera ... p. 262 

ON POISONS FORMED FROM FOOD AND THEIR RELATION TO 
BILIOUSNESS AND DIARRHCEA. 

Food and poison — Idiosyncrasies — Milk and eggs — Poisonous action of eggs — Purga- 
tive plants — Pies — Decomposition of foods — Poisonous products from food — 
Ptomaines — Splinters, mechanical and chemical — Milk diet and typhoid fever — 
Effect of temperature on fermentation — Electricity and fermentation — Baby's 
bottle — Bitterness of peptones — Peptotoxine — Products of albuminous decom- 
position — Alkaloids from albumen — Effect of the various alkaloids formed from 
decomposing albumen — Dock leaf and nettle — Alkaloids and their antagonists— 
Muscarine — Neurine — Ati'opine — Ursemia— Sausage poisoning — Poisoning by fish 
— Antidotes to ptomaines — Belladonna in poisoning by sausages, &c. — Cadaveric 
alkaloids — Exhausting diarrhoea produced by one alkaloid — Rise of temperature 
produced by another — Rise of temperature in constixjation — Action of mydalein 
— Stercorsemia — Chemical vaccination — Typhoid bacillus and food — Poisonous 
action on the heart of alkaloid formed by typhoid bacillus — Alkaloids in 
cholera — Lecithin in eggs — Relation of lecithin to alkaloids — Biliousness and 
jaundice from poisons — Hepatic stimulants — Ictrogen and lupiutoxin — Bilious 
headache and intestinal poisons — Germs of truth in popular beliefs — Action 
of aromatic substances upon the liver ... ... ... ... p. 274 



xiv CONTENTS. 

INTRODUCTORY REMARKS ON THE STRUCTURE AND FUNCTIONS 
OF THE KIDNEY. 

Function of the kidney — Medullary and cortical substance — Medullary pyramids — 
Blood-vessels of the kidney — Malpighian tufts — Tubules — Epithelium — Lymph 
spaces .„ ... ... ... ... ... ... p. 297 

SYMPTOMS, PATHOLOGY, AND TREATMENT OF ALBUMINURIA. 

Symptoms of anaemia — Effect of deficiency of blood — Pallor — Muscular weakness — 
Shortness of breath — Dyspepsia — (Edema — Palpitation — Causes of anaemia — 
Anaemia from albuminuria — Symptoms of albuminuria — Tests for albumin — 
Fallacies — Structure of the kidney — Size of molecules — Diffusion — Size of 
haemoglobin molecule — Forms of albumin — Their molecular size — ^Arteries and 
veins — Cardiac disease and albuminuria — Venous congestion — Indications for 
treatment ... ... ... ... ... ... ... p. 307 

ARSENIC IN ALBUMINURIA. 

True and false albuminuria — Effect of alterations in arterial and venous circulation 
on albuminuria — Renal congestion — Structure of the kidney — Relation between 
the quantity of the urine and the proportion of albumin — Effect of meat, fat, 
and time of day on the proportion of albumin — Albuminuria from imperfect 
digestion — Use of arsenic ... ... ... ... ... p. 322 

ON THE PATHOLOGY OF DROPSY. 

Nature of dropsy — Experiments on oedema — Short-haii-ed and long-haired dogs — 
Hard and soft muscles — Muscular and articular rheumatism — Possible relation 
between these and the hardness of muscles — Lymph pumps — Aids to flow of 
lymjjh — Obstructions to the flow of lymph — Removal of lymph by the veins — 
Flow of blood in the veins — Dropsy — Exudation of lymph — Effect of altered 
quality of blood — Anaemia — Nervous cedema — Relation of secretion to lymph 
supply — Classification of dropsies — Dropsy without vascular dilatation — Dropsy 
in "West Africa — Scarlet fever and atropine poisoning — (Edema from poisons 
formed in the intestines — Urticaria — Summary — ^Appendix ... ... p. 330 

ON THE ACTION AND USE OF DIURETICS. 

Use of water in the organism — Excretion of water — The skin as a regulator of 
temperatui'e — Relationship between the skin and kidney — Threefold function of 
the kidney — Absorption in the urinary tubules — Blood-supply of the glomeruli 
and tubules — Factors in the secretion of urine — "Vascular supply of the kidney 
— Nervous supply of the kidney — Blood-pressure in urinary secretion — Erythro- 
phloeimi — Digitalis — Modes of action of diuretics — Uses of diuretics — Hot water 
in gout and gravel — Adjuvants to diuretics ... ... ... p. 351 



XT 



CHEONOLOGICAL LIST OF PAPERS. 



ACTION OF MEECUEY ON THE LIVER ... ... ... Jan. 1873 

PHYSIOLOGICAL KESEAECHES ON THE NATUEE OF CHOLEEA Sqot 1873 

ON THE ACTION OP PUEGATIVE MEDICINES ... May and J um 1874 

ATEOPIA AS AN ANTIDOTE TO POISONOUS MUSHEOOMS ... NoV. 1874 

PHYSIOLOGY OF VOMITING AND THE ACTION OF ANTI-EMETICS 

AND EMETICS ... ... ... ... ... BeC. 1874 

THE PHYSIOLOGICAL ACTION OF ALCOHOL ... Jan. and Feb. 1876 

ON THE ACTION OF ALTEEATIVES ... ... ... Sept. 1876 

SYMPTOMS, PATHOLOGY, AND TEEATMENT OF ALBUMINUEIA iVoV. and Dec 1876 
AESENIC IN ALBUMINUEIA .,. ... ... ... June 1877 

ON DYSPEPSIA ... ... ... ... ... Dec. 1877 

ON THE USE AND ADMINISTEATION OF FAT ... ... March 1878 

ON THE ACTION OF TONICS ... ... ... ... Aug. 1878 

HEADACHE AND NEUEALGIA AND OTHEE DISEASES CON- 
NECTED WITH THE TEETH ... ... ... ... 1880 

INDIGESTION AS A CAUSE OP NEEVous DEPEESSiON Oct. and Nov. 1880 

INTEODUCTOEY EEMAEKS ON THE STEUCTUEE AND FUNCTION 

OP THE KIDNEY ... ... ... ... Aug. 1881 

HOW TO MAKE A POULTICE ... ... ... ... Oc^. 1882 

ON THE PATHOLOGY OP DEOPST... ... ... ... /S'ej:*^. 1883 

PATHOLOGY AND TEEATMENT OF HEADACHE ... ... 1883 

ON THE ACTION AND USE OF DiUEETics ... ... April and May 1%^^ 

LETTSOMiAN LECTUEES ... ... ... Jan. and Feb. ISS^ 

ON POISONS FOEMED FEOM FOOD, AND THEIE RELATION TO 

BILIOUSNESS AND DIAEEHCBA ... Aug., Sept., and Oct. 1885 



XVI 



ILLUSTRATIVE DIAGRAMS, Etc. 



Body, representation of 4 

Brain, circulation in ... ... ... ... ... ... .155 

Circulation during mastication ... ... ... ... ... 10 

„ enterohepatic ... ... ... ... ... 17 

„ the portal 24 

„ artificial, through the liver ... ... ... 25 

„ pulmonary ... ... ... ... ... 261, 267 

Emetics, action of ... ... ... ... ... ... 178 

Erythrophloeum, effect of ... ... ... ... ... 363 

Ganglion cells, in the medulla oblongata 169 

Headache • ... 102, 104, 105, 109, 110 

Heart action 148,149 

Intestinal canal 122 

Intestine ... ... ... ... ... ... ... ... 191 

„ of cat 192 

Kidney, the, section of 298,299 

,, blood-vessels of ... ... ... ... 301 — 305 

., of newt ... ... ... ... ... ... ... 356 

J, blood-vessels of mammalian ... ... ... ... 357 

„ tubules and vascular supply of ... ... ... 359 

„ secreting apparatus of ... ... ... ... ... 366 

Lymph spaces, and vessels 331, 333, 334, 337 

Malpigliian glomerulus ... ... ... ... ... 302,303 

Man, in case of massage ... 78 

Nerves, afferent ... ... ... ... ... ... ... 171 

Poultice-bag ... 211 

Pulmonary circulation ... 261, 267 

Pulsations of fontanelle of infant ... .. ... ... 11 

Pulse action ... ... 209 

Salivary gland ... 341 

Substances, excretion and reabsorption of ... ... ... 201 

Urinary tubules 355 

Uriniferous ducts and blood-vessels ... ... ... ... 303 

Uriuiferous tubes ... 304,305 



LETTSOMIAN LECTUEES 



DISOEDERS OF DIGESTIOIN" : THEIR COI^SEQUEiq"CES 
AIs^D TREATMEi^T. 



LECTUEE I. 

Delivered before the Medical Society of London, January Zth, 1885. 

Mr. President and Gentlemen, — I thank you most sincerely 
for the honour you have done me in appointing me to deliver the 
Lettsomian Lectures before you this year. The subject I have 
chosen is one of much practical interest, but it is of such extent 
that, to deal with it completely, in a course of three lectures, is 
obviously impossible. I have already discussed the j)hysiological 
processes of digestion at considerable length elsewhere,^ and I 
have therefore less hesitation in passing over those which are 
well known, with a few general remarks, and dwelling at greater 
length upon some points which are not so fully described in text- 
books, although they have important bearings on the practice of 
medicine. 

Man has been defined as a cooking animal. This definition may 
not be absolutely correct, and there may be some of the lowest 
races unacquainted with methods of cooking, although other cha- 
racteristics entitle them to be called men. Yet the definition is, in 
the main, true, and the fact that man cooks his food, while the lower 
animals eat theirs raw, is one of the most marked distinctions 

^ Digestion and Secretion, forming Peart III. of Sanderson's Sandhooh for the 
Physiological Laboratory, 1873. London: Churchill. With the assistance of Dr. 
D'Arcy Power I have revised it for the French translation by Professor Moquin 
Tandon, 1884. Paris : Felix Alcan. 



2 LETTSOMIAN LECTURES. [lect. 

between him and them. The practice of cooking was famihar 
to man at a very early stage, indeed, of his history. Long, long 
before the historic epoch, when man's only implements consisted 
of broken flints, he cooked his food by roasting, and the charred 
remains of bones, which he had roasted in order to enjoy the 
savoury marrow, have been found in caves, along with fragments 
of the skeletons of the cave-bear, woolly rhinoceros, and other 
animals long ago extinct. 

There is little doubt tha,t roasting was the first method of cook- 
ing adopted, for no implements were required, beyond a piece of 
pointed stick, to hold the food in front of the fire. Boiling is a 
considerably more complex process, and requires a vessel in which 
to hold water. This vessel need not necessarily stand fire, because 
the simplest method of boiling, and the one which was probably 
first adopted, appears to be that of heating the water by putting 
red-hot stones into it, until the temperature is sufficiently raised. 
But after man learned to make pottery, and to bake it in the fire, 
so that heat could be applied from the outside without the vessel 
cracking, the simpler plan of boiling the water by putting the 
earthen pot upon the fire, would be sure to be followed ; for man, 
as a rule, likes to save himself trouble, and usually takes what 
seems to him to be the easiest plan. 

Amongst the various pots of earthenware, early man must have 
noted the same differences that we do now. We see some pots of 
thoroughly baked earthenware so hard and strong as to resemble 
stone ; and, indeed, in the case of a Wedgwood mortar, the earthen- 
ware is more resistant than almost any stone. Other pots we see 
of fine china, thin and fragile, which must be handled with the 
greatest care, lest they break under our fingers. Yet both vessels 
are equally whole. Turn them round and round, and scan them 
most minutely, and yet you will find no flaw in either the one or 
the other. There is no difference between their wholeness, or 
wholth, or, as we now write it, health ; yet the wholeness or health 
of one vessel is strong, and the wholeness or health of the other is 
weak. The one may be put to all sorts of purposes, subjected to 
all sorts of treatment, meet with all sorts of rough usage, and yet 
it will remain whole or healthy. The other remains whole only so 
long as it is treated with the greatest care ; the slightest rough 
usage will crack or break it, and then its wholeness or health is gone. 

Our early forefathers, when framing a language by which to 
communicate with one another, had evidently been struck by an 



I.] HEALTH—STRONG AND WEAK. 3 

analogy between the implements they used in cookery, hunting, or 
warfare — those implements by which they maintained the life of 
their bodies — and those bodies themselves; for they applied the 
word health to signify soundness in both. At the present day, we 
sometimes forget the derivation of our word health ; but still we 
are accustomed to qualify it by the adjectives strong and weak, in 
much the same w^ay as one might speak of tlie soundness of an 
earthenware pot. 

By strong health, we mean a soundness of body which, like that 
of a Wedgwood mortar, will enable a person possessing it to go 
through all sorts of work, be subjected to all sorts of usage, and 
yet remain sound or healthy. By weak health, we mean a con- 
dition of body wherein all the functions go on perfectly so long as 
external circumstances are favourable, in which the person is fitted 
to do certain work, and will do it perfectly, provided the calls made 
upon him be not too great for his strength; but, if he be subjected 
to any extraordinary exertion, any unusual exposure, or rough 
usage of any kind, the feeble organism at once breaks down, and 
is damaged or destroyed. 

Not unfrequently we find that a strong earthenware pot, sub- 
jected to very rough usage, is cracked ; but the crack, instead of 
completely destroying it, reduces it only from a condition of strength 
to weakness; so that it remains to a certain extent whole, but is 
now weak ; and unless treated with care, it will readily break, 
although, if tenderly handled, it may continue useful for a long 
time. We find a similar condition also in man ; and what was 
originally strong health in a person may be so weakened by 
exposure, overwork, or the consequences of acute disease, that 
the health becomes permanently weak, instead of strong. 

Health in man, as in other animals, depends upon the proper 
performance of all the functions. These functions may be shortly 
said to be three : (1) tissue-change, (2) removal of waste, (3) 
supply of new material. For the activity of man, like the heat of 
the fire by which he cooks his food, is maintained by combustion ; 
and just as the fire may be prevented from burning brightly by 
improper disposition of the fuel, or imperfect supply of air^ and 
as it will certainly go out if fresh fuel be not supplied, and may 
be choked by its own ashes, so man's activity may be lessened 
by imperfect tissue-change, and may be put an end to by an 
insufficient supply of new material and imperfect removal of waste 
products. 

B 2 




4 LETTSOMIAN LECTURES. [lect. 

It is with the supply of new material that we have to concern 
ourselves chiefly in the present lectures, although it is so closely 
associateil with tissue-change and removal of waste, that we shall 
be obliged to consider these also to a certain extent. The old 
proverb, " There is many a slip 'twixt the cup and the lip," shows 
how clearly our forefathers recognised that neither food nor drink 
v,^as available for the wants of the body until it had actually been 
taken. Our knowledge carries us a step further than theirs ; but 
even yet we are very apt to forget that both food and drink are 
useless for the wants of the organism, so long as they are simply 
in the intestinal canal. 

The body may be roughly compared to a cylindrical box, through 
the centre of which runs a tube, open at both 
ends, but not communicating with the cavity of 
the box. Here, it is evident, that anything put 
into the tube, remains as much outside the box 
as if it were laid against the outer surface. If 
the tube be of a ditfei'ent material from the 
outer wall of the box — if, for example, it be 
more pervious, liquids or finely-divided j)owders 
Fig. 1.— Diagram- may pass more readily into the box through 
tioi^'of'thTbidy" tl^e ^^^all of the tube than they would through 
A the box. B the the outer wall of the box itself ; but so long as 
inner tube. ^^^^ ^^ ^^^ ^^^^^ through in this way, they will 

remain, to all intents and purposes, outside the box ; and this is 
the case with the intestinal tube. 

Food and drink, when swallov/ed, are still outside the body, and 
in certain circumstances remain so just as much as if they had been 
laid against the skin. For we sometimes find that food which has 
been swallowed passes through the intestine, and is evacuated, 
almost, or entirely, unchanged. It has simply fallen, so to speak, 
from the mouth to the anus, much as it might have fallen firom the 
neck to the feet, if it had been laid against the skin. 

There is, no doubt, one great difference between the skin and 
the intestine, viz., that the nerves of the intestinal tract are 
more sensitive than those of the skin, and in j)assing over the 
mucous membrane the substance may have exercised a greater 
action on the body, reflexly through the nerves, than it would 
have done in passing over the skin, but otherwise the condition 
in the two cases is much the same. 

Another difference is that the epidermis which covers the skin 



I.] SOLUTION AND ABSORPTION. 5 

is much harder and less permeable than the epithelial covering of 
the mucous membrane Hning the alimentary tract ; and, therefore, 
liquids applied to the skin remain unabsorbed, while usually they 
pass pretty readily into the body from the alimentary canal. 

Solids in a very minute state of division, and especially when 
mixed with fat, may be absorbed by the skin, as we see in the case 
of inunction with mercurial ointment, where the minutely-divided 
globules of mercury pass through the skin, are absorbed into the 
circulation, and are carried by the blood to the various parts of the 
body. It is most probable, although authoiities are not completely 
agreed upon the subject, that solid particles in a minute state of 
subdivision are also absorbed by the mucous membrane of the 
alimentary canal, but the greatest part of the food is absorbed, 
not in a state of simple minute subdivision, but in a state cf 
solution. 

In the alimentary tract, we have provision made both for solution 
and for absorption, and those two processes are included under the 
term digestion. 

Digestion, like the health generally, may be strong or weak. 
Some persons are able to take with impunity quantities of fat, 
pastry, cheese, raw apples, and various kinds of indigestible food, 
which in other persons would cause discomfort, pain, vomiting, or 
diarrhoea. Some are able to take meals at all sorts of irregular 
hours; to do hard work for a whole day without food, and then 
consume an enormous dinner ; to go through all sorts of anxiety 
without the least diminution of appetite ; and to drink aU. sorts 
of strong liquors without appearing to be any the w^orse. Their 
digestion is both healthy and strong. 

Others, again, suffer if their meals are not served exactly at 
the usual times ; a little extra work or a little anxiety will either 
destroy their appetite or impair their digestive power; a meal 
somewhat too hearty, or the slightest indulgence in wine or alcohol, 
is siire to be followed by unpleasant consequences, l^et even 
those persons may go on for months and years with comfort, 
digesting their food perfectly, provided only that they take care 
to fulfil the necessary conditions. Their digestion is healthy, but 
it is weak. 

When digestion is imperfectly performed, we say that the 
patient suffers from indigestion. Indigestion may occur in those 
who habitually have either a strong or weak digestion, and by 
proper methods it may frequently be cured in both; nay, more, 



G LETTSOMIAN LECTURES. [lect. 

we may sometimes be able to strengthen the naturally weak 
digestion, though we can hardly expect to alter the natural 
constitution of the patient, so far as to enable a man who has 
naturally what is called "a weak stomach" to compete with one 
who has naturally got the digestion of an ostrich, at a civic feast 
or at a succession of private dinners. 

We have already compared the food by which man's activity 
is sustained to the fael which keeps up a firO; but this comparison 
is not altogether correct. For man is a complex machine, and 
not only must energy be supplied to the whole body in order to 
maintain its activity, but the different parts of his body are 
composed of different materials, and the wear and tear of each 
must be replaced by its approjDriate constituents. A steam-engine 
not only needs fuel to keep it going, but metal is required to 
replace the wear and tear of its parts, and oil to lessen the friction 
of the various parts upon one another. No doubt some of those 
various necessaries may be rejDlaced by others, and we might, for 
example, use oil instead of fuel; but this would be a w^asteful 
and expensive proceeding. 

Similarly, a mixture of foods is best adapted to supply the 
energy and repair the waste in the human body. Like the steam- 
engine, we require oils or fats; proteids, which go, in a great 
measure at least, to rej)air the wear and tear of the tissues ; and 
carbo-hydrates, which may be looked upon as, like coal, supplying 
energy to the organism by their combustion. These various kinds 
of food are required in different proportions. According to Ranke, 
about 100 grammes of proteids and a similar quantity of fats are 
required daily by a man, while two and a half times as much, that 
is, 250 grammes, of carbo-hydrates are necessary. 

Very few substances indeed will supply the requisite ingredients 
in proper proportion for the wants of the body, and so we usually 
employ a mixed diet. Black bread is one of the few which contains 
very nearly the proper proportion of nitrogenous and carbonaceous 
materials, and, when taken along with a little oil or a few 
olives, it may maintain a man in health and activity, without the 
addition of almost anything else except that of a little salt, 
as is seen amongst the hard-working peasantry in the south of 
France. 

In this country we have generally a more varied diet, and, as a 
typical meal, we may take a beefsteak with a bit of fat attached, 
a piece of bread, some salt, and water. The beefsteak supplies fat 



I.] TYPICAL MEAL— MOLECULAR DISINTEGRATION. 7 

and proteids, the bread supplies caibo-hydrates, and tlie salt and 
water make up the requisite constituents of food. 

But the beefsteak and bread cannot be absorbed in their solid 
condition, and unless they are absorbed, as I mentioned before, 
they are of no use to the body. Nor is it sufficient merely to 
reduce them to a minute state of subdivision, they must be 
dissolved. The salt which we eat with the beefsteak dissolves in 
the water without more ado ; but the beefsteak itself and the 
bread will not dissolve without first undergoing some change. 

In all processes of solution, the first thing to be done is, if 
possible, to get the substance which is to be dissolved into a state 
of minute subdivision. 

If we take coarse salt in large crystals it dissolves slowly as 
compared with table-salt in fine powder, and we accelerate its 
solution very much by breaking it up, and by stirring it through 
the water. If we allow it to remain at rest, the layer of water 
in contact with it soon becomes saturated, and the process of 
solution goes on slowly, wdiereas, by stirring, we brmg the particles 
of salt constantly into contact with unsaturated water, and thus 
solution goes on quickly. In the process of solution, the particles 
of salt become separated from each other by the water, but the 
process is a physical one ; each particle still continues to be salt, 
and if the water be removed by evaporation, the residue is salt 
just as it was at first. 

During digestion, a similar process occurs in the case of proteids 
and carbo-hydrates, but it is carried a step farther, jSTot only do 
the particles of proteids and carbo-hydrates become separated from 
one another by the water, but it penetrates into the chemical 
molecules of which they are composed, so that a chemical change 
of hydration occurs, and the large chemical molecules of the 
proteids and carbo-hydrates split asunder into smaller and simpler 
ones. 

In breaking down the beefsteak or the bread mechanically, we 
see that we are able to make the particles of which they consist 
smaller and smaller, until, perhaps, we may be barely able to see 
each particle Avith the naked eye. But the process of subdivision 
does not stop at the limits of our vision, nor even at the limits of 
our highest microscopic powers. In a perfect solution, the most 
powerful microscope will fail to discover any particle, and yet we 
are able by certain methods not only to show the presence of 
particles, but even to judge of their size. 



8 LETTSOMIAN LECTURES. [lect. 

We estimate tlie size of particles that ^ve can see, by the size of 
the mesh in the sieve through which they will pass, and, by a 
similar method, we are able to judge of the size of the molecules 
of chemical substances. 

Graham showed that some bodies will diffuse through an animal 
membrane, others will not. Those that diffuse are generally 
crystalline, those that do not diffuse are generally non-crystalline ; 
but it is probable that the connection between crystallisation and 
diffusion is to be regarded as accidental rather than necessary, and 
the real cause why some substances diffuse and others do not, is 
that the molecules composing them differ much in size. 

In experiments on diffusion through artificial membranes, Moritz 
Traube found that a membrane of tannate of gelatine would allow 
nitrate of barium with a molecular weight of 130.6 to diffuse 
through it, and would also allow the passage of all compounds 
having a smaller molecular weight, but it stopped the passage of 
ferrocyanide of potassium, having a molecular weight of 211.4.^ 

Membranes may thus be regarded as atomic sieves ; and if one 
substance will not diffuse through a membrane which will allow 
another to pass, we may consider that the molecules composing 
the substance which diffuses are smaller than those of the other. 
This view has an important bearing, as we shall afterwards see, 
on the causation of certain forms of albuminuria. It is supported, 
not only by the experiments of Traube on artificial membranes, but 
by the behaviour of hsemoglobin in regard to diffusion. 

Crystalline bodies are, as a rule, diffusable, but they are usually 
also of much lower molecular weight than organic uncrystalline 
bodies. There is one crystalline substance — haemoglobin — which 
will not diffuse, but it has a very high molecular weight, and 
probably the chemical molecules of which it consists are very 
large. 

In the process of hydration, the molecules of albumin and of 
starch do not split down all at once into the smallest molecules to 
which they may be ultimately reduced by the action of digestion. 
Between the large molecules, forming the myosin and starch of 
the beefsteak and bread, and the small ones of peptone and 
maltose into which they are transformed during digestion, there 
are a number of intermediate products. In these products, the 
molecules are probably of varying size, and they diffuse with 
various degrees of rapidity. 

1 Moritz Traube, Ccntralhlatt fiir die med. Wiss., 1866, p. 114. 



I.] PROCESSES OF DIGESTION. 9 

Thus t])e large molecule of starch breaks down, first into 
dextrine, and then into sugar. The large molecules of albuminous 
materials or proteids (including in tliis term ordinary albumen or 
white of egg., cooked meat, the casern of milk or cheese, and tlie 
vegetable casein of wheat or peas) break doAvn into intermediate 
substances termed antialbumose, hemialbuniose, antipeptone, and 
hemipeptone, before they are finally converted into peptones. 
There is less necessity for the molecules of fats to be broken down 
chemically, because, as we have seen, fats are absorbed even by 
the skin, and they seem to pass through the mucous membrane of 
the intestines, and become absorbed, even without decomposition. 
Their absorption is, however, aided by their being reduced to a 
fine state of subdivision or emulsion, and this minute subdivision 
occurs all the more readily by a partial decomposition into fatty 
acid and glycerine occurring in the digestive canal. The presence 
of a slight trace of fatty acid greatly aids the formation of an 
emulsion ; and, as we shall presently find, decomposition of fats, 
with liberation of fatty acid, does occur in the process of digestion. 

It may be worth while now to take a short surv'ey of the 
digestive processes, although time will not allow us to enter at 
all fully into them. 

These processes used formerly to be subdivided into {a) those 
of primary and (6) those of secondary digestion. Those of primary 
digestion are farther subdivided into — 

1. Mastication. 4. Gastric Digestion. 

2. Insalivation. 5. Intestinal Digestion. 

3. Deglutition. 6. Absorption. 

Those of secondary digestion may be subdivided into the changes 
unclergone by the products of primary digestion, in — 

1. The portal blood. 4. The general circulation. 

2. The liver. 5. The tissues. 

3. The lymphatic glands. 

The first part of the digestive process in man is a very important 
one, and one which does not receive anything like the amount of 
attention which it ought; it is the process of mastication. As 
I have already mentioned, whenever we wish to dissolve anything 
rapidly, we must comminute it finely. All the food should, there- 
fore, be thoroughly broken up in the mouth. Thorough mastication 
not only subdivides the food mechanically, but the saliva which 
is secreted under the two-fold stimulus of the taste of the food and 



10 LETTSOMIAN LECTURES. [lect. 

the movements of mastication tends to dissolve such parts of the 
food as are soluble in water, and to convert the insoluble parts into 
a pulp. At the same time, the diastatic ferment of human saliva 
begins to convert the starch of the food first into dextrin, and then 
into malt- sugar, or maltose. This conversion goes on very rapidly ; 
and if one chews a y^^cq of stale bread, even for a couple of 
minutes, a distinctly sweet taste will usually be perceived from 
the formation of sugar in the mouth. 

But the effects of mastication are not limited to the changes 
produced by it in the food within the buccal cavity; the taste 
of savoury meat, the rolling of a sweet morsel under the tongue, 
and the movements of mastication, exert an influence both on the 
stomach and on the brain. 

The effects on the stomach are shown by the observation of 
Richet, that, in a case of gastric fistula, where the oesophagus 
was completely occluded, mastication of food induced secretion of 
gastric juice, although nothing could jDass from the mouth into 
the stomach on account of the obstruction in the gullet. 

The effects of mastication on the nerve-centres are perhaps still 
more important. For it is obvious that the secretion, both of 
saliva and gastric juice, takes place reflexly through the medium 
of the nerves; and if the nervous system be dull or depressed, 
the stimulus of food in the mouth is not likely to excite secretion 
to the same extent as when the nerve-centres are active. 

But provision seems to have been made for this ; and the mere 
act of mastication not only supplies a stimulus to the peripheral 
ends of sensory nerves in the mouth, it leads to an increased 
supply of blood to the nerve-centres. This is well sho^vn by some 
observations of Marey, who found that the current of blood in 
the carotid artery of a horse became three times as rapid during 
^^^^^^^^^^^^^^^^^^^^^ mastication as it was before. 

^^^^^^^^HfflHM^|HBH ^^'^^^^^^^ supply of blood went 

^^^^^^^^JHIQH^H^^^S to the salivary glands and to 

^H^^^^^^|^^^^H|^^^^H the muscles of mastication; but 

^H|^^^^^BE|j|||9jj|Hf^^^^^| it is almost certain that a part 

^^SBBSI^^^SSSBBB^^^^L ^^ ^^ went also to the nerve- 
^. „ ^ . , , , . ' centres. Even if one should 

i'lg. 2. — 1 racing to show tlie increased ^ , n ,^ , 

rii.pidity of circulation in the carotid deny that any part ot the extra 
artery of a horse during mastication. current of blood in the carotid, 

which is consequent upon mastication, goes to the brain, the fact 



I.] STIMULANT EFFECT OF SUCTION. 11 

would still remain that tlie movements of rolling the morsels about 
in the month, and sucking their sweetness and savour, increases 
the cn-culation in the brain, for Salathe ^ has actually observed the 
fontanelles rise in a child durino- suction. 



7ig. 3. — Pulsations of tlie fontanelle (F) in an infant six weeks old while sucking. 
R slioAvs a simiiltaneous tracing of tl:e thoracic respiration. The breast was 
offered to the clrild at the beginning of the tracing. At the time indicated 
by the third respiratory wave, which has a flattened top, the i hild began to take 
the breast. It will be noticed that the line of the tracing F rises, indicating 
increased circulation on the brain. 

When the food has been thoroughly masticated, it is swallowed, 
and the act of swallowing sets in action a mechanism which is 
calculated to increase the blood-suppl}^ not only to the nerve- 
centres, but to all the glandular structures concerned in the 
digestive tract, Kronecker has discovered that the act of swallowing 
seems to remove entirely the inhibitory action of the vagus upon 
the heart, for the time being, so that the pulse becomes exceedingly 
rapid. The extent to which this occurs will hardly be credited by 
any one who has not tried the experiment. In my own case, I find 
that sipping half a wine-glass full of water will raise my pulse from 
76 to considerably over 100, So that, in fact, a glass of cold water, 
slowly sipped, will stimulate the heart as much, or more, as a glass 
of brandy swallowed at a draught. 

The stimulant effect of sucking is soon learned by children, and 
we see them console themselves, and raise their spirits, by sucking 
their thumb when they are depressed by being chidden, or by 
any childish misfortune ; in fact under conditions similar to those 
under which children of an older growth might keep their spirits 
up by pouring spirits down, A part of the stimulant effect of 
sucking is probably due to its action on the heart as well as to 
a stimulant action upon the cerebral circulation. 

When the food arrives in the stomach, it will, if mastication 
has been properly performed, and the digestive fluids have been 
1 Marey's Travau.^ for 1876, p. 354. 



12 LETTSOMIAN LECTURES. [lect. 

properly secreted, find a supply of gastric juice already in tlie 
stomach, and this will continue to increase in quantity during the 
progress of the meal. The alkaline saliva swallowed with the food 
will act as a further stimulus to the secretion of the acid gastric 
juice, but soon the quantity of acid will be sufficient not only to 
neutralise the alkali, but to leave a little acid over. The amount 
of free acidity is, however, very slight, because the hydrochloric 
acid which the gastric juice contains, combines, for the time being, 
with pepsin and pi'oteids, forming a compound which does not give 
an acid reaction. 

The starch which has begun to be converted into dextrin in the 
mouth, undergoes still further convereion by the saliva which has 
been swallowed. It has not yet been definitely settled whether 
or not the action of the saliva is so far arrested in the stomach 
as to prevent the formation of more sugar, but, at all events, it 
appears to be certain that dextrin is formed, and this is a fact 
of very considerable importance, as we shall see when we come to 
consider the order in which food is usually taken at meals. 

Albuminoids, or proteids, under the action of the gastric juice, 
swell up, and are more or less completely dissolved. The large 
and complicated molecules which compose them appear, as already 
mentioned, to be broken up into simjDle ones by a process of 
hydration. First of all, they appear to form a compound with acid, 
termed syntonin, or acid albumen. This is soluble in acid, but when 
the solution is neutralised the albuminoid is again precipitated. 
The next stage appears to be the formation of a body known as 
pro-peptone, hemi-albumj"nose, or parapeptone. This body is not 
coagulated by heat, and is soluble in water in the presence of weak 
acids or alkalies. It is precipitated by nitric acid, but when the 
mixture is heated it dissolves, and a precipitate forms again on 
cooling. This reaction is important, because it is used to detect 
hemi-albuminose when this substance appears in the urine, as 
it sometimes does. 

The last stage is the formation of true peptones, which are not 
coagulated by boiling, nor by nitric acid, nor by acetic acid and 
potassium-ferrocyanide. They diffuse very easily through animal 
membranes, and in this respect they differ very greatly from other 
forms of albumen. By dissolving albuminous substances in artificial 
gastric juice outside the body, we can produce peptones, and these 
are sometimes of great service as nutrients in disease. We almost 
always notice that the product of such artificial digestion has a 



1.] rEPTOTOXINE. 13 

disagreeable bitter taste. The cause of this bitterness has not yet 
been thoroughly investigated. We know, however, that amongst 
the strongest bitters with which we are acquainted are some of the 
organic alkaloids ; for example, strychnine, the bitterness of which 
can be perceived in extremely dilute solutions. Now, the org?aiic 
alkaloids are, to a certain extent, related to albumen, inasmuch as 
they both belong to the aromatic series of organic compounds, and 
several alkaloids have been obtained from decomposing albumen. 
To these alkaloids the name of ptomaines has been given. This 
relationship between alkaloids and albuminous substances v/ould 
tdmost lead us to suspect that the bitterness developed during 
gastric digestion might be due to the formation of an alkaloid. 
As I have already said, it is not certain that this bitter substance 
is an alkaloid, but it is certain that an alkaloid has been obtained 
by Brieger from peptones formed by gastric digestion. By extracting 
a quantity of gastric peptones with amylic alcohol, he obtained an 
alkaloid free from peptones which had an action like that of curara. 
To this alkaloid he has given the name of peiDtotoxine. 

Every effect has got a cause, if we can only find it out ; but we 
not unfrequently ascribe effects to the Avrong causes, and perhaps 
this may be the case with regard to the activit}^ of the pylorus. 
While the food remains in the stomach, it is mixed up thoroughly 
with the gastric juice by a sort of churning movement of the 
gastric walls of the stomach, the pylorus remaining contracted, 
so as to prevent the gastric contents from escaping in any large 
quantity into the duodenum. 

At the end of three or four hours, however, the pylorus relaxes, 
and the chyme escapes out of the stomach into the duodenum. 
This alteration in the behaviour of the pylorus, at the end of a 
certain time, has been ascribed to the increasing acidity of the 
chyme ; but this seems a little doubtful, inasmuch as we frequently 
notice cases of abnormal acidity, where the food is retained in the 
stomach for an excessive time, instead of being passed on too 
rapidly to the intestines. This is a point upon which we are 
at present quite unable to speak with any certainty; but the 
discovery that an alkaloid is formed during the process of dioestion 
in the stomach opens up a new field of inquiry, and may lead us 
to ask whether the different behaviour of the stomach, at the end 
of three or four hours, is not partly due to the action of this alkaloid 
upon it, though no doubt the simplest explanation is, that it is 
merely a rhythmical function like sleep or waking. 



U LETTSOMIAN LECTURES. [lect. 

During the process of digestion in the stomach, fats become 
partially decomposed, and a small quantity of fatty acids are 
formed, which aid in emulsifying the remainder of the fat. 

When the chyme passes through the pyloric orifice into the 
duodenum, it meets with the bile and the pancreatic juice. These 
neutralise the acid chyme, and render it alkaline. The further 
action of pepsin is thus prevented, and the albuminous substances, 
which have only been converted into syntonin, or acid albumen, 
are precipitated. The pancreatic secretion is the most energetic 
and general in its action of all the digestive juices : it unites in 
itself the action of the saliva and the gastric juices, besides having 
properties of its own. Like the saliva, it converts starch into dextrin 
and sugar, and it finishes the work which the saliva had begun. 

Like the gastric juice, it dissolves albuminous bodies, forming 
peptones, though it does not dissolve them in quite the same way. 
The gastric juice causes them to swell up before they dissolve. 
The pancreatic juice attacks them from the outside, and makes 
them crumble away. We do not yet know whether there is any 
distinct difference between the peptones formed by the action of 
the pancreatic and gastric juices, but it seems not at all improbable 
that differences should exist. 

In addition to its action on starch and albuminoids, the pan- 
creatic juice emulsifies fats, and tends to split them up into fatty 
acids and glycerine. 

This emulsifying action is aided by the bile, which appears to 
have a considerable power to facilitate the passage of fat through 
animal membranes. This can be readily shown by trymg to make 
oil pass through an animal membrane wetted with water, and 
another similar one wetted with bile. The oil will pass through 
the latter much more readily than the former. The action of bile 
in dissolving fats is indeed popularly known, and it is used for 
removing oil-stains from articles of furniture. In an examination 
on physiology some years ago at South Kensington, the question 
was put, "Where is bile formed, and what are its uses?" One 
candidate's answer was, " Bile is formed in the stomach, and is used 
for cleaning carpets." The knowledge of physiology displayed by 
this student was somewhat inaccurate, to say the least of it; but 
his answer may Serve to impress upon our memories the fact that 
bile has the power not only of removing stains of grease from the 
surface of vegetable fabrics like carpets, but of enabling oil to pass 
through animal tissues, such as mucous membranes. 



1.] PUTREFACTION IN THE INTESTINE. 15 

But tlie bile has another very important function : it tends to 
prevent putrefaction. Now the minute vegetable organisms which 
give rise to putrefaction are to be found almost everywhere ; and 
they pass into the intestine with our food and drink. The healthy 
stomach, with its acid secretions, does not afford them a suitable 
nidus, but the products of pancreatic digestion seem to form a soil 
especially favourable to their development. If we digest a piece 
of meat with pancreas for twenty-four hours at the temperature 
of the body, we usually find that not only has the meat become 
dissolved, and peptones formed, but that the peptones themselves 
have undergone a further decomposition, and that leucin, tyrosin, 
naphthilamine, and a substance termed indol, nearly allied to 
iudio-o, but with an abominable smell, have been formed, Indol 
IS not a product of the decomposition of nitrogenous matter by 
the pancreatic ferment ; it is due to decomposition caused by 
the presence of putrefactive bacteria. 

The same changes which occur in pancreatic digestion outside 
tbe body may, and sometimes do, occur inside the body. In 
health, their occurrence is probably rather the exception than the 
rule ; but, were it not for the antiseptic action of the bile, their 
occurrence would probably be the rule, and not the exception. It 
may seem, perhaps, to some persons that the occurrence of putre- 
faction is of no great consequence ; but when we remember that 
during putrefaction, organic alkaloids which have a poisonous 
action are formed in the body, it is evident that, if putrefaction 
takes place to any great extent in the intestine, there may be a 
risk of actual poisoning by the absorption of organic alkaloids 
formed in the intestinal canal. 

From the duodenum onwards to the rectum, the reaction of the 
intestinal contents remains alkaline, and so there is nothing to 
arrest the further action of the pancreatic ferments. The action 
of the intestinal juice on the food is not as yet perfectly under- 
stood, and various conflicting statements have been made regarding 
it. One reason of this conflict probably is, that the action of the 
intestinal juice has been tested upon the raw constituents of the 
food, and not upon foods which have alread}'" been altered by 
exposure to the action of the gastric and pancreatic juices. The 
intestinal juice is said to have no action on coagulated albumen, 
and this appears to be the case ; but when I was working in his 
laboratory at Amsterdam, Professor Kiihne informed me that in- 
testinal juice would dissolve coagulated fibrine, which had been 



IG LETTSOMIAN LECTURES. [lect. 

previously rendered soluble, but not peptonised, by pancreatic 
juice. 

As tlie food passes through the large and small intestine, those 
portions of it which have been rendered soluble by digestion are 
gradually absorbed by the veins and lymphatics, and carried into 
the general circulation. 

Almost immediately after entering the blood-vessels, changes 
appear to occur in the peptones. These appear to be taken up, 
to a great extent, by the red blood-corpuscles, and converted by 
dehydration into a larger and more complicated albuminous mole- 
cule, namely, that of globulin. The blood-corpuscles thus form, as 
it were, a store of albuminous material, which they convey to all 
parts of the body, and give off where it is wanted.-^ 

But the whole of the peptones do not appear to undergo this 
change ; part of them appear to be arrested in the liver, and to 
form glycogen, as it has been found that the quantity of glycogen 
in this organ is increased by the injection of pej)tones into the 
bowel.^ 

The sugar also becomes dehydrated, and glycogen is produced 
from it likewise. This is stored up in the liver for a variable time, 
and then gradually given out again to supply the wants of the 
oi-ganism. The liver, therefore, acts as a wise steward, laying by 
provision for the organism in the times of plenty after a full meal, 
and giving it out again in times of fasting. 

But this is not all. The liver acts not only as a wise steward 
but as a watchful porter. We know that one of the most striking 
points in the action of such powerful poisons as the Tenom of 
vipers and curara is that, though so deadly when injected into a 
%vound, they are almost completely innocuous when swallowed. We 
know that one reason of this is, that they reach the general circu- 
lation much more slowly from the intestine than from the wound, 
so that the kidneys have time to excrete them, and prevent their 
accumulating in the blood. It is the liver which is the chief a^ent 
in retarding the absorption of poisons into the blood, and thus 
rendering them comparatively innocuous when they are introduced 
into the intestinal canal. All the blood from the stomach and 
intestines must pass through the portal vein before it can reach 
the general circulation ; and, as our forefathers recognised by the 
name they gave to the porta or gate of the liver, the hepatic 

^ G. Fano. Lo Sperimentale. Settembre e Ottobre, 1882. 
2 Seegen Pfliiger's Archiv. xxviii. p. 99. 



!•] 



THE LIVER AS A GATEKEEPER. 



17 



tissue acts the part of a prudent porter at the gate, and turns 
back or destroys dangerous intruders. Poisons injected into the 
duodenum are absorbed into the portal vein; but they are 
removed from the blood by the secreting tissue of the liver, and 
poured back again with the bile into the intestinal canal. Again, 
they undergo reabsorption, and round and round they may go 
in a circle, from intestine to liver, and from liver to intestine 
again, without ever being able to pass into the general circu- 
lation, or produce any direct effect upon heart, lung, brain, or 
kidneys (p. 41). 



Liver ivith blJo 
duct passing to 
the duodcinim. 



Fortal vein 



Mesenteric veins. .. 




Fig. 4. — Enterohepatic circulation. The broken line ■ 
and le-excretion of bile. 



Stomacli. 



Small Intestine. 



Large Intestine. 



shows the absorption 



But even this is not all. The liver actually destroys some 
organic poisons, such as nicotine ; and, were it not for the faithful 
performance of its duty, we would be in danger of poisoning by 
every meal we take. For Ludwig and Schmidt-Miilheim have 
found that peptones, when injected into the general circulation, act 
as poisons, producing loss of coftgulability in the blood and great 
depression of the circulation. We see, then, that the products 
even of healthy digestion might prove fatal if they passed rapidly 
into the general circulation ; and it is still more likely that such 
an effect would follow the absorption of the products of the putre- 
faction which occurs in cases of indigestion. Were it not for this 
power of the liver to obstruct the passage of poisons, and actually 
to destroy them, the alkaloids formed either by normal digestion 
or by abnormal putrefactive process in tlie intestine might readily 



18 LETTSOMIAN LECTURES. [lect. 

pass to the heart, nervous system, and kidneys, and cause 
dangerous or fatal consequences. 

The function of watching over the safety of the organism is not 
confined, however, to the liver, but is shared by other organs. The 
liver acts as a porter to prevent injurious substances passing from the 
intestine into the blood, but the tongue and palate are the porters, 
which prevent obnoxious substances from being taken into the 
intestinal canal. As a general rule, though by no means without 
exception, substances pleasing to the palate are useful and not 
injurious to the organism. 

The nerves of taste, like those of sight and hearing, are nerves of 
special sense, and are capable of education. But, while we usually 
regard the education of the senses of sight and hearing as a noble 
thing, we are too careless of the education of our taste, and look 
upon it rather as something degrading. 

Yet the education of the nerves of taste should be considered in 
the same light as that of the other special senses ; and cookery has, 
I think, a perfect right to be ranked with music, painting, sculpture, 
and architecture as one of the fine arts. The difference between 
cookery and music, or painting, is, that while the objects which 
give rise to sight and sound remain outside the body, we are 
oblio;ed to swallow the substances which excite sensations in our 
nerves of taste. It is not quite sufficient to turn them over in the 
mouth and put them out again, because the full sensation is only 
obtained just in the act of swallowing. For this reason devotees to 
the art of cookery must either be content with a moderate enjoy- 
ment of the pleasures of taste, or consent, like some of the Roman 
emperors of old or German students of the present day, to eject 
again the food or drink which they have already taken and enjoyed. 

Only rarely does one meet with a dinner which gives one the 
sense of high artistic perfection, although I remember having 
partaken of one such when enjoying the hospitality of a City 
company. Each course seemed to excite an appetite for the one 
which succeeded, and was accompanied by a wine so carefully 
selected that it gave zest to the food, while the food appeared to 
give additional flavour to the wine. 

This dinner was a revelation to me ; it not only showed me that 
cookery might rank as one of the fine arts, but taught me that it 
might be a powerful moral agent. I went to the dinner exhausted 
with overwork, irritable in temper, and believing that City companies 
were wasteful bodies, who squandered money that might be 



r.] " CITY DINNERS. 10 

employed for useful purposes, and that they should be abolished ; 
I came away feeling strong and well, with an angelic temper, and 
firmly convinced that Cit}'' companies had been established for the 
express purjaose of giving dinners, and ought, oa no account to be 
interfered with. IS' or was the good thus effected of a transitory 
nature; the irritability of temper, which had disappeared in the 
course of dinner, did not return ; and the morning afterwards, 
instead of awaking with headache and depression, I awoke stroug, 
well, and ready for w^ork, and remained so for a considerable length 
of time. Nor do I think that mine is a solitary case. A succession 
of heavy dinners is, no doubt, injurious; but when the organism is 
exhausted, a good dinner, with abundance of wine, is sometimes of 
the greatest possible use. But there is one condition which must 
not be neglected, or otherwise the consequences will be anything 
but satisfactory : the dinner must be well cooked, and the wines 
must be thoroughly good. 

Jt is, as 1 have said, only occasionally that one meets with real 
high artistic cookery. But, even in the courses of an ordinary 
dinnerj an order is adopted which is thoroughly physiological, and 
which shows that, whatever men may be in other things, they are 
not " mostly fools " in regard to the plan of their meals. 

The common order of courses in a plain dinner is soup, fish, joint, 
pudding, bread and cheese, and dessert. The reason why soup 
comes first has been admirably shown by Schiff in his experiments 
on digestion. This physiologist found that the stomach of an 
animal wdiich some time before had digested a full meal, hsA very 
little power to digest albumen introduced directly into it; and a 
similar fact w^as ascertained in regard to an extract made from the 
stomach itself, this extract hardly acting on albumen at all. The 
stomach seemed to be exhausted by the efi"ort of digesting a full 
meal several hours before, and to be incapable of producing pepsine. 
But if certain substances were introduced first into the stomach, the 
power to digest albumen was enormously increased. To these 
substances Schiff gave the name, of "peptogens," and the most 
powerful of them he found to be dextrin, and soup made from meat. 

If the human stomach resembles the stomachs of animals in this 
point as it does in others, then we may say that usually the power 
of the stomach to digest such substances as hard-boiled eggs or 
boiled meat, when these are taken alone, will be very slight. But 
if the meal be begun with a plate of soup and a piece of bread, the 
bread which will be partly converted into dextrin in the mouth, 

c 2 



20 LETTSOMTAN LECTURES. [lect. 

and the extractive matters of meat contained in the soup, on 
reaching the stomach will be absorbed, and will supply to the 
gastric follicles the power to secrete an abundance of pepsine. In 
this country, where our butcher's meat is tender and juicy, we not 
unfrequently find that people in the middle of the day will take a 
beefsteak or a mutton-chop without soup. 

In this case, the savoury soluble substances which the meat 
contains are quickly extracted from it in the stomach itself, and, 
being absorbed, supply the necessary secreting power to the gastric 
glands. But in other countries, where the animals slaughtered for 
food are often old and tough oxen, which have been employed for 
years in agricultural service, the meat, being less savoury and juicy, 
will not yield peptogenic matters so readily to the stomach. Con- 
sequently, the Frenchman generally boils his butcher's meat 
thoroughly, and adds pieces of bread to the soup with which he 
begins his meal, so that the stomach can absorb sufficient peptogenic 
substance before the hard and tasteless boiled beef is swallowed. 

Next to the soup, as I have said, usually comes fish, which is 
digested more easily than butcher-meat. I have already mentioned, 
more than once, that the rapidity with which anything dissolves 
depends very much on the fineness with which it is divided. Now, 
this is quite true of the different kinds of meat. Beef is acknow- 
ledged to be less digestible than mutton, and mutton less digestible 
than fish. The breast of a chicken is also reckoned very digestible. 
If we compare these different kinds of flesh, we will find that in 
beef the fibres are longer and harder than those of mutton, and 
those of mutton longer and harder than those of the breast of 
a fowl. The muscle-fibres in fish are arrayed in flaky masses, 
and are not only very short, but are very readily separated from . 
one another. . 

We see, then, that the different digestibility of different kinds 
of meat corresponds exactly to the readiness with which their 
muscle-fibres can be broken up mechanically. That it is the 
physical conformation of the muscle-fibres, rather than anything 
peculiar to the animal from which they are derived, is shown, I 
think, by the fact that, although the breast of fowls is universally 
acknowledged to be readily digestible, the legs, in which the 
muscular fibres are long and hard, are by no means specially 
adapted for weak digestions. 

With the meat, come vegetables, which are not only useful as 
supplying inorganic salts, but probably play a considerable part in 



I.] COURSES AT MEALS— STIMULANTS. 21 

aiding the recomposition of peptones into the albuminous material 
of the tissues, after their absorption. 

After the meat come the bread, cheese, and dessert. The bread 
will, no doubt, supply additional dextrin, and the cheese additional 
albuminoids ; but, if we direct our attention only to the stomach, 
and to the chemical changes wliich are going on in it, it is not quite 
easy to see why bread, cheese, and dessert should be taken at the 
end of dinner. If we turn our attention, however, to the circulation 
and the nervous system, and remember the effect which I have 
already mentioned as produced upon them by the mastication and 
deglutition of savoury food, we can at once see a good reason for 
the common manner of terminating a dinner. In order to supply 
abundant gastric juice for tbe digestion of the food introduced into 
it, the stomach rec^uires an abundant supply of blood, and the nervous 
system must be kept active in order to respond to the calls made 
upon it. The savoury cheese, swallowed in small morsels, and the 
sweet fruits, which strongly stimulate the nerves of taste, or nuts, 
which require considerable mastication, cause an abundant flow 
of blood to the nerve-centres ; while the frequent movements of 
swallowing stimulate the hearty and increase the rapidity of the 
general circulation. 

In the case of ordinary meals taken by a healthy man, the food 
is C|uite sufficient to stimulate the various parts of the digestive 
canal, the nervous system, and the circulation sufficiently to insure 
complete digestion. But'if the meal be more than ordinarily heavy, 
if the person be exhausted by long fasting, by severe exertion, or 
have a weak digestion, other aid must be invoked. One of the 
most powerful stimulants, both to secretion and the circulation, is 
alcohol ; and we find that persons of weak digestion sometimes 
take sherry and bitters before a meal, or take a glass, of sherry with 
their soup. During the course of a meal, an effervescent wine like 
champagne is taken, the carbonic acid of which will stimulate 
absorption, while at the end a pow^erful stimulus is apjilied in the 
shape of a small glass of brandy or liqueur ; and during dessert 
a quantity of wine is sipped, so that the effects already mentioned 
of the sipping upon the circulation and nervous system are 
combined with the action of the alcohol and ethers contained 
in the wine. 

Provided that all those parts of a meal have been taken in 
moderation — and when we speak of moderation, we must always 
remember that this is a relative term : what is moderation for a 



22 LETTSOMIAN LECTURES. [lect. i. 

man of strong digestion is excess for a man of weak digestion — ■ 
provided, then, that moderation has been exercised, no harm will 
result even from a heavy meal. But if the food has been excessive 
in quantity, or injurious in quality, and more especially if alcoholic 
stimulants have been taken in excess, the stomach will suffer, and, 
next day, the symptoms of gastric indigestion will probably appear. 
The most marked of these are : loaded tongue, loss of appetite, 
tendency to nausea, and, perliaps, even vomiting. The condition of 
the stomach, corresponding to these symptoms, was ascertained by 
Dr. Beaumont in the case of Alexis St. Martin. On looking into 
the interior of St. Martin's stomach, during the occurrence of such 
symptoms as these. Dr. Beaumont found " that several red spots 
and patches abraded of the mucous coat, tender and irritable, 
appeared over the inner surface." In such congested and irritable 
conditions of the stomach, the gastric juice secreted appears to have 
an alkaline, rather than an acid, reaction, and consequently to have 
comparatively little or no digestive power. The food will, therefore, 
pass from the stomach, not in the form of a fine emulsion, like 
chyme, but with undigested lumjDS in it, and these, irritating the 
intestine, will be not unlikely to produce diarrhoea ; moreover, the 
intestine itself may also suffer by extension of the inflammatory 
condition, from the stomach along the mucous membrane. Then 
we notice, in addition to the sickness and nausea, those symptoms 
to which the term of biliousness is applied. The person is dull, 
heavy, and languid, disinclined to exertion, mental or bodily, 
irritable, or peevish, the complexion is muddy, and the conjunctiva 
is slightly yellowish, and perhaps there is more or less severe 
headache. All of these point to disturbance of the functions of the 
liver ; but biliousness forms an intermediate link between indi- 
gestion and its consequences, so that the explanation of the different 
factors of biliousness must be reserved for the succeeding lecture. 



LECTURE II. 

INDIGESTION, BILIOUSNESS, AND THEIR CONSEQUENCES. 

Delivered hcfore th-c Medical Society of London, January \Wi, 1885. 

Biliousness and indigestion are terms which we use so frequently- 
together, and which are so intimately connected, that we do not 
always sufficiently distinguish between them. Yet it may be 
worth our while to inquire where the one begins and the other 
ends, and to ascertain, if we can, what the nature of their con- 
nection is. 

The condition which we term biliousness is, in all probability, of 
complex origin. Its name points to the liver as its source, while 
its close connection with disturbances of the stomach might lead 
us to ascribe a gastric origin to it. The difficulty we have in 
ascertaining the exact causation of biliousness is no doubt largely 
due to the fact that disturbance of the liver affects the stomach 
and intestines, and disturbance of the stomach and intestines affects 
the liver. Indigestion and biliousness are, therefore, so closely 
associated in many cases, that we can hardly say where the mischief 
began unless we can trace it from the commencement, although in 
other cases we get a clue to the primary origin of the disease by 
noticing whether the disturbance of function is greater in the 
stomach or in the liver. 

The close connection between the liver, on the one hand, and 
the stomach and intestines, on the other, is rendered inevitable by 
the arrangement of the blood-vessels in them. 

On looking at the liver, on the one hand, we see that, with the 
exception of a small quantity which passes through collateral 
branches, all the venous blood returning from the stomach and 
intestines must pass through the liver before it reaches the general 



24 



LETTSOMIAN LECTURES. 



[lect. 



circulation (Fig. 4). Thus, any products of imperfect digestion are 
likely to affect the hepatic functions, and not improbably to derange 
them. 

On looking at the stomach and intestines, on the other hand, we 
see that any hindrance to the flow of the portal blood through the 
liver will tend to cause venous congestion in them. 



Lungs. 



Veiiis from the 
Stomach. 

Veins from the 
Intestines. 



Vena Cava. 
Superior Hcemor- 
rhoidal Vein. 
Middle and Infe- 
rior Hccmorrhoidal 
Veins. 




Arlerics to the Brain. 



Aorta. 

Arteries to the 
Stomach. 



Arteries to the Small 
Intestine. 

Arteries to the Large 

Intestine. 
Kidney. 



ffcemorrhoidal 

Plexus. 
Ureter, 



Bectum and Hcemorrhoidal 
Plexus. 

Fig. 5. — Diagram of tlie veins forming part of the portal circulation. The pancreatic 
and splenic veins, although most important, have been omitted for the sake of 
clearness. 

On looking at the liver in a post mortem examination, it seems 
so hard and firm that we are apt to think that it is not capable of 
much dilatation and contraction in the living body. But this 
notion is perfectly erroneous. I have made a number of experi- 
ments on the artificial circulation of blood throucrh the livers of 



11.] 



SFONGINi:SS OF THE LIVER. 



25 



rabbits, and have been quite astonished to find what an elastic 
organ the liver is. When the bottle containing the blood was 
raised two or three feet above the liver, so as to increase the 



Buttle contcdning 

Blood. 




Liver. 

. Cannula for Outflow 
of Blood. 

Fig. 6. — Diagvnm to sliow the effect of artificial circulation of blood through the 
liver, under different pressures. The continuous lines indicate the size of the 
liver, and the arrangement of the apparatus during circulation, under a low 
pressure. The dotted lines indicate the increased size of the liver, and the 
arrangement of the apparatus, with a high pressure. 

pressure under which the blood flowed through it, the organ 
expanded almost like a sponge, and again contracted when the 
pressure was diminished. We do not usually notice any very 
great differences of size in healthy livers ; but the reason of this, 
no doubt, is that the pressure of blood in the portal vein is very 
low, and not liable to great fluctuations. 

But there was another point which struck me greatly in my 
experiments. Sometimes the blood would flow very easily through 
the liver, would, indeed, pour out from the hepatic vein in a full 
stream, as if no obstacle whatever had been presented to its flow 
through the hepatic capillaries. At other times, however, the flow 
would be slow and scanty, the blood evidently meeting with great 
resistance in the capillaries. These two conditions were sometimes 
found in the same liver at different periods of the experiment, and 
they appeared to depend to a considerable extent upon the quality 
of the blood which was circulating. 

Bearing in mind this power of the liver to obstruct the circula- 
tion through it, we can readily see how a vicious circle may be 
formed : indiscretion in eating or drinking disturbs the digestive 
processes in the stomach and intestines ; the products of imperfect 
digestion or of decomposition in the intestine being absorbed into 
the veins pass to the liver ; they may there induce an obstructed 
flow through the hepatic capillaries ; the venous blood returning 



26 LETTSOMIAN LECTURES. [lect. 

from tlie stomach and intestines will no longer be able to find an 
easy passage into the general circulation, and venous congestion 
of the stomach and intestines will be the result. Such venous 
engorgement as this will interfere with gastric and intestinal 
digestion, and this again will react upon the liver. Here, then, is 
a vicious circle which it is necessary to break. It may be broken 
in two ways : (1) by fasting, so as to allow time for matters to 
right themselves; or (2) by the use of medicines, as we shall 
afterwards see. 

In order to form a clearer idea of what is actually going on in 
biliousness, it may be well to take advantage of that fortunate 
accident by which Dr. Beaumont was enabled to examine the 
interior of Alexis St, Martin's stomach, and discover what was 
going on there. Although some authorities have denied that the 
state of the tongue is any index of the condition of the stomach, 
this is not borne out by Dr. Beaumont's observations, for he found 
that the state of the two corresponded pretty closely. A healthy 
tongue is of a j)ink colour, it is very slightly rough, and its surface 
is moist. The mucous membrane of a healthy stomach is of a pale 
pink colour, it lias a slightly rough velvety appearance, and its 
surface is merely lubricated by a thin layer of mucus. When it is 
stimulated by the ingestion of food, the vessels dilate, the colour 
becomes heightened, and the gastric follicles secrete a clear 
transparent juice, which goes on accumulating, and trickles down 
the sides of the stomach. From experiments upon animals we 
know what changes irritation of the gastric mucous membrane 
will produce. A slight stimuhis, as already mentioned, causes the 
circulation in the mucous membrane to become increased, and 
gastric juice to be abundantly secreted. This effect may be 
produced not only by the ingestion of food, but ^-Iso, though to a 
slighter and more limited extent, by gently rubbing with a glass 
rod or feather. But if the stimulus be excessive, e. g. if the rod be 
rubbed roughly instead of gently over the mucous surface, an 
entirely different result occurs; the vessels, instead of dilating, 
contract, the stomach becomes paler, and a quantity of mucus is 
secreted. If irritation be carried still further, the animal shoA^s 
signs of nausea, and may actually vomit. 

In indigestion and biliousness we find several stages upon which 
the experiments just mentioned throw considerable light. In the 
first the appetite is increased rather than diminished ; in the next 
stage the appetite fails ; and in the further stage nausea or vomiting 



II.] INDIGESTION AND BILIOUSNESS. 27 

occurs. Even in the first stage, however, it not unfrequently 
happens that though the appetite is craving at first, a few mouth- 
fuls of food are sufficient to satisfy it, and sometimes the appetite 
disappears merely at the sight of food, and is succeeded by nausea. 
In this case it is evident that the increased circulation in the 
stomach due to the introduction into it of food, or perhaps of the 
saliva excited by the expectation of food, has caused the condition 
of the mucous membrane to j)ass from the stage of slight to that of 
violent irritation. 

Let us now see what conditions of the stomach correspond to 
these symptoms. Dr. Beaumont mentions that on one occasion 
St. Martin's tongue had a thin whitish fur, and the appetite was 
craving. On examining the stomach, several red spots and patches 
abraded of the mucous coat, tender and irritable, appeared spread 
over the surface. The digestion, too, was slower than usual, and 
seven hours were required for the gastric digestion of his dinner, 
instead of four and a half or five hours as usual. In this condition 
we cannot say that the liver is involved. The stomach is the only 
organ affected, and the disturbances of its functions are as yet but 
slight. Here we may say there is indigestion but not biliousness. 

Two days afterwards, the indigestion had advanced further and 
tlie symptoms of biliousness had become superadded. His usual 
appetite was gone, the tongue was covered with a thin coat, no 
longer whitish but yellowish, the countenance was sallow, and on 
the interior of the stomach there were several deep red patches. 
A muslin bag which had been introduced with some food in order 
to test the rapidity of digestion, when drawn out was covered with 
a coat of mucus and yellow bile. The sallowness of the face, 
which had now appeared, may be taken as an indication that 
the liver had become affected, and that biliousness as well as 
indigestion was now present. 

On the succeeding day the coats of the stomach were still 
unhealthy and of deeper red than naturally, with patches of a still 
deeper colour, and the mucous covering abraded in places. This 
deep colour indicates venous congestion and stagnation of blood, 
and is as different from the increased rosiness consequent upon the 
arterial dilatation and rapid circulation in healthy digestion, as the 
dusky hue in mitral disease is from the rosy flush of healthy 
exercise. This venous congestion indicates, I think, that the 
liver circulation is already becoming impeded, and that the 
impeded circulation thi'ough it is beginning to tell on the venous 



28 LETTSOMIAN LECTURES. [lkct. 

radicles of the portal system in the stomach, and probably also in 
the intestines. At this time the secretion of gastric juice was 
very scanty, and the digestion slower, as well as less perfect 
than usual. 

In this instance, the indigestion seems to begin in the stomach, 
and involve the liver secondarily; but I am inclined to think, 
although it is difficult to prove, that there are some instances in 
which the indigestion may begin in the liver, and involve the 
stomach secondarily. Such cases I think are met with amongst 
persons who suffer from malaria. The malarial poison, whether it 
be a bacillus or not, appears to have a particular power to affect 
the liver, spleen, and va so-motor centres. Under its action, the 
liver may sometimes swell up enormously, and I am inclined to 
think that it frequently causes an obstruction to the portal 
circulation, even when the general circulation is unaffected. In 
such cases, we may expect to find such symjjtoms of indigestion 
as would be likely to occur from venous congestion; and this I 
think is actually the case. 

The usual symptoms of indigestion are flatulence, weight in the 
epigastrium, acidity, and pain ; and it may be worth while to try 
and ascertain the conditions to which each of those symptoms 
is due. 

First of all, let me take flatulence. Flatulence is due to the 
presence of gas in the stomach and intestines, which sometimes 
rolls about, producing borborygmi, or escapes upwards or down- 
wards, producing eructations or crepitations. If the pyloric orifice 
be closed, the gas from the intestine will not escape into the 
stomach, nor gas from the stomach into the intestine ; but if the 
pylorus be open, gas may pass freely from the stomach into the 
intestine, and vice versa. An analysis of gas from the stomach 
shows that it consists to a great extent of nitrogen and carbonic 
acid, in much the same proportion as the nitrogen and oxygen of 
air. It is therefore probable that most of the gas in the stomach 
consists simply of air which has been swallowed, but from which 
the oxygen has been absorbed into the blood, and has been 
replaced by a corresponding quantity of carbonic acid. We are 
very apt to forget that, although the mucous membranes in man 
are much specialised, so as to perform a particular function most 
efficiently, yet their power is not entirely limited to the one func- 
tion. The diffusion of oxygen and carbonic acid just mentioned 
through the walls of the stomach, shows us that the gastric mucous 



II.] CAUSES OF FLATULENCE. 29 

membrane lias, though to a very slight extent, a respiratory 
action ; and it is possible that other gases may be absorbed, though 
to a slight extent, by the gastro-intestinal mucous membrane. 
Indeed, 1 need not say it is probable, because we know for a fact 
that sulphuretted hydrogen may be absorbed in this manner. 
Some authors consider that the gastro-intestinal mucous membrane 
may secrete gas in large quantities. However this may be — and I 
think that it does not occur very frequently — it is probable that 
an interference with the absorption of gases may be a not 
unfrequent cause of flatulence. 

In patients who suffer from malaria, attacks of indigestion are 
sometimes preceded, for two or three days, by a tendency to 
flatulence, without any other symptom. This may simply be due 
to disturbance of the stomach and intestines alone; but still I am 
inclined to think that, in these cases, the disorder begins in the 
liver, and not in the stomach ; the portal circulation becoming 
obstructed first, and the oastric mucous membrane becomino^ 
congested secondarily. 

After violent exertion, such as quickly running upstairs or 
trying to catch a train, one may observe that, at the same time 
that the heart is pa,lpitating raj)idly, and the breathing becoming- 
short and difficult, there is a great tendency to flatulence. A 
similar condition is also found in j)atients with cardiac disease, and 
my friend Dr. Mitchell Bruce has called my attention to the 
frequency with which such patients complain of " heart- wind." 

Another source of flatulence is the gas given off from the food in 
abnormal processes of decomposition. In cases of chronic gastric 
catarrh, for example, the secretion of gastric juice in the stomach 
is deficient ; the food is digested slowly ; the secretion, instead of 
being acid, is nearly neutral, or perhaps even alkaline; and 
fermentation may occur with evolution of gas. It is evident, 
however, that a considerable time is required to allow gas to be 
formed in any large quantity in the stomach: and therefore 
flatulence from this cause will not occur until some time after 
food has been taken, unless the pyloric sphincter be inactive. If 
the pylorus be open, gas may pass from the intestines into the 
stomach, and distend it; and such distension may occur at any 
time of the day or night, and is not necessarily dependent on the 
decomposition of food in the stomach. 

I am inclined to think, however, that the most frequent cause of 
flatulence in the stomach is excessive swallowing of air. There is 



30 LETTSOMIAN LECTURES. [lect. 

little doutt that boluses of food may be swallowed without air ; but 
some fluids, especially those of a tenacious character, such as pea- 
soup and saliva, appear to carry down a good deal. Moreover, it 
appears to me that, when a small quantity of saliva is swallowed 
at a time, it does not completely fill the pharyngeal cavity, and that 
air is actually swallowed along with it. This does not matter — 
probably it is even beneficial — if it be not carried on to too great an 
extent. But we can easily see that, if a person goes on swallowing 
air after a meal is over, or in the intervals between meals, flatulent 
distension of the stomach may readily be produced. The conditions 
which give rise to frequent swallowing of air, so far as my 
observation goes, are — (1) a continued flow of saliva into the 
mouth ; (2) a sense of irritation or tickling at the back of the 
throat ; (3) a feeling of acidity in the stomach ; and (4) a feeling 
of weight or oppression at the epigastrium or across the chest. I 
mentioned before that stimulation of the stomach produced reflex 
secretion of saliva ; and, if the mucous membrane is irritable, the 
secretion of saliva may go on long after it ought to cease, and give 
rise to frequent swallowing and accumulation of air. 

Acidity in the stomach causes frequent swallowing, perhaps 
because the discomfort is momentarily relieved by the alkaline 
saliva as it passes from the oesophagus into the stomach. A feeling 
of oppression or constriction across the chest, like a huge iron hand 
clutching it, is due to irritation of the vagus, as we know from 
Czermak's experiments. He had an exostosis on one of his cervical 
vertebrte, and, by compressing the vagus nerve between his finger 
and this exostosis, he could stimulate it so strongly as to stop Lis 
heart. Such stimulation produced also a feeling of constriction, 
or, as it is well called by the Germans, of Beklemmuug. But 
irritation of the vagus can be produced in other ways than by 
compressing its trunk. Depressing emotions, such as sorrow, 
appear to act on the nerve-centre in the medulla, from which the 
vagus springs, and it may be stimulated reflexly from many parts 
of the body, and notably from the stomach. As Kronecker has 
shown that its action over the heart is temporarily abolished by the 
act of swallowing, we would naturally expect any one suffering from 
the feeling of thoracic oppression or constriction due to irritation 
of the vagus would swallow frequently, in order to obtain relief. 
This appears to take place when irritation of the vagus, with 
consequent oppression of the chest; are caused by grief, so tliat it 
has come to be popularly expressed in the phrase " swallowed his 



il] formation of gas. 31 

grief." So far as my observation goes, frequent swallowing also 
occurs in cases where thoracic oppression seemed to me to be clue 
to reflex irritation of the vagus from the stomach. 

Flatulent distension of tlie intestines may also be produced by 
excessive swallowing of air, and provided the pylorus be open, so 
that the air can pass through it, either temporarily, as when the 
contents of tlie stomach are passing out, or permanently, as in 
pyloric dilatation or paralysis. The enormous distension of the 
bowels in hysterical cases, and the rapidity with which it occurs, 
has often been a puzzle to medical men, and has led some to think 
that the only possible explanation is a rapid evolution of gas from 
the blood. From the observations of Ebstein and Zeckendorf,^ how- 
ever, it seen:is more probable that the true cause of this enormous 
dilatation is to be sought in a paralysis of the pylorus which allows 
the air to pass freely from the stomach into the intestines. 

But whilst the air which has been swallowed is probably the 
chief agent in the production of gastric flatulence, the gases formed 
by decomposition in the intestine constitute the chief factor in 
cases of intestinal flatulence. They are found, on chemical exam- 
ination, to consist of nitrogen, but in smaller proportion than the 
gas of the stomach, of hydrogen, of marsh-gas, and of carbonic acid; 
sometimes, also, there is a certain quantity of sulphuretted hydrogen. 
Some kinds of food are extremely apt to give rise to flatulence, and 
an analysis of Kolbe and E,uge ^ of the gases passed 'joer anum by 
a man after different kinds of food, seems to show that it is the 
formation of marsh-gas which gives chiefly rise to the flatulence. 
The proportion of mardh-gas in their analyses amounted to a mere 
trace only, on milk-diet ; to 27*5 j^er cent, on a flesh-diet ; but it 
rose to no less than 55 "9 when peas had been used as food. 

Marsh-gas can only be formed in the absence of air, and so it is 
not produced in the stomach. It is sometimes, however, passed in 
eructations. C. Anton Ewald ^ had a curious case under his care, in 
which the patient was astounded to find, on trying to light a cigar, 
that inflammable gas was issuing from his mouth. Here, however, 
there can be little doubt that the marsh-gas was formed in the 
intestines, and passed through the open pyloric and cardiac orifices 
into the mouth. 

Sulphuretted hydrogen is a product of the decomposition of 

^ Pa'Jiogen''sa chr Bauchtiimpanie Inaug. Disff. Gottiiigen, 1883. 
2 Quoted by Landois. Text-book of Human Physiologi/. Translated by Stirling, 
p. 372. 

2 Eeicliert und Du Bois-Eeymond's Aicliiv., 1S74, p. 217. 



32 LETTSOMIAN LECTURES. [lect. 

albumen, and its odour is well known as that of rotten eggs. 
Although it is usually found in mere traces, if at all, in the 
intestine, it may sometimes occur in such quantity as to make 
the eructations very unpleasant, not only to the patient himself, 
but to his friends. When such eructations occur persistently, they 
are generally indicative of serious organic disease. 

Another symptom of indigestion is acidity, and this is not 
unfrequently combined with flatulence. In some cases, as in that 
curious one of Ewald which I have mentioned, it may alternate 
with flatulence. As his patient expressed it, " sometimes he had 
within him a vinegar-manufactory, and at other times gas-works." 
The difference between these two conditions probably depended on 
the nature of the fermentation which was going on. As I have 
said, however, they are frequently associated, and I am inclined to 
think that a feeling of acidity frequently gives rise to flatulence, 
because the irritation which it causes in the stomach leads to 
frequent swallowing of saliva and air, 

I have said purposely " a feeling " of acidity, because all cases 
of acidity do not depend, as is often imagined, on an increased 
proportion of acid in the contents of the stomach, but upon 
increased sensitiveness of the stomach or oesophagus, or upon some 
abnormal condition of the cardiac orifice, which allows the contents 
of the stomach to come more persistently into contact with the 
oesophageal mucous membrane than they ought to do. ' The 
ogsophagus is much more sensitive than the stomach, as any one 
of you can easily discover for himself. If you will only swallow a 
bit of hot potato, you will be able to trace its progress right down 
the oesophagus to the pit of the stomach, and you will be able to 
ascertain precisely where your cardiac orifice is situated, because at 
that point the burning heat of the potato ceases to be felt as it drops 
into the stomach. Now this very point where the hot potato 
ceases to be felt, is the point where the feelings of acidity and 
heartburn are felt most strongly. A feeling of acidity coming on 
immediately, or very shortly, after a meal, is usually ascribed to 
increased proportion of acid in the gastric juice secreted by the 
stomach ; while acidity coming on an hour or more after meals, 
is usually attributed to the formation of acid from the food by 
decomposition or fermentation. 

There is no doubt that sometimes the contents of the stomach do 
become strongly acid from fermentation, and the matters vomited 
will not only burn the throat, but will set the teeth completely on 



II] ACIDITY— WEIGHT— PAIN. 33 

edge, just as drinking a mineral acid would do. The secretion of 
gastric juice containing an excessive proportion of acid is, however, 
by no means proven. 

It is quite possible that the stomach might secrete an exces- 
sively acid juice, but Dr. McNaught ^ has shown in a recent paper 
that, although heartburn and acidity were present to an extreme 
degree in his patients suffering from irritative dyspepsia, in no 
case was the acidity above the normal. The same thing has 
been observed by Professor Talma ^ of Utrecht, who has shown that 
the feeling of acidity is really only a feeling by putting into the 
stomach of persons who suffer from it an artificial gastric juice 
containing only the normal proj)ortion of hydrochloric acid, a 
proportion so small that, as is well known, it hardly gives an acid 
taste to the healthy tongue, much less excites any feeling of pain. 
In these persons, however, this dilute acid caused a feeling of 
acidity and pain. It is evident, then, that the feeling of acidity 
in cases of nervous or irritable dyspepsia, which is often great 
and very painful, which is usually associated with a clean 
tongue, and often occurs in gouty patients, is dependent upon 
hypersesthetic conditions of the mucous membrane, and not 
upon excessive secretion of acid by the stomach. At the same 
time, we must bear in mind that there are other cases in which 
, acidity is due, not to hypersesthesia of the mucous membrane, 
but to increased formation of acid by the decomposition of 
food.^ 

The stomach is much less sensitive than the oesophagus, and 
usually irritation of the mucous membrane in the body of the 
viscus gives rise to a feeling of weight rather than of pain — a 
point which seems to indicate that the pain of heartburn is due 
to irritation of the cardia, and of the oesophagus, rather than of 
the stomach itself. It not only occurs just at the point wliere a 
hot potato ceases to cause discomfort on its way downwards, but 
occasionally heartburn may be brought on by certain positions, 
and relieved by others. Thus, it sometimes happens, that the 
contents of the stomach cause an acrid burning feeling in the 
epigastrium when the person is lying down, and especially lying 

1 MclSTauglit, Medical Chronicle, January, 1885, p. 330. 

^ Talma, Zeitschr. fur klin. Med., Bd. viii. p. 414. 

3 Since this lecture was delivered I have seen that Eeichmann {Berlin. Jclin. 
WochenscTir ., Dec, 1884, p. 768) has found that gastric juice appears sometimes to 
be secreted with a larger proportion of acid than normal, but he also insists on acid 
dyspepsia being a neurosis due to hj'persesthesia. 

D 



34 LETTSOMIAN LECTURES. [lect. 

on the back, but the feeling disappears when the upright position 
is assumed. It sometimes happens, also, that a little escape of 
flatulence from the stomach will cause the burning feeling to 
travel up the oesophagTis. 

Frequently, however, an escape of wind gives relief. It is 
difficult to determine, with certainty,, what the cause of this relief 
is, but I am inclined to think that distension of the stomach by 
flatulence may tend to cause heartburn by pulling the edges of 
the cardiac end of the oesophagus apart, and thus exposing the 
sensitive mucous membrane to the action of the acid contents 
of the stomach. When the distensioa is lessened by eructations, 
the cardiac end of the oesophagus will close more completely, 
and thus protect the sensitive surface of the oesophageal mucous 
m3mbrane and relieve the pain. 

The stomach itself rarely contracts with such_ violence as to 
give rise to pain like that of colic, but it aj^pears sometimes to do 
so, and then the pain is excessive. 

The intestines are much more liable to spasmodic contraction, 
giving rise to the pain of colic. 

Another consequence of indigestion, or, perhaps, rather I ought 
to say, of biliousness, is the occurrence of piles, which consist, to 
a great extent, of dilated hsjmorrhoidal veins; and here, again, 
it is of great importance to remember that the blood from the 
intestines, as well as from the stomach, has to pass through the 
liver on its way to the general circulation (Fig. 4). No doubt 
some of the blood may return from the rectum by the middle and 
inferior hsemorrhoidal veins, without passing through the liver, 
but yet so much is returned through the portal vein, that any 
interference with the circulation through the liver will tell uj)onthe 
veins of the rectum, as well as those of the other abdominal viscera. 
In the fact, however, that part of the blood returns from the 
rectum, without passing through the liver, we see a new proof 
of the important function which the liver exercises in preventing 
the entrance of poisons into the general circulation. I have 
already mentioned that the liver has the power of excreting with 
the bile the poisons which have been absorbed by the portal blood, 
and also of destroying, to a certain extent, vegetable or animal 
poisons which are circulating through it. We would, therefore, 
expect that some of the vegetable alkaloids injected into the 
rectum woukl prove more fatal than when taken by the mouth, 
as they would be able to pass by the lower haBmorrhoidal veins 



ri.] PILES-^GLYCOSURIA. 35 

into tlie general circulation without passing through the liver. 
This actually appears to be the case, for Mr. Savory has shown 
that strychnine is more poisonous when administered by the 
rectum than when given by the mouth. 

While a retarded circulation through the liver may give rise to 
discomfort, and even pain, by causing congestion of the stomach or 
intestine, or by giving rise to piles, it is not without its advantages 
to the organism ; for it is in the portal blood and in the liver itself 
that the process of building up the smaller molecules of peptones 
and of sugar into the larger ones of globulins and glycogen takes 
place. If these products of digestion are absorbed in large quan- 
tity, and pass too rapidly through the liver, so that they reach the 
general circulation without undergoing sufficient elaboration, they 
may either prove injurious to the organism or be excreted as waste 
products, or both. Indeed, we find this to be the case, for we fre- 
quently meet with affections of the respiration, circulation, and 
nervous system, -which actually seem to be due to a kind of 
poisoning by products formed, either in the intestinal canal itself, 
or in the blood ; and we also meet with cases in which sugar, pep- 
tones, and albumen are excreted by the kidneys, instead of being 
applied to the repair of the tissues. 

I have elsewhere insisted strongl}^ on the distinction which is to 
be drawn between glycosuria from the mere presence of sugar in 
the urine and the disease diabetes.^ Simple glycosuria may occur 
in perfectly healthy persons, and, indeed, is much more frequent 
than people generally believe. If you will examine the urine of 
several healthy persons a couple of hours after breakfast, it is 
highly probable that you will find distinct evidence of sugar; for 
breakfast is a meal at which a much larger proportion of bread is 
eaten than at other meals, and at which, not unfrequently, a good 
deal of sugar is taken along with tea or coffee. But glycosuria 
depending on digestion is a transitory condition, whereas the 
glycosuria of diabetes is permanent. That glycosuria occurring 
during the process of digestion and absorption, is due either 
to some alteration in the circulation in the liver, or else to the 
absence from the portal blood of bodies Avhich will build up the 
sugar into larger molecules, appears to be shown by an observation 
of Lehmann.^ He found that sugar, injected into the mesenteric 
veins of a rabbit, during digestion, does not appear in the urine, 

^ On DialDetes, Eeynolds' System of Medicine, vol. t. 
* Lehmauu, Akadcm. Procfsclir., Amsterdam, 1873. 

D 2 



36 LETTSOMIAN LECTURES. [lect. 

although the same quantity, injected in the same way into a fasting 
animal, would produce glycosuria. 

Within the last few years, the occurrence of temporary albumi- 
nuria has been shown to be much more frequent than was previously 
suspected. In some statistics of life-insurance drawn ujd in New 
York,i one out of every eleven healthy persons who applied for life- 
assurance was found to present traces of albumin in the urine. 
Some experiments made by Leube^ on 119 soldiers showed that in 
4 per cent, the morning urine contained albumin, and albuminuria 
occurred in less than 16 per cent, after a severe march. The jDro- 
portion found by the American insurance-office is intermediate 
between the two values found by Leube. It is, I think, consider- 
ably higher than what one is accustomed to find in examination of 
persons proposing for life-assurance in London, but corresponds 
nearly to the proportion of cases of temporary albuminuria (12 per 
cent.) found by Parkes ^ in hospital patients. 

The prognostic importance ofalbuminuria is very great, not only 
in regard to the question of life-assurance, but in regard also to the 
dietetic and hygienic treatment of the individual. If we were to 
assunifi that because albumin is present in the urine the individual 
is suffering from serious disease, we should fall into as grave an erroi" 
as if we were to suppose that every patient whose urine contained 
sugar was necessarily suffering from diabetes. 

As Dr. Warburton Begbie says, " it is surely a satisfactory con- 
sideration that a condition of excessive albuminuria — the urine 
becoming nearly solid on the application of heat and nitric acid — 
may, after all, not indicate the existence of any structural change 
in the kidney.^ 

In my first lecture, I insisted, at some length, upon the jDrobable 
difference in the size of molecules, and mentioned that, whilst 
small ones diffuse through animal membranes, large ones will not. 
In the process of digestion, large albuminous molecules get split 
up into smaller ones, which become absorbed and then undergo 
reconstruction, being built up again in the portal blood, in the 
liver, and in the tissues, into larger molecules. The albuminous 
substances of the blood appear to consist of such large molecules 
that they will not difi"use through the glomeruli of a healthy 

1 Medical Investigations in Life-Insurance, United States Life-Iusui'aiice Company, 
261, Broadway, New York. 

2 Salkowski und Leube, Lehre voon Ham, p. 369. ^ On Urine, p. 187. 

* Albuminuria in Cases of Bronchocele and Exophthalmos, Eclin. Med. Journ., 
AprQ 1874 ; and Begbie's Works, Syd. Soc. Ed., p. 355. 



IT.] PEPTONURIA— ALBUMINURIA. 37 

kidney, but tlie products of digestion — peptones and hemi- 
albumose — will diffuse through the glomeruli, and pass into the 
urine, producing jDeptonuria or hemialbuminosuria. 

It would appear also that white of egg has a smaller molecule 
than serum-albumin, for white of egg, ijected under the skin, 
appears again in the urine, giving rise to pseudo-albuminuria, 
while serum of blood, or a solution of serum-albumin, injected in 
a similar way, causes no albuminuria. White of egg, when 
swallowed, does not usually pass into the urine as it does when 
injected subcutaneously, because it undergoes digestion in the 
intestinal canal, and is agam built up after absorption into larger 
molecules. If taken in large quantity, however, some of it will 
escape digestion, will be absorbed unchanged, and will pass out 
through the kidneys and appear in the urine. I have tried the 
experiment by swallowing six raw eggs in succession. This quantity 
was insufficient to produce albuminuria, but it brought on such a 
violent headache and sickness, that I was deterred from ever 
making the attempt again. My friend, Dr. D'Arcy Power, who 
was making the experiment at the same time, succeeded in taking 
a sufficient number to produce albuminuria. 

Coagulated albuminous bodies, such as boiled eggs or cooked 
meat, cannot be absorbed without being previously digested, and 
so are much less likely than raw eggs to produce albuminuria, 
even when taken in very large quantities. But, as I have already 
mentioned, the products of imperfect digestion, such as hemial- 
bumose, behave in much the same way as egg-albumin, and may 
give rise to a form of albuminuria. Both egg-albumin and serum- 
albumin, when present in the urine, will cause a cloud on boiling, 
or on the addition of nitric acid ; and yet it is obvious that the 
prognostic importance of the albuminous cloud, due to a dozen 
eggs swallowed one after the other, will be very different from that 
of an albuminous cloud due to degeneration of the kidney. It is, 
therefore, of great importance that we should distinguish between 
the different kinds of albumin present in the urine. This can be 
done, to a certain extent, by noting the point of coagulation, which 
is usually lower in the case of serum-albumin than it is in that of 
other albuminous substances. Time, however, will not allow me 
to enter further on this subject at present, and I have already 
discussed it elsewhere.^ 

1 Lauder Brunton and D'Arcy Power, St. Bartliolomeic's Hospital Ecforts, vol. xiii. 
1877, p. 283. 



38 LETTSOMIAN LECTURES. [lect. 

But while the mere occurrence of a httle albumin once or t^Yice 
in the urine is not to be regarded as of necessarily fatal import, it 
is not to be lightly passed over as a thing of no importance, even 
although the albumin should prove not to be serum-albumin, but 
only hemialbumose. Clinical experience had indicated a connection 
between lonof-continued digestive disturbance and organic disease 
of the kidneys, and this was experimentally demonstrated by 
Stokvis, who found that hemialbumose injected under the skin 
once or twice will pass out through the kidneys without doing 
them any apparent injury, but if the injections be frequently 
repeated, the hemialbumose in passing through the kidneys 
appears to excite in them organic disease. 

Another disturbance of the urine connected with digestion is 
oxaluria. When we find oxalate of lime crystals in the urine, we 
must not at once conclude that the patient is suffering from 
oxaluria, any more than we must conclude that h.e is suffering 
from diabetes or Bright's disease, because we find sugar or albumin 
in the urine. It is not the occasional occurrence, but the more . 
or less persistent presence of crystals of oxalate of lime in the 
urine, that is associated with a peculiar group of symptoms, of 
which the most prominent is perhaps mental dejjression. Oxalate 
of lime present in the food will be absorbed from the intestine, and 
a considerable proportion of it, at least, will be excreted again in 
the urine. We may thus expect that oxalate of hme would occur 
in the urine after stewed rhubarb had been taken for dinner, but 
there are other kinds of food which do not contain oxalate of hme, 
or only contain it in very small quantity, and yet give rise to 
crystals of oxalic acid in the urine. When I was house-physician 
to the late Dr. Hughes Bennett, a glass containing the patient's 
urine was invariably placed at each bedside, and in going rounc}^-^.^ 
the ward in the morning, I used frequently to notice in the urine 
the hummocky mucous cloud, with its sharply-defined white top, 
resembling the woolly clouds in a summer sky, which is character- 
istic of oxaluria. On inquiry, I found that this appearance almost 
always resulted from the patient's having had cabbage for dinner 
the day before. Now, according to Esbach, cabbage is really 
singularly free from oxalic acid, and the oxaluria which it produced 
must be ascribed to some other cause than simple excretion of 
oxalate of lime taken in the food. The true cause, I have httle 
doubt, is digestive disturbance ; cabbage being one of those articles 
of diet which is exceedingly apt also to produce flatulence. 



II.] OXALUIUA— ASTHMA. 39 

We do not know exactly bow oxalic acid is formed, either in the 
intestine or in the body, and any observations regarding oxaluria 
must be to a considerable extent speculative. Thus, according 
to some, it is said to be due to the oxidation of uric acid, whilst 
others say that imperfectly oxidised uric acid splits into oxalic acid 
and urea. Others attribute it to incomplete oxidation of sugar, 
starch, and fat, in the food, or of non-nitrogenous fatty acids 
formed within the body ; while others again say that it is entu'ely 
due to the re-excretion of oxalic acid taken in the food, and that 
no formation of oxalic acid in the body occurs at all. In the midst 
of these conflicting opinions, it is somewhat difficult to come to any 
conclusion, but it is worth while for us to note two facts, and see 
if there is any connection between them. The one fact is that 
pointed out by Esbach,^ who denies the formation of oxalic acid in 
the body, viz., that if a reducing agent, such as sulphuretted 
hydrogen, be added to a strong solution of urates, crystals of 
oxalate of lime are at once produced. 

The other fact, which we have already mentioned, is the tendency 
of cabbage to produce oxaluria, and also to give rise to flatulence, 
which probably depends, as it does in the case of other vegetables, 
on the production of hydrogen or marsh-gas. 

These two facts may be connected by the following hypothesis, 
that as most plants of the order Cruciferm, to which cabbage 
belongs, contain sulphur in unusual quantity, it is possible that 
this may give rise to sulphuretted hydrogen or sulphides in the 
intestine, which will act as a reducing agent, and tend to 
rejDroduce in the body the experiment which Esmarch performed 
in the test-tube. 

In cases of imperfect digestion, not only are substances that 
ought to be used for the nutrition of the body excreted as waste, 
but products of the digestive process may act as poisons to various 
parts of the organism, and produce serious symjDtoms. 

A common symptom of dyspepsia is shortness of breath, but in 
many instances this is merely of physical origin, the distended 
stomach pressing the diaphragm upwards, and interfering with the 
expansion of the lungs. There may be shortness of breath, also, 
which is of cardiac origin, the circulation being affected by the 
digestion in a manner which we will presently discuss. In addition 
to these different kinds of shortness of breath, however, we meet 
with actual asthmatic conditions, in which the entrance of air into 
^ JourncCl des Connaissances Med., 1883, p. 155. 



40 LETTSOMIAN LECTURES. [lect. 

the lungs appears to be prevented by contraction of the involuntary 
muscular fibres surrounding tlie bronchi. The pathology of asthma 
is too little understood to enable us to say whether the bronchial 
muscles are made to contract by abnormal substances circulating 
in the blood, and irritating either the muscular fibres or their 
nerves; or whether the contraction is reflex, and is excited by a 
congested condition of the mucous membrane lining the respiratory 
passages. 

There is another condition, however, namely, cough, which is 
frequently associated with indigestion — so frequently, indeed, that 
a kind of cough has come to be known as " stomach-cough." This 
popular name, though perhaps not scientifically correct, yet conveys 
a true impression. Cough is a reflex action. Reflex acts are 
generally adopted for a purpose. Cough is fitted to expel irritating 
substances from the respiratory, and vomiting from the digestive, 
passages. Irritation of the stomach will not of itself produce reflex 
coughing; the act corresponding to it is vomiting. Irritation of 
the respiratory passages, on the other hand, produces reflex 
coughing, and not vomiting. Nevertheless, it so hapjjens that 
the action of an irritant, either in the digestive or pulmonary 
tract, may be aided by irritation elsewhere ; and thus it happens 
that, when there is congestion of the pharynx and the upper part 
of the trachea, which is not in itself sufficient to produce coughing, 
the presence of any irritant in the stomach will assist this irritation 
in the respiratory passages, and coughing will occur. Thus I have 
observed a paroxysm of coughing coincident with acidity in the 
stomach, in a case where the fauces were much congested ; and 
possibly also (although I did not make a laryngoscopic examination) 
the larynx and trachea may also have participated. This irritation 
was not in itself sufficient to cause coughing, but the additional 
irritation of the acidity in the stomach at once excited cough ; and 
when the irritation was removed from the stomach by a dose of 
bicarbonate of soda, which neutralised the acid, the cough at once 
ceased. Now it is just at the pharynx — at the place where the 
respiratory and digestive tracts cross one another — that irritation 
is most likely to give rise both to coughing and vomiting; and 
this point, as we might readily expect, is one which is very readily 
affected by digestive disorders. I saw a very instructive case of 
this some time ago. A gentleman suffered from cough, which 
gave him a good deal of trouble ; the back of his pharynx was 
congested, and I ordered him a gargle. For some time it was not a 



II.] INTERMITTENT PULSE— SUDDEN DEATH. 41 

bit the better, and then, for some reason or another, somebody else 
gave him several blue pills, and the cough disappeared (cf. p. 172). 

The heart is very liable to be affected by digestive disturbance, 
and, like the lungs, it may be affected mechanically ; for there is 
nothing between the heart and the stomach but the diaphragm ; 
and when the stomach gets distended with gas, it may interfere 
with the action of the heart, and give rise to functional disturbance. 
This may evidence itself in faintness, in the shortness of breath 
wdiich I have already mentioned, or in an intermittent pulse. The 
intermittent pulse, however, as well as the faintness, may be 
produced reflexly through the nervous system, instead of merely 
mechanically. Sensory nerves run from the stomach to the medulla 
oblongata, and, through these fibres, the heart may be reflexly 
affected. The resulting effects may differ according to the kind 
and amount of irritation ; sometimes palpitation being produced 
from an affection of the acceleratory fibres, and sometimes a slow 
or intermittent pulse by an affection of the inhibitory nerves 
{vide pp. 148, 149). 

It is quite possible that, in addition to the effect produced upon 
the heart directly and reflexly by the stomach, both the heart 
itself and the vessels may be influenced by substances absorbed 
from the intestine into the general circulation, and carried, not 
only to the heart itself, but to the nerve-centres which regulate 
both it and the vessels. We have not as yet, so far as I know, any 
distinct evidence of alkaloids having an action like that of digi- 
talis or other cardiac poisons, being formed in the intestine, and 
passing from it into the general circulation. 

We know, however, that alkaloids, having an action like muscarine, 
and having, like it, a powerful action on the heart and vessels, as 
well as on the intestinal canal, are formed by the decomposition of 
albuminous substances outside the body ; and, in all probability, 
similar substances may be occasionally formed in the intestinal 
canal. It is probable that a microbe is the cause of cholera, but 
the symptoms occurring in the disease are probably due to the 
action on the tissues of a poison generated by the microbe, and not 
of the microbe itself, just as intoxication is due to the alcohol 
produced by the yeast-plant, and not to the action of the plant 
itself, on the nervous system and blood.^ 

An interesting question, on which the formation of alkaloids in 

1 For a fuller discussion of this subject, vide Researches relating to the Pathology 
and Treatment of Cholera, by Lauder Bruuton and Pye-Smith, Practitioner, November 
18S4, et seq. 



42 LETTSOMIAN LECTURES. [lect. 

the intestine may throw some light, is, " What is the cause of 
sudden death in some gouty patients ? " Such a case as the 
following is by no means rare. A hale old man, of a gouty family, 
has seemed unusually well, strong, and in good spirits. He eats an 
unusually hearty dinner, goes to bed, and is found dead next 
morning. In such a case, j^os^ mortem examination reveals nothing. 
The kidneys may be contracted, but the change in them has been 
of a chronic nature, and gives no clue to the cause of the patient's 
sudden death, unless it be that contracted kidneys will not excrete 
so quickly as healthy ones, and if a substance should be absorbed 
from the intestinal canal capable of acting as a cardiac poison, it 
will be more likely to cause death in a patient with contracted 
kidneys than in one with healthy kidneys. 

But whether alkaloids which affect the heart are formed in the 
intestine or not, we have evidence that other alkaloids are formed 
which affect the nervous system very powerfully. In a paper 
which I wrote some years ago, I pointed out the great resemblance 
between the s}mij)toms met with in indigestion, and in those in 
poisoning by curare. When an animal is poisoned with this 
substance, and the motor nerves begin to be paralysed, the increas- 
ing languor and difficulty of movement appear to strike the animal 
as strange, and it frequently looks at itself as if it were itself 
puzzling over its unwonted condition. The very same thing may 
not unfrequently be noted in cases of dyspepsia; an unwonted 
languor comes over the patient, generally about two hours after a 
meal, and the patient wonders why his limbs feel heavy, like lead, 
and why he should have such a disinclination to exercise, either 
bodily or mental I may, jDerhaps, here be allowed to quote from 
the paper to which I have just referred^ {vide p. 255), as the 
analogy which I then pointed out between the languor occurring 
in dyspepsia and curare poisoning has since received such remark- 
able confirmation, so that the languor would appear, from recent 
researches, to be due in both cases to alkaloidal poisoning. 

" The feeling of muscular weakness and lassitude, which I have 
already had occasion to mention as frequently coming on about 
two hours after meals, is not uncommonly met with in persons 
belonging to the upper classes, who are well fed, and have little 
exercise. It is, perhaps, seen in its most marked form in young 
women, or girls who have left school, and who, having no definite 

1 Lauder Brunton, Indigestion as a Cause of Nervous Depression^ PractUioner, 
October and November, 1880. 



II.] NERVOUS DEPRESSIOX. 43 

occupation in life, are indisposed to any exercise, either bodily or 
mental. I am led to look upon this condition as one of poisoning, 
both on account of the time of its occurrence, during the absorption 
of digestive products, and by reason of the peculiar symptoms, 
namely, a curious weight in the legs and arms, the patient 
describing them as feehng like lumps of lead. These symptoms 
so much resemble the effect which would be produced by a poison 
like curare, that one could hardly help attributing them to the 
action of a depressant, or paralyser, of motor nerves or centres. 
The recent researches of Ludwig and Schmidt-Miihlheim render it 
extremely probable that peptones are the poisonous agents in these 
cases, and an observation which I have made seems to confirm this 
conclusion, for I found that the weakness and languor were appar- 
ently less after meals consisting of farinaceous food only. My 
observations, however, are not sufficiently extensive to absolutely 
convince me that they are entirely absent after meals of this sort, 
so that, possibly, the poisoning by peptones, although one cause of 
the languor, is not to be looked upon as the only cau^e." 

At the time when I wrote this, alkaloids had not been shown to 
be formed in the body, and I was inclined to attribute the languor 
to the poisonous action of peptones; but now the evidence which 
we have to prove the presence in the circulation of alkaloids formed 
in the intestine is just the same as that which we have to show 
their presence when injected subcutaneously. When curare is 
injected under the skin of a frog, we know that it has been 
circulating in the blood, not only because of the effects it has 
produced upon the motor nerves, but because, if we take a little 
of the frog's urine, we find that the poison has been excreted by 
the kidneys, and that the urine will produce symjDtoms of paralysis 
when injected under the skin of another frog. Now, Bocci^ has 
found that, from human urine, an alkaloid can be extracted which 
possesses exactly the same action as curare. This alkaloid has not 
been shown as yet to be identical with the alkaloid obtained by 
Brieger^ from the peptones formed by digestion of fibrin with gastric 
juice, to which he has given -the name of peptotoxin. But v/h ether 
these alkaloids be absolutely identical or not in their chemical 
constitution, they appear to be identical in their action, both 
acting like curare in paralysing the peripheral terminations of 
motor nerves. 

^ Bocci, Arch, per le Science Med., vol. vi. IsTo. 22, 1883. 
2 Brieger, Ber. d. Deutsch. Client. Gescll., svi. pp. 1186 and 1405, 18S3. 



U LETTSOMIAN LECTURES. [lect. 

I have already insisted more than once on the function of the 
liver in arresting and destroying poisons which have been absorbed 
from the alimentary canal ; and I have already pointed out that 
excessive bitterness is of the common characteristics of organic 
alkaloids. Now, there is a curious point about the bile which has, 
I think, not obtained the attention it deserves. "As bitter as 
gall " has come to be a household phrase, and we frequently notice 
that the bile vomited in cases of indigestion is very bitter indeed, 
so bitter as to be nauseous. But bile is not always bitter, as I 
once found to my astonishment when making some experiments 
with digitalis. I had taken nearly half a grain of pure digitalin 
on each of two consecutive days, and the poison began to produce, 
as one of its effects, very violent vomiting. During this, I brought 
up a quantity of matter resembling both m appearance and taste 
the yolk of a fresh egg, and perfectly destitute of bitterness. Not 
having eaten any eggs, I could not see what it could be but bile, 
but I was so very strongly impressed with the notion that bile w^as 
always bitter, that I did not put it down in my notes definitely as 
being bile, but only as yellow and liquid, somewhat like the yolk 
of an egg.i The absence of bitterness from freshly-secreted bile 
has also been observed by Mr. W. E. Green, of Sandown, in the 
case of a biliary fistula; and I am inclined to think that the 
bitterness which is supposed to be characteristic of bile does not 
really depend upon biliary constituents, but upon admixture wdth 
some alkaloidal substance derived from digestion. Some years 
ago. Dr. Bence Jones and Dr. Dapre showed that, in the liver and 
in other animal organs, an alkaloid was present resembling quinine 
in many of its reactions, and though, for some years past, their 
observation has fallen out of notice, it is beginning to acquire new 
importance, especially since it has been shown that quinine is very 
closely associated with phenol and other bodies of the aromatic 
group, some of which are formed in the intestine. 

It is very curious to observe how views of all sorts seem to turn 
round and round ag-ain, though not so much in a circle as in a 
spiral, for at each turn they generally have advanced a little. For 
a long time the liver was regarded as a most important organ, and 
v/ell it might be, for it is the largest gland in the body ; and yet, 
for a while, it has sunk into comparative unimportance, its chief 
function being considered to be the secretion of bile. But to regard 
the liver in this light, is just about as rational as to think that an 

^ On Digitalis, with some Observations on Urine, p. 67. London : Churcliill, 1868. 



II.] BILIOUSNESS AND MELANCHOLY. io 

Atlantic steamer has been built for the express purpose of throwing 
out from its sides the two jets which are formed by the waste water 
from the engines. The condensed steam may be utilised, and so 
may the bile, but the condensation of steam is not the main object 
of an Atlantic steamer, nor is the secretion of bile the chief function 
of the liver. If we look at the liver, not as a mere secreter of bile, 
but as the organ in which probably the most important synthetical 
processes in the body go on, and in which the small molecules 
resulting from the digestion of food are built up into the more 
complex ones required to supply the waste of the various tissues 
in the body, we shall at once see a good reason for its enormous 
size, and for the important position which it occupies. If we 
recollect also its function as a porter to watch over the entrance 
into the circulation, and prevent the passage of noxious substances 
from the stomach or intestine, we shall readily understand how a 
slight disturbance of its function should give rise to such important 
functional alterations in other organs. 

The Greeks showed their wisdom when they placed the seat of 
Hypochondriasis under the ribs, and when they connected depres- 
sion of sjMrits with disorder of the liver by giving to it the name of 
Melancholy (/xeAa?, black, and X'^^V, bile). 

In her Histoire cle ma Vie, George Sand says on this subject : 
"Whether it is the bile which has made me melancholy, or the 
melancholy which has made me bilious — this would resolve a great 
metaphysical and physiological problem, which I will not take up — 
it is certain that sharp pains in the liver produce symptoms in all 
those that are subject to them, of profound sadness and a wish to 
die. Since my disease first appeared I have had happy years, and 
when it seized me again, although I was in the condition most 
favourable to love of life, 1 felt myself suddenly seized by a desire 
for eternal repose." ■"• 

Sydney Smith describes in a very humorous way the connection 
between dyspepsia and low spirits. He says : ^ " Happiuess is not 
impossible without health, but it is of very difficult attainment. 
1 do not mean by health merely an absence of dangerous com- 
plaints, but that the body should be in perfect tune, full of vigour 
and alacrity. The longer I live the more I am convinced that the 
apothecary is of more importance than Seneca ; and that half the 

^ Histoire de ma Vie, George Sand. Vol. xviii. p. 295. Paris : 1855. 
^ I am indebted for this to my friend Dr. De Havilland Hall, who showed it to me 
in Tanner's Practice of Medicine, 7th ed., voL ii. i). 100. 



43 LETTSOMIAN LECTURES. [lect. 

uuliappiness in the world proceeds from little stoppages, from a 
duct choked up, from food pressing in the wrong place, from a 
vexed duodenum, or an agitated pylorus. The deception as 
jDractised upon human creatures is curious and entertaining. My 
friend sups late; he eats some strong soup, then a lobster, then 
some tart, and he dilutes these esculent varieties with wine. The 
next day I call upon him. He is going to sell his house in London, 
and to retire into the country. He is alarmed for his eldest 
daughter's health. His expenses are hourly increasing, and nothing 
but a timely retreat can save him from ruin. AH this is the 
lobster ; and when over-excited nature has had time to manage this 
testaceous incumbrance, the daughter recovers, the finances are in 
good order, and every rural idea effectually excluded from the mind. 
In the same manner, old friendships are destroyed by toasted 
cheese, and hard salted meat has led to suicide. Unpleasant 
feelings of the body produce corresponding sensations in the mind, 
and a great scene of wretchedness is sketched out by a morsel of 
indigestible and misguided food. Of such infinite consequence to 
happiness is it to study the body." ^ 

Usually, the melancholy and depression of spirits which are 
associated with disorder of the liver are attributed, like the bitter 
taste in the mouth, to the bile, which is circulating in the blood. 
No doubt, bile is a muscular poison ; but we have already seen 
that the bitterness of bile is probably not inherent in the secretion 
itself; and there is, therefore, good reason for doubting whether 
the bitter ta,ste in the mouth is due to bile. Moreover, we some- 
times find the bitter taste with very little evidence of the presence 
of bile in the blood, the conjunctiva being, at most, only slightly 
tinged : whereas we sometimes see patients who are deeply jaundiced, 
and yet make no complaint of any such taste. For similar reasons 
we may regard it as probable that the depression does not depend 
upon biliary matters, but rather upon the noxious substances 
which have been able to pass through the liver and enter the 
blood. 

We may regard, indeed, the association of bile with other noxious 
substances in the blood in very much the same way as the associa- 
tion of disagreeable smells with noxious properties in gases. The 
presence of a disagreeable smell often warns us of the presence of 
noxious gases ; but these may occur in their most deadly form with 

1 A Memoir of the Reverend Sydney Smith, by Lady Holland, vol. i. p. 125. 
London. 1855. 



ir.] INTESTINAL SEWAGE-POISONING. 47 

little or no disagreeable smell ; and, on the other hand, we have 
disagreeable smells which are not associated with any danger. 

As a rule people are now fully alive to the risks they run from 
poisoning by sewer-gas, or, to put it more widely, from poisoning 
by products of decomposition outside the body; but perhaps we do 
not all keep before us so clearly as we ought the fact that inside 
the body there are all the conditions for the formation of putrefactive 
products, and the most favourable arrangement for their rapid 
absorption. As the late Mr. Darwin once remarked to me, after 
reading my paper on Indigestion and Nervous Depression : " It is 
a wonder that we are alive," running, as we do, a constant risk of 
poisoning by the products of our own digestion. Slight poisoning 
does, no doubt, occur, and perhaps more frequently than we 
generally suspect. Severe poisoniag is less common, but still may 
take place. One of the commonest constituents of sewer-gas is 
sulphuretted hydrogen; and Senator^ described, in 1868, a most 
instructive case in which the patient became collapsed, aud nearly 
died, with all the symptoms of poisoning by sulphuretted hydrogen 
generated in his own intestines. 

A particular class of nervous s3^mptoms, in which hypochondriasis 
and depression of spirits are accompanied by a deposit of oxalate of 
lime in the urine, has been thus described by Dr. Golding Bird : 
" The patients are generally much emaciated, excepiing in slight 
cases, extremely nervous, painfully susceptible to external impres- 
sions, often hypochondriacal to an extreme degree, and, in very 
many cases, labour under the impression that they are about to 
fall victims to consumption. They complain bitterly of incapability 
of exerting themselves, the slightest exertion bringing on fatigue. 
Some feverish excitement, with the palms of the hands and soles 
of the feet dry and parched, especially in the evening, is often 
present in severe cases. In temper they are irritable and excitable ; 
in men the sexual power is generally deficient, and often absent. 
A severe and constant pain, or sense of weight across the loins, is 
generally a prominent symptom, with, often, some amount of irrita- 
bility of the bladder. The mental faculties are generally but slightly 
affected, loss of memory being sometimes more or less present." ^ 

But in this condition we find the same difficulty of attributing 
the symptoms to the presence of oxalate of lime that we found in 
ascribing the depression of spirits in biliousness to the presence of 

^ Senator, Berlin. Tclin. Wochensclir., 1868, No. 24. 
2 Golding Bird, Urinary Deposiis, 5th ed., p. 251. 



48 LETTSOMIAN LECTURES. [lect. 

bile in the blood ; for, as Dr. Roberts ^ points out, " these symptoms 
may be present in typical completeness without oxaluria, and, 
conversely, oxaluria may exist in its highest intensity, and even go 
on to the formation of a mulberry calculus^ without evoking any of 
the above-mentioned symptoms." 

In this condition then, as in biliousness, we are almost forced to 
ascribe the symptoms to the presence of some poison, of whose 
presence in the blood the oxaluria in one case and the yellowness 
of the conjunctiva in the other are merely indications. 

The irritability Avhich occurs in gouty persons is another example 
of nervous disturbance due to the presence of injurious substances 
in the blood, and their action upon the nervous system. But this 
has been already so graphically described by Murchison in his 
book on Diseases of the Liver, that I must refer you to it, and to the 
classical work of Garrod, as the subject is too wide to enter upon here. 

There is only one so-called minor ailment connected with diges- 
tion which T will mention now, and that is headache. As I have 
pointed out elsewhere,^ headaches are usually dependent either 
upon the presence of decayed teeth, or of some irregularity in the 
eyes, more especially inequality of focal lengths between the two 
eyes, or astigmatism. The site of headache dej)ending upon decayed 
teeth varies with the teeth affected. The headache depending on 
inequality of vision is frequently frontal or occij)ital, although it 
may also be temporal (vide p. 105). 

I am at present uncertain regarding the precise way in which 
indigestion produces headache ; but I may remark that, as a rule, 
in headaches of this sort, the upper surface of the eyeball will be 
found to be excessively tender, and that the tension within the 
eyeball itself appears to be increased, so that sometimes the eyes 
feel like marbles or metal bullets under the finger when they are 
jDressed, Another curious point that I have observed regarding 
headaches is that, as persons who are subject to them in their youth 
grow older, bilious headache is very apt to be replaced by giddiness ; 
and that this change occurs about the time when the eyes are 
beginning to get a little hypermetropic, and the person begins to 
find the need of spectacles for reading. 

^ Eoterts, Urinary and Ecnal Diseases, 3rd ed., p. ^9. London ; Smith, Elder, 
and Co. 

^ Headache, Neuralgia, and other Nervous Diseases connected ■with the Teeth, 
Transaxtioiis of the Odonfological Society of Great Britain, 1880 ; and on the Pathology 
and Treatment of some Forms of Headache, St. Bartholomew' s Mosjntal Eejjorts, vol. 
xix. p. 399, 1883. 



LECTURE TIL 

PEEVENTIVE AND CURATIVE TREATMENT OF DIGESTIVE 
DISORDERS. 

Delivered lefore the Medical Society of London, February 2nd, 1885. 

In my first lecture, I mentioned that the function of digestion, 
like health generally, may be strong or weak. A strong digestion 
is capable of withstanding all sorts of adverse influences, while 
a weak digestion can remain undisturbed only under the most 
favourable circumstances. 

When any disturbances have occurred in the digestive function, 
no matter whether it were strong or weak originally, the first 
step towards restoring it to health is to remove, if possible, any 
disturbing causes which may still be acting upon it. 

One of the commonest of these is imperfect mastication. As I 
have said several times already — but the importance of the subject 
will excuse the reiteration — the first step in the process of solution 
is mechanical disintegration. Children are not long in learning 
this truth, for they soon find out that they get a fuller flavour from 
a hard sweetmeat if they break it with their teeth, than if they 
simply suck it. The child thus gets the sweetmeat quickly 
dissolved, and its sense of taste is more thoroughly gratified, but 
tlie sweetmeat does not remain so long in the mouth. If children 
of an older growth would remember this early experience, and 
apply it to their food generally, there would 'be less indigestion. 

Man is a low-pressure engine, and works almost all his organs 
considerably under their full power. All around us in a town or 
city we see men who, in a walking tovir, could do twenty, thirty, 
or forty miles without the least inconvenience, and yet in their 

K 



50 LETTSOMIAN LECTURES. [lect. 

ordinary avocations they probably do not walk two. In tlie 
country, on the other hand, we find men of good brains, who have 
perhaps distinguished themselves at college by their mental 
powers, by their close application, and by the long hours during 
which they could work, and who yet in their daily life rarely set 
themselves a harder mental task than to understand the leading 
article of a daily paper. It is the same thing with the other 
organs of the body. A healthy stomach can usually digest a good 
deal more than it is called upon daily to do. A healthy kidney 
can excrete twice or thrice as much as it ordinarily does ; and 
thus, in fact, we see that, when one kidney is removed, the organ- 
ism frequently seems hardly to feel the loss, all the waste-products 
being excreted as usual. 

But there is a limit to all things, and that limit is more easily 
reached in some cases than in others. As some one has shrewdly 
remarked, we have two kidneys and two lungs, but we have only 
one stomach, and therefore there is the greater reason why we 
should not overburden it. When a young man is called upon for 
extra exertion, either bodily or mental, he is able to meet the 
demand by making a spurt ; but, as he grows older, this power 
gradually lessens. The same is the case with the stomach. Boys' 
stomachs can digest almost anything, though half-chewed green 
apples may sometimes prove too much even for them. In a youth, 
the stomach will digest the food even when bolted half-chewed ; 
but, as the man approaches middle age, it resents this treatment ; 
it will no longer make a spurt to do the work of the jaws as well 
as its own, and indigestion is the consequence. 

Imperfect mastication frequently arises from too short a time 
being allotted for a meal, or from the mind being occupied during 
the meal with the idea of something to be done afterwards. It is 
curious sometimes to watch the phases of mastication varying in 
the same person during a single meal, according to the ideas which 
cross the mind. In some people, whenever the idea of something 
to be done occurs to them, motor energy seems to be evolved, and 
finds expression in rapid movements of the jaws and bolting of the 
food. It is, therefore, evident that, during meals, all ideas of 
action to be taken by the individual himself should be banished 
from the mind. In sensitive persons, also, it is well to banish 
the idea of action to be taken by others, because some persons 
have such strong sympathies that they throw their own person- 
ality into that of others, so that, if we watch them listening to a 



iji.] IMPERFECT MASTICATIOX. 51 

hesitating speaker, ^ve see their hps moving and their fingers 
twitching. 

Persons who are taking their roeals alone very frequently read 
during them. From what I have said, it is obvious that what they 
read at this time should not have reference to any of their avoca- 
tions, nor even to anvthino- which mav interest them very stronglv. 
such as politics, unless it he presented in an amusing form, as in 
Funch. But a solitary meal should be avoided if possible, for the 
mere presence of a companion, and, still more, occasional conversa- 
tion, acts as a pleasant stimulus, and tends to maintain the nervous 
activity to which I referred in my first lecture as an important 
lactor in perfect digestion. 

Another cause of imperfect mastication is the condition of the 
teeth. Sometimes the teeth and gums are tender, or one or more 
of the teeth may be decayed, and the discomfort or pain occasioned 
in them by mastication leads people to bolt their food, or to masti- 
cate on the other side of the mouth, if the tenderness be limited 
to one side. But where this is the case, we not unfrequentJy find 
that several teeth have already been lost on the side with which 
such a person does chew, and that these teeth have been lost in 
such a way as to make the act of mastication a mere farce. When 
all the teeth are gone, the person may chew perfectly well, not 
only by means of artificial teeth, but also without them. One of 
the puzzles of my childhood was, how my grandfather, an absolutely 
toothless old man, was able to eat and enjoy hard toast. But every 
tooth in his head was gone, and his gums were like the mandibles 
of a turtle. It is not the complete, but the imperfect, removal of 
the teeth which is the source of mischief. We not unfrequently 
find that the teeth have fallen out in such a way that only one or 
two are left behind, which oppose one another so slightly that they 
are of very little use indeed for chewing, but they thoroughly pre- 
vent the gums from coming together, and leave large spaces in 
which the food can escape mastication completely. The remedy 
in such a case as this, is to get in false teeth ; for few people, 
now-a-days, care to be absolutely without teeth at all. 

But the effect, even of thorough mastication, upon the food will 
vary a good deal according to the nature of the food itself; and 
tough substances, which can with difficulty be comminuted, Avill be 
more indigestible than those which are readily broken up. Now 
new bread is proverbially unwholesome, and the reason for this 
is not far to seek. If we take a piece of a hot roll and try to 

E 2 



52 LETTSOMIAN LECTURES. [lect. 

pulverise it between the finger and thumb, we find that it is more 
or less tough and tenacious, and that we can hardly do more than 
tear it apart into little bits. If we take a piece of stale bread, on 
the contrary, we can easily break it up into fine powder, which, of 
course, is much more readily acted upon by the digestive juices 
than lumpy flakes of new bread. Biscuits are also readily 
powdered ; and crisp dry toast, although not so easily broken up 
between the finger and thumb, is still readily digestible, because 
it must be broken up by the teeth before it can conveniently be 
swallowed, for otherwise it would scratch the throat, although 
lumps of new bread of a similar size would slip down the oeso- 
phagus easily. Battered toast is a different thing, as it cannot be 
readily pulverised, any more than new bread. Buttered muffins and 
suet dumplings are other examples of a similar kind to buttered 
toast. Potatoes are generally regarded as indigestible, and are for- 
bidden to dyspeptics, whilst stale bread is allowed. It is possible 
that there may be other reasons for this indigestibility than simply 
difference of physical condition, but I have little doubt that one 
reason at least is the fact that very many people — indeed, I think 
most people — are apt to swallow potatoes in lumps without thorough 
mastication, and these lumps will be very slowly acted upon by 
the digestive juices. 

The fine subdivision of fatty food is also of great importance in 
regard to its digestion. Many people cannot bear to eat the fat of 
hot mutton, but yet they can eat the same when it is cold. If we 
try to pulverise a piece of hot mutton-fat and a piece of cold 
mutton-fat we will see that the difference is much the same as 
that between a piece of new and of stale bread ; and probably this 
is one reason, though there may be others, why hot mutton -fat is 
so liable to make people sick. But mutton-fat may be eaten hot 
by persons with delicate stomachs if it is properly subdivided by 
admixture with farinaceous food. If, for example, it be cut up 
very small, and mashed up with potatoes, even children may take 
it without difficulty, and mutton-fat and milk is an old-fashioned 
and useful remedy. The more minutely we can subdivide the fat, 
the more easily is it digested. I have already discussed this 
subject elsewhere, but it is of such practical importance that I 
may, perhaps, be allowed to repeat part of what I have said before 
(p. 9). If we were asked to take a pat of butter whole, the very 
idea of it might make us sick, but Ave have no difficulty whatever in 
taking the same amount of butter spread upon bread. Many 



iTi.] BUTTERED TOAST— TOUGH STEAKS. 53 

years ago, my friena Professor Hugo Kronecker asked me tlie 
question, " How should butter be spread in a sandwich ? should 
the whole of it be put on one slice of bread, and the other slice of 
bread simjDly put over the top of it, or should the pat of butter be 
divided into two halves, and one of them spread on each piece of 
bread ? " I was uncertain how to reply. He answered the question 
himself, and said that "the butter should be divided into two 
halves, and one spread on each piece of bread, because, in this 
way, the butter is more minutely subdivided, and thus not only 
gives a more agreeable taste, but is more readily digested." In 
buttered toast, we get the agreeable taste from the minute sub- 
division of the fat, but the advantage obtained from this is more 
than counterbalanced by the difficulty in breaking up the toast, 
which I have already mentioned. 

In regard to butcher's meat, also, there are great differences, 
depending both on the kind of meat used and its condition at the 
time of cooking. I mentioned in my first lecture, that meats 
which have short, easily disintegrated fibres, such as fish, the 
breast of a fowl, or mutton, are much more readily digested than 
those having long or tough fibres, such as beef. But a great deal 
depends, also, upon the condition of the meat at the time of 
cooking. I once got a most useful lesson on this point. I went 
into a restaurant, and ordered a beef-steak, as I had previously got 
them exceedingly good and tender at the same jDlace. But that ' 
day, all my efforts to masticate the steak were in vain, although I 
went on till my jaws actually ached with the exertion. On com- 
plaining to the waiter, and asking where he had got that tough 
o'd meat, he said it was not old, but, though young, it was too 
new. They had had an unusual number of customers that day; 
all the usual supply of beef-steaks had been consumed, and they 
had sent to the market for more, but had got back some meat 
killed that morning. Now, the old Romans, who were great 
epicures, used to eat still newer meat than this. They suffocated 
their fowls in wine, and cooked them forthwith. We see, then, that 
meat is tender under two conditions — (a) when it is perfectly freshly 
killed, and (&) when it has been kept for a sufficient time. If we 
analyse these conditions, we see that the essential point in them 
is simply this : meat which is cooked before rigor mortis appears, 
or after it has passed off, is tender ; but meat cooked while rigor 
mortis still exists is sure to be tough. 

In the case of game, the practice of keeping the meat until it is 



54 LETTSOMIAN LECTURES. [lect. 

tender has been overdone, and it is not unfrequently kept until it 
is actually commencing to decompose. The taste for " high " meat 
is an acquired one, and is, I think, a morbid one. It is also, I 
think, not without some danger, for not only may the products of 
decomposition formed in the meat, before it is cooked, be injurious, 
but decomposition will be rather apt to occur more readily in the 
intestinal canal. The gastric juice, no doubt, has a considerable 
antiseptic power, and so has the bile, but still these powers may be 
ove.taxed, and eating high meat is one of the ways in which this 
may be done. It is, however, rather extraordinary to what an 
extent the consumption of decomposing food may be carried 
without any immediate injury, as we see amongst the Esquimaux 
and Icelanders. 

The effect of keeping may, to a certain extent, be imitated by 
the application of a vegetable digestive ferment. In the West 
Indies, a tough beef-steak is rendered tender by rubbing it with 
the juice of a fresh papaw fruit, which contains a ferment, papain, 
having an action very much like the trypsin of the pancreas. 

Another cause of imperfect digestion is, I believe, bad cooking. 
Even if we leave out of account the actual physical detriment to 
the food in the way of hardness, or toughness due to bad cooking, 
the absence of a pleasant flavour will in itself tend greatly to 
interfere with digestion. 

The mere thought of agreeable food is sufficient to make the 
mouth water, not only in man, but in animals, I remember once 
seeing a striking instance of this. While walking one evening, I 
saw a dog sitting opposite the door of a butcher's shop, gazing 
intently at the meat inside. Two long strings of saliva were 
hanging down from its jaws, half-way to the ground. Its attitude 
of eager expectancy was so striking, that I could not help going 
into the shop to buy something for it ; but it was sitting almost 
dhectly in the doorway, so that my passing through disturbed its 
delightful dream, and off it went. 

We have already seen that the secretion of saliva is the first 
link in the chain of digestive processes. The saliva stimulates the 
secretion of gastric juice, and the gastric juice again stimulates the 
flow of bile, and possibly also of the pancreatic juice. Moreover, 
pleasant and repulsive food will act on the stomach through the 
brain; so that the idea of pleasant food will excite appetite, but 
the very idea of unpleasant food will excite disgust, and even bring 
on nausea and vomiting. Other things being equal, then, food 



HI.] COOKERY AS A MORAL AGENT. 55 

that is well cooked and savoury will be much more digestible than 
the same food cooked or served in an unappetising manner. 

Even in rec^ard to servinsf, there is much to be learned in this 
country from the French and Germans. In many a restaurant in 
London we find the table-cloths spotted and greasy, the salt-cellars 
and mustard untidy, the knives and forks dirty; and, as for a 
table-napkin, such a thing is in many of them unknown. In a 
French or German restaurant of a similar class, the table-cloth is 
very likely to be of coarser linen, but scrupulously clean ; everything 
would be put down in a tidy and appetising fashion, and a clean 
napkin would be served to each guest. The food itself may be no 
better, perhaps not so good, but the way in which it is served 
would make all the difference to a delicate appetite. 

In my first lecture, I spoke of cookery as a powerful moral 
agent, capable of influencing men's opinions and feelings to a very 
great extent. That food itself is a moral agent has been long 
recognised, and has found expression in the proverb, "A hungry 
man is an angry man ; " but that the moral influence depends on 
the way in which the food is cooked, as well as on the food itself, 
is not so generally admitted. And yet it has long been known, 
for we read that Isaac directed his first-born son, Esau, to prepare 
savoury meat, such as his soul loved, so that, after he had eaten 
thereof, he might bless his first-born with all the fervour of which 
he was capable. 

Considering the different effect upon the appetite of well cooked 
meat and of unsavoury food, it would be strange if they both 
excited equally pleasant feelings, and had an equally beneficial 
effect upon the temper. 

Some may think that, in speaking of cookery as a moral agent, I 
am greatly exaggerating its power ; and they may regard it as idle 
folly if I go still further, and say that cookery is not only a power- 
ful moral agent in regard to individuals, but may be of great 
service in regenerating a nation. Yet, in saying this, I believe I 
am speaking quite within bounds, and I believe that schools of 
cookery for the wives of working men in this country will do more 
to abolish drinking habits than any number of teetotal associations. 
I do not at all mean to say that the vigorous efforts of teetotal 
societies. Good Templars, Blue Ribbon Army, and others, have 
been altogether a failure, but I do not think that their plan will 
ever be crowned with complete success, and I believe there is a 
better way of attaining their object. 



56 LETTSOMIAN LECTURES. [lect. 

Supposing you go to visit a friend and find him taking a wet 
pack. He is lying in bed, wrapped up in blankets so that he cannot 
move hand nor foot ; a fly settles on his nose, and he begins mak- 
ing faces to try and remove it. You do not hke to see him make 
faces, and \vish him to stop. Which would be the most rational 
method of doing so ? Would it be to exhort him to summon all 
his fortitude to keep his face still, notwithstanding the annoyance, 
or would it be better for you to drive away the fly ? No doubt it 
might be an excellent moral training for him to use his self-control 
anvl keep his countenance placid notwithstanding the irritation, 
but the simpler and more effective method would be to drive away 
the fly. Moreover, in nine cases out of ten, his power of self- 
control would be insufficient ; and this is exactly what occurs with 
persons who have a strong desire for intoxicating liquors. 

Many years ago, I met, in a teetotal journal called the Adviser, 
with an account of an old drunkard, who uttered the bitter 
complaint, " The neighbours always speak of my drinking, but 
they never speak of my drouth." ^ The old man was in the right ; 
and, if we are to abolish drunkenness, we must remove the thirst 
which leads to drink. I have discussed the causes, physical and 
moral, of this thirst more at length elsewhere ; ^ and the only ones 
with which I shall concern myself now are bad food and imperfect 
cookery. In my first lecture, I mentioned that, so long as the food 
is only in the intestinal canal, it is still outside the body as far 
as nutrition was concerned ; and thus the malnutrition which gives 
rise to a craving for alcohol may be a consequence of imperfect 
digestion, as well as of an insufficient sup23ly of food. 

I have spoken of food and of cookery as moral agents, but a clear- 
headed clergyman in New York has perceived that dentistry may 
be a moral agent, and he has insisted on all the people attending 
his mission-chapel keeping their teeth in good condition. If any- 
one has bad teeth, he is sent to a dentist, who fills or extracts them 
as may be. needed. A dentist is supplied who does the work for 
nothing, if the patient cannot afford to pay. Since the clergyman 
adopted this plan, he has had very much less trouble from 
drunkenness in his conojregjation.^ 

The relation between the consumption of alcohol and the quality 

' Scotcli ■word for thirst. 

^ The Influence of Stimulants and Na'-cotics on Health. The Booh of Health. 
London : Cassell and Co. 

3 The New York Medical Record, February 24th, 1883, p. 224. 



III.] COLD WATER AS A STIMULANT. 57 

of the cookery has recently been mvestigated in Switzerland, and 
it has been shown that, where tlie food is insipid and unappetising, 
the people have recourse to a glass of " schnaps " to make up for 
the deficiency.-^ 

We have no experiments at present to show how savoury and 
unsavoury food, respectively, affect the circulation in the brain; 
but it seems highly probable that savoury has a much more 
stimulating action than unsavoury food on the cerebral circulation. 
I have insisted a good deal upon the important vascular changes 
which are produced by the act of swallowing, and these changes 
appear to afford an explanation of some curious phenomena. It is 
frequently stated that a glass of beer, slowly sipped, will intoxicate 
a man ; whereas, the same quantity, sw^allowed at a draught, will 
have little or no effect. I do no not know how far this is true, but 
it is not the kind of statement that would be readily invented, so 
that I think there must be foundation for it in fact. We can easily 
see that the disturbance of the circulation, consequent upon frequent 
sipping, may so aid the effect of the alcohol that intoxication may 
ensue, although the alcohol alone could not have produced this 
effect. But, while frequent sipping may be thus used, on the one 
hand, to produce intoxication, it may be employed, on the other, in 
the cause of temperance. Some time ago, I saw in an American 
periodical a cure for drunkenness. The person was advised, when- 
ever the craving came on, to sip a glass of cold water. At first 
sight, this may seem a poor substitute for a glass of whisky, and 
very unlikely to remove the craving for alcohol; but, as I have 
mentioned in my first lecture, a glass of cold water, slowly sipped, 
has more effect upon the pulse than a glass of brandy swallowed at 
a draught ; and may therefore be a very efficient substitute, indeed, 
for alcoholic beverages. 

To prevent any misunderstanding on this point, I should 
mention that the effect of sipping upon the pulse is not a 
permanent one ; it lasts while the sipping is continued, if the sips 
be taken at short intervals ; but it passes away after the sij)ping 
ceases. While its effect upon the pulse is thus greater for the 
time than that of alcohol, it is much less permanent. When I 
wrote my paper on "Nervous Depression as a Consequence of 
Dyspepsia" (p. 255), the effect of sipping upon the action of the 
vagus had not been discovered, but its stimulant action had been 

1 Die Erndhrungsiceise cler arhcUendcn Klassen in der Scliwciz. ton Dr. Sckulcr. 
1884, Bern. Staiupflisclie Buchdnickerei. 



58 LETTSOMIAN LECTURES. [lect. 

observed clinically (I believe by Sir Andrew Clark) ; and I then 
recommended that a glass of soda-water, with or without the juice of 
a lemon squeezed into it, should be slowly sipped when the feeling 
of weakness came on, and a biscuit eaten along with it, if desired. 

But, besides cooking and mastication, we have to consider a 
most important question — the kinds of food which a person may 
eat. In a healthy man, the best guide, both as to quantity and 
quality, is the appetite. Food that is eaten with a relish is, as 
a rule, wholesome ; and sometimes it is rather astonishing to find 
how people's instincts guide them to what is suitable for them, 
in utter defiance of all a loriori notions. As Dr. Austin Flint 
very sensibly puts it, "the diet should be regulated by the 
appetite, the palate, and hj common sense." 

Too great a regulation of the diet is sometimes very injurious ; 
and this, I believe, is more especially the case in persons of a 
nervous temperament. I have already mentioned that some cases 
of acidity^ and even of severe pain, do not depend upon any 
abnormal acidity of the gastric juice, nor of the contents of the 
stomach ; nor yet do they depend upon any imperfection in 
digestion, for Leube has found that, in such cases, digestion is 
often performed very thoroughly and rapidly indeed. The pain 
in these cases depends upon hypersesthesia ; and, if the patient 
begins to cut down his diet, one article after the other may 
disappear, and the mischief will only become worse. The nervous 
system becomes more and more irritable as the blood becomes 
more impoverished, and the system may break down completely 
from inanition. In such cases, as I shall have afterwards to 
mention, forced feeding, or, as we may term it, stuffing the patient, 
is of the greatest possible service. 

But, as Dr. Flint wisely puts it, the palate and the appetite 
alone will not serve as reliable guides to the quantity and quality 
of food. They must be regulated by common sense, or, in other 
words, by experience. We find this in the case of animals. A 
horse turned loose into a field of new clover may eat so much 
as to kill himself by over-distension of the stomach and intestines. 
A cow turned loose for the first time into a pasture in which 
colchicum, or other poisonous plants, grow, may eat of them at 
first, and be ill in consequence ; but, after it has become acquainted 
with their injurious action, it will avoid them. The appetite 
which regulates the quantity of food, and the palate which regu- 
lates its nature, must both be trained; and we must also use 



m] ''GRABBING FOOD"— TABLE UHOTE. 59 

our experience, in order to make sure that we do not misinterpret 
their demands. When a person has been fasting for many hours, 
his appetite becomes ravenous, and he is ajDt to eat far more than 
is good for him. We are sometimes apt to treat ourselves as we 
occasionally treat others, and be in too great a hurry to gratify the 
demands of our own ai)petites, as well as to answer the questions, 
or grant the requests made to us by others. Solomon says of 
the man who hastens to reply to a question before he has fully 
heard it out, that, "it is a folly and shame to him," and the same 
is true of the way in which we sometimes treat our appetite. 

I remember once hearing a story of a boy who stole a marble. 
On his mother chiding him and asking him whether his con- 
science had not told him not to touch the marble, the penitent 
culprit said : " No, mother, I grabbed quick." He had not given 
his conscience time to speak, and we frequently treat our appetites 
in like manner. 

Let us take the ordinary case of a man who has breakfasted at 
eight in the morning, and has had nothing to eat till seven at 
night. He sits down with a voracious appetite, and gorges himself 
until he becomes semicomatose, and resembles a bloated boa- 
constrictor rather than a rational being; or else his overloaded 
stomach rebels, and a fit of violent vomiting and purging induces 
his relations to send in a hurry for their medical man, and urge 
him to come with the utmost sf)eed, for So-and-so is dying of 
cholera. Yet the poor appetite was not to blame. The nervous 
system had been starved and wanted food; but, as I have al- 
ready insisted more than once, food in the stomach is outsido 
of the body for the purposes of nutrition, and requires to be 
absorbed before it is available for the wants of the organism. No 
doubt the stomach, as it became gradually distended, informed 
the brain, through its nerves, that food was on its way. But still, 
this was not sufficient, and the appetite remained unapjjeased. By 
the time enough food has been digested and absorbed to satisfy 
the cravings of the nervous system, too much had been put into 
the stomach to its detriment. 

If, instead of hurrying the food down, the person had been 
content to eat slowly, with intervals between his courses, as, for 
example, if he had been put down to a table d'hote abroad, the 
chances are that the dinner would have done him no harm, for the 
long intervals between the courses would have allowed some of the 
food first taken to be digested and absorbed long before the end 



60 LETTSOMIAN LECTURES. [lect. 

of the dinner was reached ; and the craving appetite being thus 
lessened, the temptation to overeat would have been removed. 
Not unfrequently we hear people say that they are well when 
living abroad and dining at a talle d'hote, although the food that 
they get there is not nearly so good as what they get at home. 
The reason, in all probability, is, that they are obliged to spend 
more time over their meal, and are unable to swallow it down, or, 
as the Americans phrase it, "to get oitside of it" so quickly 
as they can at home. 

The remarks of Dr. Beaumont in regard to the question of 
appetite, as a regulator in eating, are so apposite that I shall 
quote them. Since they were written, medical opinion has passed 
to the opposite extreme from that which he denounces, and starving, 
rather than stuffing, has become the fashion. A reaction has set 
in against the starving system ; but let us hope (although we can 
hardly expect) that it will not pass bej^ond the just views of 
moderation which Dr. Beaumont advocates. He says : " There- is 
no subject of dietetic economy about which people err so much as 
that which relates to quantity. The medical profession, too, has 
been accessory to this error, in giving directions to dyspeptics to 
eat until a sense of satiety is felt. Now, this feeling, so essential 
to be rightly understood, never supervenes until the invalid has 
eaten too much, if he have an appetite which seldom fails him. 
Those even who are not otherwise predisposed to the complaint, 
frequently induce a diseased state of the digestive organs by too 
free indulgence of the appetite. Of this fact, the medical profes- 
sion are, generally, not sufficiently aware. Those who lead seden- 
tary lives, and whose circumstances will permit of what is called 
free living, are peculiarly obnoxious to these complaints. By pay- 
ing particular attention to their sensations during the ingestion of 
their meals, these complaints may be avoided. There appears to 
he a sense of perfect intelligence conveyed from the stomach to 
the encephalic centre, which, in health, invariably dictates Avhat 
quantity of aliment (responding to" the sense of hunger and its 
due satisfaction) is naturally required for the purposes of hfe ; and 
which, if noticed and properly attended to, would prove the most 
salutary monitor of health, and effectual preventive of disease. It 
is not the sense of satiety, for this is beyond the point of healthful 
indulgence, and is Nature's earliest indication of an abuse and 
overburden of her powers to replenish the system. It occurs 
immediately previous to this, and may be known by the pleasur- 



III.] APPETITE AND PALATE. 61 

able sensation of perfect satisfaction, ease, and quiescence of body 
and mind. It is when the stomach says enough ; and is distin- 
guished from satiety by the difference of the sensations — the 
former feehng enough, the ktter too much; the first to be pro- 
duced by the timely reception into the stomach of proper aliment 
in exact proportion to the requirement of nature, for the perfect 
digestion of which a definite Cjuantity of gastric juice is furnished 
by the proper gastric apj)aratus. But, to effect this most agreeable 
of all sensations and conditions — the real Elysian satisfaction of 
the reasonable epicure — timely attention must be paid to the pre- 
liminary processes, such as thorough mastication, and moderate or 
slow deglutition. These are indispensable to the due and natural 
supply of the stomach at the stated periods of alimentation ; for, if 
food be swallowed too fast, and pass into the stomach imperfectly 
masticated, too much is received in a short time, and in too 
imperfect a state of preparation, to be disposed of by the gastric 
juice." ^ 

Appetite and palate have both their own work to do in regulating 
the C[uantity and quality of the food ; but each of them requires, 
as Dr. Flint says, to be regulated by common sense, for otherwise 
they sometimes disagree, and the pleased and tickled palate some- 
times endeavours to force down a much larger quantity of savoury 
food and delectable dishes than appetite declares to be either 
necessary or good for the organism. Sometimes the palate is 
tempted simply by savoury dishes at meal-times, but sometimes 
idleness adds to the temptation. Dr. Combe very sensibly remarks 
on this point : " But it is with idle people as with children. 
Leave them without occupation, and their chief amusement will 
then be derived from the- indulgence of their appetites. Hence 
the prevalent pastime of forenoon visits to the pastry-cook's, where 
the appetite is indulged with as little regard to the real wants of 
\he system, or the condition of the stomach, as if digestion were 
meant merely as an appendage to taste. Many young persons do 
themselves serious injury in this way, and then complain loudly of 
the discomfort Avhich attends the subsequent indigestion of a heavy 
dinner. To relieve the weakness, arising not from exhaustion, 
but from the oppression of satiety, they resort to wine, as if, by 
adding fuel to the fire, they could reasonably hope to extinguish 
the flame." ^ 

1 Beaumont, Ex2xriments and Ohscrvations on Digestion. 

2 Combe, Physiology of Indigestion, ninth edition, by James Coxe, M.D., 1849, p. 77. 



62 LETTSOMIAN LECTURES. [lect. 

When pushed beyond a certain point, the aj^petite rebels, and 
" the fall soul loatheth the honeycomb ; " but before this point is 
reached, a good deal more than enough may have been eaten ; and 
if the same process be rejoeated every day, serious mischief will 
ultimately result, and the more accommodating the appetite is, the 
more serious will the mischief be. Many a man has been saved by 
a weak stomach, which punished its owner by sickness or headache 
Avhenever he tried to overburden it, and thus checked his tendency 
towards excess at the very outset. Where the stomach and intes- 
tines are more accommodating, and continue to digest all that is 
put into them, the burden of the work is shifted elsewhere, and 
either the liver fails to reconstruct the new material with which it 
is deluged, or the tissues are poisoned, and the overworked kidneys 
become degenerated. 

The palate, like the appetite, sometimes makes demands'which 
are apt to be misconstrued. As the late Professor Laycock observed, 
patients recovering from a severe illness not unfrequently have a 
strong desire for salt herrings, pork, or ham, things which would 
be almost certain to disagree with them if their appetite were 
indulged. But the fact is that the patients do not want the pork 
or herring; what they really desire is salt, and they crave for_ these 
articles because they contain salt. If salt be given to them in the 
form of a mixture, their appetite is aj^peased, and the harm is 
avoided which the herring or ham might have caused. 

If we were to attempt to lay down a diet-table, containing all 
the things that a person, whether healthy or dyspeptic, may eat, 
the task would be endless ; it is much simpler to say what he may 
not eat. The oldest diet-table in the world might have been a 
very long one if everything that might be eaten had been named ; 
whereas it was very short — " Of every tree in the garden thou 
mayest freely eat, but" — and here follows the one exception, of 
which Adam might not eat without injury. The next diet-table 
is still more extensive, "Every living thing that moveth shall be 
meat for you, even as the green herb have I given you all things ; 
but" — and here again comes the single exception — "the flesh 
with the life thereof, which is the blood thereof, shall ye not eat." 
In a third diet-table, intended not for mankind generally, but for 
people under peculiar conditions, we still find the same rule 
followed ; the foods that were to be eaten being classed together 
under one or two sweeping definitions, and only a few exceptions 
mentioned by name. Dyspeptics may be regarded as a peculiar 



III.] DIET FOR DYSPEPTICS. C3 

class of people, requiring fuller instructions as to diet than healthy- 
people, and a few general directions to them are by no means 
out of place. Thus, they may be directed to avoid new bread, 
buttered toast, muffins, and pastry, all of which are difficult to 
disintegrate, and sweets, which may undergo acid fermentation. 
They may be told to eat fish, or to prefer meat which has a short 
fibre, like mutton, chicken, or game, rather than to take those 
meats where the fibres are long and tough, like beef. 

There are some substances taken as food which are utterly 
indigestible. We know that prehistoric man was fond of straw- 
berries, because the seeds of some, which a man, ages and ages 
ago, had eaten and voided unchanged, still remain to inform 
us of the fact. Most seeds, when whole, are indigestible; 
and on this quality, indeed, their distribution over the earth's 
surface depends. Even when broken, like the kernels of nuts 
or almonds, they are sparingly digestible; and the same is the 
case with the skins of fruits, and the harder fibres and the stalks 
of vegetables. 

Where the intestines are slow to act, such things as strawberries, 
raspberries, figs, nuts, prunes, and apples, may be allowed, and 
even recommended; but, where the intestines are irritable, all 
such things must be forbidden. Acid fruits are not only indigestible 
in themselves, but are apt to leave irritation behind; and Dr. 
Beaumont found that, an hour after giving St. Martin some raw, 
ripe, sour apples, the stomach was full of fluid and pulp which was 
quite acrid, and irritated the edges of the fistulous opening, "as 
is always the case when he eats acescent fruits or vegetables." 
The acrid condition went on increasing to the end of an hour and 
a half, and, at the end of two hours, the mucous membrane 
appeared irritated, although the apple had passed out of the 
stomach into the intestine, probably in an undigested condition, 
and, as we know in other cases at least, it would then be apt 
to produce diarrhoea. 

Some drinks are peculiarly liable to cause indigestion; amongst 
these are sour wines, some kinds of beer, and tea. Sour wines, 
especially if taken regularly, are apt to bring on a condition of 
gastric catarrh ; and, in certain conditions of the system, a single 
glass even of good wine appears to act almost like poison. It 
seems to undergo acetic fermentation in the stomach, and produces 
acidity, discomfort, or pain. I do not know what these conditions 
of the stomach are in which a single glass of good wine will produce 



64 LETTSOMIAN LECTVRES. fLEOT. 

this effect, even in persons to wliom it is not usually injurious. 
I have noticed, however, that sometimes this tendency to acidity 
is associated with a hypersesthesia of the mucous membrane of the 
oesophagus, so that p ortor sherry causes an unpleasant burning feel- 
ing all the way down the gullet, while usually nothing more would be 
felt than a pleasant warmth, if any sensation were observed at all. 

Tea is very apt to cause a feeling of acidity and flatulence. 
Sometimes the acidity comes on so soon after the tea has been 
taken, that it is difficult to imagine that the feeling can be due 
to any actual increase in the acidity of the contents of the stomach. 
It seems much more probable that the feeling is due to some effect 
of the tea, either on the sensory or motor nerves of the stomach, or 
perhaps on its muscular fibres. Tea in the afternoon, two or three 
hours after lunch, will sometimes bring on acidity almost immedi- 
ately; and I am inclined to think that this is due either to its 
producing increased sensibility of the gastric mucous membrane, 
or, what is perhaps still more probable, to its altering the move- 
ments of the stomach, so that the mucous membrane of the cardiac 
end of the oesophagus becomes exposed to the action of the contents 
of the stomach. These are much more acid two hours after a meal 
than they are immediately after it; and they will thus produce 
a much more irritating action upon a sensitive mucous membrane. 

Tea contains a quantity of tannin, as we can readily perceive 
by the black spot which a drop of it will leave upon a steel knife, 
and it contains also caffeine and volatile oil. The effect of the 
tannin is to interfere very considerably with the digestion of fresh 
meat ; and there are many people in whom tea, taken along with 
fresh meat, will upset the digestion. It does not interfere with 
the digestion of dried meat, such as ham and tongue; the fibres 
of these having already become shrunk and toughened in the 
process of curing.^ Tea at breakfast is not so apt to cause 
indigestion, probably because bacon or tongue are more frequently 
taken along with it at this meal than fresh meat, and also because 
the long interval which has elapsed between breakfast and supper 
or dinner allows the stomach to become completely empty before 
any new food is put into it. 

A part of the mischief wrought by tea in the lower classes is 
due to their allowing it to infuse for a long time, so that a large 
quantity of tannin is extracted. This danger may be avoided by 

^ J. W. Eraser, Action of Infused Beverages on Fe'ptia Digestion, Joimi. of Anat. 
and Physiol., vol. xviii. p. 31. 



III.] TEA AND COFFEE— FATIGUE. 65 

simply allowing boiling water to stand in the tea-pot for five 
minutes or so, and then pouring it off into another tea-pot, where 
it may be kept hot for a length of time without undergoing any 
change. Another reason is that they drink it extremely hot. 
Heat is a powerful stimulant to the heart, and a cup of hot tea is, 
therefore, much more stimulating and refreshing than a cold one ; 
for not only does the hot tea act more powerftdly on the heart 
through the nerves of the stomach, but the heat will reach the 
heart directly through the thin diaphragm. The practice of sipping 
the tea almost boiling hot is, however, apt to bring on a condition 
of gastric catarrh. 

Coffee does not affect the stomach to such an extent as tea. In 
its preparation, however, a substance called caffeon is produced ; 
and this, along with the caffeine which is present in both coffee and 
tea, appears to dilate the abdominal vessels, and cause a feeling 
of fulness in the abdomen, with a tendency to piles in some 
persons. 

Cocoa is less liable to cause acidity or abdominal discomfort 
than tea and coffee ; but, when continued for some time, it is apt 
to give rise to those symptoms already described under the head 
of biliousness. In all probability, this depends partly on the 
amount of fat it contains, as cocoatina, from which the fat has 
been removed, is less likely to produce the symptoms than 
chocolate. 

Another cause of imperfect digestion is fatigue. When we 
start on a walk, it does not matter much whether the road be 
rough or not ; any little obstacle is avoided with ease, and we 
thread our way over rough stones, through tangled heather, or over 
a quaking bog, without difficulty. Our nervous system is in full 
vigour, and preserves perfect co-ordination amongst the movements 
of the different parts of the body ; so that one helps the other, and 
all difficulties are surmounted. But when we are tired, the case 
is very different ; a little roughness in the road will cause us to 
stumble, and an unexpected stone may give us a sudden fall. The 
wearied nervous system no longer co-ordinates the movements of 
the various parts of the body, so that they no longer work together 
for a common end. 

The same thing occurs with the various parts of the intestinal 
canal. In my first lecture, I described the mechanism by which 
the acts of chewing and swallowing appeared to act as stimulants 
to the circulation and nervous system, and thus to ensure the 

F 



6Q LETTSOMIAN LECTURES. [lect. 

proper co-ordination between the functions of tlie moutli, stomach, 
intestine, and liver. But, if the nervous system be exhausted by 
previous fatigue, or debilitated by illness, the requisite co-ordina- 
tion may not take place, and indigestion or biliousness may be the 
result. How often do we find that the meal taken by a person 
immediately after a long railway-journey disagrees with him, and 
either causes sickness, diarrhoea, or a bilious headache. Forty 
winks after dinner is by no means a bad thing ; but forty winks 
before dinner is frequently much better. How often do men who 
have been working hard all day, with their mental faculties con- 
tinually on the stretch, go home and have dinner forthwith. 
Exhausted as they are, how can they expect to digest properly 
what they eat ? Almost the only saving poiijt is, that many of 
them live some distance from their j^lace of business, and have a 
short time during the homeward drive to sit still and rest. This 
is sufficient for some, especially for young men ; but it is insuffi- 
cient for elderly men, and they ought to make a point of having a 
little rest at home before dinner. Some men, unfortunately, are 
so misguided as to believe that exercise after a hard day's work 
will do them good; and, instead of utilising the little time they 
have for rest after a day's labours are over, they walk three or 
four miles, or take a tricycle-ride of several more, before dinner. 
The consequence is that, under the combined mental and physical 
strain, their digestion is impaired and their strength broken 
down. 

Effects, somewhat similar to those of fatigue, may be produced 
by depressing or disturbing mental emotions, or bodily conditions. 
We know how readily excitement of almost any kind will destroy 
the appetite in some people, and depressing emotions will do it in 
almost every case. We not unfrequently hear of girls in whom 
consumption appears to have been brought on by an unfortunate 
love affair. If we accept the view that consumption depends upon 
the presence of the tubercle bacillus, we might, at first sight, think 
that there can be little or no connection between consumption and 
disappointed love ; but the depressing effect of the disappointment 

1 Amongst tlie good old-fasliioned precepts of liealtli, not the least important is — 
** After dinner rest a while." I have lately seen an illustration of its utility in a 
patient who invariably finds albumin in his urine if he begins work (as an analytical 
chemist) immediately after dinner. A rest of twenty minutes, or even of twenty-five, 
IS insufficient to prevent the occurrence of albumin, but if he rests half an hour or 
more the urine remains perfectly free from albumin even after a considerable amount 
of work. 



in.] EMOTIONAL DYSPEPSIA. 67 

will lessen the digestion, impair the nutrition, and render the body- 
more likely to afford a suitable nidus for the bacillus. 

Different emotions appear to affect specially, not only different 
organs, like the heart and intestinal canal, but different parts of 
the digestive apparatus. Thus, disgust affects the stomach, causing 
vomiting ; fear is seen, in some of the lower animals, to affect the 
rectum, causing defsecation ; compassion affects the small intestine, 
producing borborygmi ; ^ worry and anxiety, although they act upon 
the stomach and lessen ai^petite, appear to have a very special 
influence upon the liver. They sometimes produce jaundice, and 
not unfrequently cause glycosuria ; indeed, most of the cases of 
diabetes that one meets with in middle-aged persons appear to 
originate in worry or anxiety. 

In treating cases of indigestion, or its consequences, due to 
injurious mental influences, the depressing cause must be removed 
if possible. If this cannot be done, change of air and scene, with 
exercise short of fatigue, and in the open air, are serviceable. 
Bromide of potassium, either alone or combined with bromide of 
ammonium, is very useful, both in lessening the sensibility of the 
nervous system to worry, and in procuring sleep, for as Shakespeare 
truly says : 

" Sorrow's weight doth heavier grow 
Tlirough debt that bankrupt sleep doth sorrow owe." 

It is sometimes difficult to distinguish exactly between depression 
that may be called purely mental, and depression due to physical 
causes. I have already spoken of the mental depression due to 
disorders of the liver, but disorders of the genital organs are also 
apt to give rise to mental depression, and to digestive derange- 
ments. It is difficult to say whether the genital troubles give rise 
to mental dej)ression through the medium of the digestive system, 
or wliether they disturb the digestion through the emotions ; at all 
events, dyspepsia due to uterine and other genital disturbances 
is not to be overlooked. Uterine dyspepsia ^ presents the usual 
symptoms of nervous dyspepsia, epigastric pain, acid eructations, 
and sometimes vomiting after each meal. The bowels are not 
unfrequently much constipated. 

Here, also, the first thing to do is to remedy, if possible, the 
condition of the uterus ; next, to lessen the nervous excitability by 

^ Isaiah xvi. 11, and Ixiii. 15 ; 1 John iii. 17. 
2 Keiu York Med. Ecc, and Kisch, Berlin, klin. Wochenscli., No. 18, 1883. 

F 2 



68 LETTSOMIAN LECTURES. [lect. 

bromides or other sedatives, and to clear out tlie intestines by 
means of purgatives. 

We are sometimes too much inclined to regard digestion as a 
process which goes on in the intestinal canal only, and to forget 
how very intimately it is related to the other functions of the 
body. But we cannot rightly understand either the pathology of 
indigestion, or the action of remedies, unless we constantly bear in 
mind the intimate relation which exists between the alimentary 
canal and the rest of the body. 

In the treatment of indigestion we employ several classes of 
drugs, one of which is known as gastric tonics. These consist 
chiefly of vegetable bitters. There can be no doubt whatever 
about their practical utility, but it is not very easy to say hoAV 
they act. They increase the appetite, lessen flatulence, and tend 
to diminish the discomfort and languor which are apt to accompany 
indigestion. It is possible that part of this effect is due to their 
power of lessening putrefaction; but there can be little doubt that 
they have other actions which are not yet thoroughly understood. 
One of the most useful of all is nux vomica ; and the great benefit 
derived from its use is probably due to its stimulating action on 
the nerve-centres by which the co-ordination of the digestive 
processes is rendered more perfect. 

Another class of remedies is that of carminatives, which tend to 
disperse flatulence. Amongst the most powerful of these are 
ethers and volatile oils of various kinds, which probably act by 
increasing the movements of the stomach and intestines, and 
altering them in such a way as to allow the gases they contain to 
escape upwards or downwards. In addition to these, however, we 
have other remedies which, probably, act in a different way. 
Charcoal lessens flatulence, and is generally supposed to do so 
by absorbing gases in the stomach. But the power of charcoal to 
absorb gas is very slight when it is wet ; and as it will be wetted 
by the fluid in the stomach after it has been swallowed, it probably 
has but a very slight absorbing effect on the gases there. It is 
much more probable that it acts merely as a mechanical stimulant, 
and that its use in the stomach is similar to its use as a tooth- 
powder in the mouth. In the healthy stomach, the layer of mucus 
which covers the lining membrane is very thin ; but, in abnormal 
conditions, the mucous membrane may be covered with a thick 
coating of slimy mucus, which will tend to prevent absorption. 
The mechanical action of the charcoal will tend to remove this 



iTi.] STIMULANTS, THEIR PLACE AND POWER. G9 

coatino-, and at the same time the friction which it exerts on the 
mucous membrane will tend to increase the flow of blood through 
the vessels; charcoal will thus aid absorption in a double way by 
removing the mucus, and by increasing the circulation. If this idea 
regardiug the action of charcoal be correct, we should expect that 
other inert powders would have a similar action, and this, I think, 
is the case. Subnitrate of bismuth, for example, is so insoluble, that 
it probably acts to a great extent mechanically ; binoxide of man- 
ganese has a similar action; and cases of dyspepsia are reported which 
have been successfully treated by the administration of fine sand. 

1 should not venture to say, however, that preparations of bis- 
muth act in a mechanical way only, for soluble preparations of 
bismuth such as the citrate have a sedative action. Moreover 
arsenic and bismuth belong to the same chemical group, and a 
small quantity of arsenic, such as one drop of Fowler's solution, 
given before meals seems to have a sedative action somewhat 
resembling that of a comparatively large dose of bismuth. 

Closely allied to carminatives are stimulants, and foremost among 
these come alcohols and ethers. Ether, although perhaps the most 
powerful of all, is used less frecpently alone than alcohol, but ethers 
mixed with alcohol, in the form of wines, are very frequently 
employed indeed. 

The question of the employment of stimulants is one which has 
been greatly discussed, and which is apt to give rise to much excite- 
ment. Some would utterly abolish stimulants of every kind, while 
others would not only use them, but abuse them. 

There is a great deal of practical truth in the definition of dirt 
as "matter in the wrong place." The white paint which gives 
brightness and cleanliness to the woodwork of a house, ceases to be 
clean, and becomes dirt, when it sticks to a lady's dress ; and the 
pipeclay which the soldier uses to clean his belt dirties his uniform. 
So long as alcohol is in its place, it is beneficial ; when it is out of 
place, it becomes hurtful. The difficulty here is to define the place 
for alcohol. Some would deny that it has any place at ah, and 
assert that it is utterly injurious at all times, and in all places. 
But such assertions are valueless ; they contradict the common 
experience of mankind, and defeat their own end by their extrava- 
gance. It is no use to deny the existence of facts, for they will 
continue to be facts, w^hether we allow them or not. What we 
have to do is to open our eyes to their existence, and regulate 
our conduct accordingly. 



70 LETTSOMIAN LECTURES. [lect. 

' The question of the general use and abuse of alcohol is far too 
large to be entered upon here, and I have already considered it 
at some leugth in the paper which I read before the Society 
(p. 140), and which received its approval, as well as in others which 
I have written subsequently.^ The substance of the opinion which 
I have always held is, that so long as a man is young and healthy, 
he does not rec[uire alcohol, and is better without it. I think it 
better in every way for people to abstain entirely from the use of 
alcohol until they reach the age of manhood. 

I do not think it a sin to use alcohol in moderation as a luxury, 
provided always that it be used in moderation, not only for the 
individual, but for the individual at the particular time at which 
it is taken, for what is moderation at one time would be excess 
at another. 

In my first lecture, I described the advantage that I had 
derived from a good dinner with plenty of wine. I partook freely 
both of the food and wine, yet I did so in what was moderation 
for me on that particular occasion. I was exhausted with over- 
work, and depressed by the effects of a cold, and neither the 
food nor the wine caused undue excitement at the time of dinner, 
nor injurious effects afterwards. Had I repeated this dinner 
frequently — let us say every night, twice a week, or even at longer 
intervals — 07- had I even taken it when in health, the quantity 
of food and wine — which was moderate for me at the particular 
time that I took that dinner — would have been excessive, and 
I should probably have suffered accordingly. 

In regard to the use of alcohol in dysjDepsia, I think St. Paul's 
advice to Timothy is very good, "Drink no longer water, but 
use a little wine for thy stomach's sake, and often infirmities." 
It is not the young and strong who require wine, but the infirm 
and the aged. In many cases, attention to the rules I have given 
in regard to rest before dinner, to mastication, and to the quantity 
and quality of food, will do away with the necessity for any 
additional stimulus to the stomach in the way of alcohol. But 
I think there can be no doubt that, even when all these things 
are attended to, there are some persons who are the better for 
a little wine at dinner. These are generally, as I have said, 
either elderly, or a little below par. When I say below par, I 
mean in reference to their surroundings, for some of them may 

1 The Action of Alcohol. Contemporary Reriew, Vol. XXXIII. p. 691. The 
Influence of Stimulants and Narcotics on Health. The Boole of Health : Cassell & Co. 



III.] USES OF PURGATIVES. 71 

be very much above their fellow-men, physically or mentally, and 
yet be below par in reference to their work, or to the surroundings 
which put upon them such a heavy strain that they require some 
additional stimulus to help digestion. 

It is impossible to lay down a rule for the quantity necessary, 
for this will vary not only with every individual, but with the 
individual at different times. The stimulant which is most generally 
useful is probably claret. "With some persons sherry does well, 
but with others it is apt to cause acidity, a good deal of the 
difference being due to the kind of sherry, or so-called sherry, 
used. In the most severe cases of dyspepsia, brandy-and-water, 
or whisky-and-water, usually agree better than wines of any 
sort. 

The methods we have considered hitherto in regard to the 
treatment of dyspepsia have had reference to the increase of 
assimilation, to the way by which we may put more fuel on the 
furnace cf life ; but the methods we have now to consider are — 
how are we to remove the ashes, the products of waste which 
would choke the fire and extinguish the life ? The combustion 
necessary to functional activity takes place in the organs them- 
selves, and not in the intestines, and it might be more correct 
to consider tissue-change, and the action of drugs upon it, before 
we discuss the drugs which act on the intestine ; but, from another 
point of view, the latter is, perhaps, the more convenient. 

The next class of drusfs actincr on the intestinal canal which we 
will take up is that of purgatives (p. 188). 

It is evident that a regular action of the bowels is important, 
not only by removing the indigestible residue of food, and thus 
preventing ffecal accumulation, but by getting rid of some injurious 
products which have been formed during the process of digestion. 
It seems strange that one so frequently finds headache as the 
result of slight constipation, lasting perhaps only a few hours ; 
whereas, in constipation lasting for weeks, it may be entirely 
absent. This observation seems to me to afford additional support 
to the hypothesis I have advanced, that headache is due, in part 
at least, to poisonous products formed in the intestine and absorbed 
from it, for Brieger noticed that it was only in the first stages 
of albuminous decomposition that alkaloids were formed, and 
afterwards these seemed to disappear. In constipation, it seems not 
unlikely that poisonous substances are first formed and absorbed, 
but that they afterwards become either decomposed or excreted by 



72 LETTSOMIAN LECTURES. [lect. 

other channels, and thus the effect which they at first produced 
afterwards diminishes, or disappears entirely. 

We sometimes find persons in whom movement of the bowels 
takes place at very long intervals, and I have met with several 
such cases. During the time I was Casualty Physician at St. 
Bartholomew's, I must have seen 100,000 patients, reckoning that 
I saw each patient on an average three times. At first, I was 
accustomed to ask the question, " Are your bowels regular ? " but I 
afterwards gave this up, because I found it Avas ambiguous. One 
day, I asked this question of a young woman, and she answered, 
"Yes, sir." I then asked, "How often are they open?" and she 
replied, "Once in three weeks, sir." Her answer to my first 
question was perfectly correct, for her bowels were regular, but the 
term regularity conveyed a different meaning to her and to me. 
This was an exceptional case, but I met with a number whose 
bowels were open only once a fortnight. In one case, they were 
only open once in three months, and the patient objected to take 
any laxative medicine whatever, as this was her normal condition. 
Such cases of constipation, occurring without any marked injurious 
result, are generally due to the fact that the patients live almost 
entirely upon food which leaves little or no indigestible residue, 
and which contains no excess of nitrogen. Most of the cases 
which I have seen were in women who lived chiefly upon bread, 
butter, with a little tea, sugar, and milk, the greater part of which 
would be entirely digested and absorbed, passing off as carbonic 
acid from the lungs, and as urea by the kidneys. In most 
cases, however, especially among people who are better fed, 
constipation of this sort is likely to be followed by very injurious 
results. 

Where the bowels are habitually constipated, a most useful thing 
is to give a small aloetic pill before the last food of the day, dinner 
or supper, as the case may be. This slightly increases the peristaltic 
movements of the stomach and intestines, which would naturally 
be induced by the food itself; and the use of such " dinner pills " 
may be continued for very many years together without the least 
impairment to the general health. 

There are fashions in purgatives, as well as in anything else ; 
and among the fashionable purgatives at present are the saline 
natural waters, or the salts obtained from them. These are best 
given the first thing in the morning, and should be either warmed 
or given along with warm water. When crystallised salts are used. 



III.] PATHOLOGY OF BILIOUSNESS. 73 

such as Carlsbad salts, the quantity of water taken with them is of 
considerable importance. One-third to a half a tea-spoonful of the 
salts, in a large tumblerful of hot water, is usually sufficient to 
produce one loose motion immediately after breakfast ; but a larger 
quantity of salts with a smaller quantity of water often causes 
abdominal disturbance, discomfort, or even pain, with several small 
motions at intervals throughout the day. Where evacuation of 
the bowels only is desired, the saline solution may be taken at a 
single draught; but when we wish it to act upon the liver, it 
should be taken in sips during dressing. 

It is a matter of common observation that cases of hepatic 
disorder are benefited by a visit to Carlsbad, although Carlsbad 
salts or water have been productive of little benefit when used at 
home. But then they are used in very different ways at home and 
at the spring itself. In Carlsbad, the patient rises early in the 
morning, and promenades before breakfast, to the sound of music, 
for an hour, slowly sipping the water at intervals. I have already 
mentioned the jDOwerful effect of sipping upon the heart, but it has 
also an effect upon the liver. It has been shown that water, slowly 
sipped, not only increases the amount of bile secreted, but causes 
it to be secreted under higher pressure, so that, if any slight 
obstruction should be present in the bile-ducts, it will be overcome, 
and the bile will flow freely into the bowel.^ 

It so happens that pharmacology, or the study of the action of 
drugs, takes us deeper into the secrets of the body than pure 
physiology or j)athology ; and I must now touch upon one cause 
of biliousness which I omitted before, namely, alteration in the 
condition of the bile itself. In a previous lecture, I discussed the 
effect on the vessels of the liver which might be produced by 
substances absorbed from the intestine ; and I mentioned, in relation 
to it, the possible action of alkaloidal compounds formed in the 
intestine. I did not discuss the possible action of such compounds 
on the nature of the bile secreted, yet I believe this to be a very 
important condition indeed. 

We observe two kinds of biliousness, or rather, perhaps, I ought 
to say, biliousness with two different conditions of biliary flow. In 
the one kind, the stools are clay-coloured, from the absence of bile; 
in the other, the stools are either normal, or are dark-coloured 
from excess of bile. 

Now, certain bodies belonging to the aromatic series have a 

1 Zawilski, Sitzungsler. d. Wiener AJcad., 1877; Mat. Kat. AUg., Ed. iv. p. 73. 



74 LETTSOMIAN LECTURES. [lect. 

very remarkable action upon tlie secretion of bile. Salicylate of 
soda is a powerful hepatic stimulant, not only greatly increasing 
the quantity of bile, but rendering it much more watery than 
before. By thus liquefying the bile it may be useful in biliousness 
with increased viscosity of the bile, and also in cases where there 
is a tendency to the formation of gall-stones. 

Other substances of the aromatic series, especially toluylendia- 
mine, on the other hand, greatly increase the quantity of solids in 
the bile, and, indeed, do so to such an enormous extent that the 
bile becomes* so thick and viscid that it will no longer flow through 
the biliary capillaries, and jaundice is the result. Before it has 
become so thick and viscid that it will not flow at all, a part of it 
may escape into the intestines, and give to the f^cal masses a very 
dark colour. 

We do not yet know whether a similar action on the liver is 
exerted by substances — we may, perhaps, say poisons — formed 
during the process of digestion in the intestine. If such substances 
are formed, their formation might be consequent on something 
wrong, in the food which had been taken, or on some disturbance 
of secretion or absorption, or might be due to foreign organisms 
having been taken into the intestinal canal, and having produced 
there abnormal decomposition. Every now and again we find a 
number of people living in the same house suffering from jaundice, 
without any cause that we can discover ; but probably it is due to 
their having either partaken of injurious food, or having been exposed 
to injurious influences, especially to the ingestion of microzymes. 

There can be no doubt that a blue pill and a black draught, or 
a few grains of calomel, have a most beneficial action, not only 
upon the stomachy where Dr. Beaumont was able to see the 
morbid changes disappear under their influence, but upon the body 
generally. The benefit thus obtained is usually ascribed to the 
cholagogue effect of the mercurial sweeping bile out from the body 
before time has been allowed for its reabsorption. Probably this 
is, to a great extent, the correct explanation, but recent researches 
render it not improbable that mercurials have another action, 
namely, an antiseptic one, in the intestinal canal, and that a good 
deal of the benefit derived from their use is really due to their 
preventing the formation of injurious products. 

If the hypothesis I have advanced be correct, that the bile is 
sometimes rendered thick and viscid by the action of certain pro- 
ducts of digestion upon the biliary secretion, we would naturally 



in,] TREATMENT OF TORPID LIVERS. 75 

expect that anything which will assist the bile to flow through the 
ducts into the intestine will be beneficial. Now, Lord Palmerston 
very truly remarked that " the outside of a horse is the best thing 
for the inside of a man ; " and a brisk ride in the morning is better 
for most people than any amount of mercurials or salts. It is not 
merely that the person gets exercise, for a constitutional walk will 
not have a similar effect. It is the kind of exercise, the liver being 
mechanically compressed, during riding, by the diaphragm on the 
one hand, and the abdominal muscles on the other, so that bile is 
actually squeezed out of it. "Where riding exercise cannot be had, 
rowing, or even its imitation in the gymnasium, has a somewhat 
similar action ; and when people are unable to get exercise at all, 
massao-e over the liver will tend to lessen the accumulation of bile 
within the ducts. 

Closely connected with cholagogues and hepatic stimulants, is 
another important class of drugs, namely, alteratives (p. 223). 

AYe are only beginning to have some vague idea of how 
drugs act which belong to this class. INitrohydrochloric acid is a 
favourite remedy, and a very useful one in biliousness. We cannot 
yet say precisely how it acts, but it no doubt does affect the tissue 
change in the liver. The reason for supposing this is that acids — 
nitrohydrochloric acid among others — appear again in the urine in 
the form of ammoniacal salts, and the ammonia with which they 
are combined appears to be the representative of so much nitro- 
genous waste, which, instead of being converted into urea in the 
liver, has combined with the acid, and been excreted as ammonia. 
This indicates that acids act upon the liver, although, as I have 
just said, we do not yet understand their precise mode of action. 
Clinically, however, we find that nitrohydrochloric acid is exceed- 
ingly useful in persons who are troubled by eructations of sul- 
phuretted hydrogen ; and it not only removes the taste of rotten 
eggs which is so disagreeable, but lessens the depression of spirits 
which frequently accompanies this form of dyspepsia. It is also 
useful in oxaluria and depression of spirits, even when no dis- 
agreeable eructations are present. Ammonia also has a powerful 
action on the liver, and chloride of ammonium has been strongly 
recommended in hepatic disease. It is only within the last year 
or so that we have learned anything definite about the action of 
ammonia on the liver; but it has now been shown that some ammo- 
niacal salts increase the formation of glycogen.^ Our knowledge of 
} r. Eohmann, Centralblatt f. klin. Mcdecin., 1884, No. 36. 



76 LETTSOMIAN LECTURES. [lect. 

alteratives, at present, consists only of a few isolated facts, but, 
before long, we may hope to have a more perfect understanding of 
their mode of action, and, consequently, be able to apply them 
more successfully in disease. 

Another class of remedies which are also useful in indigestion 
is diuretics. Although these have no very direct action on the 
intestinal canal itself, they not only alter tissue-change in the 
body, but> affect the nervous system, through which the digestive 
processes are co-ordinated. In some cases of gouty dyspepsia, 
large quantities of hot water are exceedingly useful, both by 
relieving dyspepsia itself and by getting rid of any urinary irrita- 
tion. The diuretic action may be increased by the addition of 
alkaline salts; and effervescent citrate or tartrate of potash is 
useful both as a diuretic and as a local sedative to the stomach ia 
neurotic or gouty gastralgia. 

By the frequent use of water as a diluent, either alone or with 
salines, the consequences of indigestion in regard to the lungs, 
heart, and head, may be often averted or remedied. 

Asthma occurring in gouty subjects is, perhaps^ best treated by 
a mixture of bromide and iodide of potassium ; and the addition 
of a little arsenic is said to increase its effect. 

In cases of intermittent pulse, bromide of potassium is frequently 
very useful, though one of the best remedies for it is one which I 
believe was prescribed by the late Dr. Warburton Begbie, and con- 
sisting of two grains of powdered rhubarb, ten of subnitrate of 
bismuth, one and a half of nux vomica, and three of compound 
cinnamon-powder. This should be taken before meals; and, if 
there is much acidity, ten grains of bicarbonate of soda, or of 
magnesia, may be added to it. It may be given either in water, 
or, what is, perhaps, pleasanter, wrapped in a wafer and swallowed 
along with a little water. 

Giddiness, as I have said, frequently takes the place of headache 
in persons of middle age suffering from biliousness, and both head- 
ache and giddiness are frequently connected with disorders of 
vision. 

The most common causes of headache, indeed, are decayed teeth 
and inequalities of vision. Where the teeth are decayed, rinsing 
the mouth out with a lotion of bicarbonate of soda, or applying a 
little cucaine to the exposed pulp, will relieve the headache, and 
especially if combined with the use of a saline purgative. In many 
so-called bilious headaches, the eyes, as I have mentioned, are very 



III.] TREATMENT OF DIGESTIVE DISORDERS. 77 

tense, and tender on pressure. Such headaches are not unfrequently 
relieved by the use of small doses of salicylate of soda, half a grain 
in an ounce of water being taken every quarter of an hour or half 
an hour. How this acts, it is impossible at present to say ; for, 
though it possibly acts on the eyes themselves, its utility may also 
be due to its action upon the hepatic secretion (p. 74?). Inequality 
of the visual power in the two eyes is an exceedingly common cause 
of headache ; and I have sometimes found that a sick headache 
may be arrested, even after the well-known zigzags have become 
visible, by putting on a pair of spectacles which will ec|ualise the 
eyes ; or, perhaps even better, one which will compensate the weak 
eye, and throw the strain upon the other. Mr. Bendelack Hewet- 
son ^ has succeeded in removing migraine by paralysing the power 
of accommodation by atropine. 

In sjDeaking of the disorders of digestion, I have left to the last 
one of the most important methods, and one which sometimes gives 
results little short of miraculous. This method was first introduced 
to the profession in America and England by Dr. Weir-j^litchell, in 
his book on Fat and Blood., and How to Maize Them, but in this 
country it obtained little notice, until it was taken up by Dr. 
William Playfair. It consists essentially in passive exercises and 
abundant feeding. We ail know how active exercise increases the 
appetite. Tissue-change goes on more rapidly in the organs, waste 
is more abundantly excreted, and more food is eagerly sought for. 
But there are many feeble flabby persons who cannot take exercise, 
or if they can, will not. Moreover, there are others who are quite 
willing to exercise the voluntary muscles of the limbs, but cannot 
exercise the involuntary muscles of their internal organs. Now, 
treatment by massage helps both of these. It increases the nutri- 
tion, both of the voluntary muscles and of the internal organs ; and 
under its use patients, apparently hopelessly incurable, completely 
recover. Dr. Playfair has had wonderful success with cases of 
hysterical women ; but I have been most struck with the success 
of the treatment in the case of a man in whom all medical treat- 
ment had proved useless. This patient, whom I first saw about 
two years and a half ago, in consultation with Dr. Image, of Bury 
St. Edmunds, was a very tall, powerfully-built man, who had been 
accustomed to outdoor life, and much active exercise. He had at 
one time suffered from asthma, but this had left him, and he 

1 Bendelack Hewetson. — The Relation between Sick Headaches and Defective 
Sight. — Fam'iMet. Leeds, 1885. 



78 



LETTSOMIAN LECTURES. 



[lect. 



became liable to attacks of pain and vomiting. I was inclined to 
look upon the case as one of neurotic dyspepsia, but other phy- 
sicians, who had been consulted, both in this country and on the 
continent, regarded it as tubercular peritonitis. For two years he 
continued to become more and more emaciated, until at length he 
was reduced to the appearance of a living skeleton. Only once in 





Fig. 7. — This figure, wliich is taken from a 
photograph kindly given to me b}^ the 
patient for the purpose of engraving, 
shows his condition before Dr, Play- 
fau- begun to treat him by massage. 



Fig. 8. — This figure, also taken from a 
photograph, shows the patient's con- 
dition after massage. 



my life do I remember seeing a man so thin, and that was a person 
who was exhibited in a show. Dr. Playfair was at first doubtful 
about undertaking the case ; but as Dr. Image and I were anxious 
that he should do so, he kindly agreed, and in the course of eight 
weeks our patient was a different man. Under the use of massage 



III.] TREATMENT OF DIGESTIVE DISORDERS. 79 

and forced feeding, his muscles enlarged, until now he might 
perfectly well join a Highland regiment, and wear a kilt, without 
being ashamed. His muscles, which had almost entirely dis- 
appeared, have not only become of a normal size, but they are as 
hard as pieces of wood ; and from being a simple skeleton, he is 
now a well-developed man.^ 

From the hasty sketch that I have given of the disorders of 
digestion, their consequences and treatment, in these lectures, it 
will, I think, appear that^ although our knowledge of the subject 
is still very imperfect, a large number of observations have been 
accumulated, which we may hope will, before long, enable us to 
understand the pathology more fully, and treat these disorders more 
perfectly. 

1 This patient wrote me a letter regarding massage, wliicli is so important that I 
quote it. He says, "AVill you allow me (as one who Tcnoivs, having undergone the 
whole thing) to very strongly recommend you not to attempt any case without 
insisting on isolation. This is of the utmost im'portance. Do not attempt half 
measures or you will find the case will fail, and you will become disheartened . Eveji 
in my own case, though I was most anxious to get well, I feel sure it would not have 
succeeded had I tried it at home." Notwithstanding this advice I have tried half 
measures, and have found my patient's prediction verified by the failui'e of these 
attempts. 



MISCELLANEOUS ESSAYS. 



ON HEADACHE, NEURALGIA, 

AND OTHER NERVOUS DISEASES 
CONNECTED WITH THE TEETH. 

{Transactions of the Odontological Society of Great Britain, 1880.) 

The paiu of toothache locahsed in a decayed tooth is unfortun- 
ately so common that every sufferer diagnoses it for himself, and 
although it may be reckoned amongst the nervous disorders 
connected with the teeth, I need not say anything about it. 

But toothache may be associated with other pains, or may even 
be replaced by them, and then the diagnosis is by no means so 
easy. The true cause of the pain may, indeed, remain unsus- 
pected even by competent medical men, and their treatment may 
consequently be comparatively ineffectual. My attention was 
first drawn to the connection between decayed teeth and nervous 
disorders having little or no apparent relation to them by an 
incident which occurred a good many years ago, when I Avas a 
student. I had just heard that one of the best means of relieving 
toothache was to insert a pledget of cotton- wool, dipped in melted 
carbolic acid, into the cavity of the aching tooth, care being, of 
course, taken to squeeze out the superfluous acid, and to cover the 
pledget with some clean wool, so as to protect the tongue. I was 
very anxious to test the information I had received, and shortly 
afterwards an opportunity presented itself. A maid-servant had 
complained for some days of headache in the left temple of a 
severe neuralgic character, and associated with this was a certain 
amount of toothache, which was, however, less complained of than 
the headache. I plugged the offending tooth with cotton-wool 
dipped in melted carbolic acid, but was greatly disappointed to 
find that it produced little or no apparent benefit. In less than 
half-an-hour, however, the girl informed me that the pain in the 

G 2. 



84 ON HEADACHE, NEURALGIA, ^c. 

temjDle and the toothache were both entii^ely gone. Their 
disappearance was not due to the carbolic acid having required 
time to exert its action, but to its having been apphed to a 
different point. The girl had taken it out of the cavity of the 
decayed molar into which I put it at first, and transferred it to 
another tooth, of which she had not complained, and which I had 
not suspected. Immediately the pain disappeared, both from the 
tooth and the temple. 

In this case pain was felt in the tooth as well as the head, and 
the headache might be looked upon as simply irradiation of the 
pain from the tooth. But that headaches may occasionally depend 
upon caries of teeth in which no pain whatever is felt, is, I think, 
shown by what once happened in my own case. I had been 
suffering from migraine, the pain being limited to a spot in the 
left temple. There was tenderness on pressure on one spot, below 
and in front of, the parietal eminence. On several occasions I had 
noticed that the left eyeball was tender on pressure ; but one day 
I was suffering from headache, and jet found that the eyeball 
was not tender. I pressed my finger all over my face in the 
endeavour to find a second tender spot, and at last I found one 
under the angle of the jaw. But the tenderness here was due to 
a small gland, which was hard and painful to the touch. Hard- 
ness, enlargement; and tenderness in a gland generally indicate 
more or less inflammation in it, and the most probable cause of 
such a condition is, of course, the irritation excited in the gland by 
foreign matter conveyed to it by the lymphatic vessels. I accord- 
ingly began to examine the mouth and teeth from which the 
Ijmiphatic vessels proceeded to the gland in question. Nothing 
abnormal was to be noticed in the lips, cheeks, tongue, or gums, so 
I tested the teeth by percussion with a blunt steel jDoint, and on 
the posterior aspect of the last molar on the left side of the lower 
jaw I found a spot which was very slightly tender. I accordingly 
went at once to a dentist, and learned that caries had just begun 
at that spot, but had not caused any cavity whatever. I had 
never suffered the least pain in the tooth, and but for the headache 
which led me to percuss the teeth systematically I should in all 
probability never have suspected the caries until it was far gone. 
The connection which was here found to exist between temj)oral 
headache and a decayed tooth is, I think, interesting, not only as 
showing a causal relation between the caries and the headache, but 
as helping to explain the pathology of migraine. 



PATHOLOGY OF MIGRAINE. 85 

A good deal has been written on this subject, and there is a 
considerable diversity of opinion amongst different writers. Pro- 
fessor du Bois Reymond, who suffered a good deal from it, attributed 
it to spasm of the vessels, for he found that, during the pain, the 
temporal artery became tense and hard, like a piece of whip-cord, 
and the pupil of the eye on the affected side dilated as if the 
symj^athetic in the neck had been irritated. Others have discarded 
this explanation, because they found that the vessels, instead of 
being firmly contracted, were distended widely, and throbbed 
violently, and they have attributed the pain in the head to the 
congestion of the vessels. 

These two explanations of the pain of migraine, the one attri- 
buting it to ansemia, and the other to congestion, are apparently 
irreconcilable. My own case gives, however, I think, an explanation 
of the discrepancy. Both statements are correct, but both are 
incomplete, and the reason is that their authors have only observed 
the arteries during a part of their course, instead of tracing them 
backwards to the large trunks from which they sprang, and 
onwards to their smaller ramifications. In my own case, I have 
found that on some occasions the temporal artery was hard and 
contracted, like a piece of whip-cord, as described by du Bois 
Reymond. On others I found the temporal artery widely dilated 
and pulsating violently, and yet I could distinguish no difference 
between the pain I felt on these different occasions. So, not 
contented with noting the condition of the temporal artery only 
at its middle, I followed it onwards to its smaller branches, and 
backwards to the carotid. 

Then I found that a constant vascular condition existed durinsf 
the headache, notwithstanding the apparent differences in the state 
of the temporal artery. This constant vascular condition consisted 
in dilatation of the artery at its proximal, and spasmodic contraction 
at its distal, extremity. The carotid artery was almost invariably 
dilated and throbbing. Sometimes the dilatation would extend 
as far as the trunk of the temporal artery, but sometimes the 
temporal was contracted. Even when the temporal artery was 
dilated, if I only followed it to its smaller ramifications they were 
found to be firmly contiacted and cord-like. If one may reason 
from this single instance, connecting as it does the examples of 
vascular dilatation and contraction given by other authors, we may 
say that the pain of migraine depends neither on contraction nor 
dilatation of the vessels i^cq" se, but upon dilatation of one part of 



86 Oy HEADACHE, NEURALGIA, 4-0. 

the vessel with spasmodic contraction of another, or, if we might 
so term it, ujDon a state of coHc in the vessels themselves. This 
irregular contraction of the vessel is almost certainly due to dis- 
ordered vaso-motor innervation. The cause of this disorder is to 
be sought in the sympathetic system, and the observation of du 
Bois Keymond regarding the condition of the iris may lead us to 
connect it with the cervical ganadia. From these ganglia, vaso- 
motor fibres proceed along the carotid and its branches, and if we 
regard disorder of these ganglia as the cause of migraine we are at 
once in a jDOsition to explain some of the symptoms which occa- 
sionally accompany it. Thus, I have observed that sometimes the 
pain in the temple would suddenly cease, and be replaced by pain 
in the occipital region. Sometimes, also, we have affections of the 
sight, such as general dimness of vision, diplopia, and spectra — 
coloured or uncoloured. The transference of pain from the temple 
to the occi^Dital region is probably caused by transference of the 
spasmodic contraction from the temporal to the occipital artery, and 
the disorders of the sense of sight we may reasonably regard as 
caused by alterations in the intercranial branches of the carotid, 
similar to those which we can detect by the finger in its tem- 
poral branch. The disturbance in the sympathetic system, which 
I regard as the cause of migraine, may not always have its 
origin in the teeth ; it may, and very probably does, sometimes 
originate in the eyes, but in the instance which I have already 
noted as occurring in my own case, the irritation started from the 
lymphatic gland, on or about which branches of the sympathetic 
probably ramified. The tooth itself, although the real cause of the 
sympathetic irritation, did not produce it directly, but indirectly. 
From the root of the tooth the lymphatics conveyed irritating 
matter to the gland, and the irritation here excited acted in its 
turn as a disturber of the sympathetic nerves which furnish the 
vaso-motor supj)ly to the carotid and its branches. 

The connection between dental caries and neuralgia was first 
noticed by Neucourt,-^ and he gives rules for diagnosing a causal 
relation between caries and neuralgia. When the pain, which is 
at first widespread, gets localised, in the course of a few days, 
in the dental region, and is succeeded by redness, swelling, and 
tenderness on pressure of the gums, the neuralgia is almost 
certainly of dental origin. In these cases the patients are 
restless, and the pain is more or less constant, with no distinct 
^ F. Xeucourt, Arch. Gen., Juin, 1S19. 



LARYNGEAL PAIN. 87 

intermissions; tlie pulse is more frequent and hard, and there 
is not unfrequently sweating. If the pain is followed by a gum- 
boil, the tooth, he thinks, is certainly decayed, although it should 
present no appearance of caries, and this he considers to be also 
the case if the tooth appears longer than the others and is painful 
on percussion. Tenderness on percussion is considered by Richter ^ 
to be the most certain sign. The diagnosis may be assisted by 
noticing whether the neuralgia when disappearing lingers longest 
in one of the teeth. 

The exact pathology of neuralgia has not yet been settled, but 
A^alleix, one of the great authorities on the subject, gave as its 
distinctive points the presence of spots which were tender on 
pressure, and the effect of pressure in increasing the pain. These 
spots have been noticed by Neucourt^ in neuralgia depending 
upon dental irritation, and he has also observed the absence of 
increased pain on pressure in true neuralgia, so that no distinction 
can be drawn betw^een neuralgia due to dental irritation and 
neuralgia depending upon other causes. 

Although the most frequent seat of pain due to carious teeth 
is the temporal region, yet, as one would expect, we find it also 
in parts of the neck. A few weeks ago I was consulted by a 
lady regarding her throat. She had pain opposite the upper part 
of the thyroid cartilage on the right side, and thought that she had 
inflammation at that point. Laryngoscopic examination showed 
the larynx to be perfectly healthy, but I found one of the molars 
on the same side as the painful spot to be extensively diseased. 
The pain from wdiich she suffered, I have little doubt, was caused 
by the decayed tooth ; but, as she refused to have it extracted 
or stopped, I could not absolutely verify my diagnosis. I put 
her upon a course of tonics and the pain almost completely 
disappeared. 

This would be said by some to prove my diagnosis to be wrong ; 

fur if the pain depended on the presence of a carious tooth, how 

could it disappear while the tooth remained unattended to ? But 

we must always remember that the actions which take place 

in the animal body are not so simple as those which occur in 

the test-tube of a chemist. Yet even in the test-tube we require 

more than one reagent to produce a reaction; and if one of the 

substances or conditions necessary for the reaction be absent, it 

^ Eicliter, Schmidt's Jahriiiaher, 1850-4, xy. p. 46. 
2 F. Neucourt, Arch, Gen., Oct. to Dec, 1853; Jan., 1854. 



88 ON HEADACHE, NEURALGIA, 4-c. 

does not occur, even thougli other conditions be present. In the 
same way we know that a decayed tooth does not always cause 
toothache, and that toothache, when present, may frequently be 
removed by the use of a saline purgative. The tooth still remains 
as a source of irritation, but the state of the nervous system has 
been so altered by the purgative, that pain is no longer produced 
by the irritation. In the same way we may not uufrequently 
relieve the neuralgia originating from decayed teeth by a judicious 
course of aperients and tonics. This is so far advanta,geous to the 
patient, as it relieves him from pain ; but it is, on the other hand, 
disadvantageous, inasmuch as it causes the medical man to over- 
look the real source of the evil, and allows the dental caries to 
proceed instead of having it arrested by suitable stopping. In 
the case I have just mentioned, the pain in the larynx, which 
I attributed to the decayed tooth, did not lead to any change 
in the nutrition or functions of the larynx. Pointis,^ however, 
records a case in which, after severe toothache, the patient suddenly 
lost his voice, and the aphonia was followed by anorexia, cough, 
wasting, and feverishness, which led to the belief that he was 
suffering from laryngeal phthisis. But the lungs were sound, and 
there was no tenderness over the larynx. There was slight 
inflammation of the pharynx, all the molars on the left under- 
jaw were decayed, and the gums and periosteum around them 
were swelled. The teeth were removed, the gums cauterised, and 
gargles employed. On the very day the teeth were extracted, the 
suffocative spasms which had troubled the patient abated, and on 
the following days the other symptoms quickly disappeared. 

The irritation caused to the larynx by the j)rocess of dentition 
is well recognised, and has led to the employment of the term 
teething-cough. The existence of a real causal connection between 
couo'h and teething has been doubted ; but there are cases on 
record which seem to show that this really does exist. One very 
marked instance of this sort has been recorded by Paasch.^ A 
child, four months old, had a paroxysmal laryngeal cough, during 
which it was nearly suffocated, ojaening its mouth and throwing 
the head back. Narcotics were of no use. The gum of the lower 
jaw was swelled, and vesicular swellings ajjpeared at the part of 
the gums corresponding to the middle incisors. These increased 
in size and became dark, livid, translucent, and fluctuating. 

^ Pointis, Journ. dcs Conn. Med. Prat., Sept., 1846. 
* Paasch, JowrTi. of Kindcrkr., 3, 4, 1856. 



COUGH; DEAFNESS; BLINDNESS. 89 

During their groAvth, the cough increased ; but when the right 
incisor came through the gum, and one vesicular swelhng broke, 
the cough ceased. After twenty-foar hours it again began, though 
less violent than before. After some days the second incisor came 
through, the second vesicle burst, the cough at once began to dis- 
ajDpear, and at the end of two days had entirely and for ever gone. 

From the close connection that exists between the throat and 
the ear we would expect deafness to be not unfrequently the con- 
sequence of dental irritation. It seems, however, not to be very 
frequent, although it does exist, as shown by the following case 
recorded by Koecker.-^ A man,' aged forty-eight, suffered from 
suddenly-increasing deafness ; but after his teeth, which were 
carious, and had caused suppuration of the gums, were extracted, 
he completely regained his hearing. 

The eye is much more frequently affected than the ear, and 
blindness is by no means an uncommon result of dental decay. 
Mr. Jonathan Hutchinson has recorded some cases of this, and he 
regards the blindness as reflex, and analogous in its causation to 
essential paralysis of children. The sight is suddenly lost, but 
there are no cerebral symptoms. The optic nerve is sometimes 
atrophied, but sometimes not. The blindness is generally pre- 
ceded for a long time by facial neuralgia, associated with tooth- 
ache. A more striking case than any of Mr. Hutchinson's is 
recorded by Dr. De Witt.^ A perfectly healthy man, aged thirty- 
one, suddenly noticed, in attempting to fire off a gun, that his right 
eye was completely blind. He had neither pain nor subjective 
appearances of light in the eye. He was able to distinguish light 
from darkness with it, but nothing more. No cause for this blind- 
ness could be discovered until twelve years afterwards, when it was 
found that the patient had several teeth stopped two months before 
his blindness. For a long time afterwards he suffered from pain 
and tenderness in the first molar of the right side. The gums 
swelled and ulcerated, and frequent abscesses formed, which he 
opened with his knife. The stopping was at length removed from 
the tooth, and this at once relieved the irritation of the gums, and 
increased the power of sight. In three weeks, however, when the 
sight had already become considerably better, the gums again 
ulcerated, and the sight became immediately w^orse. The decayed 
tooth was then extracted, and the sight became permanently 

^ Koecker, Med. CMr. Rev., Jan., 1843. 
2 De Witt, American Journ., N.S., ex., p. 382, April, 1868. 



90 ON HEADACHE, NEURALGIA, ^-c. 

improved, althougli it never became quite so good as that of tlie 
other eye. 

The connection between the teeth and the sight has been long 
pojDularly recognised in the name of " eye-teeth " given to the 
canines, and this seems to depend on no popular superstition, but 
on a real scientific fact. It is believed by many that the extraction 
or decay of a canine leads to loss of sight, or inflammation in the 
corresponding e^^e, and the j)hysiological experiments of Magendie 
and Schiff substantiate this belief. 

Magendie divided the inferior maxillary branch of the fifth, and 
Schiff divided the lingual and inferior dental branches without 
injury to the ophthalmic branches.^ The dimness of vision pro- 

^ In his work on Plij'siology and Pathology, Schiff says: "Magendie, in 1838, 
showed, in one of his lectures, a smaU dog, in which he had divided the inferior 
maxillary branch of the fifth nerve some time previously. Hitherto," he said, 
"only those parts were affected to which the branch was distributed; but in the 
present instance disturbances of the visual power had appeared some days ago. There 
was no such opacitj' as that which follows section of the fifth pair of nerves in the skull, 
but only a little cloudiness between the lamellae of the cornea. Their transparency 
was not completely lost, but there was a condition intermediate between complete 
transparency and commencing opacity. It appeared to him, also, that the sensibility 
of the ej^es was somewhat altered. "When engaged in another research, I have divided, 
in a number of dogs, sometimes the lingual branch alone, and sometimes the inferior 
dental branch, high up at the j)oint where it branches off from the inferior maxillary 
nerve. Since here the nerve was exposed and divided outside the skull, neither injuiy 
nor compression of the ophthalmic branch is to be thought of. No doubt, by my 
method of operation, traction was exerted on the inferior maxillary branch which 
was seized by the forceps ; but the traction was exerted rather against the periphery 
than the centre, the dental branch being partly drawn out of its canal in the lower 
jaw. In most of the animals operated on, nothing remarkable was to be seen, but in 
about a thii'd of them (four out of eleven) an affection of the corresponding eye 
appeared from four to eight days after the operation, without my being able to 
discover any reason for this peculiarity in the way in which the operation had been 
performed. The conjunctiva became injected, and the injection went on increasing 
for two or three days, but never became so great as it does after division of the 
trigeminus. The eye was moist, and covered with a thin layer of the same mucus 
which is secreted so abundantly after paralysis of the ophthalmic nerve. The cornea 
did not become opaque, but exhibited a partial greyish dimness, which extended from 
the centre in irregular form, to a varying extent, sometimes towards the upper and 
sometimes towards the under edge. The eye exhibited no perceptible diminution of 
sensibility ; the pupil remained perfectly mobile, and exhibited all the usual syuergetio 
contractions on movement of the eyeball. 

" The dimness of the cornea increased for a short time, and in about twelve days from 
its commencement it disappeared completely, leaving tlie eye perfectly normal. 
During all this time the animals ware perfectly lively, and their general condition 
ui.dei'went no change. 

" On what do these peculiar phenomena depend ? Certainly on the weakening of the 
vasn -motor nerves in the district suppUed by the ophthalmic nerve. But, as this nerve 



TWITCHING EYELIDS. 91 

duced by these experiments is referred by Schiff to disturbance 
of the vaso-motor supply to the eye, consequent upon a partial 
paralysis of the ophthalmic branch of the fifth ; but as this nerve 
itself was not injured in the experiment, it is evident that the 
vascular alterations are of reflex origin, the irritation having been 
conveyed from the site of the wound to the nerve centres, and 
having there exerted such an influence upon them as to induce 
vascular changes in the eye. 

The eyelid may also be affected reflexly from the teeth. Some- 
times dental irritation may cause motor spasm, and at other times 
paralysis. A year or two ago I had the stump of a bicuspid tooth 
extracted from the right upper jaw. Almost immediately after the 
extraction I noticed a constant spasmodic twitching in the right eye- 
lid, which I was utterly unable to restrain. This lasted all the time 
the wound in the gum caused by the extraction of the stump was 

itself was not touched, some pathological process must needs have been propagated 
from the wound of the third branch towards the centre, and there have extended over 
the original district of that branch. This very general conclusion appears to me well- 
grounded ; for I cannot believe that in these cases the hypersemia of the ej^e on the 
side operated upon was due to chance, for this affection of the eye never occurred in 
any one of the numerous dogs which I kept under observation after other operations. 
The ophthalmic nerve here was not paralysed, for the phenomena were not very intense, 
and the sensitiveness of the eye had not suffered. 

" The explanation of this was all the more obscure, as I had previously convinced 
myself that no pathological changes could be discovered by the microscope in the 
central end of the divided nerve. Besides, I had performed the same operation on 
the third branch of the trigeminus in a great number of cats, and no affection of the 
eye occurred in them. I therefore utilised the opportunity of studying more care- 
fully the anatomical changes which are associated with this transitory condition, 
Avhich was afforded me in 1852 by two young dogs, which exhibited this dimness of 
the cornea after resection of the inferior dental nerve. The dogs were killed from 
six to ten days after resection of the nerve. The swelling and alteration of the 
divided end of the nerve were no greater than is usually the case after such resections. 
There was, as usual, an exudation of nucleated globules between the nerve-bundles in 
the neighbourhood of the wound. Neither the inferior maxillary, higher up, nor the 
ophthalmic, exhibited anything abnormal under the microscope. A slight redness of 
the coverings of the nerve immediately below the exit of the third branch from the 
cranium could only be regarded as accidental, and perhaps due to the traction on the 
nerve trunk during the operation — and all the more as this redness was greater in the 
animal killed on the sixth day after the resection, and in which the dimness of the 
eye was less than in the dog killed on the tenth day. In both animals, it appeared 
to me that within the cranium the arachnoid covering the pons on the operated side 
as well as the pons itself at the root of the fifth nerve, were more injected than on the 
corresponding parts of the other side. But any one who knows how inconstant and 
variable is the amount of blood inside the cranium will excuse me when I state this 
with considerable reserve. Both animals were killed Mnth strychnine." — Schiff, 
Untersiochungen zur Physiologie des Nervcnsystems mit JBerilcksicMigimg der Patho- 
lugie. Frankfort, 1855, p. 112. 



92 ON HEADACHE, NEURALGIA, ^c. 

open, but it ceased as soon as the gum had healed, and has never 
since returned, A case is recorded by Gaine ^ in which a carious 
tooth of the upper jaw had caused an abscess in the antrum. The 
right upper hd was paralysed, the pupil dilated, and there was no 
reaction. The optic nerve was pale, and the eye blind. On 
extraction of the tooth and puncture of the antrum the paralysis of 
the lid disappeared, although the eye did not regain sight. 

Spasmodic contraction of the masseters is another consequence 
of dental irritation. A few weeks ago a gentleman, over forty years 
of age, called upon me and told me that he was much concerned 
about a spasmodic affection of the jaw from which he was suffering. 
He was, in fact, afraid of lock-jaw. He felt obliged to keep his 
mouth open, because it seemed to him that if he once shut it he 
would not be able to open it again. I did not recollect having 
read any description of tiiis affection, but it seemed evident that it 
must depend either upon congestion of the cerebral centre for the 
movement of the jaw, which Ferrier locates at the lower end of the 
fissure of Rolando, or on reflex irritation from the mouth itself. 
The latter seemed to be much the more probable, and on looking 
into his mouth I saw that the teeth did not seem to be altogether 
in good order. I accordingly requested him to see a dentist, and, 
on inspection, the source, of irritation was discovered to be a wisdom- 
tooth, which was just making its way through the gum, but in a 
somewhat oblique direction, so that its crown was pressed against 
the molar in front of it. On louking up the literature of the 
subject, I discovered that this affection was pretty fully described 
by Germain,^ who recognised two causes of this form of trismus. 
The first is when the back molar is decayed, and a gumboil forms 
at its base, and the other is when the attachment of the masseter 
extends in front of the angle of the lower jaw, and the wisdom- 
tooth, in appearing, must break through its muscular and fibrous 
attachment. Colin ^ states that every year he sees at least one 
perfectly healthy individual become suddenly affected with 
spasmodic contraction of the masseters. There is no fever, but 
the contraction is so strong that only fluid nourishment can be 
taken. The contraction can be felt by running the finger over the 
masseter muscle. It gradually disappears in about eight or fourteen 
days. Little treatment is required except attention to the bowels, 

1 Gaine, Brit. Med. Joimi., Dec. 30tla, 1865. 

2 Germain, Gaz. Bcbcl., 1863, x. 7. 
3 Colin, Etudes CUniques de Medecine Militaire. 



INFANTILE PARALYSIS. 93 

and possibly, if tlie contraction be very severe, an injection of atropia 
into the muscular substance itself might be of service. 

We have already noticed paralysis of the eyelid as a consequence 
of dental irritation, and we have also discussed the pathology of 
temporal and occipital headache in relation to caries of the teeth. 
Sometimes, however, paralysis occurs of a much more extensive 
character, in consequence of dental irritation, especially in children. 
Teething is recognised by Komberg and Henoch as a frequent 
cause of paralysis appearing in children without any apparent 
cause.^ According to Fliess,^ paralysis of this sort occurs more 
commonly during the period of the second dentition, whereas con- 
vulsions generally occur during the first. Its onset is sudden. The 
child is apparently in good health, but at night it sleeps restlessly, 
and is a little feverish. Next morning the arm, or more rarely the 
leg, is paralysed. The arm drops ; it is warm but swollen, and of 
a reddish-blue colour. It is quite immovable, but the child suffers 
little or no pain. Not unfrequently paralysis is preceded by choreic 
movements. Sometimes recovery is rapid, but at other times the 
limb atrophies, and the paralysis may become associated with 
symptoms indicating more extensive disturbance of the spinal cord 
and brain, such as difficulty of breathing, asthma, palpitation, 
distortion of the face, and squint, ending in coma and death. 

It is only in very rare instances that we are able to gain any 
insight into the pathological anatomy of such cases, because they 
rarely prove fatal, and even when they do so the secondary changes 
are generally so considerable as to leave one in doubt as to the 
exact mode of commencement. This renders all the more valuable 
the case recorded by Fliess, in which a boy five years old, and 
apparently quite healthy, found his left arm completely paralysed 
on awaking one morning after a restless night. The arm was red, 
but the boy suffered no pain, and played about without pay in o- 
much attention to the arm. The same day he fell from a wao-o-on 
upon his head, and died in a few hours. Apart from the fracture 
of the skull, which caused his death, the anatomical appearances 
which were found were congestion of the spinal cord, and great 
reddening and congestion of the meninges, near the point of orio-in 
of the brachial nerves, where the veins were also much fuller than 
on the corresponding right side. There was no organic change 
perceptible, either in the spinal cord or in the brachial nerves. On 

1 Klinisclic TFaJirnchmungen und BeohacMimgen. 
2 i('iiess, Journ. dcr Kindcrkr., 1849, July and August. 



94 ON HEADACHE, NEURALGIA, Sfc. 

tlie other hand, the turgescence of the veins extended from the 
shoulder and neck up to the face, and was very striking in the 
sub-maxillary region. 

This vascular congestion seems to point to vaso-motor disturb- ' 
ance of a somewhat similar kind to that which we have already 
noticed in connection with occipital headache, or with migraine 
accompanied by subjective appearances of either form or colour. 

Dental irritation may give rise to choreic movements, occurring 
as the prodromata of paralysis or to chorea alone. This irritation 
may depend, according to Levick,^ either upon the second dentition, 
or upon dental caries, and the causal connection between the 
irritation and chorea is shown by the fact of its disappearing 
when the tooth pierces the gum, or when the carious teeth are 
extracted. 

According to Russell Reynolds,^ the second dentition is also a 
cause of epilepsy, and he has observed that those who are affected 
by it have often suffered from convulsions during the first dentition. 
A case is recorded by Albrecht ^ of a boy, aged twelve, who suffered 
daily for twelve months from general convulsions, which began in 
the temporal region and extended to the external auditory meatus. 
There was no decay in this instance, but the teeth were large, 
and the last molar on the right side had its crown jammed into 
the ascending ramus of the jaw. As soon as it was extracted 
the pain ceased, and the convulsions did not return. Another 
case is given by Mr. Castle * of a young man, aged nineteen, who 
had complained for four years of headache and pain in the eyes, 
stiff-neck, swelling, and numbness of the right arm. For the 
latter two years he suffered from general convulsions, which came 
on every two or three days, ending with vomiting, and often 
succeeded by partial deafness. All treatment was useless, and 
setons and blisters to the neck did no good. Nearly all the teeth 
were decayed ; nine were extracted, and almost all of them had 
matter at their roots. A gargle was given, with five grains of 
iodide of mercury twice a day, and a purgative twice a week. 
After the extraction of the teeth the fits entirely disappeared. 

In a case recorded by Lederer,^ the second left upper incisor was 
replaced in a young girl by an artificial tooth. Shortly afterwards 

1 Levick, Amer. Journ. of Med. Sciences, Jan., 1862, p. 40. 

2 Russell Reynolds's Lancet, July, 1848. 

3 Albreclit, Casper's Wochenschr., 1837. * Castle, Lancet, Jan., 1848. 

° Lederer, IVein. Med. Presse, vii. 24, 1866. 



DYSPEPSIA— DIARRHCEA. 95 

she became ill_, vomited everything, and suffered from convulsions. 
No remedy succeeded until the tooth was removed and short- 
ened. Immediately all the symptoms from which she had suffered 
di-appeared. 

Affections of the intestinal tract depending on dental irritation 
are of very considerable importance indeed. 

In adults many a case of dyspepsia is due to defective teeth. 
It may be partly caused by reflex affection of the secretory and 
motor nerves of the stomach and intestines, but partly also, 
without doubt, by the imperfect mastication of the food^ which 
is swallowed without being broken up on account of the pain 
or inconvenience which the act of mastication causes. In this 
way two evils are occasioned. First of all, the shortened sojourn 
of the food in the mouth allows no time for the secretion of 
saliva. From want of this the starchy constituents of the food 
are imperfectly digested ; and, moreover, deficiency of saliva also 
lessens the normal stimulus to the secretion of the gastric juice; 
for alkaline fluids, like saliva, stimulate the secretion from the 
stomach, and deficiency of saliva is accordingly followed by a 
deficiency of the gastric juice. But, secondly, imperfect masti- 
cation has a mechanical action in preventing perfect digestion, 
for the food, being swallowed in lumps, is not permeated by the 
digestive fluids, and thus cannot be dissolved in anything like the 
same period of time that it would otherwise be. 

The diarrhoea which comes on in children during dentition is 
well known, and is probably of a reflex character. It is probably 
produced through the gastric and intestinal branches of the vagus, 
and other branches of this nerve may be affected reflexly from 
the teeth. 

The close connection between the roots of the fifth nerve, and 
those of the vagus, can be demonstrated anatomically, and it is 
probably in consequence of this that irritation of the fifth is able 
to exert such a powerful influence upon the circulation. Some 
time ago, in a paper which I published in the British Medical 
Journal} I mentioned that one cause of death daring the extraction 
of teeth under chloroform was probably the stoppage of the heart's 
action through the inhibitory fibres of the vagus, associated with 
a reflex depression of tone in the blood-vessels. The reason why 
the extraction of a tooth in a person Avho is not under the influence 
of an anaesthetic, is followed by no ill effects, is probably this : 
1 Brit. Med. Joiirn., Dec. 4tli, 1875. 



96 ON HEADACHE, NEURALGIA, cj-c. 

that in Lim the irritation of the fifth nerve produces two distinct 
actions which counterbalance each other. It may cause reflex 
stoppage of the heart through the vagus ; but at -the same time 
it causes reflex contraction of the vessels through the vaso-motor 
centre. This contraction of the vessels maintains the pressure in 
the arterial system during the stoppage of the heart, and thus no 
harm whatever is done. When an anesthetic is used, however, 
one of these pieces of nervous mechanism may be paralysed by 
it, while the other is not, and thus the extraction of the tooth 
may stop the heart without causing contraction of the vessels. 
The blood-pressure will then sink very rapidly in the arterial 
system, and fatal syncope may be produced. If, however, the 
anaesthetic be pushed to a greater extent, so that both parts of 
the nervous mechanism just mentioned are paralysed, the vessels 
are not contracted, but neither is the heart stopped. The operation 
is therefore comparatively free from danger when no anaesthetic 
has been given, or when the ansesthesia is perfectly complete, the 
period of danger being that of imperfect ansesthesia. 

We have now seen how affections of sensation, of motion, and of 
nutrition may all be dependent upon dental irritation, but even 
the cerebral faculties themselves may also suffer from a similar 
cause. One or two very interesting cases of this sort are recorded 
by Dr. Savage in the Practitioner for June, 1876. The first of 
these was that of a farmer, aged twenty- two, with a strong family 
tendency to insanity. In May, 1875, he suddenly took to riding 
madly about the country without his coat and waistcoat. From 
May until November he was exceedingly noisy, destructive, untidy, 
almost constantly excited, and if for a day or two he was exhausted, 
he was sullen and more dangerous. In the middle of November 
he complained of very severe toothache that caused him to be 
sleepless. He bore this for two or three days, after which the 
stump was removed. There was suppuration at the root of the 
fang. From the time that the stump was extracted the patient 
steadily improved, and by the middle of December was quite well. 
Another case was that of a woman, aged thirty-four, who had a 
brother insane, and had herself been intemperate. She was 
admitted in September, 1875, suffering from acute mania. She 
was noisy, violent, and obscene. She continued to be so until 
January 20th, 1876, when she complained of great pain, with 
swelling, and redness of her right lower maxilla. She had some 
bad teeth, but did not complain of toothache. The pain and 



INSANITY. 97 

swelling increased, and at the same time she became quiet and 
reasonable. She said she could not remember much of her state 
of excitement. The swelling of her face subsided, and she 
remained quite well. This case, however, was not so convincino- 
as the first one recorded, because here there was a second possible 
cause of recovery, as she was pregnant, and said she felt quicken- 
ing about ten days before her recovery. The recovery^ however, 
was coincident with the jain and swelling of the face, and seemed, 
rather than the quickening, to be the cause of recovery. 



ON THE PATHOLOGY AND TREATMENT OF 
SOME FORMS OF HEADACHE. 

{St. Bartliolomew'' s Hospital Reports, vol. xix.) 

Of all the kinds of pain which afflict humanity, or at least 
civilised humanity, there is perhaps none which causes a greater 
amount of misery than headache. Although the pain of it may 
not unfrequently be slight, yet the number of people affected by 
it, the frequency of its recurrence, and the intensity which it some- 
times attains, raises the total amount of pain produced by it to 
such an extent, that the means of relieving or curing it becomes 
a most important therapeutical question. We all know that the 
part of the nervous system by which sensations either of pleasure 
or pain are perceived is in the brain ; for if communication 
between the head and the body or its parts is destroyed by section 
of a nerve or of the spinal cord, the individual is totally uncon- 
scious of any impressions made upon the periphery. The exact 
seat of sensation has been further localised by my friend Dr. 
Ferrier, who has ascertained that the destruction of the hippo- 
campal convolutions on the one side of the brain produces anaes- 
thesia of the opposite side of the body, so that neither pinching 
nor touching with a hot iron gives rise to any evidence of sensation. 
We may therefore look upon the hippocampal convolution as the 
seat of sensation, at least for the surface of the body, whatever may 
be the seat of sensation for internal organs. 

In a condition of health the sensory centres in the brain perceive 
no pain unless some injury is happening to a part of the body, and 
pain is thus a useful monitor, warning the individual to stop the 
mischief which is occurring before it be too late. In certain un- 
healthy conditions of the brain, however, the sensor}'- centres in 
the brain may be so affected that pain is felt although no injurious 



CENTRAL AND PErdPIlERAL PAIN— NEURALGIA. 99 

process whatever is occurring in any part of the body. Such a 
condition is probably the explanation of what we find in hysteria, 
when such intense pain may be felt in a joint, for example, as to 
induce the patient to insist upon the amputation of a perfectly 
healthy limb. In such a case as this the disease appears to be 
due entii-ely to alterations in the sensory centres in the brain, 
while the whole body appears to be healthy. I say aiJpears, 
because, even in such cases, it is possible, and indeed probable, 
that some morbid condition may be present which has escaped 
our notice, because there may have been little or nothing to direct 
our attention to it as the cause of the disease. But the sensory 
centres in the brain are securely lodged within the skull, and are 
not likely to undergo any morbid change unless it is started either 
by alterations in the quality or quantity of the blood circulating 
through them, or by impressions conveyed to them by afferent 
nerves. We find, as a rule, in the healthy body, that irritation 
of any part is felt in the place to which the irritant is applied, so 
that attention is consequently at once directed to it, and an effort 
made for its removal ; but this is not always the case, for even in 
the healthy body we find it is sometimes difficult to localise an 
impression. Perhaps no better instance of this can be given than 
the bite of a flea, which is sometimes felt two or three inches 
from the real seat of irritation. In abnormal conditions this refer- 
ence of irritation to a spot where no irritant is present may be 
greatly increased. In the case of hysterical pain in the knee- 
joint, to which I have already referred, the source of irritation is 
not in the knee, but is probably, to a considerable extent at least, 
in the sexual organs, from which affereat impulses proceed to the 
brain, and there induce morbid changes which are probably similar 
in kind to those which would have been caused by acute irritation 
in the knee-joint ; pain is thus felt by the individual, and referred 
to the knee although the joint itself is perhaps healthy. When 
siich a pain as this is felt by persons presenting certain general 
characteristics, we call it hysterical, but in its essentials it is 
simply neuralgic. The term neuralgia is a very convenient cloak 
for our ignorance, and we apply it as a rule to all acute pains for 
which we can find no apparent cause. A good deal of discussion 
has arisen regarding the nature of neuralgia, and several writers 
hold that neuralgic pain is of central origin. According to this 
view, we may look upon hysterical pain in the knee-joint as a most 
marked and typical neuralgic affection. This view is probably the 

H 2 



100 ON SOME FORMS OF HEADACHE. 

true one so far as it goes, but it is imperfect, and will, I think, 
mislead us if we do not try to find out in all cases the peripheral 
origin of the central changes, for in minor neuralgias, as in the 
case of hysterical knee-joint, the changes in the brain are probably 
started by some irritation of sensory peripheral nerves. Thus 
pain in the temple is very frequently due to the irritation of a 
decayed tooth. Sometimes a pain may be felt in the tooth as 
well as in the temple, just as in the ordinary experiment on the 
so-called funny bone, pain or tingling may be felt at the elbow 
"where the ulnar nerve is twitched as well as in the fingers to 
which its terminal branches are distributed. Sometimes, however, 
this is not the case, and the pain is felt in the temple without any 
in the teeth. My attention was first directed to the relation 
between pain in the temple and decayed teeth many years ago. A 
servant of my brother's was suffering from toothache, but com- 
plained still more of intense pain in the temple. I did not know 
Avhat to do for the pain in the temple, but thought the toothache 
might be relieved by applying solid carbolic acid on a pledget of 
cotton wool. I accordingly introduced this into a large cavity in 
one molar. To my great disappointment it gave no relief Avhat- 
ever. In the course of a very few minutes, however, her fellow- 
servants came running to tell me that cook was now quite free 
from pain ; that she had taken the cotton wool out of the tooth 
into which I had put it and placed it in another decayed tooth, 
and at once the pain vanished both from the tooth and the temple. 
In this case the irritation of a decayed tooth had produced a two- 
fold pain — a pain felt in the tooth itself, and also one felt in the 
temple ; but sometimes a decayed tooth will cause headache when 
no pain is felt in the tooth itself. I was first led to observe this 
by watching my own case. One day I was suffering from severe 
megrim, the pain being limited to the left temple ; there was ten- 
derness on pressure over the spot. On many other occasions I 
had noticed that the eyeball was tender at the same time, but on 
that occasion there was no tenderness of the eyeball. Passing my 
finger over the side of the head and face in the endeavour to find 
a second tender spot, I at last came upon one under the angle of 
the jaw. The tenderness here was due to a small gland, which was 
hard and painful to the touch. The occurrence of an enlarged 
gland at once led me to seek for the source of irritation in a 
district from which it received the lymphatic vessels, and I accord- 
ingly examined the mucous membrane of the mouth and tongue, 



HEADACHE FROM DECAYED TEETIL 101 

but without seeing anytliing abnormal. I tlicn took a steel point, 
with which I probed and percussed all my tfeth in succession. 
Every one was sound excepting the last molar on the same side as 
the headache, and on the posterior aspect of this there was a p(jint, 
tender on pressure, although no cavity could be found. I went to 
a dentist as soon as possible afterwards, and he informed me that 
caries was just beginning at the spot which I had thus discovered. 
Some time ago a clergyman of my own ac([uaintance began to 
suffer from headache so intense as completely to incapacitate him. 
After taking various medicines in vain, he went for a Continental 
tour, but came back little benefited, and as soon as he resumed 
work the headache was as bad as ever. Shortly after his return I 
saw him, and remembering my own experience, I suspected his 
teeth. On looking into his mouth, however, 1 could see nothing; 
all his teeth seemed to be perfect. I then took a steel bodkin and 
probed and percussed each tooth in succession. At last I came 
to one which was tender. I advised him to see a dentist about it. 
This he accordingly did, and the tooth was found to be carious. 
It was at once properly stopped and the headaches disappeared. 
So frequently are headaches dependent upon decayed teeth, that in 
all cases of headache the first thing I do is carefully to examine 
the teeth. Not unfrequently when I have pointed to a decayed 
molar as the origin of the headache, the patient has said, " But I 
have no pain in the tooth;" and to this I usually answer, "It is 
quite natural. You get the toothache in another part of your 
head." 

The question now arises, what is the cause of the pairi felt in 
some other part of the head instead of the seat of irritation, but 
originating in some local irritation like that of a decayed tooth ? 
Is it only due to changes in the centre for sensation in the brain, 
or to alterations in the periphery, or to both ? I am inclined to 
believe that while it may sometimes bo due to changes in the 
centre for sensation in the brain only, as in the case of hysteiical 
pains, yet sometimes functional periplieral changes either accom- 
pany these central changes, or may of themselves give rise to the 
pain. In this latter case the peripheral alterations are probably 
produced through the medium of the sympathetic system. Thus 
I have noticed that the scalp, over the place where the pain is 
felt in headache depending on a decayed tooth, becomes tender on 
pressure while the pain lasts. This tenderness, however, is very 
transitory, and I have sometimes felt the headache and accompany- 



102 



ON SOME FORMS OF HEADACHE. 



ing tenderness disappear from one part of the head and appear in 
another with great rapidity. The disappearance of the tenderness 
along witli, or very shortly after, that of the pain, shows that 
there can be no structural alteration of any importance in the 
tender part. There may, however, be very important functional 
changes in blood-vessels of the j^ainful part, and I think that 
headache is v^ery frequently due to those changes; that, in fact, 
what we may regard as a kind of cohc in the vessels occurs in the 
part, and this gives rise to the actual pain. 

The mechanism of the headache here is that the irritation in a 
tooth, for example, acting through the vaso-motor nerves, causes 
vascular spasm, and this vascular spasm causes the pain of head- 
ache. 



Cniary ganglion. 

Superior maxillary nerve. 

Sjilieno-palatine ganglion. 

Psasal nerves, 

Superior dental nerves. 



Inferior dental nerves. 
Carotid artcrj*. 




Superior cerrical ganglion. 

Otic ganglion. 

Inferior cen-ical ganglioa. 



Fig. 9. — A Very diagramatic representation of the connection between tlie Ijranche.s 
of tlie fifth nerve and the sympathetic system, intended to indicate the nervous 
channels through which irritation of the fifth nerve may afiect the vessels of the 
head. 

In cases of headache and toothache combined, the headache may 
be simply due to changes in the centre for sensation in the brain, 
or these may be accompanied by spasm in the vessels of the 
head. 

In cases of headache depending upon a decayed tooth, Avhere no 
toothache is felt, it is not improbable that the irritation in the 
tooth does not give rise directly to the sensation of pain in the 
head, but does so by acting through the sympathetic system on 
the vessels so as to cause the spasm which leads to the sensation of 
pain. If this be so, we ought to be able to alleviate headache, not 
only by treating the tooth which is the original source of the evil, 
but also by such measures as will relieve the sp:ism of the vessels 
themselves, and this, I think, is shown to be the case in practice. 



PA TIIOLOG Y OF MEGRIM. 1 03 

A great deal of di&cussion has taken place regarding the con- 
dition of the vessels in megrim. Du Bois-Reymond, who suffered 
much from it himself, attributed the pain to spasmodic contraction 
of the vessels, for he found that while the pain lasted his temporal 
artery on the same side became tense and hard like a bit of whip- 
cord, and the pupil of the corresponding eye dilated, as if the sym- 
pathetic in the neck had been irritated. Others again have held, 
also on the ground of personal experience, that the arteries, instead 
of being contracted, were widely dilated. The reason of tliis dis- 
crepancy is simply, I think, that these observers have not examined 
the arteries throughout their length. In my own case I have 
sometimes found that during an attack of megrim the temporal 
artery on the affected side was hard like a bit of whipcord as 
described by Du Bois-Reymond, but that at other times, when 
no difference between the amount and kind of pain could be 
detected, it was widely dilated and pulsating violently. But 
on those occasions, if I traced it along its course, I found that 
while the trunk of the artery was dilated at the temples, its 
smaller branches as they passed on to the forehead were hard 
and contracted, and felt almost like pieces of wire under the 
skin. The carotid artery was also widely dilated and jDulsating 
violently, as well as the temporal. The condition here then was 
a disturbance in the proper relation of the calibre of different 
parts of the same artery. The proximal end was abnormally 
dilated ; the peripheral end was abnormally contracted. The 
same condition is present in those cases where the trunk of 
the temporal artery is contracted, for if the linger be carried 
backwards, the trunk of the carotid is felt to be dilated. 

The only difference, then, between those cases of megrim in 
which the temporal artery is dilated and those in which it is felt 
to be contracted is a difference in the point of the artery at which 
the contraction takes place. The consequence of this disturbance 
in the relationship between different parts of the artery is that 
the blood, instead of being gradually regulated in its onward flow 
by the gentle action of a long artery, is suddenly checked by a 
local contraction, and the successive impulses produced by the jets 
of blood sent from the heart along the dilated arteries hammering 
upon this contracted point give rise to great pain. This pain can 
be at once relieved by compressing the carotid, so as to arrest the 
flow of blood through it ; but unfortunately a feeling of undefinable 
distress is usually produced by this procedure, so that one can 



104 ON SOME FORMS OF HEADACHE. 

generally keep it up only for a few moments. It may sometimes 
be relieved for several minutes by gently pressing on the carotid, 
so as simply to diminish its flow without entirely arresting the 
circulation in it. 

Heat and cold are two of the remedies used to lessen headache ; 
sometimes one is useful, sometimes the other; and so far as I 
know, no explanation has hitherto been given of the reason why. 




Fig. 10. — Tracings from the radial artery at the M-vist : A before and B after the 
application of a cloth dipped in cold wat3r round the arm. After Winternitz. 

I believe it is simply this : That when heat is applied over the 
contracted peripheral vessels^ it tends to relax them, and thus 
restores the equilibrium between the different portions of the 
artery; when cold is applied over the dilated vessels, it causes 
them to contract, and thus restores the equilibrium between them 
and the contracted peripheral parts. 

The effect of the local application of heat and cold over the 
course of an artery has been well shown by Professor Winternitz 
of Vienna. I have seen him place a sphygmograph on the radial 
artery, take a tracing and then apply cloths dipped in ice-cold 
water around the arm ; the consequence was, that the tracing of 
the radial artery at once became very much smaller from the 
contraction of the brachial. On tliis account cold compresses to 
the neck are sometimes very useful in headache. 

Sometimes warmth to the throat may relieve, but here the 
modiis operandi is different; the effect of the warmth in all 
probability being exerted not directly upon the vessels themselves, 
but rather upon the sympathetic ganglia in the neck by which the 
calibre of the vessels is regulated. And here 1 may perhaps say 
a word regarding this nervous mechanism. The carotid artery 
and its branches derive their vaso-motor nerves from the superior 
cervical ganglion, and to disturbance of the functions of this 
ganglion are, I believe, due the headache caused by dental irrita- 
tion, (p. 102.) I do not know that du Bois-Reymond's headaches 
depended upon a decayed tooth, but I should very strongly suspect 
it. In his case there was distinct evidence of sympathetic dis- 



TEMPORAL AND OCCIPITAL HEADACHE. 105 

turbance in the dilatation of the pupil of the affected side. In my 
own case I have never noticed any dilatation of the pupil, but 
I have observed a curious transference of pain from the temple 
to the occiput, and from the occiput to the temple again, so 
rapid that I think it can only be ascribed to a disturbance of 
the cervical ganglion. The explanation which I give of it is 
this : That at one time, the vaso-motor branches of the temporal 
are affected, at another those of the occipital artery, and the rapid 
change of the headache from one part to another is due to an 
alteration in the ganglion itself. The occurrence of occipital head- 
ache in place of temporal in my own case attracted my attention 
to decayed teeth as a cause of occipital headache, and I found that 
it is by no means unfrequent. Tlie other day I saw a scientific 




Fig. 11. — Diagram showing the seat of pain in megrim or occipital headache depend- 
"iiig on decayed teeth or defects of the eyes. The shaded area shows the seat of 
the pain. ; the spot in each area indicates the seat of tenderness on pressure. 

man who was complaining much of occipital headache on the left 
side. I at once said to him, " The second molar on the left side 
of your lower jaw is decayed." This statement was not quite 
correct, for the decayed tooth turned out to be the second molar on 
the left side of the upper jaw, but it was so near the truth that it 
astonished him greatly, because it had never occurred to him that 
there could be any connection between a pain at the back of his 
head which gave him great annoyance and a decayed tooth which 
did not trouble him in the least. 

In regard to the situation of headache depending upon decayed 
teeth, I find that a decayed molar in the low^er jaw^ usually gives a 
temporal or occipital headache, and a decayed molar in the upper 
jaw causes temporal headache which is rather farther forw^ard than 



106 O.Y SOME FORMS OF HEADACHE. 

that caused by the lower jaw. Decayed incisors or eye-teeth are 
more likely to cause frontal or vertical headache. 

Another source of headache closely allied to the teeth is sore- 
throat. Enlarged and inflamed tonsils are apt to give rise to 
headache, which usually tends to run up in front of the ears and 
over the vertex. On one occasion I suffered from inflammation 
of this sort, and found that at first the pain was diffused all over 
the head, so that one could not localise it at one point more than 
another, but that as the inflammation went on, the pain became 
more localised at the sides of the head and vertex, and gradually 
extended downwards and became more localised, until it was felt 
veiy distinctly in the throat, and hardly in the head at all. 

Perhaps a still more frequent source of headache than even 
decayed teeth are abnormal conditions of the eyes. The headache 
which comes on after working with the microscope, or after straining 
the eyes in a picture gallery, is only too well known. It is usually 
frontal, often extending over the whole breadth of the forehead, but 
sometimes limited to the forehead above one orbit. 

On one occasion I remember seeing a friend who had been 
working with a microscope, and was suffering from most intense 
headache. On entering the darkened room in which he was 
lying, I thought at first that his eyes were jaundiced, but closer 
examination showed that the apparent yellowness was due to great 
injection of the vessels of the sclerotic. 

It would be going too far to say that frontal headache is always 
due to an abnormal condition of the eyes, but I believe it is so 
much more frequently than one would at all suspect. Even the 
frontal headache which occurs in derangement of the stomach and 
biliousness is, I think, very frequently connected with an abnormal 
condition of the eyes to which the indigestion gives rise, for if 
we press the finger upon the eyeballs during a bilious headache, 
we not unfrequently find that they are abnormally tense and the 
intraocular pressure high, so that the eyeball feels almost like a 
marble under the finger. Curiously enough, too, I have noticed 
that some persons who suffered from bilious headache in early life 
begin to suffer from giddiness whenever they become bilious as 
they grow older. This giddiness during a bilious condition began 
to come on just at the time when their sight began to alter and 
they commenced to wear spectacles. 

But frontal headache is not the only one which may arise from 
abnormal conditions of the eyes, for megrim or sick headache is 



HEADACHE FROM EYE AND NOSE. 107 

very frequently associated with, and probably dependent on, in- 
equality of tlie eyes, either in the way of astigmatism, myopia, or 
hj'permetropia. 

Formerly I used to suffer myself from megrim, which might 
affect either side of tlie head, but for some years past it has almost 
invariably affected the left side. My right eye is normal, but the 
left is hypermetropic, and probably the greater strain that is thrown 
upon this eye in reading leads to the headache on the same side. 

The relationship between megrim and abnormalities of vision 
has been pointed out by several authors, amongst others Mr. John 
Tweedy, Dr. Savage, Mr. Higgins, Dr. Brailey, and Mr. Carter. 

The good effects of spectacles in megrim was well illustrated in 
the case of one of my colleagues who suffered very frequently, but 
after getting a proper pair of spectacles did not get a headache 
half so often as before. 

Although dental irritation and abnormalities of vision are pro- 
bably the two most common and most important causes of head- 
ache, vet the nose and ear are also channels through which 
external irritation may ojjerate in producing headache, and they 
must not be overlooked. As far as -my experience goes, headache 
depending upon disease of the nose is at the top of the head, just 
behind the commencement of the hairy scalp, and headache here 
should always lead to an examination of the nose. 

The frontal headache, however, which occurs in ordinary cold in 
the head, and which probably depends upon congestion of the 
mucous membrane lining the frontal sinuses, is known to every one ; 
and Dr. Hack ^ of Freiburg has observed several cases both of 
megrim and of frontal headache depending upon congestion of the 
mucous membrane covering the inferior turbinated bones, and he 
has been able to effect a radical cure in several cases by the appli- 
cation of the galvano-cautery to the inflamed and swollen mucous 
membrane. 

In the causation of headache, however, we have always to con- 
sider two things — the condition of the organism generally and 
the local source of irritation. We have hitherto directed our 
attention to the local sources of irritation, but local irritation 
alone will not cause headache. We find that numbers of people 
have decayed teeth, and yet they suffer neither from toothache nor 
headache, excepting perhaps occasionally. The source of irritation 

^ Ueber eine operative Radical- Behandlimg bestimmter Formen von Migrane, 
Astlima, Heufieber, u, s. w. A'on Dr. "Wiihelm Hack, Wiesbaden, Bergraaun. 



108 O.V SOME FORMS OF HEADACHE. 

is constantly there, and yet the effect it produces appears to be 
only occasional. The occasional pain is the reaction of the organism 
to the irritant, and its intermittent occurrence is probably to a 
great extent due to the organism being only occasionally in such 
a condition as to give this reaction. We know that the pain of 
toothache, for example, is often at once remedied by a brisk purgative, 
although the tooth remains in the same condition, the purgative 
having so altered the organism that it no longer responds in the 
same way to the irritation of the tooth. I use here the vague 
term organism in place of using the more definite one nervous 
system or cerebral centre of sensation, because we do not at present 
know the exact mechanism by means of which brisk purgatives 
produce such an effect. It is highly probable that they do so not 
directly but indirectly, by modifying the irritation or by clearing 
away poisonous substances from the intestine. 

There are several conditions of the body which tend to give rise 
to headache more especially ; these are indigestion, biliousness, 
constipation, fever, plethora, anoemia and debility, rheumatism, 
gout, and albuminuria. 

The headache of indigestion, biliousness, and constipation is 
generally frontal, but it docs not always affect the same part of the 
forehead. As a rule, derived from an exceedingly large experience 
in the Casualty Department at St. Bartholomew's Hospital, where 
one sees cases not by tens, but by hundreds and thousands, I have 
found that frontal headache associated with constipation is removed 
by the Haustus Magnesii Sulphatis^ of the hospital Pharmacopoeia; 
that headache just above the eyebrows, and not accompanied by 
constipation, is relieved by Haustus Acidi Nitro-hydrochlorici ; ^ 
while headache, also unaccompanied by constipation but situated 
higher up on the forehead, just below or at the commencement of 
the hairy scalp, is relieved by alkalies, usually given in the form of 
Haustus Calumbse Alkalinus (p. 125), twenty minutes before meals. 
Occipital headache is also sometimes associated with indigestion, and 
is sometimes relieved also by Haustus Acidi Nitro-hydrochlorici, 
but in it careful attention should be paid to the condition of the 
teeth. The headache of fevers is usually frontal, and this is, I 

^ The form\ila for the Haustus ^ The fonnula for the Haustus Acidi 

Magnesii Sulphatis is : — Nitro-hydrochlorici is : — 

Sulphate of Magnesia, 1 drm. Dihite Nitro-hydrochloric acid, 10 min. 

Diluted Sulphuric Acid, 10 minims. Spirit of Chloroform, 10 min. 

SjTup of Red Poppies, | drni. Tincture of Orange peel, 20 aiin. 

Mint water to 1 oz. Water, 1 oz. 



TREATMENT OF FRONTAL HEADACHE. 



109 



think, associated to a great extent witli alteration in the vascularity 
and tension of the eye. When resident physician in the Intirmary 
at Edinburgh, I used to see a number of cases of typhus fever^ and 
in this disease the injection of the eyes is well marked ; and I was 
strongly reminded of the eyes of typhus patients by the appearance 
which, as I have already mentioned, I observed in my friend Avho 
was suffering from headache after working with a microscope. 
Both the injection of the eyes in typhus and headache in fevers 
generally, whether it be accompanied with injection of the eyes or 
not, probably depends upon the increased circulation caused by 
the greater heat of the body in the febrile condition, and by the 
presence of morbid products or poisons in the blood, which not 



Purgatives 




Fig. 12. — To show the position 
of the fioutal headache which in 
cases of coustipatiou is relieved 
by salines. 




Fig. 13. — Showing the position 
of the frontal headaches relieved 
by acids and alkalies in the ab- 
sence of constipation. The lower 
is relieved by acids, the upper by 
alkalies before meals. The lower 
one also indicates the occasional 
position of headache caused by 
straining the eyes. 



only act upon the eyes, but upon the nervous system and the body 
generally. 

Closely associated on the one hand with the headache of indi- 
gestion, and on the other hand with that of fever, is the headache 
of p'ethora, which is usually frontal or occipital, and depends both 
on the powerful circulation which is present in this condition and 
probably also on the products of tissue waste circulating in the 
blood. 

The headache of anaemia and debility is usually vertical, and 
is usually associated with feelings of flushing, of heat, or sudden 



110 Oy SOME FORMS OF UEADACUH. 

cLilllness, and muscse volitantes, and not unfrequently also with 
gastric derangement, evidenced by pain in the epigastrium shooting 
through between the blade-bones.-'- 

The rheuinatic headache very frequently is felt over a con- 
siderable part of the head generally, and is associated with 
tenderness over a great part of the scalp. The tenderness is 
sometimes excessive. This headache is frequently relieved by 
the administration of iodide of potassium. A formula given me 
by Dr. Image of Bury St. Edmunds for this headache, and which 
is very useful, contains 5 grs. of iodide of potassium, a drachm 
of tincture of valerian, and a drachm of aromatic spirits of 
ammonia. Bat although the rheumatic headache assumes very 




Fig. 14. — Diagram to sliow tlie posillon of tlie reitlcal headaclie of anjemia. 
frequently the form I have just described, it appears to me some- 
times to show itself as a frontal or temporal headache, and to be 
associated with a rheumatic affection of the muscles of the eyes. 
On one occasion I administered some salicylate of soda for the 
relief of pains in the limbs which were associated with severe 
headache. The effect of the salicylate in relieving the headache 
was almost magical, and I have accordingly tried it in a number 
of cases since. I found that 2| grs. of the salicylate of soda, given 
either alone or with some aromatic spirits of ammonia, every half- 
hour while the headache lasts, will often after one or two doses 
cut short the headache, which would otherwise have continued for 
a whole day or more. I have been unable at present to distinguish 

1 This group of symptoms is usually much relieved by the administration of iron 
with a bitter tonic. The formula for the draught of Quassia and Iron in St. 
Bartholomew's Hospital Pharmacopceia is : — 

Solution of Perchloiide of Iron, 15 minims. 
Infusion of Quassia, 1 oz. 



SUMMARY. in 

ca gouty headaclie ^oer se from the headache of plethora or indiges- 
tion, and should suspect the gouty element only from the patient's 
family and personal history. 

In albuminuria the headache may be frontal, or may be felt as 
a tioht band surrounding the head. 

; In syphilis its situation may vary, and it is generally recognised 
by its history, by its being more or less constant, remitting instead 
of intermittent, and by its frequent association with persistent 
tenderness at a limited spot. 

I may now, in conclusion, sum up shortly the main points I 
have endeavoured to bring forward in this paper. 

Headache is usually the product of two factors — local irritation 
and general condition. 

The chief local causes are decayed teeth and abnormalities of 
the eye, although diseases of the ear and nose, inflammation of the 
throat, and local irritation of the pericranium or of the skull in 
rheumatism and syphilis, are not to be forgotten. Decayed teeth 
may give rise to temporal or occipital headache when the molars 
are affected, and also I think to frontal when the incisors are 
decayed. 

The chief abnormal conditions of the eye which cause headache 
are strain from reading, or working with imperfect light, or for 
too long a time, myopia, hypermetropia, astigmatism, inequality 
of vision between the two eyes, and last, but not least, glaucoma. 

Besides this, I think that alterations in the circulation and 
intraocular pressure are frequently produced by bile or poisonous 
substances circulating in the blood, and that probably also a rheu- 
matic condition, affecting either the eye itself or the muscles which 
move it, is a not uncommon cause of headache. Where both eyes 
are equally affected, the headache is usually frontal ; but when one 
eye is more affected than the other, the headache appears either 
in the form of brow ague or megrim. 

In treating any case of headache, therefore, the first thing to do 
is to see whether the teeth are sound and the eyes normal. If 
anything is found wrong with either the teeth or the eyes, the 
defect should be at once corrected. The throat, ears, and nose 
should also be examined to see if any source of irritation is present 
there, and the surface of the scalp tested by pressure for rheumatic 
or syphilitic inflammation. Percussion should also be tried over 
the head in order to determine whether or not there is any 
intracranial tumour. 



113 ON SOME FORMS OF HEADACHE. 

The locality of headache is probably determined chiefly by the 
local source of irritation, but this differs according to the general 
condition in a way that it is at present impossible to explain. 
Thus frontal headache with constipation is usually relieved by 
purgatives; frontal headache without constipation, just above the 
eyebrows, is relieved by acids; and a similar headache, situated 
higher up at the commencement of the hairy scalp, is relieved by 
alkalies. Vertical headache is usually associated with anaemia, 
and is relieved by iron. The more or less continuous headache 
of syphilis is usually best relieved by iodide of potassium ; but in 
order to gain relief the dose must sometimes be much larger than 
that usually given, and may range from 5 grs. up to 30 grs. for 
a dose. Smaller quantities of iodide of potassium are usually 
sufficient to cure the rheumatic headache. 



ON DYSPEPSIA.i 

(' The Praditioner,' A'ol. xir., Levemhar 1S77.) 

To the healthy body the performance of its functions is a source 
of pleasui'e. The strong muscles rejoice in work, and exercise, to 
use up their superabundant energy, becomes almost a necessity; 
the brain works easily, ideas flow readily and clearly, and thought 
becomes a delight. Both bodily and mental work, however 
pleasant, entail Avaste which must be supplied, and the pleasures of 
exercise lead to the pleasures of the table, giving a zest to the 
plainest food and enhancing the flavour of the most delicate viands. 
When the day is over, exercise and food give place to the pleasure 
of sleep, and almost as soon as the head is laid on the pillow, the 
dreamy delightful languor whicti succeeds healthy exercise passes 
into dreamless slumber, from v\^hich the sleeper awakes on the 
ensuing morn, refreshed and strengthened for the occupations of a 
new day. With such a condition as this we are probably all more 
or less familiar, and its full enjoyment during a walking tour is, to 
my mind, one of the greatest charms of an autumn holiday. But 
unfortunately the conditions of life do not allow men to remain 
constantly under the favourable conditions in which we are placed 
during our vacation. Some have hard grinding bodily fatigue, 
continued hour after hour until the tired limbs can scarcely move, 
others have the still more exhausting mental drudgery, when, 
despite the exhausted brain, the closing eyelids, and the aching head, 
the cramped fingers must drive the pen scratch, scratch, scratch, 
long past the midnight hour, into the cool grey of early mornhig. 
Excessive mental and bodily work thus become not a blessing but 
a curse, and although they generally bring some compensation by 
increasing the pleasures of sleep and rest, it is not always so. For 
although the wise man says " sleep is sweet to the labouring man, 

^ Eead before tlie Abernetliiaii Society at St. Bartliolomew's Hosijital. 

I 



114 ON DYSPEPSIA. 

whether he have eaten little or much," yet not unfreqnently 
excessive mental labour drives sleep from the couch, and weary 
work is succeeded by more uneasy rest. Too much work thus 
weakens both the muscles and the brain, and causes the exercise of 
their functions to be performed imperfectly, and attended with 
suffering, instead of being, as in the healthy state, a source of 
pleasure. Now the same is true of the digestive organs. Within 
certain limits, the stomach, liver, and intestines are very accom- 
modating, and will digest much or little food, single dishes or 
a variety of meats, with great facility, but whenever the tax upon 
their power becomes too great, they refuse to act, and in various 
unpleasant ways make known to their master that they are on 
strike, and either want less work or work of a different sort. As 
the stomach is that part of the digestive system into which food is 
first collected, and which therefore is generally the first to suffer 
from overwork, we will consider its part in the digestion of food 
first, and the indigestion due to the imperfect performance of 
its functions, without at present taking up those of the intestines 
or liver. 

We have now so much knowledge of an exact nature regarding 
the process of digestion, that we are apt to forget how recent is its 
date, and I therefore think it may not be unadvisable or unin- 
teresting to devote a few minutes to describing the successive steps 
by which it has been acquired. The knowledge that food was 
broken up and partially dissolved in the stomach must have been 
early acquired, for the ancients as well as the moderns sometimes 
overtaxed their stomach with food or drink, and led that organ to 
reject the meal which had shortly before been consumed. In the 
paintings on Egyptian tombs,^ we see ladies depicted who axe 
suffering in this way ; and although they might not be themselves 
in such a condition as would lead them to examine very closely 
into the nature of the vomited matters, it could hardly escape the 
attention of the attendants or of the physicians who might be 
called in, and who sometimes, indeed, produced vomiting,^ that 
these matters consisted of the broken down and partially dis- 
solved foods which had constituted the last meal. But how 
this solution was effected long remained a mystery. Some said 
that it was effected by the stomach grinding down the food in the 
same manner as the gizzard of a bird ; but the ancients generally 

^ Wilkinson's Ancient EgyiMans, 1854, vol. L p. 52. 
* Wilkinson, Op. cit., vol. ii. p. 350. 



PnrSIOLOGY OF DIGESTION. 115 

seem to have had the klea that it was effected by heat anil 
moisture leading to a sort of putrefaction/ or by a secretion from 
the stomach with special solvent powers.- 

The experiments of Reaumur in 1752, and of Spallanzani in 
1783, showed that the food was not simply ground by the stomach, 
for substances enclosed in perforated metallic balls, and thus 
protected from any mechanical action of the gastric walls while 
exposed to the solvent action of the gastric juice, Avere found 
to be dissolved when the metal case was after a certain time 
withdrawn from the stomach by means of a string attached to it. 
The theory of putrefaction was also disposed of by Spallanzani,^ 
who found that instead of this process going on in the stomach, 
it was immediately checked when substances in which it had 
begun were introduced into the organ* But it is highly probable 
that the ancients meant something different from ordinary putre- 
faction, although they may have used the name to designate the 
process which takes place in the stomach during digestion, and 
Boerhaave propounded the theory that digestion was a process 
of fermentation. The questions, therefore, remained to be solved 
— Is digestion a simple solution in the gastric juice ? or is it a 
change m the constitution of the food by oxidation or otherwise ? ^ 

In most experiments the gastric juice had been obtained in 
an imjDure state, and its admixture with saliva or mucus had 
rendered its reaction doubtful, but Carminati, in 1785, determined 
that it was acid when obtained pure during digestion, although 
nearly neutral during fasting in animals. Prout, in 1824, found 
that the acid was hydrochloric, and Tiedemann and Gmelin, in 
1827, finally confirmed the results of Carminati, They were 
inclined to attribute the solvent power of the gastric juice to 
the acid it contained, but their own experiments, as well as 
those of Johannes Mliller, and still more of Dr. Beaumont, showed 
that acid of the same strength had nothing like the solvent 
power of the gastric juice, and that this secretion must therefore 
contain a peculiar solvent principle. This Eberle supposed to 
be the gastric mucus, but a few trials proved that this mucus 
alone would not dissolve the food, and that digestion took place 

1 Hippocrates, etc., Hallev's Physiol, t. \i. p. 322. 
2 Paulus Aegineta, vol. L p. 91. 
3 Spallanzani, Experiences sitr la Digcslion, Geneve, 1783, p. 90. 

* Spallanzani, Op. cit., p. 310. 
* Tiedemann and Gmelin, Journ. dc Physiol. viL 1S27, p. 144. 

I 2 



116 ON DYSPEPSIA. 

only when it was combined with acid. The next step was taken 
by Schwann in 1836, and by Wasmann in 1840. They showed 
that it was not mucus in general but a special substance, pepsin, 
contained in the mucus of the stomach, which digested albuminous 
matters when combined with acid. The researches of Briicke 
have shown what the proper strength of the acid is, and that 
when it is either too strong or too weak digestion is hindered. 
The requisites for the rapid digestion of albuminous matters" 
in the stomach, then, are an abundant supply of gastric juice 
and its proper composition as regards the proportion of acid and 
the amount of pepsin present in it. These requisites are supplied 
in the healthy stomach, which secretes a large quantity of active 
juice during digestion; but in disturbed and diseased conditions, 
either of the organ itself alone or of the whole system, they are 
more or less wanting, and digestion is imperfectly performed — 
we have, in fact, indigestion. 

We owe our knowledge of the condition of the stomach in 
great measure to a fortunate accident which established a gastric 
fistula in a young man, and enabled observations to be made on 
him such as we can usually make only on animals — observations 
which were, however, imperfect, and have since been extended as 
well as confirmed by gastric fistulse artificially established in dogs. 
A young Canadian, Alexis St. Martin, was wounded by a charge 
of duck-shot, which carried away the muscles on the left side of 
the thorax for several inches, along with the anterior half of the 
sixth rib, broke the fifth, and lacerated the left lung, stomach, 
and diaphragm. Notwithstanding the extent of his injuries, he 
finally recovered under the care of Dr. Beaumont ; but the stomach 
became adherent to the abdominal wall, and preserved a perma- 
nent opening, which was usually stopped up by a valve of mucous 
membrane. This valve could be readily pushed back by the 
finger and the interior of the stomach distinctly seen. After St. 
Martin's recovery. Dr. Beaumont took him into his service and 
made numerous observations upon him, which, as I have already 
said, have been of the greatest value. 

According to Dr. Beaumont, " the inner coat of the stomach, in 
its natural and healthy state, is of a light or pale pink colour, 
varying in its hues according to its full or empty state. It is of 
a soft or velvet-like appearance, and is constantly covered Avith a 
very thin transparent viscid mucus, lining the whole interior of 
the organ. Immediately beneath the mucous coat, and apparently 



INTERIOR OF STOMA OH— APPETITE. 1 1 7 

incorporated with the villous membrane, appear small spheroidal 
or oval-shaped granular bodies, from which the mucous fluid 
appeal's to be secreted." On the application of aliment, the action 
of the vessels is increased, the colour heightened, and the ver- 
micular motions are excited. The small gastric pajjillse begin to 
discharge a clear transparent fluid, which continues rapidly to 
accumulate as aliment is received for digestion. "This fluid is 
invariably distinctly acid. The mucus of the stomach is less 
fluid and more viscid or albuminous, and sometimes a little saltish, 
but does not possess the slightest character of acidity. On apply- 
ing the tongue to the mucous coat of the stomach, in its empty 
unirritated state, no acid taste can be perceived. When food or 
other irritant has been applied to the villous membrane, and the 
gastric papillse excited, the acid taste is immediately perceptible." ^ 
It must be noted, however, that this acidity, though distinct, is not 
great, not such as to set the teeth on edge. The experiments 
of Bernard on dogs have given the same results as those just 
described, but have shown besides that while moderate stimulation 
of the stomach causes secretion, great irritation has an entirely 
opposite affect. For example, when the mucous membrane was 
gently stroked with a glass rod it became rosy red and secreted 
juice abundantly, but when violently rubbed the colour disappeared, 
it became pale, the secretion of gastric juice stopped, that of mucus 
seemed to be increased, and the animal seemed sick, and began to 
vomit. This experiment throws considerable light on the relation 
between the condition of the stomach and the appetite, and enables 
us in some degree to diagnose the condition of the stomach from 
the answer we get to our first question regarding the digestion of 
our patients — How is your appetite ? Various opinions have been 
held regarding the cause of hunger, some attributing it to the 
friction of the sides of the empty stomach against each other, 
others supposing it to be due to the gastric juice acting on the 
paucous membrane in default of anything else to attack. The 
real cause seems to be twofold. 1st. A certain condition of the 
stomach, probably consisting in distension either of the lymphatics 
or capillaries of the mucous membrane, which is relieved Avhen 
food is ingested and secretion begins. 2ncl. A condition of the 
system which is not removed by the mere presence of food in the 
stomach, but requires for its alleviation the absorption of nutritive 
material into the blood. This second condition may be observed 
^ Beauraont, Physiology of Digestion. 2nd ed., Burliugton, 1847, p. 95. 



118 ON DYSPEPSIA. 

in children suffering from tubercle of the mesenteric glands, where, 
owing to the imperfect absorption, a voracious hunger seems to 
consume the little sufferer, notwithstanding the quantities of food 
with which its stomach is constantly filled. The first cause of 
hunger or appetite, for they are merely gradations of the same 
condition, is the commonest, and the one with which we are at 
present concerned. Normally the stomach seems to prepare itself 
at regular intervals for the work it has to do, and as meal-time 
approaches the minute vessels probably become distended, and a 
feeling of appetite certainly appears. In some persons the time 
when this feeling comes on can be modified by mental impressions. 
If they know they are to dine at seven instead of at six, the appe- 
tite appears a short while before the time fixed for the meal, but 
if they think they are to dine at six and do not get dinner until 
seven, the expectant stomach begins to crave at six, and causes 
much discomfort during the ensuing hour while its wants are 
unsatisfied. In some conditions of the body we find that there 
is no appetite at first, but after a mouthful or two the desire to 
eat comes on, and the person rises from table after a full meal. 
Although I have not observed that Dr. Beaumont mentions this 
condition as occurring in St. Martin, yet we should be inclined to 
associate it with a mucous membrane paler and more flaccid than 
usual.i The lymphatics and capillaries, instead of being full 
before the meal, would only become so when the circulation in 
the stomach was increased by the introduction of food, and their 
distension, after the first few mouthfuls, in this debilitated con- 
dition of the stomach would become equal to that in the healthy 
mucous membrane before any food had been taken at all. 

In other conditions again we find that the patient has, as he 
says, a good appetite and feels very hungry before meals, but 
after the first mouthful or two he is satisfied, and cannot eat any 
more. Here we in all probability have a condition of congestion 
greater than normal, so that instead of mere appetite positive 
hunger is felt before meals, but as soon as the first mouthfuls are 
taken, the increased vascularity which they induce raises the 
irritability of the stomach, and the stimulus of the food acts upon 
the mucous membrane in the same way as rough rubbing did in 
Bernard's experiment, destroying the appetite and even producing 
nausea. As a general rule, indeed, whenever the appetite becomes 
unusually good without any apparent cause, we may look out 
1 Beaumout, riiysiology of Digestion, Burlington, 1847, Expt. 45, 3d. Ser. 



TONGUE AND STOMACH. 119 

for a so-called bilious attack, for if the irritated condition of 
the gastric mucous membrane, which is at first felt as appetite, 
goes on increasing it soon proceeds to anorexia, nausea, and 
vomiting. 

An example of this may be given from Dr. Beaumont's observ- 
ations. On examining the stomach of St. Martin one day, four 
hours after breakfast, and an hour after the chyme resulting 
therefrom had passed through the pylorus, he found that "several 
red spots and patches abraded of the mucous coat, tender and 
irritable, appeared over the inner surface.^ The tongue too had 
upon it a thin whitish fur. Yet his appetite was rather craving." 
Two days after this Dr. Beaumont introduced some food in a 
muslin bag, through the aperture, into the stomach, and on with- 
drawing it five hours afterwards, found that it came from near 
the pylorus, and was covered with a coat of mucus and yellow 
bile. "The contents of the stomach," he says, "have been 
unusually acrid since yesterday morning, and St. Martin complains 
of unusual smarting and irritation at the edges of the aperture ; 
countenance sallow, tongue covered with a thin yellowish coat; 
and several deep red patches on the inner coat of the stomacli ; 
does not feel his usual appetite." Had St. Martin been left to 
himself and continued the diet of the previous days, consisting, 
as it appeared to do, of ]3ork, steak, and fried sausages, we should 
I^robably have had him suffering from vomiting, and possibly sick 
headache, but Dr. Beaumont dropped into his stomach twelve 
grains of blue pill and five cathartic pills, which operated next 
morning with the effect. Dr. Beaumont says, of removing the 
symptoms and restoring healthy sensations and functions. Had 
no pills been given the condition of the stomach next day would 
probably have been such as Dr. Beaumont describes on another 
occasion, when the sick headache was actually present. He had 
been introducing various articles of food, amongst others fat pork 
tied to a string, into St. Martin's stomach, and two or three hours 
afterwards found the smell and taste of the fluid from the stomach 
to be slightly rancid, and St. Martin complained of considerable 
pain and uneasiness at the stomach, general debility, and lassitude. 
The next day the distress at the stomach and pain in the head 
continued, accompanied by costiveness, a dej)ressed pulse, dry 
skin, coated tongue, and numerous white spots or pustules resem- 
bling coagulated lymph spread over the inner surface of the 
^ Beaumont, Physiology of Digestion, Burlington, 1847, Expt. 17, p. ISO, Sd. Ser. 



120 ON DYSPEPSIA. 

stomach. Dr. Beaumont accordingly dropped into the stomach 
half a dozen calomel pills,^ containing four or five graius each, 
which in about three hours had a thorough cathartic effect, and 
removed all the foregoing symptoms, and the diseased appearance 
of the inner coat of the stomach. 

When looking at a patient's tongue I have often wished that 
people wore windows in their bodies, and that one could see into 
their stomachs as readily as into their mouths. This wish is to 
some extent gratified by a perusal of Dr. Beaumont's observations, 
for in the three which I have just quoted he gives us a picture 
of three very common conditions. 

In the first we have a craving appetite, tongue showing a thin 
whitish fur, and stomacb with several red spots and abraded patches. 

In the second we have loss of appetite, thin yellowish fur on the 
tongue, salloAv, or, as we should often term it, bilious countenance, 
and stomach showing several deep red patches. 

In the third the appetite is not mentioned, but we may conclude 
that there was none, as St. Martin had distress and uneasiness in 
the stomach, the tongue was coated, there was debility, lassitude, 
costiveness, depressed pulse, dry skin, and headache. The stomach 
showed numerous white spots or pustules. 

Curiously enough, however, the stomach sometimes showed signs 
of extensive disturbance without any apparent affection of the 
general health. This was especially noticeable after drinking 
spirits too freely. The mucous membrane then presented an 
erythematous appearance and livid spots, from the surface of 
which exuded small drops of grumous blood, numerous patches of 
aphthge, a thick coating of mucus, and the gastric juice mixed 
with thick ropy mucus or muco-purulent matter slightly tinged 
with blood resembling the discharge from the bowels in dysentery. 
This condition of the stomach was accompanied by a thin, yellowish 
brown fur on the tongue, and uneasy sensation and tenderness at 
the pit of the stomach, and some vertigo with dimness and 
yellowness of vision on stooping doAvn and rising again, and a 
sallow countenance, but otherwise he felt well and had a good 
appetite.^ These four observations of Beaumont's describe the 
symptoms and appearances of the tongue which we usually meet 
with in cases of transient indigestion, and depict the condition of 
the stomach which he found associated with them, 

^ Beaumont, Physiology of Digestion, Burlington, 1847, Expt. 1, p. IIS, 2nd Scr. 
2 Ibid. Burlington, 1847, p. i^52. 



CA USES OF GA S TRIQ IRRITA TION. 1 2 1 

We have now to consider tlie causes which induce these 
appearances, and we may shortly describe them as irritants of the 
stomach — ■ 

a. From excessive quantity. 

1). From improper mechanical or chemical qualities. 
A meal excessive in cpantity will act as an iriitant because a 
longer time will be required for the stomach to dissolve it, and 
during all this time the undissolved pieces of fjoil are being 
rubbed up and down the mucous membrane and irritating it 
mechanically. 

An improper quality of food may have a similar action mechanic- 
ally. Suppose a lump of cocoa-nut to be eaten, the pieces when 
swallowed will be absolutely unacted on by the stomach, however 
long they remain there, and at the time wlien the organ ought to 
contain nothing but a soft pulpy chyme, which it would pass on 
to the duodenum, its walls are stimulated by the unaccustomed 
presence of the bits of kernel, hard and unyielding as at the moment 
they were introduced. 

Other substances rre injurious on account of their chemical 
properties. Alcohol acts as an irritant by its chemical quali- 
ties, producing, when its use is continued, very extensive alter- 
ations in the mucous membrane, and it is to be remembered, 
that some substances which are not in themselves irritant may 
become so from changes which they undergo themselves, or occasion 
in other foods after their introduction into the stomach. Thus, fat 
pork is not an irritating substance — far from it ; but it may become 
rancid in the stomach, and the fatty acids thus liberated may act 
as powerful irritants. Some cheese is indigestible on account of 
its insolubility and hardness, in the same way that cocoa-nut is, 
but other cheeses not liable to this objection may prove irritant by 
inducing the formation of butyric acid from the sugar taken into the 
stomach in the food or formed there by the action of the saliva and 
starch which have been SAvallowed together. Butyric acid appears 
to be the cause of that uncomfortable feeling known as heartburn, 
for Dr. Leared found that a pill of some sweet inert substance 
dipped in this acid and swallowed reproduced the sensation of 
heartburn exactly. A very acid condition of the contents of the 
stomach acts as an irritant and may cause vomiting, the vomited 
matters being so sour as to set the teeth on edge. What the exact 
cause of this sourness is I do not know, whether it be hydrochloric, 
lactic, butyric, or other acid, nor do I know exactly the cause of 



122 



ON DYSPEPSIA. 



its productioa, but I well remember having a most violent sick- 
headache and an attack of vomiting after drinking some new beer 
which I suppose continued in my stomach the fermentation which 
ouo-ht to have been complete before it was drunk, and which at 
the same time induced other ingredients of my dinner to jom it m 
the process. 

It is a question not yet completely solved how far the mucus of 
the stomach acts as a ferment in producing acidity, and also 
whether abnormal substances formed in the intestine are absorbed 
from it by the vessels, secreted from them by the gastric glands, 
and poured out into the cavity of the stomach, just as we know 
that iodine is. 




pjrr. 15. — Diagram showing absorption from one part, and excretion from another 
part of the intestinal canal. 

Treatment of Tem])orary Indigestion. — The conditions of the 
stomach hitherto mentioned, as well as the symptoms that 
accompany them, disappear when little food and that of a bland 
and unirritating nature is given for a short time, but recovery is 
greatly quickened, as we see from Dr. Beaumont's experiments, 



LIVER AND STOMACH. 123 

by the administration of a purgative. Now comes the query, 
Does this act reflexly upon the stomach through its nerves, or 
does it clear away from the intestine substances which are being 
absorbed from it, carried to tlie gastric wahs, and excreted by 
them just as tartar emetin would be, and causing like it irritation 
of the mucous membrane ? ( Vide entero-gastric circulation in 
diagram, and compare p. 178.) 

For my own part I am inclined to take the latter view, for on 
one occasion Dr, Beaumont finding that St. Martin's stomach 
was out of order, poured in an ounce of castor-oil. This did not 
purge, and the stomach continued as before. He then gave some 
calomel, which produced purgation, and the morbid appearances 
were quickly removed. 

The question also arises, to what extent were the erythematous 
patches, and especially the lividity, due to obstruction to the 
circulation of the blood through the liver by biliary congestion ? 
Dr. Beaumont says nothing about the existence of piles in St. 
Martin coincidently with this affection of the stomach. Had he 
done so it might have given us some useful hints regarding the 
pathology, obstruction to the portal circulation being likely to 
manifest itself in the veins of the rectum as well as those of the 
iStomach. 

When the irritating substances leave the stomach they mav 
produce a similar effect upon the intestine and cause griping and 
diarrhoea. 

Having said so mucli regarding slight acute indigestion, I must 
treat very shortly the subject of gastritis. Acute gastritis, such 
as is produced by irritant poisons, I will completely pass over, 
and only say a few words regarding sub-acute gastritis, or gastric 
catarrh. If any one is obliged to inhale fine irritating dust for 
some time the mucous membrane of the bronchial tubes becomes 
inflamed, secretes a quantity of mucus or muco-purulent matter, 
and the inflammation is accompanied by more or less pain and 
rawness in the chest and attempts to expel the mucus by coughing. 
Not unfrequently the same condition comes on after exposure to 
a draught, although no irritating substance has been inhaled. 
The mucous membrane of the stomach and that of the lungs are 
not unlike in their reaction to irritation or cold. I have already 
mentioned that after St. Martin had been freely partakino- of 
spirits for some days Dr. Beaumont found his stomach inflamed, 
bleeding, and partly filled with ropy mucus and muco-puiulent 



124 ON DYSPEPSIA. 

material. From the amjole experience whicli one gets at tliis 
liospital I think we may safely say that had St. Martin gone on 
drinking for some da3^s more he would probably have got his 
stomach into such an irritable condition that he would have felt 
considerable pain and tenderness to pressure in the epigastrium, 
every morning when he rose he would have vomited some of the 
mucus which it had secreted over night, and he would have 
vomited the greater part of each meal shortly after he had taken 
it. Tlie appearances presented in such a condition would probably 
have been the same as those actually observed by Dr. Beaumont, 
but somewhat intensified. 

But a similar condition may occur in the stomach from exposure 
to cold or to a draught, just as in the case of the lungs, although 
no irritating substance has been swallowed. 

How draughts act in producing this condition is a subject not 
unworthy of the Society's attention, but time would fail me were 
I to attempt to develop a theory of catching cold either in the 
stomach or lungs, in this paper. 

Treatment. — The treatment which is very successful is to give 
about ten grains of bismuth with ten of magnesia, in a little 
mucilage three or four times a day before meals. If the vomit- 
ing be excessive it is well to combine a few drops of hydrocyanic 
acid and some bromide of potassium, and if the pain at the 
epigastrium be great a warm poultice or even a mustard plaster 
should be applied. 

We must now pass on to the chronic forms of indigestion, and 
shall first take that of chronic gastric catarrh. The condition of 
the stomach here is just that ijresented by St. Martin after his 
alcoholic indulgence, but when it has continued long the structure 
of the stomach becomes more or less altered, the gastric glands 
undergoing fatty degeneration, the connective tissue becoming 
increased and the mucous membrane firmer. 

The symptoms- are such as we should expect. There is either 
little appetite or a craving appetite, easily satisfied — sometimes 
instead there is a feeling of emptiness in the epigastrium or 
nausea, although there is little vomiting. From the irritable 
condition of the stomach there is often pain coming on shortly 
after food, or more or less constant, but increased by food. The 
secretion of gastric juice being imperfect, the food is slowly 
digested and undergoes decomposition, forming gases and acids, 
and thus giving rise to flatulence and heartburn. The constant 



TREATMENT OF DYSPEPSIA. 12.5 

discomfort and pain makes the patient irritable, and the imperfect 
digestion of the food as well as the diminished quantity taken on 
account of the pain caused by it lead to muscular weakness, and 
mental languor and depression. 

The bowels are frequently constipated, or may be subject to 
alternate fits of constipation and diarrhoea. The pain complained 
of is partly due to the tender condition of the stomach, but it is 
also caused to a great extent by distension of the stomach with 
flatus. 

This condition is very frequently seen in middle- aged or elderly 
women who come to the hospital complaining of " windy spasms." 
On inquiring more closely into their symptoms they tell you that 
they have " pain in the pit of the stomach, striking through between 
their blade-bones," and further questions will elicit most 'of the 
other symptoms already described. There are two remedies in 
the Hospital Pharmacopoeia which work wonders in such cases: 
the Haustus Gentianae cum Rheo., and the Haustus Calumba3 
Alkalinus.-" 

Both of these draughts contain bicarbonate of soda and a 
veo'etable bitter. When given before meals the alkali stimulates 
the secretion of gastric juice, while the bitter is supposed to lessen 
the secretion of mucus. The food thus becomes more rapidly 
digested, less acid and less gas are formed, and the spirit of 
chloroform, by acting as a carminative, enables such gas as is 
formed to be more readily expelled. When taken after meals 
this beneficial action of the alkali is lost, and it becomes injurious 
rather than beneficial, except in cases where excessive acidity is 
developed during digestion. 

In regard to the pathology of acute attacks of indigestion, I 

1 The foi'mulse fou tliese are : — 

Haustus Gentian^B cum Elieo. 

Infusion of Ehubarb i fl. ounce. 

Tincture of Gentian 30 minims. 

Bicarbonate of Soda 10 grains. 

Spirit of Chloroform 10 minims. 

Peppermint water to 1 11. ounce. 

Dissolve and. Aiix. 

Haustus Calumbae Alkaliiius. 

Bicarbonate of Soda 10 grains. 

Tincture of Orange Peel 30 minims. 

Infusion of Calumba to 1 fl. ounce. 

Dissolve and mix. 



126 ON DYSPEFSIA. 

mentioned that the livid spots observed by Dr. Beaumont might 
possibly be connected with obstruction through the liver. An 
additional argument in favour of this view is offered by the fact 
that chronic catarrh, such as I have just described, may not only 
result from repeated or constant irritation of the stomach by 
alcohol, tea, spiced and indigestible foods, &c., or from cancer 
or ulceration of a part of the stomach, but also from interference 
with the portal circulation, as in disease of the liver. 

Lastly, we will shortly consider atonic dyspepsia. This condition 
probably corresponds to that temporarily observed by Beaumont, 
where the mucous membrane was pale and flabby. The symptoms 
are here also such as we should expect, the appetite being almost 
absent, yet the patient is often able to eat a fair meal. The stimulus 
of the food, however, in a stomach below par does not cause a 
sufficient secretion of gastric juice, and possibly also the composi- 
tion of the juice is not all it ought to be ; the digestion consequently 
goes on slowly, there is heaviness and weight at the epigastrium 
after meals, and the belly becomes tumid from the generation, of 
gas. Eructation gives relief, but not unfrequently is accompanied 
by heartburn, acids being formed as well as gas, and coming up 
together. 

The symptoms, in fact, are those of imperfect digestion, already 
described under chronic gastric catarrh, with this difference, that 
there is no marked pain and tenderness at the epigastrium, and 
the tongue, instead of being red or covered with fur, through which 
enlarged papillae project, is rather pale, flabby, moist, and marked 
with the teeth at the edges. 

This condition depends on weakness of the circulatory and nervous 
systems. For the secretion of gastric juice demands not only an 
action of secreting cells, but also a full sujDply of rich blood to 
supply the materials needed. Both the cells and the blood-vessels 
are under the direction of the nervous system, and unless it responds 
to the stimulus of food, the cells do not secrete, the blood-vessels do 
not dilate, the juice is not poured out, and digestion does not take 
place. 

The treatment in such a condition is somewhat the same as in 
chronic catarrh, viz. alkalies and bitters ; but in addition we must 
attend to the general condition of the patient, and give iron to 
improve the condition of the blood, and the nutrition of both cells 
and nerves. Strychnia or nux vomica also is a most useful adjunct, 
as it increases the excitability of reflex centres, including those 



A TONIC D YSPEPSIA. 1 2 7 

•which preside over the vascuLirity of the stomach and the secretion 
of its cells, and thus renders them more ready to respond when the 
stimukis of food is apphed to them. At least this is the theory I 
have formed to explain the undoubted advantage which we derive 
from its use in such cases. 

In this paper T have not treated the subject of dyspepsia in the 
way in which it is usually found, either in text-books or lectures, 
but have preferred to fix upon a few points which may lead to an 
active discussion, and to a thorough knowledge of the connection 
between the symptoms we find in our patients and the conditions 
of the stomach which lead to them. 



ON THE USE AND ADMINISTRATION OF FAT.^ 

{'The Practitioner,' vol. XX., Marcli 1878.) 

Some time ago, an attemiot to swim across the Channel was 
made by Johnson, then the champion swimmer of England. At 
first he made good progress, but at length his strength seemed to 
fail, and when he was at last lifted into the boat by those who 
accompanied him, his limbs hung down utterly powerless. It 
appeared that this was not so much due to real muscular exhaus- 
tion, as to the effect of cold. We know that when a muscle is 
cooled down very much, the nerves which supply it refuse any 
longer to convey impulses to it from the nervous centres, so that 
how^ever powerful the effort of the will may be, the muscles will 
no more respond to it than they w-ould in an animal poisoned by 
curara. Prolonged exposure to the cold water of the Channel 
appeared to have induced this state in Johnson's muscles. After- 
wards, when Captain Webb proposed to attemjDt the feat, I felt 
quite certain in my own mind that he would fail, not because I 
doubted his powers of endurance, but because I thought that his 
muscles must needs be affected by the cold in the same way as 
were those of Johnson. But, as the event show^ed, I was quite 
mistaken, for Captain Vv^ebb succeeded in his attempt. In coming 
to my conclusion, I had left out of account the influence which a 
thick coat of subcutaneous fat might have in protecting a human 
being from the action of external cold, just as it does the porpoise 
or whale, this coating being no doubt aided by the porpoise oil 
with Avhich the skin of the swimmer was lubricated, and which 
still further prevented the loss of heat. One use of fat, in the 
economy, is to act as a protective against external cold. This 
protective power appears also to be useful to the individual by 
dimioishing his chances of catching cold on exposure to draughts, 

1 Read before the Medical Society of London, Dec. 10, 1877. 



FAT VERSUS CLOTHING. 120 

and where the coating of fat under the skin is deficient or absent, 
we must supply its place by non-conducting articles of clothing. 
We rarely think of covering the chest of a fat jjerson with chamois 
leather or thick flannel, but these coverings are both pleasant and 
useful for thin or emaciated persons. In cold climates, a coating 
of subcutaneous fat all over the body is a useful protection, but 
in warm weather, or in hot climates, it becomes exceedingly op- 
pressive, as one may see by watching very stout persons or fat 
animals during the heat of summer. In some animals which are 
natives of tropical climates, or of regions in which the summer 
heat is great, although the cold during winter may be extreme, 
we find that fat, instead of being distributed over the body with 
more or less uniformity, is collected in huge masses at certain 
parts. In the zebu, or Brahmin bull of India, in the yak of 
Tartary, in the buffalo of the American prairies, and in the camel 
of the African or Asiatic deserts, we find large humps upon the 
back, which consist almost entirely of solid fat. On looking at 
a camel, we see that the hump is usually firm and solid, project- 
ing stiffly from the back, but at times it may appear limp and 
loose, swaying helplessly from side to side, and doubling up like a 
half empty bag. On inquiring as to the reason of this, we are 
told that so long as a camel is well fed, the hump remains firm 
and solid, but that when the animal's food is insufficient it 
becomes thin, loose^ and flabby, a great part of the fat being 
absorbed from it, while if the camel be kept absolutely without 
food for days, the protuberance will almost entirely disappear. 
When, on the other hand, food is again given, the hump regains 
its former dimensions, so that its use is apparently that of a 
reservoir of food, which may be drawn upon when the daily 
aliment is insufficient. We all know that the same thino- takes 
place with regard to subcutaneous fat, as with the fat of the 
camel's hump, and that whenever the fat assimilated is insufficient 
for the wants of the economy, the person or animal becomes 
leaner and leaner, until the fat has almost entirely disappeared. 
To the question. Where has this fat gone ? it is difficult to return 
a very definite answer. Probably some of it has undergone com- 
bustion, without being formed into any other tissue- but another 
part of it has probably gone to supply the waste of some more 
important organs, which thus are enabled to live, parasite-like, 
at the expense of the fat. The blood contains only about one- 
half per cent, of fat, the muscles more than 3 per cent., the 

K 



130 USE AND ADMINISTRATION OF FAT. 

brain 8 per cent., and the nerves 22 jDer cent. Yet in spite of the 
large proportion of fat contained in the nerves, they are amongst 
the last organs to suffer under the process of starvation, and 
probably their waste is supplied by the fatty matters absorbed 
from subcutaneous cellular tissue, and brought to them by the 
blood. The different tissues probably require very different 
amounts of fat, and the high percentage of fatty matters contained 
in nervous substance indicates the necessity of fat for the proper 
performance of the functions of the nerves. Fat may be supplied 
to the body by various kinds of food — fatty, starchy, saccharine, 
and albuminous. For although these do not all contain fat, they 
are all capable of being converted into fat, to a greater or less 
extent, by the organism. It is not certain that the various fats 
formed from these different kinds of food have precisely the same 
composition. It is well known to feeders of cattle that fats 
differ in quality according to the food upon which the animal 
has been fattened, and that while, for example, the fat which 
horses lay on when fed upon corn is tolerably permanent, that 
produced by feeding on grass is soft, and quickly disappears when 
the animal is set to work. In his book on Fat and Blood, and 
How to Maize, Them, Dr. Weir Mitchell quotes the remark of an 
old nurse that "some fat is fast, and some is fickle, but cod-oil 
fat is easily squandered." One would suppose at first, that the 
fat taken in the food would be stored away in the adipose tissue 
without undergoing any change, but this does not seem to be 
the case. It appears rather that the fats are split up and 
modified in such a way during digestion and absorption, that, 
when deposited in the tissues, their composition becomes tolerably 
definite in each class of animal. Thus, the composition of the 
fat of a man wiU differ from the composition of the fat of a dog, 
although both may have been fed upon the same mutton suet, 
the composition of which differed from that of the fat of either. 
Subbotin found that when a dog was kept without food until 
all the fat had gone from the body, and was then fed with palm-oil 
containing palmitine and olein, but no stearin, it nevertheless laid 
on fat which contained stearin, although in somewhat less than 
half the normal quantit}^ When palmitine and stearin were given 
to a starving dog, but no olein, the fat it laid on contained even 
more than the normal quantity of olein though less stearin. 

It would almost seem, then, that fat rapidly laid on, as in the 
case of these animals, contained a greater proportion of olein than 



FORMATION OF FAT. 131 

normal, whether this were present in the food or not. That fat 
may be formed from other kinds of food, such as starchy or 
saccharine, has been shown by Lawes and Gilbert, who found that 
in fattening pigs, four or five times as much fat was produced 
among the animals as was contained in their food, and by Liebig 
and others, who found that bees could form wax, which is a kind 
of fat, although they were fed on nothing but sugar. This is 
supported also by the fact that negroes grow fat during the time 
when sugar-canes are ripe, and when they are constantly sucking 
the saccharine juice. That fat may be formed from albuminous 
substances has been clearly shown by Yoit and Bauer, in their 
researches on fatty degeneration, of which we will speak more 
particularly hereafter. Before the different kinds of food can 
become available for the wants of the tissues, they must be 
brought into such a condition as to pass through the walls of the 
intestine into tlie blood, and be carried about through the circula- 
tion. The starch is converted into soluble sugar by the ferments 
of the salivary glands and pancreas in the mouth and small 
intestine, although while it remains in the stomach this change is 
diminished or arrested by the acidity of the gastric juice. How 
the sugar yielded by the starch is converted into fat we do not 
precisely know, although it seems probable that the change of part 
of it at least into lactic or butyric acids may be one part of the 
process. Tiie albuminous matters are converted into peptones by 
the stomach and pancreas. Some of these peptones are further 
split up during pancreatic digestion, so as to yield leucine, which 
belongs to the group of fatty bodies. The fats themselves are 
partially emulsionised, as well as partially saponified, by the 
pancreas. They then pass either through or between the 
epithelial cells, which cover the villi, into the lymph spaces in 
their interior, and thence through the lacteals, mesenteric glands, 
and thoracic duct into the general blood-current. The amount of 
fat in the blood may be very considerably increased by food. In 
a dog, which had fasted for four days, a diet of bread raised the 
proportion of fat in the blood from 2*6 in the thousand to 
8"1 ; meat raised it to 3"8 ; and suet and starch to 4'1, a most 
important observation, to which we shall again have occasion to 
refer. All these foods, as we thus see, raise the proportion of fat ; 
but besides the fat they all supply other substances to the blood 
which may be beneficial, but which, in excess, may prove more or 
less injurious. Thus bread supplies sugar as well as fat. If this 

K 2 



132 USE AND ADMINISTRATION OF FAT. 

sugar undergo the proper changes in the body, it is useful, but if it 
be in such excess that its combustion is insufBcient, it will produce 
thirst and the other symptoms which we meet with in glycosuria. 
If the apjDetite or digestion will not allow of the consumption of 
sufficient bread to produce this, we may have a deficiency of fat. 
Meat also, as we have seen, produces fat, but supplies also a large 
quantity of nitrogenous material which may, like the sugar, prove 
injurious when in excess. We usually suppose that a diet of meat 
is the best cure for failing strength, and for weakly persons we are 
accustomed to recommend beef-tea whenever they feel faint. But 
Kanke observed that an exclusively meat diet, instead of produc- 
ing strength, caused weakness and muscular fatigue, the excess of 
waste nitrogenous products proceeding from the decomposition of 
this food in the organism seeming to act as a muscular poison. 

In order, then, to keep the balance true, and supply the wants 
of the various tissues without having any excess of waste pro- 
ducts, we must have an admixture of various kinds of food, and 
if one or other be deficient, we either throw additional work 
upon the organism by making it consume more than a fair share 
of another sort, and excrete the residue which it does not want, 
or the tissues and organs which most require the missing food 
will suffer in consequence. Now, the food which is more fre- 
quently deficient than any other is fat, and this may be either 
because the fat cannot be obtained, or because it cannot be 
digested. The late Dr. Hughes Bennett used to say that two of 
the main causes of tuberculosis were the dearness of butter and 
the abundance of pastrycooks. For fat is an expensive article of 
diet, — well-fed meat is dearer than badly-fed and lean meat. 
Butter is expensive, and amongst poor families its place is very 
often taken by molasses or jam, which no doubt gives a relish 
to the bread, and is enjoyed by the child, but does not sujDply 
the place of butter as a food. Hence, amongst the lower classes, 
both children and adults suffer because they are unable to obtain 
a sufficient proportion of fat in their food. The pastrycooks 
whom Dr. Bennett accused of causing tuberculosis amongst the 
upper classes, did it, he said, by disordering the digestion, of 
young girls especially, by puff-paste, and other things of that 
sort, and thus spoiling their appetite for food, and especially for 
the fat which they might obtain in abundance if they liked. 
The result is the same in both classes, for unless the fat be 
absorbed and assimilated, the result is the same as if the 



HOW TO EAT FAT. 133 

patient could not obtain it. But we notice that in both upper 
and lower classes there are numbers of children who refuse 
fatty food, although their parents or guardians are sufficiently 
careful to prevent them from injuring their digestions by puff- 
paste, or anything of the kind. There are many children who 
will utterly refuse to eat a piece of fat meat. They will eat the 
lean, but carefully cut off every scrap of fat, and lay it at the side 
of the plate, and will submit to severe punishment rather than 
eat it. Some persons are in favour of punishing such children, 
and compelling them to eat fat, but such a course I regard as a 
total mistake. The instinct of the child is perfectly right, and its 
indications ought not to be disregarded. If the fat be swallowed 
under compulsion, it generally disagrees with the child, and makes 
it sick, as the poor thing well knows. In such cases the proper 
thing to do is to give the fat in another form. If any one of us 
were to swallow a lump of butter, by itself, it would very prob- 
ably make us sick ; but if we spread the same butter upon pieces 
of bread, we can take it not only without discomfort, but with 
enjoyment. Professor Hugo Kronecker once illustrated this to 
me very strikingly. He said : " Suppose you get a piece of 
butter, and are asked to make a sandwich, would you take the 
whole of the butter, spread it on one slice of bread, and then 
put tlie other unbuttered slice on the top of it ? If you did, 
your sandwich would not be half so palatable as if you divided 
your butter, spread it upon both slices, and then put them 
together," The reason of this is simple, for in the latter case we 
get the fat in a much finer state of subdivision, and the more finely 
it is subdivided, the more do we enjoy it, and the more readily is 
it digested, A piece of solid butter swallowed alone would melt 
in the stomach, float about without undergoing digestion, and 
would probably begin to decompose and yield acrid fatty bodies, 
which would irritate the stomach and cause sickness. When finely 
divided by admixture with particles of bread, it would form a 
creamy mass, which would quickly pass into the duodenum, and 
be digested and absorbed. In the same way, these very pieces 
of fat which a child will cut from its meat and put aside, may 
be rendered quite palatable by being mixed with flour or potatoes. 
A piece of fat bacon, or the liquid fat in the plate, which would 
certainly make the child sick if swallowed alone, will be taken 
with great relish if chopped up finely and well mixed with a 
mashed potato. Whatever the fat may be which we wish a person 



134 USE AND ADMINISTRATION OF FAT. 

to swallow, we should endeavour, by every means in our power, 
to subdivide it minutely, if there be the least difficulty in digesting 
it. Besides this, we ought to seek to maintain this state of sub- 
division in the stomach. For although the fat may be finely 
subdivided at the time it is swallowed, yet during its sojourn in 
the stomach it may be melted by the warmth of the body, and the 
globules gradually agglomerating may again form a solid mass, 
which will have somewhat the same effect upon the stomach as 
if it had been swallowed in a solid mass at first. For this reason 
I think it is advisable, in administering cod-liver oil, to give it an 
hour or so after, instead of immediately after, a meal, becaiise it 
will then have a shorter time to stay in the stomach, and will pass 
out quickly into the duodenum. I think it is better to give cod- 
liver oil in the form of an emulsion, with gum acacia, rather than 
with solution of potash or carbonate of potash, because the gum 
is little, if at all, affected by the gastric juice, whereas the potash 
will be neutralised, and its emulsifying properties destroyed, so 
that the particles of oil can again run together. This emulsion 
with gum acacia is borne by many persons who cannot take pure 
cod-liver oil, and with whom the potash emulsion also disagrees. 
Besides the differences in the digestibility of fat due to the 
mechanical condition of aggregation or subdivision, there are 
differences also which are due to their chemical composition. 
Thus, mutton fat is difficult of digestion, while pork fat is easily 
digested. Butter, too, can be readily taken, and is greatly enjoyed 
by some persons who cannot take other sorts of fat ; and cod-liver 
oil is usually very well borne, and very easily assimilated. Many 
opinions have been advanced regarding this ready digestibility of 
cod-liver oil, and some have sought for its cause in the fact that 
this oil contains propylene in combination with fatty acids instead 
of glycerine, like most other fats. Others, again, have attributed 
it to the minute quantities of iodine, and others to the biliary 
matters which are found in the oil. The last seems by far the 
most reasonable supposition. For it has been shown by Neumann 
that oil of any sort will pass much more readily through a filter, 
or through an animal membrane moistened with bile, than through 
one moistened with water. This is still further borne out by the 
fact which the late Dr. Hughes Bennett used to mention in his 
lectures, and which has recently been confirmed by the observations 
of my friend Dr. Russell, that the coarser kinds of cod-liver oil, 
though more disgusting to the taste, are sometimes more easily 



COD-LIVER OIL— BRONCHITIS. 135 

dio-ested than the so-called better qualities. These coarse oils are 
obtained from livers which have been longer exposed to heat, and 
contain more of the biliary substances. But it is not improbable 
that the peculiarity in the chemical composition of the oil which 
I just now mentioned, may have also something to do with its 
digestibility and utility. The remark of the old nurse quoted by 
Weir Mitchell, that cod-liver oil fat was soon squandered, seems 
to point to the greater mobihty, if we may so term it, of the cod- 
liver oil than of other fats, so that it is both more readily laid 
on and more readily reabsorbed from the tissues than other fats. 
Perhaps it is to this greater mobility that the beneficial effects 
of cod-liver oil, as compared with those obtained from the use 
of other fats, such as butter, are to be ascribed. In a former part 
of this paper I observed that the quantity of fat circulating in the 
blood could be greatly increased by food. Now it may not matter 
very much to tissues of tolerable permanency, such as the sub- 
cutaneous fat, what the fatty substances in the blood may be, as 
time is allowed for these substances to ■ undergo any necessary 
modifications before they become deposited in the permanent 
adipose cells. But the case may be different with mobile tissues, 
such as the colourless blood corpuscles, which are going to form 
pus, or with the rapidly developing young cells which help to 
compose the muco-punilent expectoration in bronchitis. For these 
it may.be a matter of great importance that the fat should be easy 
of assimilation, the time allowed for such assimilation before the 
cells are thrown off being very limited. 

Some time ago I went to a lecture on sick-room cookery. The 
lecturer described and demonstrated the different methods of pre- 
paring gruel, and observed that whenever the gruel was required 
for a case of bronchitis, a piece of butter should always be added to 
it, " because," said she, rubbing her chest with her hand, " butter 
is so very healing to the inside." She was evidently under the 
impression that the piece of butter got into the chest, ran all about, 
and thoroughly greased the air-passages. Her notions of physiology 
were very confused, but I think her practical observation was 
perfectly correct. It appears to me that in bronchitis, both acute 
and chronic, a little cod-liver oil is generally much more serviceable 
than cough mixtures, and patients express themselves very grateful 
for the relief which it affords by lessening the cough. Indeed, in 
many cases of chronic bronchitis, it seems to me to be almost the 
only remedy which affords any marked relief. The use of this 



136 USE AND ADIIINISTRATION OF FAT. 

oil in phthisis is now so universal that I need say nothing about it, 
but I will pass on to consider the use of fats as a nervous food. I 
have read that a well-known barrister always swallowed a large 
dose of cod-liver oil before going to plead a case^ because it enabled 
him to do better mental work than anything else he could take. I 
myself, after a trial of various things, have come to the conclusion 
that fat bacon is one of the most satisfactory things upon which to 
do hard mental work, and I invariably take it for breakfast when- 
ever I have first to see a number of patients and afterwards to 
deliver a lecture. We have already seen that the nervous system 
contains a very large proportion of fat, and we can well imagine 
that if fat be deficient from the food, that system must necessarily 
suffer; and more especially is this likely to be the case if, in 
addition to the deficiency of fat, we have an excess of the products 
of nitrogenous waste, such as we get from an almost exclusively 
animal diet. A distinguished physician has made the observation 
that the prevalence of Bantingism has thrown a great number of 
nervous cases into the doctor's hands, and a friend lately narrated 
to me the case of a relative of his own who used to suffer from 
undefined nervous symptoms. Sometimes he sat and moped about 
all da}^, simply because he felt that he could not go out alone, and 
that he was unable to do anything. He would sometimes start for 
a walkj and after j)roceeding a short distance, would turn back 
again. He lived to a great extent on animal food, and, notwith- 
standing this disinclination to go out alone, he took a great deal of 
exercise, both hunting and shooting, so that his symptoms were 
neither due to want of food nor lack of exercise. Some time 
afterwards he went to Ireland, and whilst there lived on very fat 
meat and whisky. All the time he did this he felt perfectly well, 
but whenever he came back and resumed his animal diet, the 
symptoms returned. 

In persons of a gouty temperament, living to a great extent 
on animal food, especially when they reach middle age, we not 
uufrequently observe sugar in the urine. It is, I think, a mistake 
to term this diabetes ; it should rather be called gouty glycosuria. 
The cause of it appears to be that the oxidation in the body is 
insufficient to consume all the substances taken in as food, and one 
or other of them must needs undergo imperfect combustion. 
Accordingly we find that it is sometimes the nitrogenous products 
of waste which pass out in a state of imperfect oxidation, large 
quantities of uric acid and urates appearing in the urine instead of 



FATTY DEGENERATION. 137 

urea. At other times it is the non-nitrogenous products, such as 
sugar and fat, which escape oxidation, the uric acid being absent 
from the urine whilst sugar appears, or both uric acid and sugar 
may be wanting, and fat is accumulated. These processes of 
imperfect oxidation seem to be very closely connected indeed, for 
Seegen has noticed, in his work on diabetes, that the disease is 
often preceded or accompanied by an immense accumulation of fat, 
so that one patient, who went to be under his treatment at Carlsbad, 
had actually to be conveyed in a luggage van instead of an ordinary 
railway cai'riage. We also notice very frequently that the gouty 
glycosuria of middle age occurs in stout persons. The same 
deficiency in oxidation which leads to the accumulation of fat in 
the subcutaneous cellular tissues, or about the viscera, may also 
lead to fatty degeneration of organs. The pathology of fatty 
degeneration has been exceedingly carefully worked oiit by Voit 
and Bauer, and the method they adopted was to study the changes 
which took place in animals during phosphorous poisoning. It is 
well known that after poisoning by phosphorus the organs of 
animals are found to be in a state of intense fatty degeneration, 
and the question which Yoit and Bauer tried to solve \vas, " Whence 
did this fat come ? " It might, they said, have come from the food, 
or it might have been absorbed from the subcutaneous cellular 
tissue and deposited, for example, in the liver, or it might have 
been formed in the liver and other organs from the albuminous 
constituents of these organs themselves. They solved the question 
in the following way : — they starved a dog until all its fat had 
completely disappeared, and then poisoned it with phosphorus. 
At its death its organs were found to be in a state of exquisite 
fatty degeneration. The fat here could not have come from the 
food, for the animal got none ; it could not have been absorbed 
from the subcutaneous cellular tissue and deposited in the liver, 
for all the subcutaneous fat had gone before the phosphorus was 
administered. It must therefore have been formed in situ, from 
the albuminous constituents of the organs themselves. So much 
being ascertained, they had next to discover whether the fat was 
due to increased tissue change, or diminished oxidation. The 
albuminous constituents of the organs, they considered, were split 
up into some nitrogenous substance, and into fat. Normally, both 
of these undergo oxidation, the nitrogenous substances into urea, 
and the fat into carbonic acid and water, the splitting up of the 
tissue and the oxidation going on nearly ;pari ;passu. If the tissues 



138 USE AND ADMINISTRATION OF FAT. 

split up too rapidly for tlie products of their decomposition to be 
oxidised, it is obvious that we shall either have the fat accumu- 
lating, or the nitrogenous products imperfectly oxidised, as, for 
instance, in the case of fever, or of gouty glycosuria. If the amount 
of oxygen received by the tissues be diminished below the normal, 
a similar result will occur. In phosphorous poisoning both of 
these were observed, for the urea was greatly increased, showing 
that the nitrogenous tissues were split up more rapidly than usual, 
while the amount of carbonic acid exhaled was diminished, showing 
that the combustion going on in the body was less than usual. 
The combustion of the tissues is kept up by the oxj^gen carried to 
them from the lungs by the red blood-corpuscles, and Avhenever 
the supply of oxygen to the tissues is diminished, either by 
impoverishing the blood of these corpuscles, or by lessening the 
flow of blood through the part, accumulation of fat or fatty 
degeneration is likely to ensue. This fatty accumulation from 
insufficient oxidation may sometimes be observed in women after 
severe flooding, the patient becoming exceedingly anaemic, and at 
the same time very fat. The fatty degeneration due to insufficient 
oxidation is seen in the muscles of a paralysed limb, where want 
of exercise has nearly stopped the flow of blood, or in the heart, 
where the coronary arteries have been rendered too small for the 
normal heart by calcareous degeneration, or where the hypertrophied 
heart has grown too big for these arteries to supply it. This fatty 
degeneration of the heart is frequently met with in persons of a 
gouty habit, tending to become fat, and at the same time suffering 
from bronchitis, sometimes complicated by emphysema. In treating 
such persons the question arises, " Does a fatty condition of the 
heart, and the tendency to accumulate fat under the skin con- 
traindicate the use of the cod-liver oil which might be beneficial 
to the bronchitis ? " For my own part I am inclined to say no. 
It is quite true that the oil, after being absorbed, will very probably 
undergo oxidation more readily than the fat which has been forming 
in the tissues, but it may be nevertheless beneficial by supplying 
the Avants, not merely of the young cells in the bronchial tubes^ 
which form the expectoration, but by supplying the wants of 
the nervous centres. In such cases I sometiu:ies give cod-liver oil, 
notwithstanding the fatty condition of the heart, and trust to 
increase the oxidation by administering iron so as to increase the 
number of the red-blood corpuscles, at the same time trying to 



FATTY HEART. 139 

eliminate some of tlie waste materials by keeping the bowels freely 
open. 

If I were to pursue this subject into all its ramifications, I should 
take up more time than could be allotted to several papers such as 
this; and therefore in the present one I have merely attempted a 
slight sketch of some of the more prominent uses of fat, and tried 
to give a few hints derived from ^physiological observation, and 
confirmed, I feel certain, by the experience of many medical men 
resfardimr the method of administerinsf fats, and the diseases in 
which fat is chiefly serviceable. 



THE PHYSIOLOGICAL ACTION OF ALCOHOL.^ 

{' The Practitioner,' vol. xvi., Jany. and Feb. 1876.) 

Is alcohol a food or a poison ? Is it one of the greatest boons 
ever given to mankind, or one of the greatest curses wherewith 
they are afflicted ? These are questions to which we will receive 
different answers, according to the circumstances under which they 
are asked. If we ask the man who has just watched by the bedside 
of his dearest relation during the crisis of a fever, and seen the 
parched tongue grow moister, the delirium lessen, the quivering 
pulse grow stronger and steadier under the influence of alcohol, he 
will probably tell us that if not a food of the same kind as bread 
and beef, it is, under certain circumstances, better than either^ and 
a blessing whose greatness can hardly be over-estimated. If, on 
the other hand, we address ourselves to the squalid wife of a 
drunken husband, who, instead of employing his time in work, and 
properly spending his evenings, lies in a state of idleness and 
incapacity for one half the week, and spends the greater part of 
the wages he receives for the other half in brutalising himself at a 
gin-palace, we shall probably hear that it is the greatest curse upon 
earth, a poison destroying soul and body ; and she will tell us that 
but for it she would be a happy woman, instead of a trembling 
slave living in constant fear of blows or death, her husband would 
be a respected member of society instead of a brutal coward, and 
her home would be a Paradise instead of a Pandemonium. 

If we inquire why people drink it at all, the answers we receive 
are no less contradictory. The negro sweltering under a tropical 
sun drinks it to cool himself; the London cabman shivering at his 
stand on a wintry morning drinks it to warm himself; the weary 
traveller drinks it to strengthen his flagging muscles, and help him 
onwards to his destination; the literary man drinks it to give 

* Read in part before tlie Medical Societj' of London. 



ACTION ON THE SKIN. 141 

subtlety to bis intellect, or brilliancy to bis wit; tbe overworked 
man of business drinks it to rouse him from bis apatby, and give 
sharpness to bis bargains; the gamester quivering with excitement 
drinks it to steady his trembling hand ; and the man or woman 
broken dowm by misfortune, and weary of life, drinks it to drown 
care in temporary oblivion. 

Irreconcilable as these answers to our questions may seem, we 
nevertheless know that they are all more or less true ; and^ in 
studying the physiological action of alcohol, our endeavour must 
be to discover how it is that one drug can produce such opposite 
effects. This is undoubtedly a difficult task, and one which we 
cannot at present hope to accomplish perfectly. All that we can 
do is to take the facts we find and arrange them to the best of our 
ability, trusting to future research for information on those points 
of which we are now ignorant. In doing this we must bear in 
mind that alcohol has a threefold action. 1st. Its local action on 
the skin or mucous membrane with which it comes in contact. 2nd. 
Its reflex action on other organs, through the sensory nerves of the 
skin or mucous membranes. 3rd. Its action on the brain, spinal 
cord, and other organs to which it is conveyed by the blood. 

The action of alcohol is modified, too, by the degree of concen- 
tration in which it is employed, and by the admixture with it of 
other substances, such as ethers of various kinds, hops, vegetable 
acids, &c. Thus, if we moisten the skin with pure alcohol, in the 
form of eau de Cologne, or diluted with its own bulk of water, as 
brandy, and allow it to dry spontaneously, a decided sensation of 
cold will be produced ; but if we employ it in a still more diluted 
form, as wine or beer, the cold will be much diminished, or become 
quite imperceptible. This cooling action is due simply to the 
volatility of alcohol, which during its evaporation abstracts heat 
from the skin and cools it down. If pure it evaporates quickly 
and produces much cold, but if mixed with much water the 
evaporation of tbe mixture is too slow to produce any marked result. 
Any other volatile substance would have a similar effect, although 
its other actions upon the body might be utterly different from 
those of alcohol. 

And, indeed, we get a very different result from alcohol itself, 
if, instead of allowing it to evaporate spontaneously, we prevent 
evaporation altogether by covering the moistened skin with gutta 
percha tissue. Instead of coolness we get a burning feeling, most 
intense if we use pure alcohol,- or eau de Cologne, less with wine 



U2 THE PHYSIOLOGICAL ACTION OF ALCOHOL. 

and imperceptible with beer. "We have got rid of the action which 
alcohol owes to its volatility^ and we have brought into play another 
which it owes to its chemical properties. So long as it could 
evaporate readily it acted almost entirely on the epidermis, but 
w^hen evaporation is prevented it soaks through the epithelium and 
acts on the vascular tissues beneath. This is better seen if, instead 
of aj)23lying the alcohol to the skin, where the epidermis presents a 
considerable resistance to its passage, we put it into the mouth, 
where the thinner epithelium offers less obstruction. Almost im- 
mediately after its introduction we experience a burning sensation, 
which increases for a little while, and then gTadually diminishes. 
If we keep it in the mouth long enough, we notice that the mucous 
membrane changes its character, and becomes whiter, more opaque, 
and somewhat corrugated. Although the burning feeling appears 
to be accompanied by an increased flow of blood to the part, and 
its disappearance by a diminished flow, yet it is not due to the 
warmth of the blood, for water at a temperature much above that 
of the blood produces no such feeling in the mouth. Both the 
sensation of burning, and the visible alteration in the mucous 
membrane, are due to the action of the alcohol upon the tissues, 
and we shall better comprehend the nature of this if we compare 
it with that of other substances. A piece of hot metal, or a solution 
of corrosive sublimate, will also cause a burning feeling, and an 
alteration in the mucous membrane, but, instead of being transitory, 
it will be more or less permanent. Now there is one point in which 
they all agree, viz. they all coagulate albumen ; and the whitened 
appearance of the mucous membrane of the mouth after brandy 
has been long applied to it, is no doubt due to the precipitated 
albumen on the surface obscuring the red colour which the circu- 
lating blood imparts to the tissues beneath. But there is this great 
difference between the action of alcohol and that of heat, or of 
corrosive sublimate. The latter produce permanent coagulation 
while the coagulum formed by alcohol readily dissolves again in 
water, or in the liquids of the body.-^ Thus its action is more 
transient ; and, if it is only allowed to act for a short time, its effect 
is counteracted by the blood which dissolves the albumen as fast as 
it is coagulated, so that we do not see any opacity of the mucous 

^ The coagulation of albuminous fluids by alcohol seems due in the first instance 
to the simple abstiaction of water, and when this is again added, they re-dissolve. 
If the alcohol acts for a long time upon them, however, their constitution seems to 
undergo a change, and they become insoluble in water. 



ACTION ON THE MOUTH. 143 

membrane of the mouth, unless alcohol has been acting on it for a 
good while. When frecjuently applied to the skin, and allowed to 
evaporate, it seems to act on the epithelium and harden it, and thus 
it is frequently used to prevent the formation of bedsores and 
cracked nijiples. 

Most substances which possess the power of coagulating albumen, 
such as tannin, catechu, kino, logwood, sulphate of copper, sulphate 
of zinc, &c., act as astringents when taken internally, and even 
corrosive sublimate, although not usually reckoned among their 
number, is strongly recommended in some forms of diarrhoea by 
Professor Sydney Ringer. Alcohol is no exception to the rule, and 
we all know that a person suffering from an attack of diarrhoea 
usually flies to the brandy- bottle for relief before he thinks of 
consulting a medical man. We know too little about the action of 
astringents to say positively that alcohol owes its efficacy in this 
respect to its power of coagulating albumen, but we certainly can 
say that this properly appears to be the only one it possesses in 
common with catechu and kino. 

The simple experiment of putting a little brandy in the mouth 
is instructive not only by showing us the local changes which 
alcohol produces in the mucous membrane, but by reminding us 
of the second kind of action which alcohol exerts, viz. reflexly 
through the nervous system. At the same time that the burning 
is felt, the saliva begins to flow copiously into the mouth. The 
alcohol has not come in contact with the salivary glands at all, but 
through the sensory nerves of the mouth it has acted on the 
nervous centres, and through them upon the vessels and secreting 
cells of the gland. If we swallow the brandy instead of ejecting 
it, the feeling of warmth which we experience along the course of 
the oesophagus and in the stomach itself, informs us that it acts on 
the mucous membrane of these organs in the same way as on that 
of the mouth. So far as I am aware, we are at present ignorant 
of the reflex actions which alcohol exerts through the mucous 
membrane of the oesophagus, but those which it produces through 
the stomach are of great importance. First of all come those 
which concern the secretions and movements of the stomach itself. 
When the stomach is empty its mucous membrane as seen through 
a gastric fistula is pale and only covered with a little mucus. If a 
little alcohol is now introduced the blood-vessels of the mucous 
membrane dilate and it becomes of a rosy red colour, its glands 
begin to secrete copiously, beads of gastric juice stand upon its 



U4 THE PHYSIOLOGICAL ACTION OF ALCOHOL. 

surface, become larger and larger until they can no longer preserve 
their form, when they coalesce and run down together in a little 
stream. 

Now every slight stimulation of the stomach seems to be felt as 
appetite, and thus we find that substances having the most diverse 
properties induce a desire for food. Alcohol does this in a marked 
degree, and a nip of brandy is very frequently taken as an appe- 
tizer. But appetite seems really to be only an expression of shght 
uneasiness on the part of the stomach. It cannot distinguish sens- 
ations like the mouth, and alcohol which on the tongue causes 
burning, quassia which causes bitterness, and minute doses of 
arsenic or tartar emetic which would cause congestion if they 
stayed in the mouth as they do in the stomach, all cause appetite. 
Perhaps they do this only by exciting a certain amount of conges- 
tion in it, for food itself causes the vessels of the mucous membrane 
to dilate and its glands to secrete in the same way as we have 
described after the injection of alcohol, and we all know that a 
person who begins a meal with no appetite at all often eats with 
zest after the first bite, and finishes with astonishment at the 
amount he has consumed. But if the irritation is too strong the 
whole condition becomes changed.^ The mucous membrane loses 
its rosy hue and becomes pale, the secretion of gastric juice ceases 
while that of a slimy mucus is increased, appetite disappears and 
is replaced by nausea, and finally vomiting occurs. This change is 
often clearly seen in a so-called bilious attack, where the irritation 
of the stomach first manifests itself as an abnormal craving for food, 
which gives place as the irritation increases to nausea and vomiting. 

Now the amount of irritation necessary to produce these totally 
different conditions of increased secretion with appetite and 
diminished secretion with nausea varies in different stomachs, 
and in the same stomach under different conditions. If the 
stomach is sensitive an irritation will cause nausea, which would 
only produce appetite if it were less irritable, and vice versd, a 
sluggish stomach will be benefited by an amount of irritation 
which one normally sensitive could not bear. Thus we know 
that in some cases articles of food, such as lobster, which in 
normal stomachs frequently cause indigestion and nausea, are 
readily digested while ordinary food is not digested. Tlie stimulus 
which an ordinary diet gives to the stomach seems here to be 

^ Bernard, Archive d'Anat. Gdn. et de Physiologie, Jan. 1846, c[Uoted by Power 
in Carpenter's Fhysiology.— Ed. p. 149. _ . 



LOBSTER AND BRANDY. 145 

insufficient to excite the secretion of gastric juice, wljile the more 
irritating substances do so and are digested instead of causing 
over-irritation and vomiting as in the normal condition. But if 
this explanation be correct, how is it that we take a glass of spirits 
with our lobster "to digest it" ? Is not this adding fuel to fire 
and increasing the irritating effect of the lobster on the stomach 
by that of the alcohol ? By no means — the fibres of lobster are 
probably in themselves no more irritating than fibres of beef, but 
only less soluble in gastric juice, so that they retain their form and 
hardness instead of being reduced to a pulp, and by thus exerting 
for a longer time a mechanical irritating action upon the stomach 
they produce nausea and indigestion, not immediately after they 
have been swallowed, but in the course of some hours. If, how- 
ever, an increased secretion of gastric juice be jDroduced by means 
of a glass of spirits swallowed at the same time with the lobster, 
we may expect that digestion will take place more rapidly, the 
fibres will be dissolved, and the prolonged irritation of the stomach 
being avoided no nausea "will ensue. 

If insufficient stimulation of the stomach then does not induce 
a flow of gastric juice, and if excessive stimulation causes nausea, 
under what circumstances is alcohol likely to be useful ? Healthy 
stomachs with ordinary food do not require it, although in small 
quantities it may do little harm, and as an adjunct to lobster may 
be positively beneficial. A large quantity however is certain to be 
injurious. Moreover, if regularly used, even in small quantities, 
the stomach may become habituated to it, and refuse to resj^ond 
to the stimulus of food alone, unless supplemented by that of alcohol. 
The case is different when we have to deal with a stomach whose 
sensibility is below par, either permanently or temporarily. In 
patients convalescent from an acute illness, or weak delicate anaemic 
persons, the food does not sufficiently stimulate the weakened 
stomach, the secretion of gastric juice is small, and the meal lies 
for a long time like a weight at the epigastrium. The same is 
the case with the merchant, tiie lawyer, or the doctor, who comes 
home from his counting-house, his office, or his rounds, and sinks 
exhausted into his easy-chair, weary and worn out by a long day's 
work. In such cases the diminished sensibility of the stomach 
must be compensated by an extra stimulus, and the glass of sherrv 
which to a healthy person not exhausted by over-fatigue would be 
superfiuous, will in them restore the normal ec|uilibrium and 
quicken the otherwise slow and imperfect digestion. 

L 



U6 THE PHYSIOLOGICAL ACTION OF ALCOHOL. 

I do not mean to discuss the wisdom of tliese men's conduct 
in thus exhausting their energies, or the question how long such 
a course can be pursued without ending in an utter breakdown, 
for it is in many instances sheer necessity which drives them to 
it, and no remonstrance or warning is of any use. But I would 
say a word about the amount of stimulants to be employed and 
the probable effect of excess on the stomach itself. Not only does 
the sensibility of the mucous membrane become blunted so that 
it no longer secretes gastric juice in proper quantities when stimu- 
lated by food alone, but it secretes mucus in large quantities, and 
this not only imjDedes digestion, but facilitates fermentation, by 
which various injurious substances are formed. Amongst these 
may be mentioned butyric acid, which causes an acrid burning 
sensation in the stomach itself, and may, according to Otto Weber 
and Senator, be absorbed into the blood and there act as a nerve 
jD jison, still farther reducing the business capacities of the unfor- 
tunate patient, which may already have been sadly diminished by 
over- work and inability to assimilate proper nourishment. 

While then it may be very beneficial to take a moderate 
quantity of alcohol with meals, an excessive amount will be 
injurious to the stomach itself, not to mention its action on the 
nervous system. 

In connection with this power of the stomach to adapt itself to 
the stimulus it ordinarily receives, I may mention that in one part 
of the Austrian empire the peasantry Kve almost exclusively on a 
mixture of oatmeal and water which is allowed to ferment and 
become sour. Although this diet would in all probability so irri- 
tate the alimentary canal of any ordinary person as to produce 
vomiting and diarrhoea, these people thrive upon it and are very 
strong and healthy. When the young men however enter the 
Emperor's army, and come to Vienna, where they get well-cooked 
food, they nearly all suffer from indigestion, lose flesh, and become 
weak and ailing — exactly the contrary of what one would have 
expected. Of course various exjDlanations may be given of this 
fact, but I am inclined to believe that the indigestion is due to the 
well-cooked food being less irritating than the sour meal, and not 
sufficiently stimulating to the stomach and intestines accustomed 
to the other. 

Alcohol taken into the stomach increases the movements of 
the organ as well as its secretion, and by mixing its contents more 
thoroughly with the gastric juice accelerates digestion. At the 



REFLEX ACTION OF ALCOHOL. 1-17 

same time it causes the expulsion of gases, and a little brandy is 
one of the carminatives most commonly employed by those who 
suffer from flatulence. But in this respect also the stomach after 
a little while becomes accustomed to the stimulus, and those 
habituated to the excessive use of alcohol not only suffer from 
flatulence due to the processes of fermentation already mentioned, 
but are less readily relieved by the usual remedies.^ 

We now come to consider the effects which alcohol produces 
reflexly on other organs through the nerves of the stomach before 
it has actually been absorbed. The glow which is felt in the 
stomach after taking a glass of brandy diffuses itself so rapidly 
over the body that many authorities have considered that it could 
only do so through the nervous system. Others again believe that 
absorption takes place so rapidly that the warmth may quite well 
be, and is, due to the action of the alcohol on the heart and vessels 
after it has got into them. In this case, as in many others, it is 
probable that both parties are right, and the effect is due partly to 
the one cause and partly to the other. For if you wish to warm 
a man cpiickly who is shivering with cold you give him a glass of 
raw brandy, and you do not dilute it with a tumblerful of water. 
And yet, according to Dogiel,^ the diluted spirit will be more quickly 
absorbed than the strong ; and if the warming effect is produced 
by the alcohol only after it gets into the vessels the dilute spirit 
should act more c^uickly than the neat. The fact seems to be that 
the brandy at first increases the circulation and warms the man by 
acting reflexly on the heart and vessels through the nerves of the 
stomach,^ and that afterwards the alcohol is very f[uickly absorbed 
into the blood, and keeps up the primary effect by its special action 
on the nervous system, and through it upon the circulation. 

When a large dose of alcohol is swallowed at once, the person or 
animal very often falls down immediately in a state of perfect 

^ In reference to congestion of the stomacli as a cause of appetite vide Beaumont, 
Experiments and Observations on the Gcistric Juice and Physiology of Digestion, and 
Buchheim's Arzneiraittellehre, p. 42. On the secretion of gastric juice aud the effect 
of alcohol upon it, xi().e Beaumont op. cit., Bernard Physiologie Experimcntale, vol, 
ii. p. 388, and Kiihne, Physiologisehe Chemie, p. 28. 

2 Dogiel, Pji'uger's Archiv., vol. viii. 

2 Keflex contraction of the intestinal vessels probably occurs and drives the blood 
to the surface. Compare the experiments of Hermann and Ganz {Pfi'dger's Archiv., 
vol. iii.), and of Meyer and Pribram {Wiener Akad. Sitzung.sber, JuJy, 1872), where 
cold di-inks and mechanical irritation of the stomacli raised the blood pressure, -with 
those of Heidenhain {Pflilgc/s Archiv., 1871, vol. iv. p. 1 to 119), where a rise in 
blood-pressure increased the flow of blood through the cutaneous vessels. 

L 2 



148 THE PHYSIOLOGICAL ACTION OF ALCOHOL. 

vincoDsciousness, and unless medical assistance be at hand may 
never awake. Sir Benjamin Brodie, who made several experiments 
on this point, attributed this condition to reflex action from the 
stomach upon the heai't and vessels.-^ The irritation applied to 
the inside of the viscus by the alcohol had produced shock in very 
much the same way as a blow on the epigastrium would have done.^ 
But when alcohol is injected into the veins the animals fall into 



'^- J- -CEREBELLUM- 
'■'/-MMaULLA 
i OBLONGATA 



«K<JS-/-U\ 



)1;V--Sir 



■4- -STOMACH 
imSO-INHIBITORY 
/ NER\/ES 

' -IIVTESTINAL 
VESSELS 



Fig. 16. — Diagram showing tlie reflex action on the heart and vessels of large doses 
of alcohol introduced into the stomach. The irritation produced by it is conveyed 
by the different nerves to the medulla oblongata, and thence by the vagus to the 
head, which it either slows or stops entirely. The mode of action on the in- 
testinal vessels is not certain. It maj^ simply arrest the normal action of the 
vaso-motor centre upon the intestinal vessels, or may be conducted down to them 
by vaso-inhibitory nerves, as represented in the diagram. In either case it will 
cause them to dilate. 



much the same condition as when it is introduced into the stomach, 
and therefore several authorities have thought that Brodie's con- 
clusions were wrong. They are, however, in great measure correct, 
for he found that a somewhat small dose of alcohol injected into 
the stomach of a cat knocked it down senseless, and in this con- 
dition it remained for about eight minutes. Then it recovered and 
walked about. There was no time here for the elimination or for 
the destruction of alcohol in the system, and consequently this 
effect which passed off so rapidly could not be due to the presence 
of the drug in the blood, and must be attributed to its action upon 

1 Brodie, Philos. Trans., vol. ci. p. 179. 

2 Vide the author's article on "The Pathology of Shock and Syncope," Practi- 
tioner, voL xi. p. 2i3. 



ACTION ON THE HEART. 



149 



the stomach before absorption. But when larger quantities were 
given the animal did not recover in this short time. Then the 
primary shock lasted so long that before it passed off absorption 
had time to take place, the alcohol having found its way into the 
blood was carried by it to the nervous centres, acted upon them, 
and the shock passed into alcoholic coma. 

While large doses thus paralyze the heart more or less com- 
pletely, moderate doses stimulate it to act with increased rapidity, 
and at the same time with increased force. I consider this 



f>=i)CtREBELLUM 
-/■MEDULLA 
/ OBLONGATA 



ACCELERATING^S-S 
•NERVES 7 



vm 



HEART— -/-i-y'y 



Wafperent nerves 



'\VASO-MOTOR 
\ NERVES 



'-^^-f—— INTESTINAL 
VESSELS 



Fig. 17. — Diagram showing tlic reflex action upon tlie Leart and vessels of moderate 
doses of alcohol. The irritation is conve3'ed to the medulla, as- in Fig. 12, but 
instead of calling into action the vagus and vaso-inhibitory nerves, it excites the 
accelerating nerves of the heart, and probably the vaso-motor nerves of the in- 
testines, thus increasing instead of diminishing the circulation in the body 
generally. This difference in the reflex action of large and small doses of alcohol 
upon the heart and vessels corresponds to the different action, already noticed, of 
slight and great irritation of the stomach, mechanical or otherwise — the slight 
stimulation iacreasing, and the great diminishing or arresting the circulation and 
secretion. 

stimulating action upon the heart through the nerves of the 
stomach, even when no absorption has taken place, to be one of 
the most important properties of alcohol, for I believe it is reflexly 
in this way that we restore the circulation where it has nearly 
ceased by pouring a glass of brandy down a man's throat. When 
a person has been nearly drowned, or is dying from exposure to 
cold — when the pulse at the radial has ceased and the cardiac 
pulsations can hardly be perceived — -we cannot imagine that 
absorption will go on very quickly from the stomach, and yet the 
good effects of the spirits we give quickly become evident. 



1^0 THE PHYSIOLOGICAL ACTION OF ALCOHOL. 

Having said so much regarding the local action of alcohol on the 
stomach and its reflex; action upon the heart through the nervous 
system, let us consider the efifects it produces after its absorption 
into the blood. It must be constantly borne in mind that these 
effects are independent of those vrhich alcohol produces roflexi}^, 
and may be antagonistic to them ; so that after axohol has acted 
on the nerve-centres, it may prevent any farther reflex from the 
stomach. 

Most authorities agree in saying that absorption tahes place by 
the veins and not by the lacteals, but some consider it to occur 
chiefly in the stoniach, others in the intestine. In all probability 
it occurs in both, and slight differences in the fulness of the stomach 
may alter the proportion taken up by it and by the intestine 
respectively. Strong alcohol injected directly into the biood causes 
coagulation, but this of course cannot occur when it is absorbed 
from the stomach. For if by any possibility it should enter the 
absorbing venous radicles in a concentrated state the coagulation 
it would there induce Avould at once bar its further j^rogress. 

It is therefore only with the action of more or less diluted alcohol 
on the blood and vessels \^jth which we have to do. It acts on 
the white blood corpuscles by at first increasing and then dimin- 
ishing their amoeboid movements. What the effect of its action 
on the movements of the white corpuscles will be upon the body as 
a whole it is difficult to say, but the result of its action on the red 
coi'puscles is more easy to trace. George Harley^ and Schmiedeberg 
have found that it lessens their power of giving off oxj^gen, and 
must consequently more or less diminish the oxidation of the 
tissues. Now, both the functional activity of organs and the 
production of heat in the body depend on the process of oxidation 
within them, and it is obvious that any interference with these 
processes is not likely to bs beneficial so long as they are going on 
in a healthy way, and not too rapidly. As we shall afterwards see, 
however, this effect is to some extent counteracted, or even more 
than counteracted, by the action of alcohol in accelerating the 
circulation, and if the quantity taken be small, and not frequently 
repeated, little or no harm will ensue. If it be frequently taken, 
however, by persons in average health, and with fair digestion, its 
effects wiU become manifest in the imperfect combustion of fat, 
and its consequent accumulation in the tissues. This seems to 
occur especially in the skin, which acquires a velvety feeling. 
^ Froceediiigs of the Royal Society, vol. xiii. 1864. 



ALCOHOL IN FEVER. 151 

From this quality of the skin I have seen Professor Neumann 
of Vienna diagnose the potatory habits of a man whom one 
would otherwise never have suspected. If much saccharine or 
other fat-forming matters be taken at the same time with frequent 
doses of alcohol the subcutaneous tissue also becomes loaded with 
fat, as we so frequently see in brewers' draymen, and if the 
consumption of alcohol be excessive it causes fatty degeneration 
of various organs. This power of alcohol to lessen oxidation, 
useless or even injurious in health, increases the value which its 
other properties give it in the treatment of febrile diseases, where 
oxidation is going on too quickly, and rapidly destroying the 
tissues. The very increase of temperature which this oxidation 
causes helps of itself to accelerate 1,he disintegration of the tissues, 
for a high temperature causes them to split up, even although they 
do not undergo oxidation. Thus the albuminous tissues probably 
become decomposed and yield urea, other nitrogenous substances, 
and fat. The fat does not undergo complete combustion but 
accumulates in the tissues from which it has been formed, and 
thus the heart of patients who have died of pyrexial diseases, 
instead of being purely muscular, is generally to a great extent 
fatty. 

In such a condition of pyrexia alcohol will diminish the ex- 
cessive waste in two ways. Firstly, it will impede oxidation, and 
secondly, by thus lessening the temperature, it will diminish 
tissue-disintegration. 

But while alcohol thus modifies the blood, does it undergo no 
change itself? Does it simply course through the vessels for 
some time until it can be eliminated unchanged by the various 
emunctories, or does it undergo combustion in the blood as the 
grape sugar from which, it is derived would do, and thus deserve 
like it the title of food ? '--.- :,^^-.;,-^. 

Great numbers of experiments have been made to decide this 
question, and diametrically opposite opinions have been founded on 
them. Liebig classed it as a food along with sugar and starch, and 
no doubt was thrown on the correctness of this classification, until 
Lallemand, Perrin, and Duroy published their experiments, from 
which they concluded that alcohol is entirely eliminated in an 
unchanged condition, and can therefore in no sense be termed a 
food. Their conclusions, however, were much more general than 
their experiments warranted, and they did not pass unchallenged. 
What their research actually showed was not that the whole of the 



/ 



152 THE PHYSIOLOGICAL ACTION OF ALCOHOL. 

alcohol injected passed out of the body, but only that a part of it 
is excreted. Similar experiments were made by Baudot, who 
instead of using large doses used small ones, and lie found that 
instead of the Avhole or a great part of the alcohol being excreted, 
only a small fraction, so small as to amount practically to nothing, 
found its way out through the kidneys. The question was then 
taken up by the late Dr. Anstie, who did much to solve it; and 
had he only lived to complete the researches on which he Avas 
engaged at the time of his death would have settled it completely. 
His experiments, as well as those of Thgdipiyam, Dupre, and 
Schulinus, confirra Baudot's, and show that only a trifling fraction 
is eliminated. A year or two ago, Subbotin published some 
experiments, in which he found a much larger proportion of the 
alcohol to be excreted than the other observers just mentioned had 
done, but he, as well as Lallemand, Perrin, and Duroy, used very 
large doses. Now we all know that grape sugar is a most valuable 
food — the food we may say par excellence of the body, for others are 
converted into it in the liver — and in moderate quantities it under- 
goes complete combustion in the body, and is not eliminated in the 
urine. But a man may be rendered temporarily diabetic by giving 
him a large quantity of syrup at once, for the organism not being 
able to consume more than a limited amount at a time, the excess 
is thrown out by the kidneys. It is therefore not to be wondered 
at that alcohol should be excreted after large doses have been 
taken ; in fact, the wonder would be if it were not. 

The importance of the question whether alcohol undergoes 

oxidation in the body or not consists in this ; if it is oxidized it 

will supply energy for muscular exertion, or for keeping up the 

animal heat, or for both, and will therefore be entitled to rank as 

a food, while if it is excreted unchanged it will have no claim to 

the name, and must be classed with such substances as the organic 

alkaloids, which after acting on the nervous and muscular systems, 

while they are circulating in the blood, pass out after a while by 

the emunctories. It is the merit of Baudot, Anstie, and others who 

have worked at this subject, to have shown that alcohol is oxidized, 

and is thus to be reckoned as a food and not merely as a drug. 

But still more satisfactory evidence of its claim to the title of food 

'^orded by the fact that it will keep up the weight of the body 

\olong life when the supply of other food is in.=;ufficient or is 

\wanting. 

mmond found that when he took an insufficient diet and 



ALCOHOL IN FEVER. 153 

was daily losing weight, tlie addition of alcohol not only prevented 
this loss of weight, but converted it into an actual gain.^ In his 
work on '' Stimulants and Narcotics," Dr. Anstie has collected a 
number of cases in which persons have lived for a considerable 
time either upon it alone or along with a quantity of food so small 
as to have been utterly inadequate without it. 

From a survey of all the evidence on this subject, I think we 
may conclude that in moderate doses alcohol undergoes combustion 
in the body, and will supply energy, yield warmth, and tend to 
sustain life in the same way that sugar would do, and is therefore 
to be reckoned as a food. At the same time it has a power of 
diminishing oxidation which prevents its employment as a food 
to any great extent in health, but greatly increases its utility in 
disease. 

In feverish conditions it diminishes tissue waste, and thus keeps 
up strength in three ways : — 1. It undergoes combustion itself as a 
food instead of the tissues. 2. It lessens oxidation in them. 3. It 
lowers the temperature which itself increases tissue degeneration. 
It may perhaps seem rather contradictory to say that it undergoes 
combustion and yet diminishes combustion, but in this respect we 
may compare it to the sulphur which some people are accustomed 
to throw into their grate when the chimney takes fire — the sulphur 
burns itself, but it puts out the blazing soot. 

We now come to the action of alcohol upon the heart and 
vessels, and in order to prevent any complication from the reflex 
action of which we have already spoken, let us suppose that instead 
of pure brandy dilute spirits or some light wine has been taken, 
which will have little or no irritating effect upon the gastric 
mucous membrane. One of the best possible opportunities of 
studying the earlier and slighter effects of alcohol is afforded by a 
public dinner. If we look at our own hands or those of our 
neighbours before going in, especially if the ante-room is somewhat 
cold, we may find them somewhat pinched-looking ; the colour 
somewhat dusky and distributed in patches instead of being 
uniform ; the veins very thin, almost like threads. They are of a 
somewhat dark blue colour, and on emptying them by pressure 
they fill very slowly, showing that the circulation is languid. After 
a few glasses of wine, however, their appearance begins to change. 
The hands now assume a uniform rosy tint, showing that the 
capillaries are now dilated and filled with bright arterial instead 

^ Hammond's Physiological Eesearches, p. 55. 



154 THE PHYSIOLOGICAL ACTION OF ALCOHOL. 

of dark venous blood ; the veins swell up, become prominent, of 
a light blue colour almost like arteries, and when emptied by 
pressure fill rapidly, showing that the circulation has become very 
quick, and that they, like the cajjillaries, are now filled with blood 
which is tolerably bright, if not quite arterial, instead of the dark 
blood they previously contained. The hands entirely lose their 
shrunken look, little wrinkles in the skin disappear, indeed the 
hands become larger than usual, or, as my neighbour at a dinner- 
table one expressed it, they become "podgy," from the amount of 
blood and intercellular fluid in the vessels and tissues ; and rings 
previously loose become almost too tight. This dilatation of 
vessels, so readily seen in the hands, is not confined to them, but 
occurs generally throughout the body. The warm blood pouring 
from the inteiior of the chest and abdomen over the surface 
imparts to it a pleasing glow, and a most agreeable feeling of 
comfort pervades the whole frame. The face shares the general 
flush, and the pulsation of the temporal arteries not unfrequently 
becomes easily visible. The current of blood throughout the body 
is more rapid than before, and this rapidity does not depend simply 
on the dilated vessels offering less resistance to the current of the 
blood. No ! the alcohol has stimulated the accelerating nerves of 
the heart, which cause it to pulsate not only more rapidly but more 
powerfully, so that in animals, despite the dilatation of the vessels, 
the pressure has been found to rise in the arteries.^ Here we have 
one at least of the most important conditions for the nutrition of 
all the tissues. The slight diminution in the oxidizing power of 
blood which alcohol occasions is many times over compensated 
by the amplitude of its current, and, as this is flowing rapidly 
through the tissues, bringing them new food and carrying off their 
waste products, is it any wonder that they work with more than 
usual vigour ? The muscles acquire new strength ; the work 
which previously fatigued them is done with ease; the mental 
faculties become much more acute, and new ones, previously 
unsuspected, may even apj^ear. The merchant will be able to 
drive a harder bargain, the student will solve the problem which 
previously baffled him, the man who tries with difficulty to speak 
in a foreign language finds his stammering disappear and his 
tongue run on with ease, the melancholy man may sing a merry 
ditty, and the sedate man, whom no one would ever have sus- 
pected of such a thing, may succeed in making an excellent joke. 

' Dogiel, PJlugcr's Archiv., vol. viii. p. 605. 



ALCOHOL AS A FOOD. 155 

Provided the liquor has been good, or, in other words, provided 
the alcohol emj^loyed has been free from all injurious admixture, 
all these effects, I believe, may be produced, and may pass away 
without any bad effects. 

In the preceding lines I have sketched the action of alcvohol in 
its fairest aspect, but its effects are not always so pleasant ; for not 
a few persons, instead of becoming more bright, lively, active, and 
intelligent after taking a little alcohol, become heavy, sleepy, and 
stupid. These different effects are partly dependent on the 
different constitution of the individuals, and partly on the quantity 
and kind of the alcoholic beverage. AVe find that the same 
differences exist in the effect of walking exercise upon the mental 
powers. Exercise, like alcohol, both dilates the vessels and 
increases the action of the heart. The mental processes of some 
persons go on very slowly when they are walking, and if they are 
asked a question they stand still to think and answer it.^ They 
can think still better when they sit, and their brains are perhaps 
yet more active if they lie doAvn. Others, again, do their brain- 
Vv'ork more easily when walking about, and so instead of remain- 
ing at their desk they pace the room incessantly while thinking, 
and only take the pen in their hand when they are ready to 
write. At first sight, it seems odd that the conditions most 
favourable for thought should be so different in two persons, and 
yet when we come to examine them more closely we find that both 




Fig. 18. — Tracing showirg tLe increased circulation in the brain caused by inc''iinng 
the head and body forwards. The tracing was taken by Brissaud and Francois- 
Fianck, fiom the parietal region of a woman who had lost a large piece of bone 
from syphilis. — Mareifs Traxauxfor 1877, p- 147- 

persons, in different ways, are seeking the same thing, viz. a fuller 
supply of blood to their brains. Position has a good deal to do 
with this, the head receiving more blood when it is lowered than 

1 It must be remembered that the effects here discussed may be due in great 
measure to diversion of nervous energy {ride the author's article on "Inhibition 
Central and Peripheral," West Biding Asylum Reports, vol. iv. p. 210), and not 
entirely to altered distribution of blood. 



156 THE PHYSIOLOGICAL ACTION OF ALCOHOL. 

M'lien it is high. Ahiiost every one unconsciously shows this by 
bending forward instead of sitting upright when engaged in lively 
conversation, and more especially in debate, when the greatest 
possible mental activity is desired.^ The influence of position also 
makes itself felt, in the kneeling posture — for example, during 
prayers in church, where sometimes, very much against the will of 
the icdividual, thoughts utterly unconnected with the devotions 
in which he appears to be engaged whirl through his brain, new 
projects are formed and problems solved with a rapidity surprising 
to himself. In some persons whose blood-vessels are lax, either 
from natural constitution or in consequence of debility or exhaus- 
tion, the recumbent posture, which allows a free current of blood to 
the head, is the most favourable for thought.^ Now both exercise 
and alcohol have the effect of dilating the vessels, and, at the same 
time, of increasing the action of the heart. In some persons the 
relaxation of the blood-vessels caused by exercise is greater than 
the stimulation of the heart, so that, although this organ is beating 
somewhat more vigorously, the dilated vessels of the body draw 
away the blood and leave the brain more ansemic than before. 
Consequently such persons do not think so well while walking, 
and they may be rendered rather stupid than lively by alcohol. 
Others again, in whom stimulation of the heart is more easily 
induced than relaxation of the vessels, either by exercise or 
alcohol, so that the rapid and powerful cardiac pulsations increase 
the current of blood to the brain more than the dilated vessels can 
diminish it, think well while walking about, and have their mental 
power increased by alcohol. 

A moderate quantity of alcohol may thus enable a man to 
overcome a sudden difficulty, but can its effects be kept up so as 
to help him with a prolonged effort ? Does the alcohol supply 
new strength, or does it merely enable a man to use up his 
reserve of energy? If it really supplies strength we ought to 
find it doing so each time it is administered ; but if it merely 
helps to use up reserve energy, we will find that each successive 
time it is given the organism responds less and less readily to 
the call, just as a man gives more and more grudgingly at each 
successive demand upon his purse. Now the question was 

' This statement is well illustrated by the tracing (Fig. 18), which here accompa- 
nies it, but which was not published until a year after this paper. 

2 This is, however, often interfered with by some other factor, possibly some 
reflex action from the skin of the head, which induces sleep in this position. 



ALCOHOL AS A STIMULANT. 157 

thoroughly tested during the Ashanti campaign, and the following 
are the results as recorded by Professor Parkes:^ — 

" The first effect of alcohol, when given in a moderate dose (for 
example, what is equal to one fluid ounce of absolute alcohol), is 
reviving, but this effect is transient. The reviving effect goes off 
after at the utmost two and a half miles of additional march, and 
sometimes much before tliis; then the previous languor and sense 
of exhaustion not only return, but are sometimes more intense, and 
if alcohol is again resorted to, its effects are now less satisfactory. 
Its reviving power is usually not so marked, and its peculiar 
anaesthetic and narcotising influence can often be distinctly traced. 
The men feel heavy, dull, disinclined to march, and are less walling 
and cheerful." 

From this it is evident that alcohol does not impart strength, 
but rather enables a man to use up in a short time the energy 
which he usually would have taken a much longer time to expend. 
If he only reqiiires to make a single effort and can rest afterwards 
until he has replaced his exhausted store, the additional temporary 
strength obtained by using alcohol may enable him to overcome an 
obstacle which Avould otherwise have baffled him, but if he has to 
make prolonged exertions alcohol is injurious. 

Now the heart seems to be affected by alcohol in the same way 
as the body generally. No new strength is imparted to it, but it 
is enabled to draw on its reserve. Thus Parkes has found that 
when brandy is given to healthy men the pulse becomes quicker, 
but after the effects of the brandy have passed off it becomes 
slower than natural, so that the number of pulsations and amount 
of work done by the heart in twenty-four hours is much the same 
whether brandy have been taken or not, unless the doses be large 
and repeated.^ 

The question therefore at once arises, — Is alcohol only useful in 
stimulatino' the heart to do additional work, and thus avertino: the 
danger of failing circulation for a short time only, or can it be used 
in diseases wdiere this danger is to be averted for clays, and even 
weeks, together ? Before attempting to answer this question, I 
would remind you that a heart which is beating more quickly than 
usual wears itself sooner out than one which is acting slowly. It 
has been found that a heart which has been made to pulsate slowly 
for some time by irritation of the vagus, will continue to beat for 

^ On th-e Issue of a Spirit-PMtion during the Ashanti Campaign of 1874, p. viii. 
2 Pavkes, Proceedings of the Royal Society, No. 150, 1874, p. 190. 



158 THE PHYSIOLOGICAL ACTION OF ALCOHOL. 

a good while after it has been removed from an animal's body ; 
while, on the contrary, it very soon ceases to beat if the vagi, 
instead of being irritated, have been cut, so as to allow the pulsa- 
tions to be very rapid for some little time before the animal's 
death.i What is observed in these excised hearts is only an 
exaggerated representation of what occurs in the body, and although 
in it the pulsations may continue days instead of minutes, yet the 
final result will be similar. If alcohol always Q^uickened the pulse 
in disease as it generally does in health it would probably be 
injurious in prolonged illness, as it was found to be in prolonged 
exertions by the soldiers in Ashanti. But this is not the case, for 
in fever the quick pulse frequently becomes slower after the 
administration of alcohol, and, indeed, an excellent rule of practice 
is not to give alcohol if it increases the rapidity of the pulse 
already too quick. Alcohol thus economises the vital power of the 
heart, and tends to prevent death from exhaustion. It is difficult 
to say precisely how the slowing of the pulse is effected. Probably 
it is due partly to stimulation of the vagus, for alcohol stimulates 
this nerve as well as the accelerating nerves of the heart, and 
partly to the alcohol increasing the power of the weakened vaso- 
motor centre, either by acting upon it directly or by increasing the 
supply of blood to it, and thus giving greater tone to the vessels 
and raising the pressure in them. It may be also partly due to 
the action of the alcohol in lowering temperature. For heat is a 
stimulant, and cold is a sedative to the ganglia of the heart both 
in and out of the body, and other things being equal, its pulsations 
will be quick or slow according as the temperature is high or low,^ 
And j ust as hearts which have been beating quickly in consequence 
of division of the vagi, soon lose their vitality, so do hearts which 
have been pulsating rapidly in consequence of heat, soon cease to 
beat, while those which have been exposed to a lower temperature 
and have been beating more slowly, retain their vitality for a 
considerable time.^ 

The power of alcohol to reduce the animal heat is assisted by its 
property of diminishing oxidation, but is chiefly, no doubt, due to 
its action upon the vascular system. As I have already mentioned, 

1 Czermak and Piotrowsky, Wiener Akad. Sitziongsherichtc, xxv. p. 431. 

2 Paimm, Bibliotlick fiir Lager, Bd, xi. p. 468, and Schmidt's Jahrh. 1858. For 
other references, and for some original experiments on this subject, see the author's 
article on "The Influence of Temperature on the Mammalian Heart, aud on the 
Action of the Vagus," St. Bartholomew s Hosjntal Reports, vol vii. 

3 Panum aud others, op. cit. 



ALCOHOL AND COLD. 159 

it produces a rosy flush and a glow on the skin by dilating the 
cutaneous vessels and allowing the warm blood from the interior of 
the body to circulate freely through them. This agreeable warmth 
is popularly believed to be due to increased production of heat in 
the body, and persons leaving a warm room for a cold walk or 
drive Avill often take a glass of spirits " to keep out the cold." But 
alcohol instead of really heating the body, only warms the skin at 
the expense of the heart, lungs, and intestines, and so really lets 
in the cold to these organs from which nature tries hard to exclude 
it. For, in a healthy man external cold causes all the vessels of 
the skin to contract, so that very little blood flows through them, 
or none at all. The skin itself thus becomes cold and blue, but 
the deeper structures retain their normal warmth, for heat passes 
from them to the skin very slowly indeed by simple conduction, 
and it is the circulation which maintains among them an equality 
of temperature. When alcohol is taken, however, this arrangement 
is disturbed, the cutaneous vessels instead of contracting become 
dilated, and the blood pouring through them warms the cold skin 
comfortably. But in doing this it loses heat itself; it returns to 
the heart at each revolution a little colder than it left it ; soon the 
temperature of the whole mass of blood and of the internal organs 
becomes reduced, and the last state of that man is much worse 
than the first. Where men are subject to great and prolonged 
exposure to cold, experience has taught them the danger of taking 
spirits while the exposure continues. My friend Dr. Fayrer told 
me that when crawling through the wet heather in pursuit of deer 
on a cold day, he offered the keeper who accompanied him a pull 
from his flask. The old man declined, saying, " No, thank you, it 
is too cold." The lumberers in Canada who are enaaofed in felling 
timber in the pine forests, living there all winter, sleeping in holes 
dug in the snow, and lying on spruce branches covered with buffalo 
robes, allow no spirits in their camp, and destroy any that may be 
found there. The experience of Arctic travellers on this subject is 
nearly unanimous ; and I owe to my friend Dr. Milner Fothergill 
an anecdote which illustrates it in a very striking way. A party 
of Americans crossing the Sierra Nevada encamped at a spot above 
the snow line, and in an exposed situation. Some of them took a 
good dealof spirits before going to sleep, and they lay down warm 
and happy ; some took a moderate quantity, and they lay down 
somewhat but not veiy cold ; others took none at all, and they lay 
down very cold and mis3rable. Next morning, however, those who 



IGO THE PHYSIOLOGICAL ACTION OF ALCOHOL. 

had taken no spirits got up feeling quite well, those who had taken 
a little got up feeling cold and wretched, those who had taken a 
good deal did not get up at all, they had perished from cold during 
the night. Those who took no alcohol kept their heart warm at 
the expense of their skin, and they remained well; those who took 
much warmed their skin at the expense of their heart, and they 
died. 

But while alcohol is thus injurious during prolonged exposure 
to cold, the case is very different after the exposure is over, and 
its administration may then be very beneficial. Supposing a man 
after being out all day comes home much chilled to a warm fire- 
side. He stands before the grate and turns himself round and 
round, but he cannot get himself warmed through. The cutaneous 
vessels so long contracted by the cold will not relax all at once, 
and the deeper tissues gain heat very slowly, just as they lose 
it very slowly, by mere conduction through the skin. If a little 
spirits be now taken, and especially if it be taken hot, the cutaneous 
vessels dilate, allow the blood to circulate through them and. 
become warmed by the fire, it returns warm to the internal organs 
and soon the whole body is in a pleasing glow. At the same time 
the dilatation of the cutaneous vessels opens new channels to the 
blood which has been pent up in the interior of the body, and thus 
lessens any tendency to congestion or inflammation of internal 
organs, so that a glass of hot brandy and water at the proper time 
may possibly prevent a bronchitis or pleurisy. Here I may just 
mention that although alcohol during continued exposure is gener- 
ally injurious, yet in some instances where pain or cramp in the 
internal organs seem to indicate more risk from their engorgement 
than from diminution of the general temperature of the body, it 
may be beneficial, even while the exposure continues. 

The dilatation of the vessels produced by alcohol has other con- 
sequences than equal distribution of heat between the surface and 
interior, for the dilatation does not occur equally in every vascular 
district. Generally the vessels of the brain are especially dilated, 
as is seen both from the mental activity usually manifested, and 
from direct observation of the vessels themselves ; but sometimes 
those of other jjarts, probably those of the intestines, would seem 
to be more particularly affected, and the blood beiag thus drained 
away from the brain, it becomes anaemic and sleep ensues. 

We have now to consider the effects of alcohol when given in 
such quantities as to evidence its poisonous qualities and produce 



IN TOXIC A TION. 1 Gl 

intoxication. Excepting when the dose is so excessive as to pro- 
duce shock, the symptoms of intoxication are always preceded by 
those of stimulation already described. It is (as I have already 
observed) very difficult to say how far the stimulating action 
depends on the increased circulation through the nervous centres 
only,, or how much of it may be due to the action of the alcohol on 
the nervous structures themselves. The symptoms of intoxication 
must, however, be referred to a paralysing action of the alcohol on 
the nerve centres, for although as intoxication progresses a dimi- 
nution in the activity of the cerebral circulation occurs, and the 
Avell-nourished brain becomes anaemic, this alone is insufficient to 
acount for the effects we observe. The first of these are weaken- 
ing of the mental faculties and of the power of co-ordination. 
The higher faculties seem to go first, and a man's judgment 
becomes impaired while his memory and imagination are still more 
lively than usual. Then these faculties diminish and the emotions 
become more prominent, so that a man is either ready to swear 
eternal friendship all round, or becomes as anxious for a fight as an 
Irishman at Donnybrook ; is gay, mirthful, and hilarious, or subdued 
and lachrymose, melting into a flood of tears without any apparent 
cause. 

At the same time that the cerebral faculties are disappearino- 
one after another, the power of co-ordination becomes impaired. 
This is most evident in the tongue and legs, the speech becomino- 
thick and indistinct, so that the pronunciation of the words 
" British Constitution " becomes next to an impossibility, and 
locomotion becomes staggering and uncertain, Althouo-h loss of 
the mental faculties and loss of co-ordination power generally cro 
hand-in-hand, yet either of them may occur a good while before 
tlie other, so that persons who seem stupefied by drink may rise 
and walk with, the utmost steadiness, while others who seem 
perfectly unaflected while sitting and can discourse on any subject 
with freedom will find great difficulty in steering their way from 
the table to the door. In popular language, one man is said to be 
drunk in his head and another in his legs. It is not, however, 
the legs that are in fault, as the drunk man himself well knows, 
but the nervous apparatus that directs them, and this in all 
probability is the cerebellum, as Flourens supposed it to be. This 
physiologist found that when he sliced away the cerebellum bit by 
bit the animals walked exactly as if they were drunk,"* and on the 
^ Froprities et Fonctions du Hystmxe, Nervcux, p. 3-27. 

M 



1G2 THE PHYSIOLOGICAL ACTION OF ALCOHOL. 

other hand, when he examined the cerebellum of drunk animals he 
always found it to be congested. The researches of my friend 
Professor Ferrier render it all the more probable that the cere- 
bellum is the nervous centre on which this loss of locomotory 
power depends, for he has found it to be the centre for regulating 
the movements of the eyes and co-ordinating the motions of the 
bod}'- with them. Now double vision is one of the most marked 
symptoms of alcoholic intoxication, and the staggering of a drunk 
man seems to be dependent on erroneous conceptions of the 
position of surrounding objects, for he not unfrequently vehe- 
mently asserts that he is perfectly steady but everything else is 
drunk, and all his troubles are owing to an ill-disposed lamp-post 
which went out of its way to bump him, or an evil-minded pave- 
ment which rose up and hit him on the nose. 

The cerebrum and cerebellum are thus the first parts of the 
nervous system to suffer, and even after their functions are com- 
pletely abolished the spinal cord will perform its functions, and a 
man incapable of thinking, speaking, or walking, will be able to 
ride, the impression made on his legs by the saddle causing reflex 
contraction of his adductors and enabling him to sit tolerably 
firmly although the upper part of his body may be swaying help- 
lessly about. At this time, however, the reflex action of the nerve 
centres regulating the heart's vessels is much impaired or almost 
entirely abolished,^ and herein is one source of safety to the drunk 
man. For sometimes a person in this condition may be seen riding 
furiously along a road, the horse swerves or turns a corner quickly 
and the rider is pitched forcibly off. The bystanders rush up 
expecting to find him dead, but no, beyond a severe bruise or two, 
and perhaps some tear or cut, he is nothing the worse. The fall 
which would have killed a sober man has not hurt the drunk one, 
for the alcohol has paralysed the nervous apparatus,^ through which 
shock would otherwise have been produced.^ The medulla oblon- 

^ Vide Dogiel, Pflligcr's Arch. viii. ^ Practitioner, vol. xi. p. 250. 

3 Leslie Stephen tells the following anecdote regarding a guide which illustrates 
this subject : — 

"Michel was one day descending from the well-known path which leads from 
the so-called Eismeer to Grindelwald in an unduly convivial frame of mind. Just 
above the point where mules are generally left, the path runs close to the edge of an 
overhanging cliff, the rocks below having been scooped out by the glaciers in old 
days when the glacier was several hundred feet above its present level. The dangerous 
]dace is guarded by a wooden rail, which unluckily terminates before the cliff is quite 
passed. Michel, guiding himself as it may be supposed by the rail, very naturally 
stepped over the cliff when the guidance was prematurely withdrawn. I cannot 



SUMJIAPiY. 1G3 

gata continues its functions after the cord has ceased to act, 
but by and by it also succumbs ; and if the dose be sufficiently 
large the respiration becomes weaker and weaker, and finally death 
ensues. 

The motor ganglia of the heart are also weakened by the action 
of alcohol upon them, but, in general, death is due to stoppage of 
the respiration, and not of the circulation, except in cases where 
shock has been produced by enormous doses of alcohol swallowed 
at once. 

To resume, the chief points in this paper are : — 

1. Alcohol, in small quantities, increases the secretion of gastric 
juice and the movements of the stomach, and thus aids digestion. 
Although unnecessary in health, it is useful in exhaustion and 
debility. 

2. It increases the force and frequency of the pulse, by acting 
reflexly through the nerves of the stomach. 

3. In large doses it impairs digestion by over-irritating the 
stomach, 

4. It may j)roduce death reflexly by shock. 

5. After absorption into the blood, it lessens the oxidising power 
of the red blood corpuscles. This property renders it useful in 
reducing temiDorature ; when constantly or very frequently present 
in the blood, it causes accumulation of fat, and fatty degeneration 
of organs. 

6. It undergoes combustion in the body, maintains or increases 
the body weight, and prolongs life on an insufficient diet. It is 
therefore entitled to be reckoned as a food. 

7. If large doses be taken, part of it is excreted unchanged. 

8. It dilates the blood-vessels, increases the force and frequency 
of the heart by its action on the nervous centres to which it is 
conveyed by the blood, imparts a feeling of comfort, and facilitates 
bodily and mental labour. It does not give additional strength, 

state the vertical height through which he must have fallen on to a Led of hard 
uncompromising rock. I think, however, that I am within the mark in saying that 
it cannot have been less than a hundred feet. It would have been a less dangerous 
experiment to steji from the roof of the tallest house in London to the kerbstone 
below. Michel lay at the bottom all night, and next morning shook himself, got 
up, and walked home sober, and no broken bones. I submit two morals for tlio 
choice of my readers, being quite unable, after much reflection, to decide which ig 
the most appropriate. The first is : Don't get drunk when you have to walk along 
the edge of an Alpine cliff ; the second is, Get drunk if you are likely to fall over an 
Alpine cliff." The Plmjgroimd of Euro'pa, p. 87. 

M 2 



464 THE PHYSIOLOGICAL ACTION OF ALCOHOL. 

but merely enables a man to draw upon liis reserve energy. It 
may thus give assistance in a single effort, but not in prolonged 
exertions. 

9. The same is the case with the heart ; but in disease alcohol 
frequently slows instead of quickening the pulsations of this 
organ, and thus economises instead of expending its reserve 
energy. 

10. By dilating the vessels of the skin, alcohol warms the 
surface at the expense of the internal organs. It is thus 
injurious when taken during exposure to cold, but beneficial 
when taken after the exposure is over, as it tends to j)revent 
congestion of internal organs. 

11. The symptoms of intoxication are due to paralysis of the 
nervous system ; the cerebrum and cerebellum being first affected, 
then the cord, and lastly the medulla oblongata. It is through 
j)aralysis of the medulla that alcohol usually causes death. 

12. The apparent immunity which drunken men enjoy from the 
usual effects of serious accidents is due to paralysis of the nervous 
mechanism, through which shock would be produced in a sober 
condition. 



ON THE PHYSIOLOGY OF VOMITING AND THE 
ACTION OF ANTI-EMETICS AND EMETICS. 

(' The Practitioner,' VOL. xiii. p. 409, Dec. 1874.) 

The act of vomiting consists in the forcible expulsion of the 
contents of the stomach through the oesophagus and mouth. It 
may seem almost unnecessary to mention the oesophagus at all, 
for anything passing from the stomach to the mouth must needs 
do so through the oesophageal tube. And yet this fact is not 
always borne in mind, and the active share whicb the oesophagus 
takes in producing emesis being forgotten, a false conception of the 
mechanism of vomiting is formed. For a long time opinions were 
divided regarding the part taken by the stomach in the expulsion 
of its contents. Some stated that this was chiefly effected by the 
active contractions of the gastric walls. Others affirmed that the 
stomach was entirely passive, and was merely emptied by the 
mechanical pressure exerted upon it by the simultaneous con- 
traction of the diaphragm and abdominal muscles. It has now 
been shown that the first view is incorrect, and that the movements 
of the stomach cannot expel its contents^ except in rare instances.^ 
Yoioiting consists essentially in the simultaneous contraction of 
the abdominal muscles and diaphragm, which press on the stomach 
so as to squeeze out its contents. When these muscles are pre- 
vented from acting, either by cutting them across or by paralysing 
them with woorara, vomiting does not occur, although the stomach 
may be moving actively. 

On the other hand, vomiting may be produced by the contraction 
of the diaphragm and abdominal muscles, although the stomach 

^ Magendie, Mimoire sur le vomissemciit, p. 23 ; Gianuzzi, Ccntralllatt cler mcd. 
WissoiscTiaften, 1865, p. 3. 
^ Budge, Die Lehre vom Erhreclicn, p. 34. 



166 ANTI-EMETICS AND EMETICS. 

remains perfectly quiet, and even when it is replaced by a simple 
bag. This was shown by the well-known experiment of Magendie.^ 

This physiologist removed the stomach of a dog and attached a 
pig's bladder filled w^ith fluid to the oesophagus in its place. He 
then injected tartar emetic into the veins of the animal, and found 
that vomiting occurred in the same way as if the stomach had 
been in situ. He noticed, too, that vomiting could be produced by 
the contraction of the diaphragm alone, after the whole of the 
abdominal muscles had been cut away, the linea alba ouly being 
left,2 and also, though imperfectly, by the contraction of the 
abdominal muscles alone, after the diaphragm had been rendered 
nearly motionless by section of the phrenic nerves.^ In ordinary 
vomiting, however, the diaphragm and the abdominal muscles 
co-operate together. 

But it is quite evident that in vomiting there is something more 
than'mere pressure of the stomach between the diaphragm and the 
abdominal muscles. In severe coughing the stomach is squeezed 
violently, but its contents are not usually expelled. The reason of 
this is, that in coughing the oesophagus remains firmly contracted, 
and prevents anything escaping from the stomach. In the act of 
vomiting, on the contrary, the oesophagus relaxes, and allows the 
gastric contents to pass freely through it.* In vomiting, therefore, 
there are two factors, viz. (1) pressure on the stomach ; (2) a 
relaxed condition of the oesophagus, especially at its under end, 
just where it joins the stomach. This under end is sometimes 
called the cardiac sphincter of the stomach, although there does 
not appear to be any distinct band of fibres thicker than the rest 
at this point, as the name would imply .^ 

If either factor be wanting, vomiting will not take place. The 
relaxation of the sphincter is of no use if the muscles do not 
contract, and they will exert themselves in vain if the cardiac 
sphincter remain contracted. This is seen in retching, which 
sometimes occurs without vomiting, even when the stomach is 
tolerably full. 

The relaxation of the cardiac sphincter is effected by contraction 
of the longitudinal fibres which run along the under end of the 

^ Magendie, op. cit., p. 19. 

2 Ibid. op. cit., p. 23, and Budge, Die Lelira vom Erlrcclien, p. 43. 

8 Ihid. op. cit., p. 21. 

* Schiff, Molescliott's Untersuchicngcn, Bd. x. p. 378. 

5 Gianuzzi, Centralblatt der mcd. JFiss., 1865, p. 3. " 



PHENOMENA OF VOMITING. 1G7 

oesophagus below the diaphragm, and then radiate obliquely over 
the stomach. When these contract, they draw the cardiac end of 
the stomach nearer to the diaphragm, and at the same time dilate 
the cardiac orifice,^ When they are paralysed, vomiting becomes 
impossible. If their innervation be disturbed, so that they do 
not work in concert with the diaphragm and abdominal muscles, 
vomiting will occur only rarely, or not at all ; for in such a case 
when the abdominal muscles contract, the cardia will probably be 
closed ; and when the cardiac orifice is open, the abdominal muscles 
will probably not contract.^ Thus, neither action is of any use, 
and it is only when, by some accident, they happen together, that 
vomiting takes place. 

It would be difficult for the muscles to exert any great pressure 
on the stomach if it were nearly or quite empty, but they will do 
so effectually if it be full. For this purpose it will not matter 
very much whether it is filled with food or air; and so it seems 
that both animals and men swallow air before vomiting. The 
emptier the stomach, the more air do they require in order to 
distend it, and the oftener do they swallow air. But it is im- 
possible to swallow air alone; saliva must be swallowed at the 
same time. The ordinary secretion of saliva would probably be 
insufficient for this purpose, and we generally find that vomiting is 
preceded by such profuse salivation as will enable many swallowing 
movements to be made rapidly one after another. 

When the stomach is very full, vomiting is somewhat difficult, 
for the organ then turns forward in such a way as to form a fold 
at the lower end of the oesophagus, and thus partially prevent the 
exit of its contents. Vomiting never occurs in the horse or rabbit, 
and rarely in guinea-pigs. This is probably due to the great length 
of that part of the oesophagus which lies between the diaphragm 
and stomach, so that the contraction of the longitudinal fibres 
causes it to fold and obstruct the cardiac orifice instead of opening 
it as in other animals. 

The phenomena of vomiting maybe thus described. Uneasiness 
is felt ; the inspirations become deeper ; several swallowing move- 
ments are made which sometimes carry down sufficient air to distend 
the stomach moderately. After several deep inspirations there 
suddenly comes one which is deeper still. Then, instead of this 
being followed by expiration, the glottis shuts to prevent the escape 
of air, the diaphragm contracts still more, thus descending more 
1 Schiff, op. cit., p. 380. 2 jjji^i p. 399, 



168 ANTI-EMETICS AND EMETICS. 

deeply into tlie abdomen, and pulling the ribs together ; the 
abdominal muscles forcibly contract ; the left half of the stomach 
is drawn upwards/ and the cul-de-sac flattened out; the cardiac 
orifice dilates, and the contents of the stomach are forcibly expelled. 
The pylorus remains firmly contracted, and allows but little to 
escape into the intestines. The closure of the pylorus has been 
ascribed by Budge,^ partly to mechanical compression by the liver, 
which is pushed down upon it by the diaphragm, and partly to 
contraction of its muscular fibres induced by the irritation of the 
pressure. It seems more probable, however, that the contraction 
of the pylorus is not due to any local cause, but is regulated, like 
that of the other muscles, by the nsrvous centre which presides 
over the act of vomiting. 

This centre is situated in the medulla oblongata, and it is 
identical with, or closely connected with, the nervous centre which 
regulates respiration. It is connected with the abdominal muscles, 
the diaphragm, the stomach, and the oesophagus, by the intercostal, 
phrenic, and pneumogastric nerves respectively. Along these it 
sends the motor impulses which make the muscles contract and 
produce vomiting. For the sake of simplicity these nerves have 
not been represented in the diagram. 

The nervous centre for vomiting is supposed to be closely con- 
nected or identical with the respiratory centre in the medulla 
oblongata. The reasons for this supposition are (1) that the 
movements of vomiting are excessively great and somewhat 
modified respiratory movements, and (2) that emetics excite the 
respiratory centre, while depression of the respiratory activity stojDS 
vomiting. Usually it is easy, by vigorous artificial respiration, to 
saturate an animal's blood with oxygen, and then, having no longer 
any need of fresh air, it ceases to breathe for a while ; and any 
person after taking a few deep breaths will find that he can hold 
his breath a much longer time than before. The condition in 
which no respiration is needed, and consequentl}^ no movements 
of breathing are made by the animal, is termed apnoea by the 
Germans, while v\^e use the same term to signify an aggravated 
condition of dyspnoea. I use the term in its German sense. If 
emetics are injected into the veins, the respirations become more 
frequent ; and it is stated by Hermann and Grimm, that no apnoea 
can be produced by the most vigorous artificial respiration. And 

1 Schiff, op. cit., p. 362. 
"^ Budge, Die Lchro vom Erbrcclicn, p. 49. 



VOMITING CENTRE. 



1G9 



on tlie other hand, tlie artificial respiration prevents the occurrence 
of vomiting so long as it is continued.-^ This seems to indicate that 
the respiratory and vomiting centres are closely connected, and it is 
by no means improbable that some of the nerve cells and fibres which 
compose the respiratory centre in the medulla oblongata also form 
part of the centre for vomiting. Yet the movements of respiration 
and vomiting, although somewhat alike, differ very considerably from 
each other ; and we are, I think, justified in supposing that the 
centres for respiration and vomiting are not absolutely identical,^ 
although a part of each may possibly be common to both. More- 



Vojniting centre. 



Ins]piratory centre. 
Cough centre. 

Ex^piratory centre. 




Respiratory centre. 



Fig. 1 9. — Diagrammatic representation of varions groups of ganglion cells or " centres " 
in the medulla oblongata. The arrows indicate the directions in Avhich the 
norve-currents pass. Those pointing to the cells indicate sensory nerves, those 
pointing from the cells indicate motor nerves. 

over, the centre for vomiting may be completely paralysed by 
narcotics, such as opium, chloral, or chloroform, while the respiratory 
movements continue or may even be increased.^ I have also found 
that in chloral narcosis it is easy to produce apnoea after tartar 
emetic has been injected into the blood and sulphate of zinc into 
the stomach. This could hardly be the case if the centres for 
respiration and vomiting were identical. I shall therefore speak of 
them as distinct. 

The nervous centre for vomiting is usually excited to action 

^ Grimm, Ffliiger's Archiv, iv. p. 205. 

2 Harnack, Arch. f. exp. Path. u. Pharmalcol, ii. p. 285. 

3 Ihid. p. 90. 



170 ANTI-EMETICS AND EMETICS. 

reflexly by irritation of certain afferent nerves. They may be 
divided into two classes : {a) those which pass upwards from the 
body to the medulla, and (6) those which pass downwards to it from 
the brain. It is easy enough to allot a few nerves to one or the 
other of these classes, but there are many others which we cannot 
with certainty place in either division. Thus, the pharyngeal 
branches of the glosso-pharyngeal nerve pass upwards to the 
medulla and act upon it independently of the brain, for tickling 
the fauces will produce vomiting in a man whose cerebral faculties 
are so besotted with alcoliol that he hardly feels blows or bruises 
which would cause him severe pain when sober. On the other 
hand, the nerves of taste and smell only act on the vomiting centre 
through the brain, for persons in the mesmeric sleep will drink the 
most nauseous mixtures with a smiling face, while the very remem- 
brance of disgusting tastes, sights, and odours would .make thetu 
sick in their ordinary waking condition. But we cannot so readily 
say how the vomiting centre is excited by those nerves which 
convey painful impressions from various parts of the body. Severe 
pain will often cause nausea and vomiting, although the pain may 
originate in the most various parts of the body. Thus, a person 
suffering from a loose cartilage in the knee-joint tells me that the 
pain it occasions always brings on nausea and vomiting. A painful 
wound may produce a similar effect, and Helmont ^ relates that 
after dislocating a joint, nausea and vomiting came on, and lasted 
until the bones were replaced. A blow on the testicles, an inflamed 
ovary, and the passage of a calculus along the gall-duct and ureter, 
all cause pain and often vomiting. Some say that the vomiting 
is due to the pain, and that it only lasts while the pain continues, 
the pressure of the calculus and the irritation it thereby causes 
having nothing to do with it. It may be the case, then, that the 
irritation of the nerves of a limb in the case of a loose cartilage or 
a dislocation, of the hepatic and renal nerves in the case of a 
calculus, and of the intestinal, ovarian, and other nerves, all act 
through the sensory portions of the brain ; but it is not yet certain 
that they do so, and it is so much more convenient to represent 
them as going direct to the medulla, than as going round to it vi'X 
the cerebrum, that I have given them a direct course in the accom- 
panying diagram. In it I have represented the following as the 
afferent nerves which pass up directly from the body to the medulla 
oblongata, and excite to action the vomiting centre situated there : 
^ Quoted by Budge, op. cit., p. 15. 



REFLEX VOMITING. 



171 



—Pharyngeal brandies of the glosso-pharyngeal ; pulmonary 
branches of the vagus; gastric branches of the vagus; gastric 
branches of the splanchnic ; hepatic branches of the splanchnics (of 
the vagus?); renal nerves; mesenteric nerves; uterine nerves; 
ovarian nerves ; vesical nerves. 

Those fibres which a-re represented as passing down from the 
brain may indicate the path by Avhich the vomiting centre is 



P/VA'jRYNX 



Liver and 
Gall, bladder 



Inte:st/ne--\— 



Bladder vv*^ 

Vesical V _)^ 

N'EBVEs] 




i NERVOUS CENTRE 
J or VOMITINC IN 



\ THE Medulla 



Pulmonary 
Branches. 

-Splanchnics 



-/. /?£IVAL NERVES 



_i UTEFIINC 

1 Ner ves 



Fig. 20.— Diagram showing the afferent nerves by which the vomiting centre may- 
be excited to action. 

excited by impressions of sight, taste, smell; by simple recol- 
lections or imaginations; by blows on the head, or inflammation 
of the brain or its membranes. 

After this general description, we will proceed to examine these 
nerves more particularly. 

They are— 1. The branches of the glossc -pharyngeal nerve, 



172 ANTI-EMETICS AND EMETICS. 

distributed to the soft palate, root of the tongue, and pharynx.^ 
TickHng these parts with the finger or with a feather is one of the 
readiest methods of inducing vomiting ; and sometimes, as in cases 
of poisoning by mushrooms, the stomach can be emptied more 
readily by it than even by tartar emetic. When they are inflamed, 
they not unfrequently give rise to a cough, which is distinguislied 
by violent expulsive efforts, nearly resembling retching, and not 
unfrequently accompanied by true retching, or even vomiting. 
This is often seen in children. One may frequently hear parents 
chide their children for coughing so noisily, and say to them, 
" Don't cough so loud," " Restrain your cough." Whenever these 
expressions are used, one may be almost certain that the chief 
cause of tlie cough is inflammation of the fauces, although this may 
sometimes be accompanied by bronchitis. 2. The gastric branches 
of the vagus and splanchnic nerves. It has been found by Blondlot 
and Bernard that when the mucous membrane of the stomach is 
gently tickled it becomes very rosy, and secretes gastric juice freely. 
If the mechanical irritation is carried further, so as to produce 
pain, the rosiness disappears and the surface becomes pale; the 
secretion of gastric juice is arrested; ropy mucus is poured out 
instead ; and the movements of the stomach are much increased. 
At the same time the animal shows signs of uneasiness and nausea, 
and if the irritation be continued vomiting occurs, and bile has been 
observed to flow into the stomach.^ Similar phenomena are pro- 
duced by various kin.ls of food and medicine. Thus, the intro- 
duction of food into the stomach usually causes secretion of gastric 
juice; but when it is hard and indigestible, or irritating, it may arrest 
digestion and cause vomiting. Dilute bitter infusions give appetite, 
and seem to aid digestion ; but a strong infusion of quassia will act 
as an emetic. As the vagi are the sensory nerves of the stomach,^ 
and several of these phenomena can be produced by irritating their 
trunks, it is * probable that they have a good deal to do Avith the 
conduction of impressions from the stomach to the vomiting 
centre. But they are not the only afferent nerves from the stomach ; 
for irritation of -this organ will produce vomiting after they have 
been cut.^ In this case it is probably through the splanchnic 
nerves that the irritation is conveyed to the medulla. 3. The 

' Budge, Die Lclire 'com Erhrechcn, p. 131. 

'^ Quoted in Carpenter's Physlolorjy, 7th edition, p. 123. 

3 Budge, Die Lchre vom Erhrechcn, p. 127. 

* Itutherford, Trans. Roy. Soc. Ediu., 18. * Budge, op. cit., p. 94. 



REFLEX AND CEREBRAL VOMITING. 173 

branches of the vagi and splanchnics going to the liver and gall- 
duct. Vomiting is of frec^uent occurrence in hepatitis, and during 
the passage of a calculus through the gall-duct.^ It is probably 
due to irritation of these nerves ; although, as we have already- 
said, it is diuicult to decide whether the nerves act directly on the 
medulla or only indirectly through the brain. 4. The pulmonary 
branches of the vagus. Irritation of these branches is not a very 
common cause of vomiting, and it may be doubted whether they 
cause vomiting directly or only indirectly. It is possible that the 
vomiting in the early stages of phthisis ^ may be due to these 
nerves, and it may be well to bear them in mind, and to examnie 
the lungs in cases of vomiting without any obvious cause. 5. The 
renal nerves. Vomiting occurs in nephritis and when calculi are 
irritating the pelvis of tlie kidney or passing down the ureter. 
6. The mesenteric nerves. Vomiting is almost always present in 
cases of strangulated hernia or intussusception. It also occurs in 
animals after a ligature has been tied firmly round a piece of the 
small intestine. It may be arrested by dividing the mesenteric 
nerves passing from the ligatured point." Its occurrence in general 
peritonitis is probably due likewise to irritation of the mesenteric 
nerves. 7. The vesical nerves. It is somewhat doubtful whether 
the vomiting sometimes observed in cystitis is due to irritation 
of these nerves or to irritation of other nerves by the extension 
of the inflammation from the bladder to the adjoining parts.^ 

8. Uterine nerves. Irritation of these nerves is one of the common- 
est causes of reflex vomiting. It may be produced either by the 
presence of the foetus in tlie uterine cavity, by inflammation of 
the womb itself, or by electrical irritation of the uterine plexus.^ 

9. Ovarian nerves. Vomiting is a symptom of inflammation of the 
ovaries.'' 10. Irritation of various parts of the brain. Vomiting 
may be produced by mental states excited by a disagreeable taste, 
by the sight or smell of disgusting objects, or even by the mere 
recollection of these ; by emotions, such as anger, suspense, grief, 
joy, &c. ; continued and intense thought, &c. ; '^ by concussion; by 
the irritation consequent on loss of blood, or caused by the with- 

^ Watson, Practice of Physic, 4th edition, pp. 586, 606. 

2 Craigie, Practice of Physic, vol. ii. p. 996 ; Watson, op. cit., vol. ii. p. 617, 

3 Schiff, Moleschott's Uritersuchtmgen, Ed. x. p. 390. 
* Craigie, Practice of Physic, vol. i. p. 930. 

^ Pflugers Archiv, Bd. viii. p. 351. 

^ Hooper's Physician's Vade Mecum : Oophoritis. 

' Budge, op. cit., p. 153. 



174 . ANTI-EMETICS AND EMETICS. 

drawal of blood from the general circulation and its accumulation 
in the abdomen in cases of shock.^ Yomiting is one of the most 
marked symptoms in meningitis and cerebritis, and is noticed also 
in some cases of tumours of the brain. Budge states that the 
cerebral centre for the movements of the stomach is the right 
corpus striatum and optic thalamus, especially the latter.^ Irrita- 
tion of these parts causes the stomach to move, while irritation of 
the corresjDonding parts on the left side of the brain have no action 
on the stomach whatever. From this observation we are led to 
suspect that when any irritation exists in the right hemisphere it 
will occasion vomiting more readily than irritation in the left 
hemisphere ; and, according to Budge, this is actually the case. 

There are thus many conditions of the brain which induce 
vomiting, and if we knew a little more about them we might 
separate them as we have done the nerves of the stomach, 
uterus, &c., instead of representing them all together, as we have 
done in the diagram. But even if we count them as one, we 
have altogether no less than ten nerves indicated in the diagram 
as exciting the vomiting centre reflexly. I shall not attempt to 
enter here on the means of diagnosing between the vomiting 
arising from irritation of all these nerves, but shall enter at once 
on the treatment. 

As vomiting is generally a reflex act consequent on the irrita- 
tion of some nerve, its rational treatment is either to remove the 
irritant, or, if this is impossible, to lessen the irritability of the 
nervous centre in the medulla, so that it no longer responds to 
the irritation. Not unfrequently we combine both methods. In 
inflammation of the fauces we use soothing or astringent gargles, 
confections, or glycerines. When the stomach is irritated by 
indigestible food or acrid matters present in its cavity, a large 
draught of warm water and mustard will often cause their ejection, 
and thus forms one of the best means for arresting further 
vomiting. If the irritant consist in an inflamed condition of the 
mucous membrane of the stomach itself, such treatment would be 
of little service, and we must endeavour to lessen the inflamma- 
tion and to render the sensory nerves of the stomach less irritable. 
This we do by the use of bismuth and of hydrocyanic acid. It is 
well known that if one holds the finder over the mouth of a 
bottle of hydrocyanic acid for a few minutes it becomes numb 

^ Practitioner, vol. xi. p. 250. 
2 Budge, op. cit., p. 116. 



POSITION IN VOMITING— PHTHISIS. 175 

and loses its sensibility ; and we have every reason to suppose that 
the acid acts in the same way on the nerves in the wall of the 
stomach, so that the inflammatory condition present there no 
longer irritates them to the same extent. At the same time, 
however, we may give some drug to lessen the irritability of the 
vomiting centre in the medulla^ such as morphia or chloral. 
Bromide of potassium has a considerable power to lessen most 
reflex actions, that of vomiting among the rest, and my friend 
Dr. Ferrier has used it with great success in sea-sickness. Acting 
on his suocrestion, I have found the followinsj formula very useful 
in gastric catarrh and subacute gastritis : — 

1^. Bismuthi subnit, gr. x. 

Potass, bromid., gr. xv.^xx. 
Acid hydrocyan. dil., \\\ v. 
Spt. chloroform, rn, x. 
Mucilag. tragacanth, fl. 5 ij. 
Aqua, ad. fl. 5 j. 
Sg. To be taken every three or four hours. 

The mediciue should be given about ten minutes before food, 
so as to diminish the irritability of the stomach and prevent the 
rejection of the nourishment, and it is often advisable to make 
the patient lie down on the left side either during or immediately 
after the meal. A tendency to vomit is often increased by lying 
on the right side. This is attributed by Budge ^ to the greater 
pressure exerted by the liver upon the stomach in this position, 
and«this may be correct. It seems to me probable, however, that 
the mere weight of the stomach itself and of its contents will 
exert a drag upon it, directed more or less towards its pyloric 
end, either in the sitting posture or when recumbent on the right 
side. Now, the stomach is much more sensitive to any pull 
exerted in this direction than to -one towards the cardia, even in 
the noruial condition, and it is likely to be still more so when 
rendered hyperaesthetic by inflammation. I am therefore inclined 
to ascribe the benefit derived from lying on the left side to the 
absence in this position of any drag on the stomach and the 
irritation it would cause, rather than to any change in the relations 
of the liver. 

I have already mentioned that it is doubtful whether irritation 
of the pulmonary branches of the vagus induces vomiting directly 
1 Budge, op. cit., p. QQ. 



176 ANTI-EMETICS AND EMETICS. 

in tbe same way as irritation of the gastric branches does ; but 
vomiting, occasionally of a very obstinate kind, is certainly found 
in phthisis, and it may be due to this cause. When it seems to 
be caused by the cough, it is sometimes checked by doses of six 
to ten grains of alum. This is rather hard to explain on the 
supposition that the vomiting is here due to the irritation of the 
pulmonary nerves, for the alum can have but little sedative action 
either on the lungs themselves or on the medulla. If we look at 
a patient coughing and mark the swollen veins on the forehead 
and neck, and remember that these are merely the visible signs of 
the general congestion throughout the whole venous system, 
including the veins of the stomach, we can hardly help thinking 
that the constant distension of the gastric veins during the almost 
incessant paroxysms must either in itself act as an irritant and 
thus induce vomiting, or lead to such a condition of the gastric 
mucous membrane as will do so. If this be so, the action of 
alum as a local astringent in removing congestion of the stomach 
may well explain its beneficial effect in arresting vomiting. 

The same principles prevail in the treatment of vomiting due 
to irritation of the other abdominal nerves as of those of the 
stomach ; but in them we can less easily soothe the irritation by 
local means, and we are obliged to de]3end still more on remedies 
which will act on the medulla. But we by no means neglect to 
remove the irritant as far as possible. In hepatitis we strive to 
subdue the inflammation by blisters and depletion; in intussus- 
ception we try to restore the bowel to its normal condition by 
copious injections of water or oil; in strangulated hernia we 
relieve the incarcerated bowel by an operation; and in inflam- 
mation of the uterus, ovaries, and bladder, we have recourse to 
depletion, blisters, and other appropriate local remedies. Even in 
pregnancy, if other means fail, we are sometimes obliged finally to 
remove the irritant by inducing premature labour, and sacrifice 
the offspring in order to save the life of the mother. 

But in such cases we base our hopes of arresting vomiting rather 
on our ability to diminish the excitability of the vomiting centre 
by means of opium, bromide of potassium, chloral, or hydrocyanic 
acid, than our power to remove the irritant. 

In sea-sickness it is difficult to say what the irritant is which 
excites the vomiting centre to action. For my own part, I am 
inclined to believe that it is the shaking and dragging of the 
abdominal viscera caused by the motion of the ship. Subjective 



CLASSES OF EMETICS. 177 

sensations point unmistakably to this as the cause, and the testimony 
they afford is strengthened by the fact that the sickness becomes 
less troublesome if the movements of the abdominal viscera are 
restrained by a tight bandage applied externally, or even by dis- 
tension of the stomach with food. Whatever be the cause, however, 
the treatment is chiefly directed to the vomiting centre, and my 
friend Dr. Ferrier has found bromide of potassium in large doses of 
especial service in preventing as well as arresting the distressing 
nausea and vomiting which make many persons regard a trip across 
the Channel with perfect horror. 

Thus far we have directed our attention to the act of vomiting, 
chiefly with the view of arresting it. Sometimes, however, we wish 
to induce it, and for this purpose we employ various substances 
which are generally all classed together as emetics. They naturally 
divide themselves into two subdivisions. Those belonging to the 
one act, like mustard, only when introduced into the stomach; 
those beloncring to the other act like tartar emetic, both when 
introduced into the stomach and when injected into the veins. 
The first class includes, besides mustard, the sulphates of zinc and 
copper, as well as other irritant substances not usually employed as 
emetics : they induce vomiting reflexly by irritating the nerves in 
the stomach ; and as the effect they produce is the same as that 
of scratching the mucous membrane, they are sometimes called 
mechanical emetics. The second class includes tartar emetic, 
ipecacuanha with its active principle emetia, and apomorphia ; as 
well as veratria, delphinia, cyclamin, asclepiadin, and sanguinarin, 
which also cause vomiting when injected into the veins, but are 
not used medicinally as emetics. 

It used to be considered certain that emetics of this class produce 
vomiting by acting directly on the nervous centre in the medulla 
oblongata, to which they were conveyed by the blood, and not by 
exciting it reflexly through irritation of the stomach, like the me- 
chanical emetics. This view seems to be to a certain extent correct, 
and the vomiting which follows the injection of such a substance 
as tartar emetic into the veins is probably partly due to its direct 
action on the vomiting centre, but partly also to its reflex action on 
this centre through irritation of the stomach. For, as Buchheim 
has pointed out,^ when emetics are injected into the blood, they 
are carried by it to the stomach as well as to the nerve centres, 
and thus they may irritate it and induce vomiting in exactly the 

] Buclih.eim, Arzncimittellehre, 1853-56, p. 304. 

N 



178 



ANTI-EMETICS AND EMETICS. 



same way as if they had been passed into it through the oesophao'iis. 
Tartar emetic, for example, will cause vomiting, either when injected 
into the veins or when swallowed, but in both cases it reaches tbe 
mucous membrane of the stomach and irritates it. It is true that 
when injected into a vein it reaches the vomiting centre also, but 
when swallowed it is sometimes rejected almost entirely, so that 
little or none reaches the vomiting centre. In both cases, then, the 
emetic acts on the stomach, but only in one does it act on the 
medulla. Yet vomiting occurs in the one case as well as in the 
other, and it is therefore only natural to attribute it to the action 



Vessels of lung. 

Veins of general surface 
of body. 



Liver. 

Veins of stomach. 

Biliary circulation. 

Veins of intestine. 




4rieries going to nerve 
centres. 



Arteries to muscles. 
Arteries to stomach. 

Arteries to intestines. 
Kidney. 

Excretion by kidney. 



Fig. 21. — Diagram to show that emetics, &c., when absorbed by the superficial vein, 
will be carried both to the stomach and nerve centres. 

on the stomach, and not to its action on the medulla. Besides, 
tartar emetic only precipitates albumen when in presence of an 
acid; the gastric juice in the stomach therefore causes it to pre- 
cipitate the albumen in the mucous membrane. This produces 
irritation and inflammation in it, when no change whatever can be 
detected, either by the naked eye or the microscope, in other 
organs, such as the medulla.^ It may thus be fairly said that, 
until we do find a change in the medulla, we ought to ascribe the 
vomiting only to the action of the emetic on the stomach. 

But having said thus much on the one side of the question, let 
us turn to the other, and see what arguments may be adduced in 
proof of the action on the medulla being the true cause of vomiting. 
First of all comes the somewhat staggering fact, that after 
Magendie had removed the stomach of a dog altogether and 
replaced it by a bladder, the animal vomited when tartar emetic 



1 Ipecacuanha does so also. Gubler, Comment. Tlierap., 1868, p. 627 ; and 
D'Ornellas, Bidl. de Thdrap., tome Ixxxiv. p. 199. 



CENTRAL AND REFLEX ACTION. 179 

was injected into the veins. If the drug only caused vomiting by- 
irritating the stomach, how can it do so after the stomach is 
removed ? Hermann/ who supports the gastric action of tartar 
emetic, tries to get over this difficulty by supposing that it irritates 
the mucous membrane of the oesophagus and pharynx, and that 
the vomiting in Magendie's experiments was induced by its action 
on these parts. This explanation may be correct, but these parts, 
instead of being acid, like the stomach, are alkaline, like the 
medulla, and there is therefore no reason why the tartar emetic 
should act on them rather than the nervous C3ntre. This experi- 
ment of Magendie's in itself affords great support to the old 
doctrine of the central action of tartar emetic, and recent experi- 
ments on the action of apomorphia render it strongly probable that 
apomorphia, another emetic of the same group, likewise acts on 
the medulla directly. Apomorphia, although of recent introduc- 
tion, having been discovered by Mathiesson in April 1869, and 
first investigated by Gee a month afterwards, bids fair to supplant 
other emetics, as it is so rapid and certain in action, and can be 
applied either subcutaneously or administered by the mouth with 
equal ease. Gee noticed that small doses of |- of a grain caused 
vomiting in dogs, and large ones occasioned in addition a curious 
mandge movement, the animals running round in a circle ^ in some- 
what the same way that Longet noticed them to do after a wound 
of the optic thalamus.^ 

This effect of apomoi'phia points to an action of the drug in the 
nervous centres, and is all the more interesting when we remember 
that Budge placed the cerebral centre for the stomach in the right 
thalamus. 

Gee's experiments were repeated and extended by Siebert,*' who 
noticed that apomorphia produced great acceleration of the respir- 
ation, pointing distinctly to excitement of the respiratory centre, 
which is closely connected with the centre for vomiting. Now, the 
respiratory centre, like the vomiting centre, may be excited reflexly 
by irritation of the vagi ; but Harnack,^ in a recent research, has 
found that the excitation caused by apomorphia is not reflex, but 
is due to the direct action of the drug on the respiratory centre 

1 Hermann, Pflilger's Arcli. v. p. 280. 

2 Gee, Clinical Socictijs Transactions, vol. ii. p. 168. 
2 Longet, Train clc Physiologic. 

* Siebert, Unicrsuch. uher d. physiol. JFirkungen clcs ApomoriJhi'ns. Inang. Dis3. 
Dorpat, 1871, p. 60. 

* Hainack, Arch. f. exp, Pathol, ti. Phcirmakol., Bd. ii, p. 283. 

N 2 



180 ANTI-EMETICS AND EMETICS. 

itself. As this centre and tliat for vomiting are so closely con- 
nected, it seems a fair inference that the apomorphia acts directly 
on the vomiting centre also, and produces emesis by irritating it. 
As both tartar emetic and ipecacuanha excite the respiratory 
centre also, it is jDrobable that like apomorphia they act directly 
on the medulla, and thus we are led back to the old notion of the 
central action of this group of emetics. But as these are such 
weighty arguments in favour of their reflex action, we can hardly 
help coming to the conclusion that they may act either centrally 
or reflexly, and in all probability usually combine the two actions 
whenever they are introduced into the blood. When apomorphia 
is injected subcutaneously or into a vein, a smaller dose is sufficient 
to produce vomiting than when it is introduced into the stomach,^ 
while a larger dose of tartar emetic must be injected than would 
be sufficient if administered by the mouth. This seems to show 
that the eoietic effect of apomorphia is due chiefly to its action on 
the medulla, and less to its action on the stomach, while tartar 
emetic acts less on the medulla and more on the stomach. It has 
been already mentioned that tartar emetic only acts as a powerful 
irritant when it comes in contact with an acid, especially hydro- 
chloric acid, as it does in the healthy stomach. Consequently, its 
irritant action on the stomach will be much less if the hydrochloric 
acid usually present in the organ should be diminished or absent. 
Now, it has been found by Manassein ^ that the proportion of acid 
in gastric juice is diminished, or the acid altered, during the febrile 
condition ; and clinical experience long ago showed that tartarated 
antimony did not exert its usual emetic action in persons suffer! og 
from pneumonia, or, as physicians were accustomed to express it, 
there was a tolerance of the drug. 

The employment of emetics is not nearly so extensive now as 
it formerly was. They may be administered (1) for the simple 
purjDOse of evacuating the contents of the stomach and duodenum ; 
(2) for the effect of the muscular movements during vomiting 
upon other organs ; (3) for their effect on the nervous system. 

In cases of poisoning, the first thing to be done is to remove the 
poison from the stomach, and thus prevent it either from injuring 
the gastric walls themselves or from being absorbed into the blood. 
We usually employ sulphate of zinc or of copper as an emetic for 
this puqoose. 

' Greve, Berlin. Klin. TFocJienscJi. , 1874, p. 351. 
* Mauassein, Virchow's Archiv, 1872, Iv. p. 413. 



EMETICS IN DYSPEPSIA AND BILIOUSNESS. 181 

In Indigestion, the case of the patient is often really one of 
slight poisoning, although we are rarely accustomed to regard it 
as such. Not only do the undigested articles of food act as 
mechanical irritants to the stomach, bat they undergo fermenta- 
tion, and the products of this are real poisons. Butyric acid, for 
example, is frequently produced by the fermentation of food in the 
stomach, and, as Otto Weber has shown, it is a powerful poison. 
Tire same is the case with the sulphuretted hydrogen, which gives 
the disagreeable odour of rotten eggs to the eructations of some 
patients. The irritating matters in the stomach not unfrequently 
cause nausea and headache, without leading to vomiting ; but if 
they should be ejected, nausea generally ceases. Therefore, the 
best treatment frequently is to give copious draughts of warm 
water, or warm water and mustard. We use warm or tepid water 
because cold lessens the irritability of the stomach, and thus 
prevents emesis altogether; and we add the mustard in order ta 
stimulate the gastric walls. But it is not those matters only 
w^hich have been introduced into the stomach which are evacuated 
by vomiting. A quantity of the gastric secretions is also ejected, 
and anything they may happen to contain is thus removed from 
the body. 

In a former paper ^ I explained that certain substances, when 
swallowed, were absorbed by one part of the intestinal canal, 
excreted by another, and a,gain re-absorbed, so that they may sojourn 
a long time in the body before being finally eliminated (vide p. 201). 
Thus iodide of potassium is absorbed by the stomach, excreted by 
the salivary glands, and re-absorbed by the stomach, so that it goes 
round and round in the gastro-salivary circulation. Most metals, 
lead probably among the rest, are excreted in the bile and absorbed 
by the small intestine, so that they go round in the entero- 
hepatic circulation. Purgatives, by hurrying the secretions through 
the intestinal tube, prevent re-absorption to some extent, and thus 
aid in the expulsion of the metals or other substances they contain. 
But it is much further from the duodenum to the anus than from 
the duodenum to the mouth ; and anything taking the longer route 
is much more likely to be absorbed than if it took the shorter way. 
In violent vomiting, bile is evacuated by the mouth without getting 
a chance of re-absorption ; and a course of emetics, therefore, seems 
far better suited to remove bile and anything contained in it — such 
as lead or copper — than a course of purgatives can be. It is not 
1 Practitioner, vol. xii. p. 408. 



182 ANTI-EMETICS AND EMETICS. 

improbable tliat it is so ; and a mixed course of emetics and purga- 
tives is really exceedingly useful in lead-poisoning ; - but the dis- 
comfort which attends vomiting causes a very decided preference 
to be given to purgatives. Nor are metals the only substances 
which circulate in this way ; bile itself does so, and its removal by 
vomitinof gives relief in biliousness. Lussana^ also thinks that 
•malarial poison, whatever that may be, circulates with the bile 
in the portal system ; and it is exceedingly interesting to learn 
that the natives of Morocco, as my friend Dr. Duckworth informs 
me, having no quinine, actually treat intermittent fevers by eme- 
tics. It is stated also by eminent physicians that an emetic at the 
beginning of a continued fever, such as typhus, is of great service ; 
and it is possible that it acts there in the same way as we suppose 
it to do in intermittent fevers, viz. by removing the fever poison. 

The violent expulsive efforts in vomiting do not act only on 
the stomach ; they affect also the lungs and expel anything in the 
air-passages still more effectually than can be done by coughing. 
Emetics are therefore used in croup and bronchitis. The gall- 
bladder is also much comj)ressed by the descending diaphragm, 
and the bile is forced through the common bile-duct, instead of 
trickling through it with almost no pressure at all, as it usually 
does. Any obstruction in the duct which the ordinary pressure of 
the bile would never move, will then be pressed on into the duo- 
denum, unless it be too firmly impacted. Gall-stones in the duct, 
and jaundice depending on the obstruction they occasion, can thus 
be removed by the action of emetics ; but there is always the 
dansfer that, if the obstruction is at all firm, the violent efforts 
may burst the gall-bladder and lead to the death of the patient. 

Finally, emetics may be used to produce an " impression on the 
nervous system," — a vague term which may mean anything or 
nothing, and may be explained by every one as best he pleases. 
The facts are, that in cases of epilejjsy, where the fits tend to recur 
every few minutes and the unconsciousness may last for hours, an 
emetic may sometimes put an end to the attack. An impending 
ague fit may sometimes be arrested by an emetic given just before 
it is expected to begin.^ It may be also useful in hysterical fits ; 
but these are so readily arrested by a galvanic shock, that few 
would think of using anything else while a battery is at hand. 

^ Dictionnaire des Sciences Medicalcs, 1815, tome ii. p. 522, 

* Lussana, Lo Sperimentale, tome xxix. , 1872, p. 358. 

' Materia Mcdica, &c., by H. C. Wood, p. 362. 



SUMMARY. 183 

It seems probable that the nervous excitement which causes the 
epiletic or other fit, discharges itself in the exertion of vomiting, 
but it would take too long to enter on this subject here.^ 

To sum up, the chief j3oints in relation to vomiting and the 
action of drugs upon it are : — 

1. Vomiting consists in two factors, viz. (1) the simultaneous 
compression of the stomach by the abdominal muscles and dia- 
phragm, and (2) the opening of the cardiac orifice by the contraction 
of the longitudinal fibres of the oesophagus. 

2. When innervation is disturbed, these two factors do not occur 
together, and thus retching may occur without vomiting. 

3. The movements of vomiting are correlated by a nervous 
centre in the medulla oblongata, from which impulses are sent 
down through various motor nerves to the muscular structures 
enojao-ed in the act. 

4. This nervous centre is probably closely connected with the 
respiratory centre, but is not identical with it. 

5. It is usually set in action reflexly by irritation of the pharyn- 
geal, gastric, hepatic, enteric, renal, uterine, ovarian, and possibly 
also by the pulmonary and vesical nerves which come from the 
periphery towards it. It may also be excited by impressions sent 
down to it from the brain. 

6. Vomiting may be arrested in two ways, either by removing 
the irritant which is exciting the vomiting centre, or by lessening 
the excitability of the centre itself, so that it no longer responds to 
the impressions made on it from without. 

7. Emetics may be divided into two classes : those which act 
only on the stomach, and those which act on the vomiting centre 
also. 

8. Tartar emetic probably acts in both ways. Tolerance of it is 
probably due to want of hydrochloric acid in the stomach. 

9. Emetics may be used to evacuate the stomach and duodenum. 
They thus remove irritating matters, poisons generated in the 
stomach by putrefaction, bile, and metals or fever poisons (such as 
that of ague) circulating in the entero-hepatic circulation. 

10. They may be also used to empty the bronchi and gall- 
bladder, or to cut short epileptic and to prevent ague fits. 

1 See Lauder Brunton on Inliibiiion, West Riding Asjdum Reports, 1874. 



ACTION OF MERCURY ON THE LIVER. 

{' British Medical JournaV for January 5th, 1873.) 

The valuable report of tlie Edinburgli Committee of the British 
Medical Association on the Action of Mercury on the Liver added 
very largely to our knowledge of the subject, without altogether 
settling a great many important questions concerning the thera- 
peutics of the drug.^ 

Few physicians who have had any practical experience of the 
use of mercurial purgatives in cases of so-called " biliousness," will 
deny that their immediate effect is decidedly beneficial, although 
many may be deterred from employing them by the belief that, 
once begun, they must be continued, and will ultimately prove 
highly injurious to the patient,^ The relief occasioned by a blue 
pill and a saline purgative is a matter of every day observation ; 
but the modus operandi of the mercury is a question on which 
much difference of opinion prevails, and any attempt to answer it 
must depend, to a considerable extent, on the view taken of the 
pathology of " biliousness." Do the dull, heavy, and languid feel- 
ings, the disinclination to exertion, mental or bodily, the in-itable 
or peevish temper, the failing appetite, the muddy complexion, and 
dingy conjunctiva, which most persons know, alas ! too well, owe 
their origin to catarrhal changes in the gastric and intestinal 
mucous membranes alone ? or is popular pathology partly right in 
ascribing them to " bile in the blood " or a " sluggish liver " ? For 
our part, we are inclined to hold the latter opinion, and to believe 
that not without reason are the disappearance from the eyes of the 

1 Report of the British Association, 1868, p. 187, and Brit. Med. Journ., 1868, 
vol. ii. pp. 78 and 176, and 1869, vol. i. p. 411. For an excellent resume of the 
literature on this subject, see Eraser's article in the Edinhiorgh Medical Joiornal, 
April, 1871. 

2 Front, Stomach and Renal Diseases. 5th Edition, p. 52. 



SECRETION AND EXCRETION OF BILE. 185 

yellowish tinge which seems as if it only required to be somewhat 
deepened to become jaundiced, and the coincident appearance of 
bile in the stools after a mercurial purgative, pointed to as proofs 
that too much bile in the blood is (partly at least) the cause of 
biliousness, since with its removal from the system the symptoms 
disappear. So long as it was supposed that bile was formed in the 
blood, and only separated from it by the liver, such a view as this 
might meet with ready acceptance ; but how are we to reconcile it 
with the doctrine of most physiologists, that bile is not sejjarated 
from the blood by the liver, but is formed within that organ itself ? 
Fortunately, this is not difficult, for Schiff has shown that we have 
been latterly accustomed to take too narrow a view of the functions 
of the liver, and that it separates bile from the blood, or, as we 
may term it, excretes, as well as forms or secretes it,^ This he did 
by tying the ductus choledochus in dogs, and putting a cannula into 
the gall-bladder, so that he could collect the whole of the bile 
secreted by the liver. Immediately after the operation the flow of 
bile was abundant, but in the course of half an hour it became 
greatly diminished, and remained so, never again reaching the 
amount at first observed. This curious result Schiff found to be 
due to the bile being all removed from the body by the cannula, 
instead of passing, as it normally does, into the duodenum, whence 
it is reabsorbed into the blood, and again excreted by the liver. 
In the first half-hour after the fistula was made, the liver Avas 
excreting bile as well as forming it, and so more flowed from it 
than in any subsequent period when it was only forming bile. 

"Whenever Schiff introduced bile into the blood, either by 
injecting it directly into the veins, or putting it into the duo- 
denum, stomach, or areolar tissue, the flow of bile from the liver 
was at once increased, but again diminished when the additional 
bile had been excreted. By another series of experiments, he also 
found that not only can a certain quantity of bile be present in the 
blood without producing jaundice, but that it probably is always 
present. We thus see that, normally, a great part of the bile goes 
round in a circle, from the liver into the duodenum, thence into 
the blood, so to the liver again, while another part is carried down 
by the contents of the intestine, and, after becoming more or less 
altered, passes out of the body with the faeces. 

Let us now consider what the result will be if the quantity of 

1 Pfliiger's Archiv, 1870, p, 598, and Lussaua, Lo Sperimentalc, torn. xxix. 1872, 
p. 337. 



186 ACTION OF MERCURY ON THE LIVER. 

bile circulating in this way should be increased. All observers are 
agreed that abundant food increases the secretion of bile ; and we 
will suppose that this has been done by continued good living and 
a succession of heavy dinners, such as most Englishmen are accus- 
tomed to indulge in at Christmas time. The stomach and intestines, 
in all probability, also become disordered, and it would be hard to 
say Avhat part of the condition in which the patient then finds 
himself is to be assigned to them and what to the bile ; but this 
we can readily see, that all the symptoms that an excess of bile 
in the blood can produce, short of jaundice, will be occasioned; nor 
can these be removed by any purgative medicine, which, like aloes, 
will merely act on the large intestine. The colon may be cleared 
of its contents, but the bile will go on undisturbed in its accustomed 
round, Yery different, however, will be the result if a purgative 
be administered which will act on the duodenum, as we will assume 
mercury to do, more especially if it be combined with such an one 
as sulphate of magnesia, which will act on the rest of the bowels. 
The mercury stimulates the duodenum to peristaltic contraction, 
the bile is hurried rapidly downwards, the remainder of the 
intestine is likewise contracting vigorously, and in a short time 
all chance of reabsorption is gone, for the bile has been finally 
evacuated. All excess of bile has thus been got rid of, and, as 
far as it is concerned, the liver, duodenum, and other organs may 
now go on performing their functions in the normal way, until 
some fresh indiscretion on the part of the patient again causes 
a disturbance. 

In the account we have just given of the action of a mercurial 
pui-gative, we have assumed that it acts on the duodenum. Now, 
this we cannot at jDresent directly prove ; but we have the indirect 
proof afforded by the fact, observed by Radziejewski,-^ that leucine 
and tyrosine, which are products of pancreatic digestion, appear in 
the faeces after the administration of mercurials, as well as that 
yielded by the large evacuations of bile which calomel produces, 
and which, as Buchheim has shown,^ really give their characteristic 
green colour to the so-called " calomel stools." By thus causing 
elimination of bile, and lessening the amount circulating in the 
blood, calomel acts as a true cholagogue, in the sense in which the 
word was employed by those physicians who looked upon the liver 

^ Eeicliert u. Du Bois Eeymond's ArcMv, 1870, p. 1. 

2 Buchheim, Arziicimi'tellchre, p. 262. See also Scott, Archives of Medicine, 
No. iii. p. 224, and Mosler, Virch. Arch., xiii. p. 41. 



MERCURY AS A CHOLAGOGUE. 187 

merely as an excreting organ, although, as modern experiments 
have proved, it may lessen the amount actually secreted. This 
it can do in a double fashion, for not only does it diminish the 
quantity which has to be excreted by the liver in the manner 
already explained, but, as the Edinburgh Committee of the British 
Medical Association have shown, it likewise lessens the formation 
of bile. In their experiments, the diminished secretion which 
followed mercurial purgation could not be due to 'the prevention 
of reabsorption, for the whole of the bile was regularly removed 
from the body as quickly as it was secreted, and we are, therefore, 
obliged to attribute it to diminished formation. What the cause 
of this may be, we are not at present in a position confidently to 
state; but we know that fasting lessens the formation of bile, and 
if the food be hurried out of the intestine by a purgative before 
it has time to be absorbed, it might just as well not have been 
eaten at all. 

We have now seen how an excess of bile may be present in the 
blood without the liver being either "sluggish" or "torpid; " and 
it seems to us that the difference of opinion which has hitherto 
prevailed regarding the action of mercurials is in great measure 
due to attention having been directed to the amount of bile poured 
out from the liver, instead of to what is of much more importance 
in reference to " biliousness " — viz. the quantity which remains in 
the blood after a dose of blue pill or calomel. 



ON THE ACTION OF PURGATIVE MEDICINES. 

{' The Practitioner,' VOL. Xll. May and June 1874.) 

Before entering upon their use, it will be well to consider the 
question — How do certain substances act as purgatives ? 

It is generally believed that most purgatives increase the number 
of the stools, and render them more fluid in a double manner; 
firstly, by stimulating the intestine to increased peristaltic action, 
and secondly, by inducing a discharge of fluid from its mucous 
surface, and thus to some extent washing out its contents.^ Some 
purgatives, such as aloes, are supposed to act almost entirely by 
stimulating the peristaltic movements, their effect on the secretion 
from the intestine being almost nil ; while others, like bitartrate 
of potash, are supposed to induce a very free secretion from the 
mucous membrane, while they have so little influence upon the 
peristaltic movements that the fluid poured out from the intestinal 
wall after their use may remain in the torpid intestine so long as 
to be again reabsorbed.^ Others again, like croton oil, are supposed 
to increase the flow of liquid into the intestine, and at the same 
time to stimulate the peristaltic movements. 

This view of the action of purgatives is the one generally held 
in this country. It is supported by several French authorities, but 
is rejected by some of the most eminent German pharmacologists. 

All are agreed in believing that the action of many purgatives 
is due to their power of quickening peristaltic action, but several 
German authors are inclined to regard increased peristalsis as the 
only, or almost the only, cause of purgation, and to deny that there 
is any increased flow of fluid from the intestinal walls. They con- 
sider that purgative medicines, by quickening the peristaltic action, 

1 Pereira's Materia Meclica, vol. i. p. 247 ; Stille's Therapeutics and Materia 
Mcdica, vol. ii. p. 404 ; Kinger's Therapeutics, 3d ed. p. 154. 
^ Garrod's Materia Mcdica, 3d ed. 1868, p. 401. 



MODE OF ACTION. 189 

cause the contents of the intestine to be hurried along and expelled 
per anuni before there has been time for the absorption of their 
fluid constituents. Instead, therefore, of the stools being firm and 
consistent as in the normal condition, they are loose and watery 
like the feecal matters which one usually finds in the small intestine 
on post-mortem examination. By making a fistulous opening in 
the ascending colon of a dog, Radziejewski, the distinguished 
pharmacologist, whose untimely death is much to be deplored, has 
found ^ that the intestinal contents, when poured from the small 
into the large intestine, almost exactly resemble the stools produced 
by the use of purgative medicines. He therefore, and several 
German authors who follow him, attribute the watery condition of 
the stools observed after the administration of vegetable purgatives, 
such as castor or croton oil_, to increased peristalsis only. The 
objection may be raised that the stools produced by elaterium, for 
example, are more watery than the contents of the small intestine 
usually are ; but this can readily be met. For it is not merely the 
peristaltic action of the large intestine which is quickened so that 
the fajces are expelled in much the same condition as they entered 
it. The movements of the small intestine are also accelerated, so 
that little absorption can take place in it, and its contents will 
therefore leave it in a more watery condition than usual, and beino- 
quickly hurried through the large intestine, will produce a liquid 
motion. 

This explanation may seem satisfactory enough in regard to the 
action of vegetable purgatives, and of such mineral ones as calomel ; 
but it hardly explains the effects of salines, such as bitartrate of 
potash or sulphate of magnesia. These are allowed by Buchheim 2 
to have an additional action besides that of increasing peristalsis. 
They retain water with great avidity, they diffuse slowly, and by 
thus preventing the water which is taken with them or swallowed 
shortly afterwards from being absorbed, at the same time that they 
quicken the intestinal movements, they wash out the whole 
alimentary canal from end to end, in much the same way as a 
simple injection washes out the rectum. A large quantity of fluid 
is normally poured into the intestine by the liver, pancreas, and 
intestinal glands, and this alone, according to Kuhne,^ is greater 
than the amount expelled in the most profuse diarrhoea. When, 

^ Eeictert u. Du Bois-Eeymond's Archiv, 1870, p. 95. 

.^ Bnehheim's ArzneimitfeUehre, p. 136. 
^ Kuhne, Lehrhuch dcr physiologischen Chemie, p. 151. 



190 ON THE ACTION OF PURGATIVE MEDICINES. 

in addition to this, tlie quantity of fluid ingested by the mouth is 
taken into consideration, it seems j^erfectly unnecessary to believe 
that any increased flow of- fluid takes place from the intestinal 
walls. Moreover, direct experiments seemed to show that purga- 
tives did not increase the flow of fluid from the intestinal walls. 
Such a flow might be of two kinds : it mio-ht consist of a transuda- 
tion from the blood-vessels, as supposed by Schmidt,^ or of a secre- 
tion from the intestinal glands. In the former case it would contain 
a considerable quantity of albumen like the fluid in ascites or peri- 
carditis; while in the latter, albumen might only be present to a 
very slight extent. A consideration of the structure of the intestine 
alone is suflScient to show the improbability of a direct transudation 
of fluid from the vessels : but Radziejewski^ has set the matter at 
rest by examining the composition of faeces before and after the use 
of purgatives, and proving that the stools produced by them do not 
contain albumen to anything like the amount they ought to do if 
transudation fluids were present in them to any considerable extent. 
The most decisive experiments, however, were those which were 
first made by Thiry by means of the intestinal fistula which bears 
his name. These seemed to show in the most conclusive manner 
that purgatives neither increased the flow of fluid from the intesti- 
nal walls by transudation nor by secretion. In order to discover 
exactly what went on in the intestine, Thiry conceived the idea of 
isolating a portion of it and attaching one end of this piece to an 
opening in the abdominal walls while its nerves and vessels remained 
uninjured, and the whole piece was as nearly as possible in a normal 
condition. He therefore divided the jejunum or ileum in two 
places, a few inches apart from each other, served up one end of 
the piece thus isolated, and attached the other end to the wound 
in the abdomen. The short cul-de-sac thus formed remained at- 
tached to the mesentery and received its vascular and nervous 
supply as usual. The divided ends of the intestine were then 
sewn together, and the continuity of the alimentary canal restored.^ 
This is represented in the accompanying figure (Fig. 22), where 
B indicates the place where the piece C D, which originally lay 
between A B and B E, has been cut out, and the two ends of A B 
and B E sewn together so that the alimentary canal is again com- 
plete though a few inches shorter than before. F, G^ D, is the 

^ C. Sclimidt, CJiaracterisUk dzr epidemischen Cholera. Leipzig, 1850, p. 90. 

2 Radziejewski, op. cit. p. 75. 

3 Thiry, SitzungsbeHcM der Wiener Aeadcmie, 1864, vol. L. p. 77. 




EXPERIMENTS ON PURGATIVES. 191 

abdominal wall, and a and 5 are the vessels and nerves in the 

mesentery. 

The little bag of intestine C D can be easily 
reached from the outside of the body, and the 
result of any experiment upon it readily ascertained. 
It apparently remains in a perfectly healthy condi- 
tion, and when tickled with a feather readily secretes 
intestmal juice. But a purgative medicine intro- 

_. „- duced into it neither increases the secretion nor 

Ficf. 22. 

causes transudation from the vessels, althouQ-h the 

drug produces brisk purgation if administered to the animal by the 
mouth. Thiry^ in his experiments used croton oil, senna, and sul- 
phate of magnesia. Schifi"^ repeated them with aloes, jalap, and 
sulphate of soda; and Radziejewski^ with croton oil and sulphate 
of magnesia. All these observers obtained a like negative result. 
Further proof seems superfluous to show that purgatives act only 
by accelerating peristaltic action, and not by increasing the flow 
of fluid from the intestinal wall; and I have not only believed 
but have taught this, till the publication of some experiments 
of Moreau,* their verification by Vulpian, and the results I have 
myself obtained on repeating them, have led me to alter my 
opinions. 

These experiments were made by opening the abdomen of an 
animal, and tying four ligatures tightly round the small intestine 
a few inches apart from each other, so as to isolate three portions 
of intestines (Fig. 23). A purgative medicine was then injected by 
means of a subcutaneous syringe into the middle part, and the 
intestine being then returned into the abdominal cavity, the wound 
in the abdominal jDarietes was sewn up. A few hours afterwards 
the animal was killed, and on examination the middle portion of 
intestine, into which the purgative had been injected, was found 
full of fluid, while the portion on each side was completely empty. 
All three pieces having been equally empty at the commencement 
of the experiment, and all three having been ]olaced under exactly 
the same conditions, we cannot attribute the copious secretion 
into the middle loop to any other cause than the action of the 
purgative injected into it. Moreau's experiments have been 

^ Thiry, op. cit, p. 95. 
* Schiff, NiMve ricerche sulpotcre dcgerente, &c. II. Morgagni, July 1867, p 5. 
2 Eadziejewski, op. cit., p. 85. 
* Moreau, Archiv Generalcs de Medecinc, August 1870, p. 234. 



192 ON THE ACTION OF PURGATIVE MEDICINES. 

repeated by Vulpian,i and I subjoin the notes of the results which 
I have obtained. 

Exp. I. — A cat was chloroformed, and an incision about 1^ 
inches long: made through the abdominal walls in the middle 
line about the umbilicus. A coil of small intestine was drawn 
out, and four ligatures tied tightly round it so as to isolate three 
loops of intestine. One-hundredth of a drop of croton oil mixed 
with one drop of alcohol was then injected into the second loop 
bj means of an extremely fine Wood's syringe. (The quantity 




Fig. 23. 

of croton oil was obtained by thoroughly mixing 1 part of oil 
and 99 of alcohol ) The intestine was then replaced, the wound 
sewn up, and the animal allowed to recover from the chloroform. 
About four hours and a quarter afterwards it was instantly killed 
by a single blow on the head with a hammer, and the intestine 
examined : — 
Loop 1. 



(igth 3 ,-Q inches . . 


. Contained 7 minims of fluid, 


i» lt% J) • < 


^0 


S 4 


• » l" )> !» 



Exp. II. — A cat was operated on in the same way as the first, 
and y\- of a drop of croton oil with 10 drops of alcohol was injected 
into a loop of intestine which, as in the former case, lay between 
two others likewise isolated by ligatures. About four hours and 
a quarter after the operation the cat was killed in the same way 
as the first: — 



Loop 1 . Lengtli 2-^''^ inches 
•-> « 1 



Completely empty. 
Contained 80 minims of fluid. 
Empty. 



Yulx4an, Bulletin General de Therapcutique, tome Lxxxiv. 1873, p. 522. 



Loop 1. 


Length i-SL inches 


„ 2. 


K 9 


„ 3. 


„ e^i. „ 



301 


3 I. 


Length G/^- inches 


)> 


2. 
3'. 


J) 5A- „ 



EXPERUIENTS ON PURGATIVES. 193 

Exp. III. — Made in the same way as the preceding ones. One 
drop of croton oil and 9 of alcohol injected into loop No. 2. Four 
hours and a quarter afterwards : — 

. , Empty. 

Contained 110 minims of fluid. 
. . Empty. 

Just about the middle of loop No. 2 the mucous membrane or 
about 1\ inch was thickened, much reddened, and inflamed. 

Exp. IV. — Made in the same way as the preceding ones. Ten 
drops of croton oil were injected into loop of intestine No. 2. 
I am not quite certain that the whole of the 10 drops found 
their way into the intestine, as the oil passed very slowly through 
the fine ho] low injecting needle, although considerable force was 
used. The syringe at one instant became detached from the 
needle, and a little oil escaped. I tried to guess the right amount, 
however, and injected it afterwards. Four hours and a quarter 
after iujection : — 

Contained 155 minims of fluid. 
. . „ ISO „ 
. . ,, 75 „ 

The fluid, as measured, was not quite accurate, for a tapeworm 
was present in the intestine, and parts of it helped to swell the 
apparent bulk of the fluid. 

In the middle loop of No. 2 the mucous membrane was much 
inflamed for about two inches or rather more. This is the part 
with which the oil would come in contact after its injection 
through the intestinal wall. 

The mucous membrane of all three loops, as well as that for 
four or five inches above the upper and below the lower loop, 
was much thickened, and the lumen of the intestine partially 
filled with a glairy fluid. Above and below these parts the 
intestine was firmly contracted and natural, just as when the 
injection was made. The mucous membrane in all the coils was 
somewhat pale, as also at the thickened parts outside. At the 
other parts where it appeared unaltered, its inner surface was of a 
yellow colour, probably from adherent biliary or faecal colouring 
matter. 

Exp. V. — A cat was experimented on as before. A small 
quantity of elaterin (probably about yV of a grain) suspended in 
80 drops of water was injected into loop No. 2. About four hours 
and a quarter afterwards : — 

o 



194 ON THE ACTION OF PURGATIVE MEDICINES. 



Loop 1. 


Lensrth 5y\- inches . . 


, , Con taint 


;d 60 minims of fluid. 


9 

)) — 


,r 6J^ ,, . , 


,, 


110 „ 


„ 3. 


5 5- 


. . Empty. 





In all three loops, as well as for five or six inches beyond the 
loops, the mucous membrane (or whole intestinal wall ?) was pale 
and somewhat thickened. 

Exp, YI. — A cat was chloroformed, an incision made in the 
abdominal walls, and three loops of intestine isolated by Hgatures. 
Into the middle one (No. 2) about two grains of gamboge made 
into an emulsion, with about 60m. of water, were injected at 11.15. 
The wound was then sewn up, and the animal allowed to recover. 
About four hours afterwards the cat was killed by a blow on the 
head and the intestine examined : — 

Loop 1. Length 4j inches . . Empty. Mucous membrane 

yellowish on the surface. 
„ 2. ,, 5| „ ... Contained 185 minims of 

j-ellowish turbid fluid with 
numerous flocculL The 
surface of the mucous 
membrane was slightly 
paler than in No. 1, 
„ 3, ,, C| „ ... Empty. Colour like Xo. 1. 

Exp. VII. — The experiment was performed on a cat in the 
same way as the previous one. Into the middle loop of intestine 
about one grain of jalapin in a small quantity of spirit (proof) 
and water (equal parts) was injected. The intestine was examined 
about four hours afterwards. The cat seemed sleepy, and the 
respiration appeared to be impeded by fluid in the respiratory 
passages : — 

Loop 1. Length 5|- inches . . . Quite empty. Surface of 

mucous membrane nonnal. 

„ 2. » 6j „ ... Contained 17 minims of 

tenacious fluid. Surface 
of mucous membrane 
moister than in No. 1. 

„ 3. » 5j „ ... Mucous membrane moist. 

Covered with bloody 
mucus. 

Exp. YIII. — The experiment was made in the same way as 
the preceding ones. Into the middle loop, No. 2, about 7 grains 
of sulphate of magnesia disselved in 105 minims of water were 
injected. Into each of the side loops 105 minims of water 
were injected. The intestine was examined about four hours 
afterwards : — 



EXPERIMENTS ON PURGATIVES. 195 

Loop 1. Length 5 inches . . . Quite empty. 
„ 2. „ 'l\ „ ... Contained 320 minims of 

fluid. This was of a pale 
amber colour and glairy 
consistence, mixed with 
flakes of whitish mucus. 
Not the slightest trace of 
congestion was noticealjle. 
Mucous membrane was 
quite natural in No. 2. 
„ 3. „ 5|- „ ... Quite empty. 

Exp. IX. — The experiment was conducted like the others. 
Into the middle loop of the cat's intestine 85 minims of a 
saturated solution of sulphate of magnesia were injected. Oa 
examination four hours afterwards, the middle loop, which was 
7 5 inches long, contained 425 minims of fluid. The other two 
loops were quite empty. 

Exp. X. — The experiment was conducted as before. Into the 
middle loop of the cat's intestine about 90 minims of a saturated 
solution of sulphate of magnesia were injected. The loop was 
about 6 inches long. After about five hours the loop was 
found to contain about 250 minims of fluid. The loop above it 
contained a little bloody mucus, the one below it was entirely 
empty. 

These experiments show that croton oil, elaterin, gamboge, and 
sulphate of magnesia all cause a copious secretion from the 
intestine. Jalapin did not do so in the single instance in which 
it was tried ; but I am not quite certain that the whole of it 
went into the intestine, as it formed a resinous mass which I 
had considerable difficulty in getting to pass through the nozzle 
of the syringe. The fluid contained in the intestine after the 
use of the other purgatives appears to be a secretion, not a trans- 
udation, for it does not contain much albumen as a transudate 
would do. In Exp. VIII. it amounted to about 42 minims, and 
in Exp. IX. to about 56 minims per square inch of intestine 
acted on by the purgative. The greatest secretion was caused by 
sulphate of magnesia ; next came croton oil, elaterin, and gamboge ; 
while jalapin stood last of all. 

Such positive results as these seem to prove that purgatives 
do cause a flow from the intestinal wall, quite as conclusively 
as experiments with Thiry's fistula do the opposite ; and as the 
conditions under which the purgatives act on the intestines more 
nearly approach the normal in Moreau's than iu Thiry's experi- 
ment, there can be but little doubt that purgatives produce a 

o 2 



196 ON THE ACTION OF PURGATIVE MEDICINES. 

decided secretion of fluid from the intestine, as well as accelerate 
peristaltic movements. 

Having now come to a conclusion regarding the manner in 
which purgatives act, let us consider some of their effects upon 
the body. It is evident that the increased peristaltic action of the 
bowels will hurry along the food and cause its expulsion before the 
nutritive matters it contains have been fully absorbed. 

If a purgative be taken immediately before or shortly after a 
meal, the result will be much the same as if less food had been 
taken or the meal entirely omitted. Many persons who are 
accustomed systematically to eat more than they require will 
regularly take a "dinner pill" or a course of Seidlitz or PuUna 
waters, although they cannot be j)ersuaded to deprive themselves 
of a single opportunity of enjoying the pleasures of the table or 
to put the least restraint upon their appetites. 

Increased peristaltic action will also remove fsecal matters as 
well as food from the intestine, and it will be greatly assisted ia 
this by the increased secretion from the intestinal wall which 
purgatives induce. 

I have already mentioned that mechanical irritation, such as 
tickling with a feather or rubbing with a glass rod, will cause 
secretion from the c%d cU sac of intestine in Thiry's fistula, and 
hardened faeces seem to have a similar action. Thus diarrhoea is 
not unfrequently caused by the presence of scybalous masses or 
other irritating matters in the intestine, and nothing cures this like 
a dose of castor-oil. At first sight it seems odd that the scybala 
are not washed away by the fluid which they cause to be secreted, 
but this secretion will probably be poured out only at or below the 
point where they lie, and thus it will have little effect on them, 
though it may wash out the lower part of the bowel thoroughly 
enough. A dose of castor-oil, on the contrary, will induce secretion 
in the bowel above the scybala, and the fluid in its downward rush 
will carry the fsecal masses along with it. 

Irritating substances in the intestine, besides acting locally upon 
the bowel in the manner just indicated, may exercise an influence 
upon distant organs through the medium of the nervous system. 
Sir Charles Bell ^ observed a case in which ulceration of the ileum 
was found in a man who had suffered severely from tic, but there 
was nothing wrong whatever with the fifth nerve, in which the pain 
was felt. He therefore felt convinced that although the pain was 

^ Bell, Practical Essays, p. 85. 



CONSTIPATION AND CEREBRAL CIRCULATION. 197 

felt in the cheek, its true source Wcas irritation in the ileum. Acting 
on this beHef, he administered croton oil (xV of a drop in combina- 
tion) in tic douloureux for the purpose of removing any morbid 
condition of the bowel, and obtained the happiest results from its 
employment ; and Newbiggimg ^ has found it equally efficacious in 
sciatica. 

It is difficult to say whether the pain felt in the cheek is simply 
due to the irritation of the intestinal nerves being reflected, as it 
is termed, along the fifth nerve, or whether the irritation induces 
such a change through the va so-motor nerves in the blood-vessels 
of the cheek as actually to set up a new irritation in the course of 
the fifth nerve itself. At any rate, the vessels of the face and head 
are very easily affected by any irritation of the stomach or intestines, 
as is easily seen from the extraordinary pallor which at once over- 
spreads the face when a state of sickness and nausea has been 
induced. The effect of constipation in causing a feeling of fulness 
in the head is well known, and Ludwig and Dogiel^ found that 
when the intestines of an animal were moved by the finger the 
rapidity with which the blood flowed through its carotid arteries 
was greatly increased. The frontal headache which so frequently 
accompanies gastric or intestinal derangement may possibly be due 
to some of the intestinal contents which ought to be evacuated 
being absorbed and acting as poisons on the vessels of the head 
themselves. I am inclined to think, however, that although this 
may have much to do with it, yet the headache very often depends 
to a great extent on some alteration in the cerebral circulation 
caused reflexly by the condition of the abdominal organs ; for I 
have myself had a headache, though not a frontal one, which alter- 
nated with nausea. The nausea would last for a few minutes, 
during which the headache would entirely disappear; then the 
nausea would leave me, and the headache instantly took its place- 
.A.fter evacuation of the stomach, both the headache and nausea 
disappeared, showing that in this instance at least they were due 
to irritation in the stomach. But in many instances no doubt, not 
only headache but much more serious symptoms may be due to 
the decomposition of food in the intestinal canal and the absorption 
of its products. Thus Senator ^ relates a case where a simple 
gastric catarrh without fever was brought on by eating something 

1 Newbigging, EcUn. Med. and Surg. Journ., Jan. 1, 1811. 

'■* Ltidwig's Arheitcn cm-') der 2^hysiotogischcn Andalt zu Leipxirj, 1867, p. 253. 

3 Senator, Berliner Klinische Wochcnschrift, 1868, No. 24, p. 254. 



198 ON THE ACTION OF PURGATIVE MEDICINES. 

wliicli disagreed witli the patient. This was followed on the second 
day by great belching of gaS; smelling like sulphuretted hydrogen 
or rotten eggs. The nrine also contained sulphuretted hydrogen. 
As soon as this occurred the patient collapsed suddenly, and became 
pale and giddy, with a small, frequent, and compressible pulse. 
The patient remained conscious, and in a minute and a half or two 
minutes the collapse passed away. A similar attack came on again 
during the same day, but after the bowels which had been consti- 
pated were opened, the patient rapidly recovered. Senator con- 
siders that the collapse was due to i^oisoning by the sulphuretted 
hydrogen absorbed from the intestine, and it certainly seems 
probable that this was one cause of the attack, even if it were 
not the only one. 

Other poisons besides sulphuretted hj'drogen may be formed 
in the alimentary canal and absorbed into the blood, where they 
exert their deleterious action. Among these may be mentioned 
butyric acid, which has frequently been found in the stomach in 
considerable quantities.^ According to O. Weber ^ it is very poisonous, 
exerting its action chiefly on the nerve-centres. The nervous 
symptoms which frequently accompany gastric derangement or 
disease of the intestines may therefore be frequently occasioned by 
poisons formed in the alimentary canal in consequence of imperfect 
digestion. 

The administration of a brisk purgative or small doses of Epsom 
salts thrice a day is a most effectual remedy for frontal headache 
when combined with constipation ; but if the bowels are regular, 
the morbid processes on which it depends seem to be checked and 
the headache removed even more effectually by nitro-hydrochloric 
acid or alkalies given before meals. If the headache is immediately 
above the eyebrows, the acid is best ; but if it is a little higher up, 
just where the hair begins, the alkalies appear to me to be more 
effectual. At the same time that the headache is removed, the 
feelings of sleepiness and weariness which frequently lead the 
jDatients to complain that they rise up more tired than they lay 
down, generally disappear. 

Somewhat analogous to the neuralgia of the fifth nerve in Sir 
Charles Bell's case, or to frontal headache, is the pain which we 
frequently meet with in persons having decayed teeth. The pain 
may be felt in the offending tooth itself, but very often it seems to 

^ Kiiline, Physiologisehe Cliemie, p. 58. 
2 0. Weber, Deutsche KlviiJc, 1864, p. 438. 



CONSTIPATION AND NEURALGIA. 199 

give little or no uneasiness. The patients complain of neuralgic 
pains above the ear or along the jaw, and will often deny that they 
have any decayed teeth at all. It would almost seem that neither 
the irritation in the tooth nor irritation in the intestine alone is 
sufficient to produce pain, though they do so when acting con- 
jointly ; for extraction of the tooth, or stoppage of the cavity with 
cotton-wool steeped in melted carbolic acid, will often remove the 
pain although no medicine is given internally, while on the other 
hand a brisk purgative may also afford relief though the tooth be 
left untouched. It is best, however, to combine both methods of 
treatment, and if the tooth is not extracted or stopped, the pain is 
very apt to return ; and it seems to me probable, though I am by 
no means certain of it, that this recurrence is connected with the 
renewal of gastric or intestinal irritation. According to Heincken,^ 
otalgia may also depend on the presence of irritating matters in 
the intestine ; and Sir Charles Bell observes that accumulations in 
the colon will give rise to pains in the loins, spermatic cord, or 
groin. Pain at the lower angle of the scapula is referred by him 
to disorder and distention of the duodenum. This pain is very 
often accompanied by flatulence, and is described by patients as a 
"pain in the pit of the stomach shooting through between the 
blade-bones," and it is not unfrequently termed by them " windy 
spasms." It is relieved by rhubarb and alkalies given before 
meals. 

Having said so much regarding the faecal contents of the intes- 
tine and their local and remote actions, we must now consider a 
matter of no less importance, viz. the effect of purgatives upon the 
secretions which are poured into the intestinal tube by the various 
glands connected with it. The saliva which flows into the mouth 
from the submaxillary and parotid glands is swallowed and aids 
the digestion of starchy food in the stomach, and probably the 
intestine. A part of its active principle, ptyalin, is reabsorbed, 
and some of it is excreted in the urine ;^ but as we shall here 
afterwards see, it is probable that another part is excreted again 
by the salivary glands and thus does its work twice over. This is 
at present, only a probability as regards ptyalin, but it is a 
certainty in the case of several substances which are excreted by 
the salivary glands, such as iodide of potassium, for example, 

^ Heincken, Be MorMs Nervorum ex Ahdomine, quoted by Sir Charles Bell, op. 
cit., p. 9. 

2 Cohnheim, Virchotv's ArcJiiv, xxviii. p. 250. 



200 ON THE ACTION OF PURGATIVE MEDICINES. 

■wliich can be detected with great ease. When this substance is 
swallowed, it is absorbed from the stomach, passes in the blood to 
the salivary glands, and is excreted by them much more readily 
than by the kidneys. It again passes down with the saliva to the 
stomach, is reabsorbed, and again excreted. Thus it may go round 
and round for a long time without getting entirely out of the body. 
(See gastro-salivary circulation. Fig. 24.) If we wish to remove it 
quickly and completely, we must give a purgative so as to prevent 
its reabsorption from the intestinal canal by causing its speedy 
expulsion. The same is the case with other iodides, such as those 
of lead or iron. Iodine has been shown by Bernard to possess the 
power of making iron pass readily through the salivary glands, the 
iodide of iron being found in the saliva soon after it has been 
injected into the blood, while other salts of iron, such as lactate, 
never make their appearance in it at all.^ Several years ago 
iodide of potassium was proposed by MM. Guillot and Melsens as a 
remedy in cases of lead-poisoning. The lead, they consider, is 
present in the body in the form of an insoluble compound ^ which 
it makes with the tissues, but by the administration of iodide of 
potassium it is rendered soluble. It then finds its way into the 
circulation, and is excreted by the kidneys and other emunctories. 
But the iodide of lead is partly excreted by the salivary glands, for 
M. Malherbe, of Nantes, and Dr. Sieveking have found it in the 
saliva of persons suffering from lead-poisoniug, and who were being 
treated by iodide of potassium. The lead salt being swallowed 
with the saliva, is again reabsorbed, and thus the cure is com- 
paratively slow when patients are treated with iodide of potassium 
alone. I frequently see patients suffering from lead-poisoning 
brought on by working in white lead, and for some time I have 
been accustomed to treat them with five grains of iodide of potas- 
sium, three times a day, and a sufiicient quantity of sulphate of 
magnesia or other purgative either thrice or once a day, to keep 
the bowels very freely open, and cause the expulsion of the lead 
from the alimentary canal as quickly as it is secreted into it. I 
have not made comparative experiments on the effect of this treat- 
ment and of that by iodide of potassium alone, or by purgatives 
alone, but from what I remember of cases treated by the late 
Professor Syme with castor-oil, I am fully satisfied with the treat- 

1 Bernard, Physiologie Experimeiitale, torn. ii. p. 99. 

2 Guillot and Melsens, Archives Generales cle Medecine, itli ser. iv. p. 517 ; and 
Melsens, Anmiles cle C'himie, June 1849. 



ENTERO-HEPATIO CIRCULATION. 201 

ment T now adopt. The same plan would probably prove equally 
useful in chronic poisoning by copper or mercury. 

But the gastro-salivary circle, as we may term it, from stomach 
to salivary glands and from salivary glands to stomach again, is not 
the only one in which those metals move. Their circulation in 




Fig. 24. — Diagram showing the manner in which substances are excreted by one organ 
and reabsorbed by another, so that they circulate a long while in the organism 
before being expelled. ^ 

the portal system, or entero-hepatic, as it is termed by Lussana,^ is 
still more important. (See Fig. 24.) Iron is eliminated in great 
part by the bile : copper and manganese appear in it also, accord- 
ing to Albini and Moser,^ and it seems probable that manganese, 

^ The absorption of substances excreted by the salivary gland is indicated in the 
figure as taking place in the stomach, and then* circulation is called gastro-salivary ; 
but it is very probable that a considerable portion of them passes through the stomach 
into the intestines, and that entcro-salivary might be a better term. Similarly, the 
absorption of bile has been represented as taking place in the duodenum, and that 
of pancreatic and gastric juices in the jejunum, but this is only to avoid confusion 
in the drawing, and not to indicate the part of the intestine where absorption really 
takes place. ^ Lussana, Lo Spcrimentale, tom. xxix. 1872. 

3 Quevenne, Albini, and Moser, quoted by Lussana, Lo Sperimentale^ tom. xix. 
1872, pp. 340, 343. 



202 OK THE ACTION OF PURGATIVE MEDICINES. 

lead, and all the heavy metals pass out of the body by this 
channel. From the liver they pass into the intestine, are reab- 
sorbed from it, and again pass to the liver and recommence their 
course. They may be present in considerable quantities in the 
blood of the portal system without reaching the general circLilation 
or getting a chance of passing out in the urine. They are there- 
fore much more closely locked up in the entero-hepatic circulation 
than in the gastro-salivary one, for the salivary glands are supplied 
by the systemic circulation, and any blood which brings lead or 
any other substance to them must also carry it to the kidneys. 
The power of the entero-hepatic circulation to retain metals within 
the body being much greater than that of the gastro-salivary one, 
it is evident that the beneficial effects of purgatives in lead-poison- 
ing are due to their removing the metal from the portal circulation 
still more than their action on the gastro-salivary one which has 
already been discussed. Other poisons, such as curare and 
probably serpent's venom, may also circulate in considerable 
quantity in the portal system without reaching the s^'^stemic 
circulation, and probably this is one of the causes, though by no 
means the only one, which renders these substances to a great 
extent innocuous when swallowed.^ 

But the circulation of iron, lead, curare, &c., in the portal 
system, important though it may be, is of far less interest than 
the circulation of the bile itself. For the sake of convenience I 
have merely stated that lead, mercury, &c., are excreted in the 
bile, and have hitherto assumed that bile circulates in a similar 
way in the portal system, without giving any reason for doing so. 

It used to be thought by many that bile was formed in various 
parts of the body, and was simply excreted by the liver. This 
view is now given up by most physiologists, who believe that bile 
is formed by the liver only. But in altering their views regarding 
the function of this organ they went too far, and supposed that it 
only formed bile, which, when it had once found its way into the 
intestine and mixed with the intestinal contents, became decom- 
posed and finally expelled with the faeces. A year or two ago, 
however, Schifif ^ found that this view of the hepatic functions was 
too limited, and that the liver removed bile from the blood or 
excreted it as well as formed or secreted it.^ He observed that when 

1 Lussana, op. cit. 2 gchiff, Pfillger's ArcMv, 1870, p. 568. 

* Although it is not correct to do so, I use the term " secreted " here as synonymoTis 
witu "formed," for the sake of conveniently distinguishing between the formation 
of bile in the liver and its removal from the blood. 



FASTING IN BILIOUSNESS. 203 

all the bile "was drawn away from the liver by means of a fistulous 
opening in the gall-bladder after ligature of the ductus choledochus, 
the quantity which flowed from the liver rapidly diminished after 
the fistula had been established, but could again be quickly 
increased by the simple process of putting bile into the duodenum. 
The bile was at once absorbed and again excreted by the liver, and 
it did not make much difference whether the bile just removed 
from the fistula in a dog was again injected into its duodenum, or 
whether ox bile was used instead. In the normal state of the 
animal the liver is always doing two things : it is forming new 
bile, and it is excreting old bile which it has received from the 
intestine by means of the portal vessels. When a biliary fistula is 
made and the bile is drawn away as fast as it is secreted, none gets 
into the intestine, and therefore no old bile reaches the liver; con- 
sequently, the quantity collected represents only the new bile 
formed in the liver, and is of course much less than that which 
would normally pass through the ductus choledochus into the 
intestine. If all the bile vrere absorbed there would be no need 
for the liver to go on forming it, but this is not the case, for only a 
part of it is reabsorbed, and the remainder is decomposed and 
excreted with the feeces. 

So long as the liver does its duty properly, and excretes again 
all the bile which is absorbed by the portal blood from the intestine, 
very little bile can pass through the organ into the vena cava and 
thence into the general circulation. But whenever so much bile is 
taken up from the intestines that the liver cannot excrete it all, it 
will find its way out of the portal into the systemic circulation, 
and will exert an injurious action on the nervous system. The 
same effect will follow anything which diminishes the excreting 
power of the liver and renders it unable to excrete the normal 
amount. It is evident that if anything should cause the Hver to 
form more bile than usual at any time, it will have extra work to 
do in the way of excreting it after its absorption, and there will be 
more bile circulating in the portal blood for some time afterwards^ 
or at any rate until the extra quantity has been got rid of or com- 
j)ensation has been established by the liver forming less. Many 
experiments have shown that an abundant supply of food causes 
the liver to form more bile, and we all know that heavy dinners are 
apt to cause biliousness. Fasting, on the other hand, diminishes 
the quantity of bile seci'eted, and every one knows that if he fasts 
for a day after taking an especially heavy dinner he may be none 



204 ON THE ACTION OF PURGATIVE MEDIGINES. 

the worse for it, but if he dines out every night he is almost sure 
to become bilious unless he takes measures to prevent it by using 
purgatives. 

It has not yet been shown by direct experiment that the 
symptoms usually grouped under the head of "biliousness" are due 
to the presence of an excess of bile in the blood ; but the rapidity 
with which they disappear after the removal of bile from the 
system, either by vomiting or purgation, renders it extremely 
probable. Frequency Ave find that the fit of vomiting which has 
expelled a quantity of bile is hardly over when the appetite 
returns, the brownish-white fur disappears from the tongue, the 
face loses its dingy hue, the languor disappears, the irritability of 
temper is replaced by equanimity, and stupidity and laziness give 
place to sprightliness and activity. But vomiting is a disagreeable 
process, and few submit willingly to it, although it would be well 
worth while if the same end could be gained by no other means. 
As most old practitioners have found, however, a mercurial pill and 
a saline purgative produce all the good effects of vomiting without 
its trouble and discomfort, and they have long been in the habit of 
ascribing the beneficial action of the mercury to its "cholagogue" 
properties. They felt convinced that biliousness was due to bile in 
the blood, and believed that its removal was due to the liver being 
stimulated by the mercury to excrete the bile more rapidly. But 
the careful experiments made by the Edinburgh Committee of the 
British Association^ on dogs with biliary fistula showed that 
neither mercurials nor other purgatives increased the flow of bile 
from the liver, and these results seemed at first sight to contradict 
the views entertained by most practitioners regarding ■ their 
cholagogue action. The contradiction is apparent, but not real, for 
in the experiments the bile was regularly removed from the body 
as soon as it was formed, and none of it ever reached the intestine. 
Consequently, any diminution in the quantity collected simply 
showed that the liver was forming less. Other experiments have 
given somewhat different results from those of the Edinburgh 
Committee, and Kohrig^ has found that the administration of 
purgatives, as well as other measures which increase the circulation 
in the portal system, augment the formation of bile. The important 
question in regard to the treatment of biliousness, however, is not 
whether the liver forms more or less new bile, but whether the bile 

^ Report of the British Association, 1868, p. 214. 
* Strieker's Mcdicinische Jahrbucher, 1873, p. 250, 



MERCURY AS A CIIOLAGOGUE. 205 

already circulating in the blood is removed from it. The liver may 
be doing its best to effect this purpose, but it will not succeed if the 
bile it removes from the portal blood is again absorbed as quickly 
as it is poured into the intestine. But if the peristaltic action of 
the "whole intestinal canal is quickened by a purgative, the bile will 
be hurried rapidly onwards and evacuated before there has been 
time for its reabsorption, and the liver being thus relieved will be 
able to excrete any bile still remaining in the blood. This result 
will not be affected by any purgative acting on the large intestine 
alone, for a considerable part of the bile will in all probability have 
been absorbed before it gets so far ; but any simple purgative or 
mixture of purgatives which stimulates the duodenum and small 
intestine as well as the large one will prove most effectual. Now, 
the green colour which the fasces present after the administration 
of mercurials, and which is so distinctive that the name of " calomel 
stools " has been applied to them, has long been regarded as an 
evidence of bile and appealed to as a proof of the cholagogue 
action of these remedies. The opponents of this doctrine have 
declared that the colour was simjDly caused by the presence of 
black sulphide of mercury, just as a somewhat similar colour may 
be occasioned by the jiiresence of a small quantity of sulphide of 
iron after the administration of mild ferruginous preparations. 
Their statement has been disproved by Buchheim, who has shown 
that the colour is really due to bile, and thus established the fact 
that calomel induces its expulsion from the intestine. It may 
therefore well be called a cholagogue, and it is evident from what 
has already been said that it must diminish the quantity circulating 
in the blood, whatever its effect may be on the amount formed by 
the liver. 

Other substances besides bile are found in calomel stools, and 
among the most important of these are leucin and tyrosin. 
These bodies are produced by the action of pancreatic juice on 
albuminous substances, and their presence, >which was discovered 
by Radziejewski, indicates that the contents of the duodenum 
and small intestine have been expelled before much absorption 
has taken place. Now, the duodenum not only contains half- 
digested food and bile, but also the gastric and pancreatic juices 
and the ferments to which they owe their activity. It is generally 
taken for granted that after these ferments have once aided in 
digesting a meal they are destroyed or evacuated, and no import- 
ance, so far as I know, has ever been attached to their reabsorption. 



206 ON THE ACTION OF PURGATIVE MEDICINES. 

It appears from the experiments of Briicke, who found pepsin in 
the muscles/ that it is reabsorbed, at least in part, and is indeed 
excreted in the urine, as is also a diastatic ferment derived from 
the saliva or pancreas.^ Pancreatic ferments also are probably 
absorbed, for Hlifner has found ferments possessing like them the 
properties of digesting fibrin as well as converting starch into sugar 
in the salivary glands and lungs.^ If these ferments, then, are 
poured into the intestine and absorbed from it again in the same 
way as bile, it seems highly probable that they also ai'e excreted 
by the same glands which formed them. (See entero-gastric and 
entero-pancreatic circulations, Fig. 24.) The function of the gastric 
follicles and pancreas would thus be a double one like that of the 
liver, and they would constantly excrete the ferments absorbed 
from the intestine and brought to them by the blood, as well as 
form new quantities of them to replace those which were carried 
off in the faeces or destroyed in the process of digestion. This 
view derives some probability from the observation of Schiff, that 
after the stomach has already digested a copious meal and become 
empty its power to digest albumen is almost entirely lost,^ and 
the fact noticed by Bernard that when the pancreatic juice is 
drawn away by means of a fistula, what flows from the gland some 
time after the operation frequently does not possess the power of 
digesting albumen like the juice which has been collected imme- 
diately after the insertion of the cannula.^ These facts have been 
explained in a different way by Schifif and Bernard, but it seems 
to me that the explanation just given supplements without 
excluding theirs, and clears up some points which they have not 
touched. 

There is this important difference between the glands just 
mentioned and the liver, viz, that the bile can circulate in the 
portal system between the liver and intestine without reaching 
the systemic circulation, but the gastric and pancreatic ferments 
absorbed from the intestine cannot reach the stomach and pancreas 
again without mixing with the general current and the blood, 
and being conveyed to other organs as well. Pepsin cannot act 
in an alkaline fluid like the blood, but pancreatic ferment can; 

^ Briicke, SitzimgshericM der Wiener Acadcmie, 1861, xliii. pp. 622, 619. 

2 Cohnheim, Virchow's Archiv, xxviii. p. 250. 

3 Hiifner, Journal fur practischen Chemie, vol. v. p. 372. 
* SchifF, Physiologie cle la Digestion, torn. ii. p. 195. 

5 Bernard, Physiologie Experimentale, torn. ii. p. 229 ; compare also p. 223, where 
he states that the juice becomes watery towards the end of digestion. 



FERMENTS AND FEVER. 207 

and although I do not know that any experiments have been made 
with it, yet Binz and Siegen found that a ferment derived from 
the hver, and possessing hke the pancreatic one a diastatic power, 
raised the temperature of an animal when injected into it.^ This 
rise was due to its action as a ferment, and not to its mere presence 
in the blood as a foreign body, for it had no action whatever when 
it was injected after its fermentative power had been destroyed by 
boiling. It is therefore quite possible that the temperature of 
the body is normally maintained to some extent by means of the 
pancreatic ferments circulating in the blood, and if purgatives 
diminish its quantity in the way I have sup230sed they will tend 
to lower the temperature. 

It must be remembered that these are only suppositions as 
yet, and require much further substantiation, but the}'' help us at 
any rate to form some idea of the way in which purgatives prove 
useful when given at the commencement of a fever. They also 
give us some notion of the reason why persons so often take 
cold after the use of purgatives, and one of the dangers of their 
administration to old people, who produce little heat at any rate, 
and can only slowly form new supplies of any ferment once carried 
away. 

It is possible that purgatives have an additional action in 
remittent and intermittent fevers due to malaria, and even in 
continued fevers due to other poisons. Lussana supposes that 
the malarious poison which certainly produces some of its most 
marked sfFects on the spleen and liver, circulates like other poisons 
in the portal circulation.^ If this hypothesis be correct, purgatives 
may be productive of benefit by removing part of the poison as 
well as by lessening the temperature. 

The pancreatic and gastric ferments have a very positive and 
certain use in digesting food in the intestine, even should they 
not possess the hypothetical action in the blood to which I have 
just referred ; and if they are usually absorbed and excreted again, 
a constant course of purgatives will seriously diminish their 
quantity. In consequence of this, the digestion of food will be 
carried on slowly and imperfectly, and the general health will 
suffer. But this will only be the case if purgatives are used 
which act on the whole of the bowels, for those which affect the 

^ Siegen, Uchcr die pliarmamlogisclien Eigenschaften von Eucalypius GlobiUtcs 
Inaugural Dissertation. Bonn, 1873, pp. 32, 34. 
2 Lussana, op. cit., p. 358. 



208 ON THE ACTION OF FURGATIVE MEDICINES. 

large intestine only will interfere but slightly with the ferments, 
a considerable portion of which will probably have been absorbed 
before they get so far. We can thus perfectly understand how a 
constant course of blue pill ^ and black draught ^ may have most 
disastrous consequences, while an aloetic pill may be swallowed 
nightly for months together, without doing any appreciable harm. 

The experiments of Moreau and Vulpian, as well as my own, 
show that a large quantity of fluid is drained away from the blood 
into the intestine by the action of purgatives, and we can thus 
readily understand their use in removing fluid in dropsies. The 
abstraction of so much fluid will tend to empty the blood-vessels, 
and at the same time the irritation caused by the purgatives will 
attract a larger proportion of blood to the intestinal vessels, and 
thus still further lessen the blood-pressure in other parts of the 
body. The blood being no longer urged onward with the same 
force, the congestion in any inflamed part diminishes, and the 
painful throbbing which is felt at every pulsation when certain 
parts of the body are inflamed will be diminished, or may dis- 
appear, at least for a time. The diminished tension in the arteries 
which purgatives induce is clearly seen from the accompanjnng 
sphygmographic tracings, which I owe to the kindness of Mr. 
Mahomed. 

When the kidney is the organ affected, the benefit afforded by 
purgatives will be twofold, for they both diminish the work it lias 
to do by eliminating water by the bowels, and at the same time 
lessen congestion, and thus remove an impediment to the proper 
performance of its function. Accordingly the administration of 
a purgative such as elaterium is found to lessen and sometimes to 
remove albumen from the urine, to render the secretion copious 
even when no diuretic has been given, and greatly to increase the 
activity of diuretics, which may have been unable to produce any 
action so long as the bowels were left alone. ^ 

In conclusion I give a short r6sum6 of the chief points in this 
paper. Purgatives act by stimulating the secretion of fluid from 
the intestines, as well as by increasing peristaltic action. They 
prove useful in many ways. They hurry the food out of the 
alimentary canal, and thus lessen the injurious effects of over- 
eating. By expelling irritating substances from the intestine they 

1 Prout, Stomach and Benal Diseases, 5tli ed., p. 52. 

2 Pancreatic ferment appears in the faeces after the use of senna. (Radziejewski, 
Reichert, and Du Bois-Reymond's Archives, 1870, p. 72.) 

' Geo. Johnson, Brit, Med. Journal, 1868, March 7, p. 215. 



SUMMARY. 



209 



arrest diarrlicea, and remove headache and other pains, caused 
either by the abdominal irritation or by the absorption of poisonous 
matters produced by imperfect digestion and decomposition of food. 
They relieve biliousness by removing bile, and are most efficient 
aids in the treatment of chronic poisoning by lead, mercury, or 




Fig. 25 is a sphygmographic tracing from the pnlse of a healthy man before taking 
a purgative. The somewhat oblique I'ise, slow descent, and comparatively slight 
dichrotism of the pulse- wave indicate that the arterial tension is moderately high. 




Fig. 26 is a tracing from the same person after the use of a purgative. The more 
abrupt rise and quicker fall, and decided dichrotism of the pulse-wave, as well as 
t/ie greater frequency of the pulse, as indicated by the shortness of the waves, show 
that the tension in the arteries is much less than in Fig. 25. 



other metals. It is probable that pepsin and pancreatic ferment 
are absorbed from the intestine and circulate in the blood, where 
the latter assists in the production of animal heat. They are then 
secreted anew by the stomach and pancreas, and do their work 
again. Purgatives lessen their quantity as well as that of the 
bile ; and they thus may be useful in fevers, but they injure old 
and feeble persons, both by diminishing their calorific power and 
impairing their digestion. They relieve inflammation by lowering 
the blood-pressure and thus diminishing congestion ; and they 
prove beneficial in dropsies, both by abstracting water from the 
bJood and diminishing congestion in the kidneys. 



HOW TO MAKE A POULTICE. 

(' The PractUio7ier,' \oi,. xxix., Oct. 1882.) 

At first sight the title of this paper may seem to many of my 
readers absm'd, and the idea that medical men require any 
instruction in making a poultice preposterous, but I have been 
led to write it from seeing that many students and some prac- 
titioners do not distinguish between the proper methods of making 
a poultice for surgical and for medical use. Many, perhaps most, 
students spend a great part of their four years' curriculum in 
surgical study, and devote a comparatively small portion of it to 
medicine. This may j)art]y be the reason why they do not learn 
the best ways of making j)oultices for the relief of internal j)ain : 
but another reason is, that in hospitals poultices are made in 
certain ways for the sake of cleanliness and economy, and these 
ways are not always the best possible for private patients, although 
they may be the best under the conditions which obtain in 
hospitals. Every one knows the relief which a poultice affords 
when the finger is inflamed, and has noticed how the painful 
throbbing diminishes after its apj)lication. Most people have 
noticed also that dipping the finger in cold water has a similar 
action, and it seems strange to many that the opposite conditions 
of heat and cold should have a similar effect. The reason probably 
is that both heat and cold lessen the force of the impulse with 
which the blood is driven through the dilated arteries of the 
inflamed parts against the block which exists in the capillaries. 
Cold causes the afferent arteries to contract, and lessens the impact 
of the blood by diminishing the quantity sent to the inflamed 
part; a poultice lessens the impact by dilating the cajsillaries 
surrounding the seat of inflammation, and affording a ready side 
outlet into the veins. In surgical cases we usually use the warmth 
and moisture of the poultice to act directly on the surface. We 



POULTICES FOR ABDOMEN OR CHEST. 



211 



therefore make the poultice with crushed linseed or with linseed 
meal and oil, spread it on some tow and apply it to the skin 
without anything intervening. But useful though this method 
may be for wounds, ulcers, and abscesses, it is not the best form 
of application in cases of inflammation of the thoracic or abdominal 
viscera, or where spa&m is present without inflammation. In such 
cases we may, no doubt, do some good by applying the poultice 
to the surface exactly as in surgical diseases. We may draw off 
some of the blood to the surface ; and we may also exercise a reflex 
action through the nerves upon the vessels of the inflamed organ 
below, but this will not be so great if we influence the surface 
only, as when we allow the heat to penetrate to the inflamed or 




Fig. 27.- -The upper figure represents the bag empty ; the lower one the bag filled 

and sewn up. 

irritated organs themselves. If Ave apply the poultice directly to 
the skin it must be allowed to become tolerably cool before the 
patient can bear it, and thus half its advantage is lost. In order 
to relieve spasm, as in colic — intestinal, biliary, or renal; to relieve 
inflammation of the pleura, the lungs, the liver, or other organs, we 
want to apply the poultice as hot as possible, while we protect the 
skin from being scalded. 

In order to do this, a flannel bag should be prepared, a convenient 
size being twelve inches by eight ; this should be closed at three 
edges and open at the fourth ; one side of it should be about one 

V 2 



212 HOW TO MAKE A POULTICE. 

inch or one inch, and a half longer than the other, as represented 
in the diagram, and it is convenient also to have four tapes attached 
at the points which form the corners when the bag is closed, in 
order to keep the poultice in position. Besides this, another strip 
of flannel should be prepared of the same breadth as the length of 
the bag, and long enough to wrap round it once or oftener. Crushed 
linseed, bowl, and spoon should then be got together, and the spoon 
and bowl thoroughly heated by means of boiling water; the poultice 
should then be made with perfectly boiling water, and rather soft. 
As soon as it is ready, it should be poured into the bag, previously 
warmed by holding it before the fire ; the flap which is formed by 
the longest side of the bag should now be turned down and fastened 
in its place by a few long stitches with a needle and thread, it 
should then be quickly wrapped in the strip of flannel (also 
previously warmed), and fastened in siht, if necessary, by means of 
the tapes. It may be covered outside with a sheet of cotton wool. 
In this way the poultice may be applied boiling hot to the skin 
without burning ; the two layers of flannel which are at first dry 
allow the heat to pass very gradually indeed to the skin ; as the 
moisture of the poultice soaks through them, they become better 
conductors, and the heat passes more quickly, but the increase is 
so gradual as not to cause any painful sensations whatever, but 
only one of soothing and comfort. The poultice also naturally 
keeps much longer hot, and the necessity for changing it arises 
much less frequently. 

The difference between the effect of a poultice made in the 
ordinary way, and in the manner just described, is sometimes 
exceedingly striking. It is, perhaps, less marked in cases of 
inflammation than in those of spasm. I have seen a patient 
suffering from intense abdominal pain at once relieved by a 
poultice made in the way just described, although a succession of 
poultices made in the ordinary way had been utterly useless. This 
way of making poultices is one of the minutiae of medical practice ; 
apparently extremely trivial, but really, I believe, very important. 
The relief which I have seen afforded by poultices made in this 
way, and the knowledge that some practitioners at least are ignorant 
of the method, must be my apology for drawing attention to such 
a trivial detail. 



ON THE ACTION OF TONICS. 

(' The Practitioner,' vol. xxi., August, 1S78.) 

DuEiNG the heat of summer many people feel limp and weak, 
and are disposed to sympathise, in imagination, with a collar which 
has just been washed, but not starched. They ajopl}'' to their 
doctor for a tonic, take the medicine which he prescribes, and feel 
themselves much the better for it. There can be no doubt that 
the word " tonic " conveys a certain meaning both to doctor and 
patient, definite enough in one way, but very vague in another. 
Both understand that the tonic will increase the strength, and 
remove the weariness and languor, but how it does so probably 
neither has attempted to find out. On turning to Pereira we find 
that tonics are defined as agents which increase the tone of the 
system : but if we inquire further what is meant by tone, and what 
by the system, it will not be quite so easy to give a definite answer. 
Perhaps the easiest way of doing this is to take the want of tone, 
as we term it, for which tonics are administered, and to analyse 
the various symptoms which we find. First of all, then, there is 
a feeling of languor and disinclination to exertion, mental or 
bodily. The person may be roused by some excitement to make 
considerable exertions, but these are succeeded by a greater than 
usual feeling of fatigue ; the appetite is generally diminished, the 
pulse is softer and more compressible than usual. Not unfre- 
quently, too, there is less power" than usual to resist the attack 
of disease. Want of tone, then, consists in diminished functional 
activity of the muscular, nervous, circulatory, and digestive systems, 
and a tonic is something which will increase this activity. Some 
tonics, however, act more on one system than another : and so we 
have vascular tonics, nervous tonics, and digestive tonics ; as well 
as general tonics which seem to influence all the systems together. 
The functional activity of the body, and of the various organs which 



214 ON THE ACTION OF TONICS. 

compose it, depends upon the combustion whicTi goes on in it and 
in them, and this combustion may be increased by increasing the 
nutriment, by quickening oxidation, or by removing more quickly 
than usual the products of waste, just as a fire may be made to 
burn more brightly by heaping on coal, by using the bellows, or by 
raking out the ashes. We may increase the functional activity of 
the body to a certain extent by increasing the food which a person 
takes, although there are limits to this, and an excessive quantity 
of food may prove injurious, just as one may smother a fire by 
heaping on too much fuel. The first class of tonics, gastric or 
digestive tonics, enable the patient to take more food, and with 
a greater relish. The most typical examples of this class are the 
so-called bitter tonics, such as calumba, quassia, gentian, cascarilla, 
and hops, either alone or in the form of bitter beer. In the mouth, 
these drugs produce a transient bitter taste, and increase the 
secretion of saliva. Thus they will tend to aid the digestion of 
starchy matters. In the stomach they cause a slight irritation, 
and the stomach, not having the same power of discriminating 
sensations that the mouth has, feels this, not as bitterness, but as 
appetite; unless the dose of the bitter should be too gTeat, or too 
concentrated, and then it is felt as nausea, and is fjllowed by 
vomiting. The appetite, however, which small doses excite, induces 
the patient to take more food, and to take it with greater relish. 
The increased relish is not to be disregarded. It would not be the 
same thing if the patient were simply to cram down, against his 
inclination, the same amount of food which he takes after his 
appetite has been excited by a tonic. We have not yet succeeded 
by pharmacological experiment in ascertaining precisely the effect 
of different emotions upon the stomach, but there can be Httle 
doubt that the pleasant feeling resulting from gratified appetite, 
aids digestion, while that of disgust and satiety interferes with it. 
Experiment has not shown that bitters increase the secretion of 
gastric juice in the same way that they do that of saliva, but they 
have an important action in lessening the tendency to putrefaction 
in the stomach. It is not impossible that in this way they prevent 
the formation during digestion of such substances as butyric acid, 
which is a direct nervous poison, and which, when absorbed into 
the circulation, would of itself tend to cause weakness and debility. 
It must not be forgotten that a man may be poisoned by substances 
formed in his own intestines, as well as by poisons taken into them 
by the mouth. 



SEWER- GAS IN TEE INTESTINES. 215 

We all greatly dread the inhalation of sewer-gas into the lungs, 
but probably very few of us think that noxious gases formed in the 
stomach and intestines are readily absorbed by the blood, some- 
times producing very serious results, and probably in many other 
cases leading to weakness and depression, the cause of which is 
never suspected. Experiment has shown that bitters, if they do 
not increase the secretion of gastric juice, at least tend to diminish 
the secretion of mucus, and lessen in this way, as well as by the anti- 
septic action just mentioned, the fermentation which mucus is apt 
to set up. It has been found by Kohler that even simple bitters 
in large doses will raise the blood-pressure by acting on the vaso- 
motor centre. It is doubtful whether they do so in the small doses 
usually administered or not, but there are other remedies — so-called 
vascular tonics — which combine this action to a considerable extent 
with one upon the stomach. Thus, infusion of digitalis does not 
greatly increase the secretion of saliva, nor produce a feeling of 
appetite in the stomach. It acts, after its absorption, upon the • 
vaso-motor centre and upon the heart, rendering the cardiac pulsa- 
tions slower, and more powerful by contracting the vessels, and thus 
making the pulse firmer and less compressible. This improve- 
ment in the circulation makes itself felt in every organ of the 
body. Thus the stomach is relieved of congestion, digests the 
food more easily, is less liable to secrete mucus, and is much less 
apt to be distended by flatulence. This is perhaps best marked 
in cases of mitral disease, where the venous congestion which 
accompanies such a condition often leads to an accumulation of 
flatus, sometimes termed by patients heart-wind. The pathology 
of this condition has not been precisely made out, but we must 
not forget that interchange of gases goes on between the blood in 
the capillaries of the stomach and the gas contained in its cavity 
in the same way, though to a much less extent, as between the 
blood in the capillaries of the lung and the air contained in the 
pulmonary alveoli. The action of another drug, very different 
from digitalis, namely, charcoal, upon flatus of the stomach, is 
very marked, and is usually ascribed in text-books to the power 
which the charcoal possesses of absorbing gas. But charcoal only 
does this when it is dry; it loses its power when moist, and it 
seems incredible that a teaspoonful of charcoal swallowed after a 
meal and mixed with the contents of the stomach, including per- 
haps a pint of beer, in addition to all the gastric juice, should, 
after being churned up with the food in the stomach, absorb so 



216 ON THE ACTION OF TONICS. 

much gas as to have any effect whatever upon the flatulent dis- 
tention. It seems much more probable that its action is simply 
mechanical, and that by the small insoluble particles acting upon 
the mucous membrane, the circulation through it is so stimulated 
that the blood, flowing more rapidly through the vessels, absorbs 
and carries away a part at least of the accumulated gases. In 
respect, then, of its action upon the circulation in the stomach, 
charcoal may have some similarity to digitalis, but here the simi- 
larity ends. Charcoal has no action upon the heart. It cannot 
restore the balance of the circulation like digitalis, and it has none 
of the general effects upon the heart and vessels produced by the 
friction in the wet sheet so well described by Dr. Winternitz. 

The improved circulation produced by vascular tonics makes itself 
felt in the liver and intestines as well as in the stomach. The yellow 
tinge, indicating biliary congestion, will disappear from the eye, 
and hsemorrhoidal engorgement will be lessened or removed. The 
brain and nervous centres, under the influence of a freer current 
of blood, act more readily and powerfully, thought comes with less 
effort, and exertion, both mental and bodily, can be continued for 
a much longer time, without any sense of fatigue. Two conditions 
also disappear, which, although apparently contradictory, afflict 
debilitated persons at the same time. These are drowsiness and 
sleeplessness. Frequently do we hear debilitated patients com- 
plain that they are so heavy for sleep that when sitting in their 
chairs or going about their work an irresistible drowsiness comes 
over them, and they fall asleep in the midst of an unfinished task, 
but when they lay their heads on the pillow and seek rest the 
conditions are at once reversed, drowsiness disappears, they toss 
about from side to side in the vain attempt to fall asleep, and 
perhaps it is not until they get up and walk about for a little 
that they are able to effect their purpose. Both of these condi- 
tions, apparently so dissimilar, depend upon the atonic condition 
of the vessels, so that instead of resisting the pressure of blood 
within them, they yield before it. In consequence of this the 
blood gravitates, while they are in an upright position, to the 
vessels of the abdomen and legs, leaving the brain anasmic and 
thus inducing sleep. On the other hand, when the horizontal 
position of the patient allows the blood to flow more easily to the 
head, the carotids and their branches, instead of contracting and 
keeping back the blood, allow it to circulate rapidly through the 
brain, and thus the unfortunate patient, unable to think at the time 



VASCULAR TONICS. 217 

when he wishes to, is plagued by a rapid and incessant flow of 
ideas at the very moment when he least desires them. By giving 
dio'italis so as to excite the vaso-motor centre the vessels are made 
to contract moderately, they no longer yield to the pressure of 
the blood, and thus the blood is prevented from gravitating to 
the abdomen and lower limbs, and a free circulation through the 
brain enables it to discharge its functions satisfactorily, notwith- 
standing the force of gravity which in the upright position always 
tends to make it ansemic. Again, Avhen the patient retires to rest, 
the blood, which tends in a horizontal posture to rush towards the 
brain, is checked in its course by the carotids and their branches, 
which under the influence of the vaso-motor centre, stimulated by 
the vascular tonic, contract and regulate the cerebral circulation so 
as to allow only sufficient blood to pass to the brain for the purpose 
of nutrition, but not enough for functional activity. 

It seems highly probable that a similar action is exerted upon 
the vessels of the spinal cord, and that thus the patient feels 
increased muscular power and is equal to more prolonged exertion.' 
But this is not all, for the subcutaneous cellular tissue, and 
probably also the muscles themselves, are also benefited by the 
improved circulation. In the case of the subcutaneous tissue, the 
improvement is visible and palpable, as it is also in the muscles, 
though perhaps rather less plainly. In persons suffering from 
debility, even although there be no cardiac disorder, we find 
the feet swollen at night, so that the patients complain of 
their boots being too tight, and the ankles may be seen to 
pit upon pressure. Under the action of vascular tonics this 
condition will disappear, the ankles no longer swell, and deep and 
continuous pressure pioduces little or no mark upon the skin. 
The muscles, too, which were previously soft and flabby, seem to 
undergo a similar change, and become firmer, harder, and more 
elastic. The mode in which this is effected seems to be twofold — 
less fluid is poured out from the vessels into the tissues, and more 
is absorbed from the tissues into them. Thus, instead of plasma 
stagnating in the intercellular places of the muscles and connect- 
ive tissue, a brisk circulation is kept up, by which fresh oxygen is 

^ For a fuller explanation of the modus ojMrancli of contraction of vessels in the 
cord in increasing muscular strength, we may refer to a paper on the curative eifects 
of mild and continued counter-irritation of the back in cases of general nei'vous 
debility and in certain cases of spinal ii-ritation, by Arthur Gamgee, M.D., F.R.S., 
in the Fractitioner, vol. sviii. p. 113. 



218 ON THE ACTION OF TONICS. 

supplied, and the products of waste are removed. The tissues are 
thus put into the most favourable condition for performing their 
functions, for, as we have already stated, functional activity depends 
upon the rapidity of combustion which goes on within the tissues 
or organs. It is quite possible to paralyse a muscle by stopping the 
supply of blood to it, and thus preventing it from obtaining 
oxygen, but it is still easier to paral;^se the muscle by allowing 
the products of its own waste to accumulate within it. The 
easiest way to stop combustion in the muscle is, so to speak, to 
smother it in its own ash. It has been shown by Kronecker that 
if we remove the products of waste from a muscle which has been 
kept in a state of tetanus until it refuses to contract any longer, 
we can restore its contractile power even although we supply no 
fresh oxygen to it. In all probability it is the accumulation of 
the products of waste in the muscles in debilitated persons, which 
is, to some extent at least, the cause of the languor which they 
feel. That such is the fact, is, I think, shown by the feeling of 
comfort which they experience when the legs are gently sham- 
pooed, the pressure being always exerted upwards so as to favour 
the return of the fluids from the tissues. Such a procedure tends 
to give a lightness and corkiness to the limbs, which can hardly 
be attributed to any change in the nervous system generally, but 
must rather be ascribed to the removal from the muscles of those 
waste products which were partially paralysing them. 

In talking of the nervous system, of the brain, and of the spinal 
cord, we have not taken into account this action of vascular tonics 
increasing combustion and removing waste from the nervous tissue, 
but probably, although we cannot see it so readily as in the con- 
nective tissue and muscles, the same process goes on in the nervous 
centres, and has much to do with the beneficial action of tonic 
remedies. I have stated that the action of tonics upon the inter- 
cellular fluid in the tissues is probably twofold — that they pre- 
vent excessive exudation from the vessels at the same time that 
they produce increased absorption. The reasons for believing that 
they lessen the exudation of fluid from the vessels are derived 
from a consideration of the pathology of oedema as made out by 
Kanvier. The first experiments upon the subject of oedema were 
made by Lower, who, in 1680, tied the vena cava, and found that 
oedema appeared in the lower extremities. A similar condition 
was noticed by Bouillaud in patients suffering from thrombosis of 
the iliac veins, and thus it appeared clear that the occurrence of 



(EDEMA. 219 

oedema was due to the absorption of the intercellular fluid being 
prevented by venous congestion. Lower's exj^eriments, however, 
were repeated by Valsalva, Hewson, and others, without producing 
oedema, and the cause of its production therefore remained obscure. 
It was reserved for Ranvier to clear up this question, and to show 
that the occurrence of oedema usually depended upon increased 
exudation from the vessels as w^ell as diminished absoi-ption by the 
veins. He tied the vena cava in the abdomen of a dosr, and 
found, like Valsalva, that oedema did not come on. The quantity 
of fluid exuding from the arteries was so small that the lymphatics 
were able to absorb it without any assistance from the veins, and 
thus it did not accumulate in the tissues, but on cutting the 
sciatic nerve on one side, intense oedema occurred in the corre- 
sponding leg. Venous congestion was equally present in both legs 
as the vena cava itself had been tied, but in one the nervous 
influence proceeding to the arteries through the sciatic nerve kept 
them contracted and prevented the exudation of more fluid than 
the lymjDhatics could absorb. In the other leg, however, where 
the nerve had been paralysed by a division, the vessels dilated, the 
limb became rosy and warm, and so much fluid was poured out 
that the lymphatics alone could not absorb it without the aid of 
the veins. Ranvier next proved that this dilatation of the arteries 
was due to paralysis of the vaso-motor and not of the motor fibres 
contained in the sciatic, by cutting, in different experiments, the 
motor and the vaso-motor nerves in the lumbar region before 
they had united to form the nervous trunk. When the motor 
strands were divided, as they issued from the lumbar vertebrae 
before they had been joined by the sympathetic fibres, complete 
paralysis of the leg was produced but no oedema occurred ; but if, 
on the other hand, he divided the sympathetic fibres, passing to 
the sacral plexus, there was no motor paralysis — the animal could 
still use its limb, but the vessels dilated and oedema occurred. 

These experiments show pretty conclusively that dilatation of 
the vessels by paralysis of the vaso-motor nerves is one factor in 
the production of oedema. In them, of course, we see in an 
exaggerated condition the same phenomena which are observed 
in cases of debility, because in these experiments the vaso-motor 
nerves were completely paralysed, whereas in our patients they 
are simply weakened. We may sometimes see very clearly in 
persons whose vascular system is deficient in tone, the effect of 
dilated vessels in causing oedema even when there is no great 



220 ON THE ACTION OF TONICS. 

obstiniction to the return of blood. Such persons, when walking 
about in a warm day, with their arms hanging by their sides, 
sometimes find their hands become so swollen that they can 
hardly close their fists. The combined effect of heat and exercise 
upon their already debilitated vascular system, aided by the 
effect of gravitation, has caused so much fluid to escape into the 
tissues of their hands, that the veins and lymphatics are together 
unable to absorb it, and thus the fingers become swollen. The 
absorption of fluid from the tissues is, like its exudation into 
them, greatly controlled by the central nervous system. This is 
shown by some experiments of Goltz and Nasse. The former 
found that when a fluid was injected under the skin of the back 
of a frog, it was rapidly absorbed so long as the brain and spinal 
cord were uninjured, but when they were destroyed, little or no 
absorption took place. As the ordinary action of the nerve-centres 
causes absorption to go on, we would naturally expect, that any 
increase in their activity would quicken the absorptive process, 
and this indeed was actually shown by Nasse to occur. It is 
well known that irritation of a sensory nerve stimulates the 
vaso-motor centre reflexly, and causes the vessels to contract. 
But, in addition to this action, Nasse found that irritation of a 
sensory nerve also caused increased absorption. It has not yet, 
so far as I know, been proved experimentally that such a drag 
as digitalis, which undoubtedly stimulates the vaso-motor centres, 
has a similar action to stimulation of that centre by irritation 
of a sensory nerve. Some time ago I made a few experiments 
upon this subject, but from imperfect graduation of the dose, the 
results I obtained were unsatisfactory, as the heart was too much 
affected by the drug, and the circulation became entirely arrested. 
There seems, however, no reason to believe that direct stimulation 
of the vaso-motor centre by digitalis will have a different action 
from its reflex stimulation through a sensory nerve, and we may 
therefore, I think, confidently assume that vascular tonics Kke 
digitalis increase the absorption of fluid from the tissues. They 
will thus remove the products of waste, and by keeping up a 
constant circulation of fresh intercellular fluid wiU assist combustion 
and functional activity in the tissues. 

Another most valuable tonic, strychnia, has an action even 
more widely extended over the body than digitalis. It is at once 
a gastric, vascular, and nervous tonic. It aids digestion like other 
simple bitters in the way already described. It has, with the 



DIGITALIS— STRYCHNINE. 221 

exception of quinine, a more powerful action tlian most other 
bitters in preventing putrefaction. It excites the sensibihty of 
the vaso-motor centre, thus exerting a beneficial effect upon the 
circulation, and likewise directly stimulates the nervous tissue of 
the sjainal cord itself. So great is its effect upon the vaso-motor 
centre that by its means physiologists have discovered that instead 
of being confined to the medulla oblongata, as was formerly 
imagined, this centre extends do^vn the spinal cord. It has just 
been said that an impression made upon the sensory nerves, 
reflexly stimulates the vaso-motor centre, contracting the vessels 
and raising the blood-pressure, but when a cut is made across the 
spinal cord just below the medulla oblongata this result is not 
produced. From this experiment it has been concluded that the 
vaso-motor centre was entirely confined to the medulla oblongata 
above the place of section ; but if a little strychnia be now injected 
into the veins of an animal in which the cord has been thus 
divided, and a sensory nerve be then irritated, the vessels will 
contract and the pressure of the blood will rise. It thus becomes 
evident that the vaso-motor centre extends doAvn the cord from 
the medulla, although its spinal portion is so feebly developed that 
under ordinary circumstances it has no power to contract the 
vessels when reflexly excited by stimulation of the sensor}^ nerve. 
But strychnia has the power to increase its excitability so much, 
that reflex stimulation in this way will produce through it a 
decided effect. ISTow when we consider that sensory impulses are 
proceeding every moment from the skin to the vaso-motor centre, 
we can readily perceive how a slight increase in susceptibility 
produced by strychnia will have a wonderful effect in raising 
the tone of the vessels, and aiding the circulation. The mode in 
which quinine acts is not so clear, but we know from observation, 
that it also, in small doses, renders the pulse stronger and less 
compressible. 

We have now seen how tonics may increase the quantity of 
nutriment taken into the body generally, how by their action on 
the vessels they quicken the circulation of inter-cellular fluid in 
the tissues, and by thus aiding its oxidation, and removing the 
products of waste, they greatly increase the functional activity of 
the various organs of the body. 

We have now to consider how they affect the removal of waste 
from the body generally. The inter-cellular fluid in which these 
products are contained is absorbed into the general circulation 



222 OxV THE ACTION OF TONICS. 

by the veins and lymphatics. Unless some provision were made 
for its removal, it would soon accumulate in the blood and arrest 
the functional activity of the various tissues, beginning with the 
most susceptible of all, the nervous tissue, and causing death. But 
these substances in all probability undergo further oxidation in 
the blood after their absorption and before they are finally excreted. 
This oxidation will be assisted if the respjiratory movements by 
which oxygen is taken into the lungs are rendered deeper and 
more frequent, and also if the blood itself should acquire greater 
power to absorb this oxygen. Now strychnia has an action ujjon 
the respiratory centre in the medulla oblongata similar to that 
which it exerts upon the vaso-motor centre, and under its action 
respiratory movements become both cpicker and deeper. No 
such effect is produced on the medulla by such a tonic as iron, 
but under the influence of this remedy the blood coi'puscles not 
only become greatly increased in number, as was shown by Dr. 
Gowers in a paper in the Practitioner, vol. xx. p. 1, but they 
also contain a greater amount of hsemoglobin. Oxygen is thus 
more rapidly carried from the lungs to the tissues, and the process 
of combustion can thus go on more readily, both in the tissues 
themselves and in the minute blood-vessels into which the 
products of waste have been absorbed. 

The rise in blood-pressure which occurs under the influence of 
tonics not only affords, as we have just seen, the most favourable con- 
ditions for oxidation in the tissues and for the removal of the products 
of waste from them, but it also assists in their elimination from the 
body itself. It has been shown by Ludwig and his scholars that 
the secretion of urine is, generally speaking, proportional to the pres- 
sure of blood in the renal glomeruli, and thus the pressure would 
rise along with the tension in the vascular system generally. The 
contraction of the vessels which tonics produce will therefore raise 
the tension in the kidney as well as in other parts of the body, 
and thus aid in the elimination of the products of waste. 

From what has just been said, then, it would apjjoear that 
strychnia or nux vomica is one of the most valuable tonics which 
we possess. When combined with nitro-hydro-chloric acid it is 
perhaps one of the most efficient remedies that we can give 
for the debility which is so often noticed in warm weather, and 
when the ordinary tonics, such as gentian, calumba, cascarilla, or 
quinine do not produce the desired results, the addition of a little 
nux vomica or strychnia to them may give us the wished-for efifect. 



ON THE ACTION OF ALTERATIVES. 

(* The Praditiomr' for September 1876.) 

If we were to take the word alterative in its widest sense, it 
would embrace all the medicines we employ ; for all of them are 
used for the purpose of producing some alteration or other in 
the bodies of those to whom they are administered. Nor is the 
alteration confined to them alone; it may also influence their 
offspring, and Buchheim very truly says that we are quite justified 
in calculating what the influence of a purgative, which we take 
to-day, will be upon the bodily and mental well-being of our 
great-grandchildren. I know a lady who believes that ill-temper 
in children is due to illness, and whenever any one of her own 
family was naughty during their childhood, she invariably adminis- 
tered a dose of Gregory's mixture to the offender. The practice 
was most successful, mind and body were purged together, the 
ill-temper fled with the evacuation of the bowels, and a wholesome 
dread lest the dose should be repeated co-operated with its 
physical action to prevent a return of the naughty fit. Who 
shall say that the temper and disposition as well as the bodily 
health of this lady's children and grandchildren are not altered 
for the better by her judicious use of rhubarb and magnesia, 
and who shall deny to Gregory's mixture an honourable place 
among the alteratives ? And yet if we saw its name appearing 
in a list of them we would be very apt to say that it was like 
Saul among the prophets — it had a perfect right to be there, 
but it would have been better elsewhere — Epsom salts, jalap, 
and other purgatives being more suitable companions for it than 
iodide of potassium, arsenic, and the other remedies to which 
we usually give the name of alteratives. For custom has now 
excluded from this class all medicines which give external signs 
of vigorous action by purgation, sweating, or diuresis^ and has 
restricted the term to such remedies as do their work slowly 



224 ON THE ACTION OF ALTERATIVES. 

and secretly but none the less effectually. In short, we use the 
word alteratives very much as a cloak for our ignorance. For 
example, a patient comes to us complaining of more or less constant 
headache just above the eyebrows. We generally associate such 
frontal headache with disturbances in the digestive apparatus, and 
we accordingly at once inquire into the condition of the tongue, 
appetite, and bowels. We find that the tongue is fairly clean, 
the appetite fairly good, but the bowels are constipated. We 
give a drachm of sulphate of magnesia three times a day, get 
the bowels to act properly, and in four cases out of five the 
headache disappears. But in the fifth case it remains, although 
the constipation has been removed and the evacuations are free. 
We order the medicine to be continued, but in addition give a 
calomel and rhubarb, or a blue pill at night, and now we obtain 
the desired effect. The sulphate of magnesia alone was unable 
to remove the cause of the headache, but the mercury seems 
to touch the right spot and put things in proper order again, so 
that no farther paia may be experienced for a good while to come. 

What the probable reason of this is I will mention by and by, 
but at present I wish to contrast the action of these two remedies 
with that of a third. 

Suppose, then, that we see, as we very often do, a patient com- 
plaining of pain above the eyebrows but with all the functions 
of the alimentary canal apparently in good order. These cases 
axe frequently met with amongst girls from fourteen to twenty. 
The tongue is fairly clean and moist, although it may be slightly 
marked with the teeth at the edges, there is no complaint of 
wind in the stomach, there may be no pain after eating, and the 
bowels may be quite regular. We order them ten minims of 
dilute nitro-hydrochloric acid before meals and the pain disappears, 
just as it did in the other cases after salts or calomel. But here 
we have no sign of action produced by our remedy exce|3t the 
disappearance of the patient's complaint. There is no purgation 
by which to explain the results : we cannot say that the morbid 
matter which caused the pain has been forcibly removed from the 
alimentary canal or from the blood. Our remedy has corrected 
the nutrition of the body in some mysterious and secret way, 
as mysterious and secret as the manner in which a hearty meal 
sustains the nutrition, and we class our medicine among the 
alteratives just as we class the substances composing the meal 
among the nutritives. 



now DO ALTERATIVES ACT? 225 

Or let us take another example. The skin, which ought to be 
soft and uniform in colour and smooth on the surface, becomes 
covered with round reddish spots, on which the epidermis accumu- 
lates, giving them a somewhat silvery hue, and from which it falls 
in scales. We give arsenic internally, and even without the use of 
any local application to the skin, although these are undoubtedly 
useful, we may find the scales fall off, the reddened spots disappear 
and the skin assume its normal appearance. 

Here again our medicine acts in the same slow, secret way, 
causing the skin once more to return to its proper healthy mode of 
nutrition, or, in other words, causing the cells which compose it to 
take up, assimilate, and use in the proper way the nutritive, 
materials brought to it. 

jSTow I find the question, How do alteratives act? to be an 
extremely difficult one ; and I do not feel at all certain that I 
shall be able to give the correct answer to it. But the difficulty of 
the question is not merely personal — it has been felt by every 
writer of a textbook on Materia Medica ; and on looking through 
the standard works on the subject I see that an exjalanation of the 
mode of action of alteratives is rarely or never attempted. 

I have, therefore, less delicacy in bringing the subject under 
notice, as my attempt to explain their action, even though incor- 
rectly, may, by awaking criticism, and directing- general thought 
to this question, lead some to a better solution of it than the one 
at which I have arrived. 

We have already seen that there is a striking resemblance 
between nutritives and alteratives in the quietness with which 
they effect their purpose ; and I believe that it will greatly assist 
our comprehension of the mode of action of those remedies which 
alter nutrition if we first take a glance at the way in which nutri- 
tion is normally maintained. A railway navvy, working with 
pickaxe, shovel, and barrow, striking hard into the firm earth or 
the solid rock^ lifting heavy weights and wheeling heavy loads, 
violently exerting every muscle in his body and perspiring at every 
pore, would soon exhaust both his muscles and glands, if he were 
to abstain entirely from food and drink, and not replace the solid 
matter and liquids which he is continually losing while at work." 
He would get thinner and weaker, and would quickly die ; while 
if he has an abundant supply of bread and butter, beefsteak and 
salt, with as much water as he wants, he may go on working day 
after day, week after week, and month after mouth, without his 



226 ON THE ACTION OF ALTERATIVES. 

strength undergoing the least diminution or his body becoming 
lighter by even a single ounce. It may be remarked that I have 
put salt here in the list of foods, and I draw special attention to it, 
because the quantity of it which we use is so much less than that 
of the other sorts of food that we are apt to forget it. And all the 
more so because we get it added to our bread by the baker, or to 
our butter by the dairyman, or get it thrown on our beefsteak 
while it is cooking, and thus forget that we may take a good deal 
during the day although we never put a particle of it on our 
plates during meals. And yet the simple experiment which we 
find in every boy's book of chemical tricks, of telling into which 
basin of water a hand has been put by the turbidity which occurs 
on testing it with nitrate of silver, shows how constantly we are losing 
salt from the skin ; and if we put our tongue to our hand after 
we have been perspiring freely, the taste will convince us that the 
quantity of salt we lose by the skin is not inconsiderable, even if 
w^e were to leave- out of account the much greater loss which takes 
place by the urine. We find no difficulty in understanding how 
the salt lost by the various emunctories is replaced by that which 
we take into our stomach. For salt dissolves readily in water, 
and when in a state of solution it diffuses easily through animal 
membranes. Thus when it is taken into the stomach it is soon 
dissolved by the liquids it finds there, is absorbed into the blood- 
vessels, and travels with the blood to all parts of the body. 

But with regard to the bread, butter, and beefsteak the matter 
is not so easy. It is true that fats may be made to pass through 
animal membranes, but not very easily, and the difficulty is greater 
when the membranes are moist, as they are in the body. Starch, 
of which the bread is composed, and albuminous substances, 
such as those of the beefsteak, hardly pass at all, and in order to 
be made available for the wants of the body, they must first be 
rendered soluble. Nor is this all. In order to render them 
soluble they must undergo a chemical change, the starch of the 
bread being converted into grape sugar, the myosin of the beef- 
steak into soluble albumen and peptones, and the butter being 
partially split up into fatty acids and glycerine. Now all these 
changes can be effected by the chemist in his laboratory, or by the 
manufacturer in his factory, but both of them require to use much 
force in the shape of heat to pull apart the atoms of the starch, 
albumen, or fat, and allow them to enter into new combinations. 
Thus starch is converted commercially into grape sugar by boiling 



FERMENTS. 227 

it witli sulphuric acid ; albumen into peptone, not by simply boiling 
it, but by boiling it under pressure in a Papin's digester \Yitli 
dilute hydrochloric acid ; and fat is split up into fatty acid and 
glycerine by treating it with superheated steam. But the 
processes which require so much expenditure of heat — heat which 
might drive a railway-engine or a steam-hammer — are all carried 
on within the body at a gentle temperature by means of certain 
ferments. These ferments possess the wonderful power of doing, 
without any apparent effort, the same work of decomposing bodies, 
as only a considerable heat could do without them. In fact w^e 
might compare them to such things as nitro-glycerine, of which a 
small quantity will shiver into fragments a solid rock on which 
many and heavy blows of a powerful steam-hammer would have 
made but a slight impression. The ferments in the alimentary 
canal are pepsine, the pancreatic ferments, and the ferments of 
the intestinal juice. Pepsine differs from the other two in only 
acting in an acid solution, while the others act in neutral or alka- 
line ones, and this I consider to be a very important difference 
indeed, as you will presently see. 

Although these ferments split up starch and albumen with such 
force, they do not seem to be used up in doing so, and a very small 
quantit}^ of ferment will go on for a long time without seeming to 
be exhausted by its work. Now no manufacturer would ever think 
of throwing away anything with such valuable properties as this, 
and yet we used to imagine that nature improvidently threw them 
away, and allowed them to be excreted by the fseces. Some time 
ago, howevei", it was found by Brilcke that the whole of the pepsine 
was not voided in this way, for part of it was absorbed, and could 
be detected in the muscles and in the urine. Yon Wittich also 
found a ferment in the liver and bile, which, like that of the 
pancreas, would convert starch or glycogen into sugar ; and Hlifner 
found ferments which also possessed, like that of the pancreas, the 
double power of digesting fibrine, and converting starch into sugar 
in the lungs. From these facts I ventured some time ago, in a 
paper on the Action of Purgative Medicines, which I published in 
the Practitioner, to advance the hypothesis that the digestive 
ferments were reabsorbed from the intestinal canal, and being 
again carried by the blood to their respective glands, did duty over 
and over again. For if bile is either injected into the intestine or 
injected under the skin, it passes to the liver and is excreted by 
it ; urea injected into the blood goes to the kidneys, and thus it 

Q 2 



228 OX THE ACTION OF ALTERATIVES. 

seems probable that pepsine, like these substances, will find the 
way to its own peculiar secreting organ, the stomach; and pan- 
creatine to the pancreas. 

But if this notion be correct, there must be pepsine and pan- 
creatine very constantly in the blood. -^ Now this will not matter 
very much in the case of pepsine, because it will only act in acid 
solutions ; but the case is different with pancreatine, which acts 
in neutral and alkaline solutions, and there seems to be nothing to 
prevent it from acting on the muscles and other albuminous tissues. 

And, indeed, when we come to think of it, how can the albu- 
minous substances of the body be split up and consumed, excepting 
by the aid of ferments ? If we lay a piece of raw meat on the fire, 
it does not burn readily, and the fire must be pretty hot to con- 
sume it entirely ; and yet, for my own part, I used to accept it as 
a fact, that the albuminous substances of the body were oxidised 
into urea and carbonic acid, without ever thinking how this com- 
bustion was effected. But, as we have seen that these ferments 
possess the same disintegrating power as heat, and as we have seen, 
moreover, that they have been found in various tissues of the body, 
I think we may assume that they are the means by which the 
tissues become broken Vi\y and finally oxidised. 

According to this view, then, the whole process of nutrition is 
carried on by means of ferments. Through their agency the food 
is rendered soluble, so as to be fitted for building up the tissues, 
and by their agency, too, the tissues themselves are also, although 
more slowly, broken down. It is obvious, then, that any alteration 
in the quantity or quality of the ferments in the intestine or blood 
will greatly influence nutrition, and this brings us to the question, 
How do alteratives act ? 

And, first of all, we will consider the action of such alteratives 
as not improbably act upon the ferments in the intestine. I have 
already alluded to the similarity between the effects of nitrohydro- 
chloric acid and sulphate of magnesia, either with or without a 
blue pill. Now sulj^hate of magnesia excites a copious secretion, 
washes out the intestine, and carries away some of the bile also. 
But it has j)robably much less effect upon the duodenum than 
mercury has, and thus does not greatly hinder bile, which has been 
thrown by the liver into that part of the intestinal canal, from 

1 When this paper was ■written little was known regarding the possible reconver- 
sion of ferments into zymogens. D'Arcy Power and I have found pancreatine in the 
nrine. {St. Bo/rtholomcw' s Hospital EciMrts, 1877, vol. xiii. p. 300.) 



DEPRESSANT ACTION OF PURGATIVES. 229 

being reabsorbed. Mercury, on the other hand, probably excites 
the duodenum to active peristaltic motions, the bile is hurried 
downwards and washed out, without any time being allowed for 
reabsorption. Now, according to my supposition, the ferments 
contained in the duodenum will share the fate of the bile — they 
will be swept out of the body in the faecal evacuations, and conse- 
quently the quantity in the blood will be diminished. The tissue 
change which these produce in the body will also be lessened, and 
tlius we can see how purgatives, and especially mercurial and 
saline purgatives combined, may be useful at the commencement 
of a fever. 

We can also see how people may readily catch cold after the use 
of purgatives, and how these remedies are specially depressing to 
old people, whose heat-producing powers are already low, and who 
probably have difficulty in again forming new ferments to replace 
those they have lost. 

It is not easy to say precisely in what way nitrohydrochloric acid 
will affect the ferments in the duodenum and liver, but that it 
does do so is, I think, shown both by its effect in frontal headache, 
without either dyspepsia or yellowness of the skin, or conjunctiva, 
and by its use in oxalui'ia. 

In an interesting paper published in Vol. II. of the St. Bartholo- 
mew Hospital Reports, Dr. Dyce Duckworth showed that the urine 
of patients, presenting no other symptoms than a tongue fissured 
longitudinally, and great depression of spirits, was generally found 
on examination to present the white hummocky cloud characteristic 
of oxalate of lime, and on microscopic examination to display 
numerous crystals of this substance. The oxalate of lime, in such 
cases, frequently alternates with a sediment of urates. Under the 
use of nitrohydrochloric acid, the patients recover their spirits, and 
the oxalate of lime disappears. 

Now the alternation of lithates with oxalates is, I think, very 
suggestive, and points to the liver as the part affected. For it 
would appear that it is to a great extent in the liver that such 
albuminous matters as are to be used up at once, and are not to 
form permanent tissue, are broken up. Thus a meal of beefsteak 
alone will yield, in the liver of a dog, glycogen, and nitrogenous 
bodies which usually are converted into urea, but which, if im- 
perfectly oxidized, will probably appear as urates. Now if the 
albumen is split up too quickly, as it would be by too much ferment 
in the liver, we would naturally expect the products of decomposition 



230 ON THE ACTION OF ALTERATIVES. 

to be less thoroughly oxidized than they would otherwise be, and 
according as one or other took the available oxygen, so would be 
the waste product. If the glycogen got the oxygen, the nitro- 
genous j)roducts would be imperfectly oxidized, and lithates would 
appear ; if the nitrogenous products got the oxygen, the glycogen 
would be more or less deprived of it, and thus, instead of under- 
going complete combustion into carbonic acid and water, sugar 
might appear in the urine, or products of imperfect combustion, 
such as oxaHc acid, might be formed. Lithates appear in the 
urine after a heavy dinner with wine, or some other cause of 
digestive disturbance, whereby we may suppose the decomposition 
of albuminous matter in the liver to be increased, and they also 
appear after violent bodily exercise, which will increase the decom- 
position of albumen in the muscles. 

It would be a matter of much interest to observe whether nitro- 
hydrochloric acid lessens the urates in the second case, though 
undoubtedly it would be a work of considerable difficulty. For 
my own part 1 am inclined to think that nitrohydrochloric acid 
acts chiefly in the intestine and liver, and slightly, if at all, in the 
tissues. 

There are other alteratives which have little or no action in 
the intestine, but have a powerful influence upon the tissues 
generally. They may have an action, and very often have one, 
upon the changes which go on in the liver, but they do not all 
have it. 

Let us now take a glance at some of these alteratives more 
particularly ; and as time will not permit me to enter into a 
lengthened discussion of the mode of action of each, I will 
content myself with a few remarks. The use of potash is seen 
2Jar excellence in gout, not merely as a remedy, but as a prophy- 
lactic. A very gouty old gentleman told me that by two methods 
he had succeeded in warding off an attack for a long time. The 
first of these was to drink a large quantity of water early in the 
morning. " Too little water," said he, " is a great cause of gout ; 
and whenever you get gouty patients in the upper classes, always 
ask them how much water they drink. You will generally find 
that they tell you, We take a small cup of tea in the morning, 
and a small cup of coffee at night ; and this is all the water they 
take, except what they get in the shape of wine and beer, or 
brandy and soda. Water, pure and simple, many of them never 
touch ; in such persons gout may often be warded off by simply 



COMMON SALT IN EPILEPSY. 231 

washing out their tissues. Give tliem a large draught of water 
the first thing in the morning, and make them take more water 
and less wine at meals. 

"But if this is not enough, and the gout still threatens, give 
them 30 grains of bicarbonate of potash, and 20 of nitrate, in a 
large tumbler of water." 

Now colchicum, as we all know, is useful in gout, and it used 
to be supposed that it was so by increasing the elimination of uric 
acid. But this is not the case, for Garrod and Parkes have shown 
that the elimination of uric acid is rather diminished by it. The 
explanation I would give of its action is that it affects the ferments 
by whose action the uric acid is formed, and thus by lessening its 
formation produces somewhat the same effect as increasing elimina- 
tion. Iodide of potassium has a special action on the lymphatic 
system, and it is in affections of this system that we see its 
beneficial effects most clearly. For the fasciae and other fibrous 
structures are nothing but lymphatic pumps, pumping up the 
waste material from the muscles and sending it on into the 
lymphatic trunks (p. 333). 

It has been supposed that the action of iodides is owing to the 
chlorine already in the body having a stronger affinity for bases 
than iodine, and thus setting the iodide free. If this were the 
case we should expect that the effect of an iodide would be greater 
when much chlorine is present in the body ; in this case the iodine 
would be more readily freed. The action of chloral is said by 
Liebreich to depend on the liberation of chloroform in the blood 
by the action of the alkalis contained in it, and when talking 
with him he told me that chloral was apt to lose its effect when 
given for a long time, unless the alkalinity of the blood was kept 
up by the administration of alkalis. It is possible that in the 
same way iodide of potassium may become less powerful, if we 
neglect to keep up the chlorides in the body, and that its action 
may be increased by the administration of common salt. It is 
only lately that this thought occurred to me, and I have not yet 
had an opportunity of testing it, but perhaps some here may 
already have done so. 

In a case' of epilepsy, however, I once tried common salt with 
complete success, the fits being entirely stopped. In the next one 
it had no effect. Since thinking over the subject of alteratives, 
it occurred to me that possibly the success in the first case was 
due to the previous administration of a bromide, but unfortunately 



232 ON THE ACTION OF ALTERATIVES. 

I have lost tlie notes of the case and cannot now ascertain if this 
were so or not. 

Mercury seems to have as special an action on the albuminous 
tissues as iodides have on the lymphatics, and the breaking down 
of lymph by it in iritis seems more to resemble the digestion of 
fibrine by pepsine, or pancreatine, than anything in inorganic 
chemistry. This special affection of mercury and iodides for 
different structures may give us a key to the proper employment 
of these drugs singly or in combination. Are the albuminous 
tissues to be acted on ? — give mercury. Are the lymphatics to 
be set in action, either for the purpose of carrying away the 
albuminous debris resulting from the effect of mercury, or for 
the absorption of enlarged glands, or removal of pain, hardening, 
&c., connected with tendinous or aponeurotic structures ? — give 
iodine. 

Time will not permit me to enter upon the actions of phosphorus, 
arsenic, and antimony, or to show the wonderful resemblance 
between them, and I would simply, before concluding, recapitulate 
one or two of the chief points in this paper, as it may assist the 
discussion upon it. 

All medicines may be called alterative, but the name is specially 
applied to those which imperceptibly modify nutrition. 

Nutrition is carried on in the intestine, and probably in the body, 
by means of ferments. 

Alteratives probably modify nutrition by modifying the action 
of these ferments. 

Nitrohydrochloric acid probably acts in headache, and also in the 
depression of spirits associated with oxaluria, by modifying the 
action of ferments in the intestine or liver. 

Lithates are probably formed in the liver, and also in the muscles. 
The question arises — Is nitrohydrochloric acid useful only when 
the lithates arise from disorders of the liver and digestion ; or is it 
also useful when the lithates arise from other causes ? 

Colchicum is probably useful in gout, by diminishing the pro- 
duction of uric acid. 

Iodide of potassium acts on the lymphatics. 

Mercury acts on the albuminous solids. 

Is the action of iodides or bromides increased by giving salt ? 



mDIGESTION AS A CAUSE OF NERVOUS 
DEPRESSION. 

(' The Practitioner,' vol. xxv., October and November, 1880.) 

To most men who are engaged in intellectual work, an autumn 
holiday has become a matter of necessity, and is not to be regarded 
as a mere luxury. During eleven months of the year many who 
are engaged in brain work systematically overtax themselves, 
trusting to the month's hohday to bring them again into proper- 
working order. Formerly this was not the case. Men seemed to 
be able to go on, not only month after month, but year after year, 
without any vacation at all. The circumstances under which they 
lived were different from those which exist now. The very means 
which facilitate our holidays — the network of railway which puts 
us into complete and easy communication with any part of the 
Continent of Europe, or the quick ocean steamers which enable us 
to enjoy half of a six weeks' holiday on the other side of the 
Atlantic, as well as the telegraphic communications which will 
warn us in a moment, even at the most distant point of our travels, 
of any urgent necessity for immediate return — all these are the 
very means which increase our labour during the greater part of 
the year. We live at high pressure, letters and telegrams keep us 
constantly on the qui vive, express trains hurry us miles away from 
home in the morning and back again in the evening, and the 
pressure of competition is so great that few men can afford either 
to take their work easily or to modify the constant strain of it by 
breaks of a day or two at a time. Wearied and exhausted, the 
hard-worked man goes off for his autumn holiday and, if he can, 
will spend most of it in the open air, either yachting, walking by 
the sea-shore, strolling in the country, shooting on the moors, 
or climbing the Welsh hills or the Swiss mountains, ^fter a 
month spent in any of tbese ways, the brain-worker comes back 



234 INDIGESTION AND NERVOUS DEPRESSION. 

to town feeling himself a different man. Instead of his work being 
a slavery to him, as it was before he started, he feels it to be a 
pleasure ; he gets through it with ease, and feels not only that the 
amount he can accomplish is greatly increased, but that the quality 
is also improved. Perhaps for a short time after his return he is 
hardly in a condition to do brain- work at all. He sits down to his 
desk but feels cramped in the unaccustomed posture, and he would 
rather work off the superabundant energy within him by a long 
walk or a stiff climb, than restrain it with difficulty to the simple 
task of driving a quill. After a week or two he settles down and 
works steadily along with comfort and ease for a couple of months 
or more, when he again begins to sink below par. His apprehension 
is no longer so acute, his power of concentration is diminished, he 
can no longer fix his attention for any length of time upon one 
subject without a severe effort. His mental vision becomes less 
perspicuous, his ideas succeed each other more slowly, and find 
expression with greater difficulty, so that he communicates his 
thoughts with less fluency and less clearness than before. His 
temper, too, undergoes a change. Instead of regarding the daily 
occurrences of life with equanimity, and making the best of what 
cannot be helped ; irritation so slight as to be unfelt at other times 
provokes him to anger or peevishness, and even when he possesses 
sufficient self-control to restrain his feelings and prevent them 
from being manifested outwardly, to the annoyance of his friends 
or neighbours, the very eff"ort of restraint seems to increase the 
internal irritation, until at last it either explodes in an ebullition 
of wrath on some comparatively trivial circumstance, or tells upon 
the digestion and nervous functions of the individual himself, 
diminishing the appetite or causing intense muscular weariness. 
In others, again, we find that along with, or taking the place of, 
irritability there is great mental depression. Everything is looked 
at from a gloomy point of view, himself, his friends, and his 
surroundings'." He does not feel equal to his work ; nothing that 
he does pleases him ; he is apt to become distrustful of himself and 
jealous of others ; apt to think that his friends are slighting him, 
or to fancy that he has offended them. Even when all external 
circumstances leave nothing to be desired, the unfortunate victim 
cannot enjoy life. His mind is occupied with gloomy forebodings 
of miseries to come, or he becomes a prey to melancholy and 
depression without any apparent reason. This melancholy weighs 
most deeply upon him during the night, and if he happens to wake 



SLEEPLESSNESS-DROWSINESS— LANGUOR. 235 

in the small hours of the morning, as he not unfrequently does, life 
seems not worth living, but a burden of which he would willingly 
be quit. Melancholy is at times associated with sleeplessness, and 
then the two evils re-act upon and increase each other. For this 
causeless sorrow has a similar effect to that of real sorrow. As 
Shakespeare says : 

" Sorrow's weight doth heavier grow, 
Through debt that bankrupt sleep doth sorrow owe." 

At other times, instead of sleeplessness there is an abnormal 
tendency to drowsiness, which sometimes comes on almost irresistibly 
at the very moment when some important work, requiring all the 
best powers of the intellect, has to be performed, and rendering 
its performance either imperfect or completely impossible. As 
soon as the person goes to bed he falls asleep, and sleeps like a log 
till morning, when he rises with difficulty, feeling almost more 
exhausted than when he went to bed the night before, with 
perhaps a little tightness or pain over the forehead, eyes, or 
temples. After breakfast he feels somewhat revived, and will 
work comfortably for a short time, but about one and a half or two 
hours after the meal weariness overtakes him, again passing off 
after it has lasted a variable time. During the day this is repeated, 
fits of more or less energy alternating with periods of languor and 
exhaustion. These languid fits may be noticed two or three hours 
after lunch or dinner, and the sufferer is not unfrequently tempted 
to have recourse to the decanter of sherry or the brandy-bottle, not 
only to obtain relief from the feeling of personal discomfort, but to 
supply the energy which he feels to be necessary to enable him to 
do the work he has in hand. But this is a i-uinous course to adopt, 
for not only does it pave the way to habits of confirmed drunken- 
ness, and leads to tissue changes which will ultimately abolish the 
functional activity of the most important organs of the body, and 
bring the individual to a premature grave ; it enables him to do 
his work only imperfectly at the time. After an application to the 
decanter or bottle his powers may seem to himself to be as great 
or greater than usual, but this is to a considerable extent a sub- 
jective feeling only, as he will probably be able to discover by 
results. 

Now how is it that such a change has come over the man in a 
few months, so that he seems to be a different individual from the 
one who returned, bright and lively, from his autumn holiday ? 



236 INDIGESTION AND NERVOUS DEPRESSION. 

How is it that the even-tempered man lias become irritable, the 
clear-headed man muddled, the active lazy, the sober perhaps a 
tippler, and the cheerful and buoyant depressed and melancholy ; 
that the brain performs all its functions with difficulty, and the 
mind is so altered that it does not seem to be that of the same 
individual ? And yet, after all, the man is the same, and the brain 
the same, at least in its essential structure, as it was a few months 
ago, and as it will be in a few months more, after another holiday 
has again put it in good working order. What has happened to it 
in the mean time to cause such a dreadful alteration ? Not only 
does the brain seem exhausted, but the whole system appears to be 
languid and weak ; instead of the man being able for a twenty or 
thirty miles walk, one of a mile or two will produce fatigue, and 
sometimes an intense languor is felt without any exertion at all. 
And yet all this time he may have been trying to keep up his 
strength. He takes butcher's meat three times a day, perhaps also 
strong soups, to say nothing of wine, or brandy and soda to pick 
him up. His tissues ought to be getting sufficient nourishment to 
enable them to do their work, and yet it is evident that they are 
not in a condition to do so. The man, and very likely his friends 
also, wonder at his condition, and when he goes to his medical 
attendant to describe his case he says, " I take all sorts of strengthen- 
ing things, and yet I feel so weak." If, instead of using these 
words, he were to say " Because I take all sorts of strengthening 
things I feel so weak," he would express a part at least of the truth. 
He, and his friends who wonder with him, forget that all the 
functions of life are more or less processes of combustion, and that 
they are subject to laws similar to those which regulate the burning 
of the coal in our fireplaces. Two things are necessary for the 
combustion, fuel and oxygen; sometimes it is the fuel that fails, 
but not unfrequently it is the oxygen. Sometimes, no doubt, our 
fires go out because the fuel is quite exhausted, but this is very 
rarely the case. It is only under very exceptional circumstances 
that we find a fire burned away so completely as to leave nothing 
but ash. Almost invariably some fuel still remains — often, indeed, 
enough to make up a good fire when properly put together. If we 
sift the ashes from the grate we generally find a quantity of cinders, 
sufficient to make a fire, and these have ceased to burn because 
they were unprovided with oxygen, which was prevented from 
reaching them by the ashes with which they were covered. 

The reason why our fires burn low, or go out altogether, either 



PHYSIOLOGICAL ASHES. 237 

is that we put on too much coal, or that we allow them to be 
smothered in ashes. It is the child who pokes the fire from the 
top to break the coal and make it burn faster; the wise man 
pokes it from below so as to rake out the ashes and allow free 
access of oxygen. And so it is with the functions of life, only 
that these being less understood, many a man acts in regard to 
them as the child does to the fire. The man thinks that his brain 
is not acting because he has not supplied it with sufficient food. 
He takes meat three times a day, and beef tea, to supply its wants, 
as he thinks, and he puts in a poker to stir it up in the shape of 
a glass of sherry or a nip from the brandy-bottle. And yet all the 
time, what his brain is suffering from is not lack of fuel, but 
accumulation of ash, and the more he continues to cram himself 
with food, and to supply himself with stimulants, although they 
may help him for the moment, the worse does he ultimately 
become, just as the child's breaking the coal may cause a tempo- 
rary blaze, but allows the fire all the more quickly to become 
smothered in ashes. It would seem that vital processes are much 
more readily arrested by the accumulation of waste products 
within the organs of the body than by the want of nutriment to 
the organs themselves. In all cases of fasting, whether voluntary 
or compulsory, life is prolonged to a much greater extent if water 
be freely supplied. Without water the individua] quickly dies, 
however much other nourishment he may get, but with abundance 
of water he may live for a considerable time, even if he take no 
solid nutriment at all. Here it is not that the water acts as a 
food ; it supplies no new energy to the body, for unlike starch, or 
sugar, or fat, or proteids it has already undergone, complete com- 
bustion. It cannot like them unite any further with oxygen and 
thus supply energy. 

And yet it is more essential to life than any of them, for without 
it the products of waste cannot be removed from the tissues, and 
the vital fires, so to speak, are smothered in their own ash. If we 
take the excised muscle of a frog and stimulate it to repeated 
contraction, the contractions become feebler and feebler, until at 
last they cease altogether. But this is not because the fuel which 
the muscle contains in itself has been so completely burned up 
that none of it is left to furnish the requisite energy to the muscle, 
it is because the chemical processes necessary to the contraction 
of the muscle, are arrested by the accumulation of the products 
of its own waste. If we wash these out of the muscle by sending 



208 INDIGESTION AND NERVOUS DEPRESSION. 

through its vessels a solution of common salt, which supplies to 
it no new material, but which removes these waste products, the 
contractile power of the muscle will be restored. 

This restoration takes place still more quickly and thoroughly if 
we employ a fluid which will supply oxygen, such as a solution 
of permanganate of jDotash, instead of a simple solution of salt, 
which merely washes out the muscular waste. The muscle is like 
a fire in the grate, which goes out long before the coal is entirely 
consumed, on account of the ash which smothers it, and just as we 
can revive the smouldering embers by supplying them with oxygen 
by the use of bellows, so the muscle revives more quickly when its 
supply of oxygen is increased. The quicker the fire burns the 
sooner will it be choked in ash, and the more rapidly the muscle 
contracts the sooner will it lose its powers. 

The same is the case with the heart. The slowly beating heart 
of a crocodile will pulsate for a day or more after it has been cut 
out of the body, but the rapidly pulsating heart of a mammal will 
very soon cease to beat ; and the more rapidly it has been beating 
before the animal's death, the sooner will it cease to contract 
afterwards. If the vagi are cut in the living animal so that the 
cardiac pulsations become excessively rapid, the heart's movement 
ceases almost as soon as the animal dies; but if during life the 
vagi are irritated so as to make the heart contract very slowly 
indeed, it comes to resemble more nearly the heart of the crocodile, 
and continues to pulsate for a considerable time after the animal's 
death. The heart, too, resembles voluntary muscles, inasmuch as 
if we wash out of it the products of its own waste it will continue 
to beat for a much longer time than if we allow them to accumulate. 
By simply allowing a saline solution to circulate through the heart 
of a frog it may be kept beating for many hours longer than if 
it were left to itself. Both voluntary muscles and involuntary 
ones, such as the heart, cease to act, almost invariably, not from 
exhaustion of their energy-yielding substance, but from accumulation 
of the waste products within them ; and muscles, both voluntary 
and involuntary, are much less sensitive to this process of choking 
than the delicate structures of the nerve centres. The gastrocnemius 
and the heart of a frog may retain their irritability for very many 
hours after their separation from the body, but the spinal cord of 
the same animal will rarely retain its irritability for a single hour 
after the circulation through it has been arrested. In warm- 
blooded animals the spinal cord is much more sensitive than in 



UNACCOUNTABLE SENSATIONS. 239 

the frog, and if the circulation in the lower part of the spinal cord 
be arrested in a rabbit by the pressure of one's thumb upon the aorta 
for three or four minutes, the hind legs of the animal will become 
completely paralysed. Still more sensitive than the spinal cord 
is the brain, and i^ the circulation in the latter be arrested, con- 
sciousness is almost instantaneously abolished. In the animal 
body, as in the steam-engine, the governing and directing parts are 
much more sensitive and easily acted upon than the working parts. 
A single touch of the hand to the steam-valve will set the engine 
in action or stop its movement, although the power of a thousand 
men applied to the fly-wheel would avail little or nothing. And 
in animals the nerve centres are most sensitive and respond most 
readily to those circumstances which affect the organism. Not 
only are they exceedingly sensitive to the accumulation within 
them of the products of their own waste, but they are easily 
affected by alterations in the blood which circulates through them, 
and which conveys to them not only the products of muscular 
and glandular "\vaste formed in other parts of the body, but also 
substances introduced from without, or absorbed from the intestinal 
canal. A single whiff of nitrite of aniyl is sufficient to dilate the 
blood-vessels ; a fraction of a grain of pilocarpine will stimulate 
the sweat-glands to the most profuse secretion ; and half a drop 
of pure hydrocyanic acid is enough almost instantaneously to 
abolish consciousness and destroy the functional activity of the' 
entire nervous system. In the case of the nitrite of amyl, the 
pilocarpine, or the hydrocyanic acid, we are able to distinguish the 
relation of cause and effect between the administration of the drug 
and the resultingf changes in the organism. We do this, how- 
ever, because of our knowledge, obtained by observation and 
exjDeriment. Sometimes we cannot do this. I have seen, for 
example, a person become aware of a peculiar sensation which, 
to the patient, was quite unaccountable, but of which I understood 
the reason, as I knew it to be due to the fumes from a bottle 
of nitrite of amyl, which the patient could not see. We may 
notice a similar occurrence in poisoned animals. The poison of 
the cobra causes paralysis of the spinal cord and nerves, and 
induces intense weakness, so that the limbs of the animal fail 
under it. I have seen an animal in this condition attempt to walk 
and look round at its legs with a puzzled air, as though it could 
not understand what was the matter with it. It could not connect 
the weakness in its limbs with the introduction of the poison some 



240 INDIGESTION AND NERVOUS DEPRESSION. 

time previously, although the connection between them was to me 
perfectly clear. 

In the same way as the action of the cobra poison was a mystery 
to the animal, an epidemic of typhoid fever was formerly to us a 
mvsterious occurrence for which no reason could be assigned, but 
we now trace it to the absorption into the bodies of the sufferers 
of typhoid poison introduced from without. We are now com- 
pletely alive to the important results produced by the absorption 
from the intestinal canal of poisonous matters, such as tyj)hoid 
germs, arsenic, or strychnine introduced into it from without. But 
perhaps we are not yet sufficiently alive to the important results 
produced by the absorption from the intestinal canal of substances 
generated in it by fermentation or imperfect digestion. We recog- 
nise the danger of breathing gas from a sewer, but probably we do 
not sufficiently realise that noxious gases may be produced in the 
intestine, and, being absorbed from it into the circulation, may 
produce symptoms of poisoning. And yet we know, from recorded 
observations, that such is the case, and that one at least of the 
chief components of sewer gas, viz. sulphuretted hydrogen, may be 
produced in the intestine. This gas, which is so readily recognised 
by its smell resembling rotten eggs, was found by Dumarquay^ 
to be very quickly absorbed indeed from the intestine when 
injected into the rectum, and to be quickly excreted from the 
lungs, sometimes appearing to j)roduce, during its elimination, 
some inflammation of the trachea and bronchi. This was especially 
the case when small quantities were injected, and it seems not 
improbable that the production of this gas in the intestine may 
have something to do with the bronchitis which is notunfrequently 
observed in connection with digestive disturbance (p, 40). In cases 
of indigestion this gas seems to be not unfrequently formed, because 
persons often complain of the taste of rotten eggs in the mouth or 
in the eructations. Even in such small quantities it is not 
improbable that it may exert a deleterious influence both upon 
the nervous system and upon the blood, for it is a powerful jooison, 
in its action somewhat resembling hydrocyanic acid, though not so 
strong. It destroys ferments, and robs the blood corpuscles and 
the seeds and roots of plants of their power to decompose peroxide 
of hydrogen; and as this faculty seems to be closely associated 
with the processes of life, the sulphuretted hydrogen may be 
1 Comptes Eendus, ix. p. 724. 



SULPHURETTED HYDROGEN. 241 

regarded as a powerful protoplasmic poison. Upon plants it has 
a curious action, differing very markedly from sulphurous acid. 
When a plant is exposed to sulphurous acid, the leaves shrivel 
up, wither, and fall off, but if the plant be now removed from the 
noxious influence of the gas, and placed under favourable conditions, 
it will recover, and send out fresh shoots. But if it be exposed 
to the action of sulphuretted hydrogen, the leaves, instead of 
shrivelling, simply begin to look flaccid, and droop. This seems, 
at first sight, to be a less deadly action than that of the sulphurous 
acid, but when the leaves have once begun to droop in this way 
the plant is dead, and does not recover when removed from the 
action of the gas. This gas is rarely generated in the intestine in 
such a quantity as to give rise to symptoms of acute poisoning, but 
it has sometimes this effect. A case is recorded by Senator^ in 
which a strong and previously healthy man became affected with 
a slight gastro-intestinal catarrh in consequence of some error in 
his diet, and on the second day afterwards he had frequent eruc- 
tations, smelling strongly of sulphuretted hydrogen. At the same 
time he suddenly became collapsed, pale, giddy, and with a rapid, 
small, compressible pulse. This lasted for 1^ to 2 minutes, and 
then passed off. The urine which he passed shortly afterwards 
contained sulphuretted hydrogen. On the same day he had a 
second attack of a similar sort, and then, the bowels having been 
opened, he recovered completely. Nor is sulphuretted hydrogen 
the only gas which may be formed in the stomach. Marsh gas 
is sometimes formed there too, and in an exceedingly interesting 
case recorded by Dr. Ewald,^ the quantity was so great that it first 
attracted the patient's attention by taking fire as it issued from his 
mouth while he was lighting a cigar. In this curious case the 
formation of gas alternated with the production of a great quantity 
of acid fluid in the stomach,, which led to vomiting, or, as the 
patient himself expressed it, sometimes his gas factory and some- 
times his vinegar factory was at work. It is possible that this 
gas may be formed in small quantities in many more cases than 
has hitherto been suspected, but its absorption does not seem 
to have anything like the same deleterious action as that of 
sulphuretted hydrogen. Nor was the acetic acid which was found 
by chemical analysis to exist in the acid secretion of the stomach 
in this case likely to be productive of any injurious effects after its 

1 Serliner Klin. TFochejisdiri/t, 18Q8, 'So. 24. 
2 lieichot's und Du Bois Rcymond's Archiv, 1874, p. 217. 

a 



242 INDIGESTION AND NERVOUS DEPRESSION. 

absorption. But butyric acid, wliicb is sometimes formed in the 
stomach in other cases of indigestion, has been shown, by 0. Weber, 
to be a powerful poison acting chiefly on the nerve centres. 

It seems probable, however, that the substances, both gaseous 
and solid, formed in the stomach and absorbed from it, are upon 
the whole less poisonous in cases of indigestion than those which 
are produced lower down in the intestinal canal. We often find 
that patients are affected with severe gastric disorder without any 
affection of the nerve centres beyond the weakness produced by 
the inability to digest food, while in many persons the mere omission 
to evacuate the contents of the bowels at the usual time will lead 
to a headache in the course of the day. No doubt such a headache 
as this may be due, to some extent, to the nervous irritation caused 
by the presence of the faeces in the intestine, but it seems quite 
possible that it is also due to the absorption of some of the fsecal 
matter itself. Nor do we at present know what effects are pro- 
duced by the absorption of the various digestive juices themselves. 
That such absorption takes place there can be little doubt. It has 
been demonstrated in the case of the bile, which is absorbed with 
great rapidity from the intestine and re-excreted by the liver, so 
that it does not pass into the general circulation at all. But what 
becomes of the other digestive fluids, and the ferments they contain ? 
The pepsine finds its way in minute quantities through the liver, 
and has been discovered in various tissues of the body and in the 
urine. This, however, matters but little, for it cannot act upon 
the tissues themselves, inasmuch as they possess an alkaline re- 
action. But the case must be somewhat different with pancreatine, 
and if pancreatic fluid be absorbed from the intestine and pass 
through the liver unchanged, we should expect that it would have 
a very powerful action upon the tissues throughout the body, 
because there appears to be no reason why it should not act upon 
them just as it does upon the food in the intestine itself. It seems 
not at all unlikely, then, that the liver has got another function 
besides those usually assigned to it, viz, that of preventing the 
digestive ferments from reaching the general circulation so as to 
act upon the tissues. Now we do find in the liver itself and in the 
bile a ferment having the same diastatic power as the pancreatic 
juice, but it does not appear in such quantities as one would expect 
if the whole of the pancreatic ferment were simply re-excreted by 
the liver along with the bile, and as we have no evidence that the 
ferment is destroyed during its action in the intestine, we are 



ZYMOGEN. 243 

naturally led to think that it may undergo a change in the liver, 
the converse of that which it undergoes in the pancreatic gland 
during the process of secretion. In the pancreas itself we have no 
ready-formed ferment, but we have a ferment-forming substance, 
which has recently become known under the name of zymogen, 
given to it by Heidenhain, but the writer heard it described by 
Kiihne in his lectures on physiological chemistry delivered at 
Amsterdam in 1869. I quote verbatim from the notes which I 
took at the time of his lecture on the pancreas. " Glands which 
have no action on fibrine can be made active by digesting in very 
dilute acid and then neutralising or alkalising ; there seeming to 
exist a ferment-forming substance in the pancreas." During 
digestion this ferment-forming substance or zymogen splits up and 
yields free ferment, and it seems not improbable that it is in the 
liver that this very ferment, after its digestive work is done, 
becomes again converted into the ferment-forming substance which 
may circulate throughout the tissues without doing them any 
injury. 

Whether this be the case or not, however, with regard to the 
ferments of the gastric, pancreatic, and intestinal juices, all of 
which must pass through the liver before they reach the general 
circulation, there can be no doubt that the products of intestinal 
digestion do undergo very marked changes indeed in the liver, as 
is shown by the formation from them of very large quantities of a 
new substance, glycogen — a substance which is not contained in 
the products of the gastric and intestinal digestion which reach the 
liver, and yet which is of the highest importance for the nutriment 
of the body. Under ordinary circumstances, nearly the whole of 
the sugar formed in the intestine and absorbed from it, is arrested 
in the liver, so that very little passes into the general circulation 
and appears in the urine, although even in healthy persons traces 
of sugar are excreted by the kidneys. Under exceptional circum- 
stances, however, sugar may pass through in considerable quantities, 
as, for example, when the individual takes, on an emj)ty stomach, 
a large quantity of syrup. However healthy his organs may be, 
sugar will then appear in the urine. The same is the case in 
regard to albumen. Usually, the whole albuminous constituents 
of our food are so transformed in the stomach, intestines, and liver, 
that no albuminous substances of the kind which can pass through 
the kidneys get into the general circulation. But if one takes 
such a quantity of eggs as to completely overtask the digestive 

B 2 



244 INDIGESTION AND NERVOUS DEPRESSION. 

powers, the egg albumin will pass unclianged into the blood, and 
be excreted by the kidneys.^ 

Other albuminous substances, the products of intestinal digestion, 
and peptones also, occasionally make their appearance in the urine, 
as well as egg albumin. Even when the processes of assimilation 
are not so seriously interfered with as in these instances, we observe 
that products of nitrogenous waste frequently occur in the form of 
lithates in the urine. An excess of these indicates some patho- 
logical condition, even although it may be very trivial. "We cannot, 
indeed, say what the exact condition is, because we find lithates 
appearing in the urine after violent muscular exertion accompanied 
by profuse sweating, so that they may possibly represent some of 
the products of muscular waste ; but we also find that they occur 
in large quantities in the urine after slight indiscretions in diet, 
although no muscular exertion has been undergone, and in these 
cases we can hardly do otherwise than regard them as products of 
the imperfect assimilation of nitrogenous matters which ought to 
have been eliminated, not in the form of urates^ but of urea. Now 
physiological experiments and observations indicate that the liver 
is the chief, if not the only, part of the body in which urea is formed. 
This at least appears to be the case excepting in febrile conditions, 
in which, possibly, the urea may also be formed, to a considerable 
extent, in the muscles. The old notion, then, which connected the 
appearance of lithates in the urine with disordered function of the 
liver, is probably in a great measure correct. There is little or no 
reason to believe that these lithates are formed in the kidneys. 
They are, probably, simply separated by them from the blood, and 
their presence in the urine would therefore indicate their presence 
in the blood and tissues. Now lithates in themselves do not appear 
to have any particularly injurious effects, either upon the nervous 
tissues or the muscles, but as their presence indicates deficient 
assimilation, they may be accompanied by other substances which 
have a much more pernicious action, just as there are many bad 
smells which, per s&, though very disagreeable, have no marked 
poisonous action, while other very poisonous substances have com- 
paratively little odour. Yet the disagreeable odours which ac- 
company sewer gas, although perhaps not always dependent upon 
its poisonous constituents, warn us of the presence of gases which 
may be intensely poisonous. Nevertheless, just as the poisonous 
gases may be present without any disagreeable smell, so we may 
1 Brunton and Power, Bartholomcvf s Ilosirltal BciJor's, 1877, p. 283. 



" AS BITTER AS GALL" ? 2-15 

have substances circulating in the blood which have the most 
injurious effect upon the nerve centres, without the presence of 
urates in the urine. 

The importance of the functions of the liver in reference to 
assimilation is now generally recognised, although for a long time 
this, the largest gland in the body, was considered to have no other 
office than simply to secrete bile. Although the bile is useful in 
digestion it is not of primary importance in this process ; but its 
proper secretion is probably associated very closely with the assimi- 
lative functions of the liver, and if the biliary secretion does not 
take place properly we can hardly expect the assimilation to be 
perfect. 

The greatest care appears to have been taken in the construction 
of the liver to prevent the bile from coming in contact with the 
blood, the ultimate radicals of the bile ducts, or biliary capillaries, 
being placed as far from the blood capillaries as the structure of 
the liver will allow. Notwithstanding this care, the distance 
between the blood and the bile capillaries is small, though it is 
sufficient, under ordinary circumstances, to prevent the absorption 
of bile into the blood. But whenever an obstruction takes place 
to the exit of bile, and the pressure of bile in the biliary capillaries 
increases, an absorption of this secretion occurs. Bile is secreted 
under very low pressure, and a very slight increase in this is 
sufficient to cause re-absorption. Such an increase as would not 
materially affect the secretion of other glands, such as the salivary 
gland, is sufficient to prevent the exit of bile through the biliary 
ducts, and cause its re-absorption into the blood. The excretion 
of bile is greatly aided by the pressure which is exerted upon it 
by the movements of the diaphragm during respiration, and, indeed, 
so low is the pressure under which the bile is secreted that, but 
for the assistance given by the respiratory movement, it would just 
barely find its way into the duodenum. Although we are ac- 
customed to say " As bitter as gall," according to my own observa- 
tions fresh human bile is not bitter. When it is thrown up in 
consequence of indigestion it is intensely bitter. On one occasion, 
when making experiments with digitalis, I had taken in the course 
of two days one grain of pure digitalin, and brought on symptoms 
of poisoning, with intense vomiting. During this I brought up a 
quantity of bile of a golden-yellow colour, and without the least 
trace of bitterness. This circumstance struck me as being so 
peculiar that in my published results I hesitated to call it bile, 



246 INDIGESTION AND NERVOUS DEPRESSION. 

although I did not see what elsf* it could be.^ But when it remains 
long in the gall-bladder it undergoes changes^ and in some cases 
of vomitingf that I have seen the vomited matters have been of a 
bright grass-green colour. When examined, also, after death, the 
bile in the gall-bladder is not unfrequently found of a dark colour, 
and the same is probably the case when it is retained in the gall- 
bladder for any length of time during life. How the Greeks 
arrived at the notion of giving the name " Melancholy," i. e. black 
bile, to depression of spirits, we do not quite know, but certain it 
is that depression of spirits is very often associated with indigestion, 
and, moreover, that the form of indigestion with which we find 
depression of spirits associated, is not so much gastric as intestinal, 
or, more probably, hepatic. According to Herbert Spencer, we 
require rapid evolution of nervous energy in order to have ex- 
hilaration of the spirits, and depression of nervous energy is 
associated with melancholy. Now the effect of bile acids circu- 
lating in the blood, as shown by physiological experiments, is to 
depress the reflex function of the spinal cord, to lessen the functions 
of the brain, producing drowsiness ending in coma, and to weaken 
the circulation by paralysing the cardiac ganglia.^ Such a com- 
bination of actions is just the one required by Mr, Spencer's 
hypothesis to produce melancholia, and here we find ancient 
notions joining hands with modern science. 

But bile is not the only substance which produces a depressing 
effect upon the circulation when absorbed into it from the portal 
system. I have already mentioned that certain albuminous pro- 
ducts of intestinal digestion and peptones occasionally make their 
appearance in the urine. Amongst the former is an albuminous 
substance, not precipitated by boiling, but by nitric acid in the 
cold. This substance I have observed in the urine of a healthy 
man after he had drunk a large quantity of strong beef-tea at a 
draught upon an empty stomach. My attention was drawn to 
the urine by the froth remaining upon it for a somewhat unusual 
time. On examination, this substance was discovered in it. On 
examining the beef-tea which the person had taken a similar 
albuminous substance was found in it, so that there can be little 
doubt that in this case the albumen was simply absorbed so 
rapidly from the stomach or intestines that it passed without 
change through the portal system into the general circulation, and 

1 Brunton On Digitalis, p. 67. 
2 Yicla 'VVickliain Legge, Bile, Jaundice, and Bilious Diseases, pp. 207, 216, 217. 



PEPTONES AS POISONS. 247 

thus readied the kidneys, where it was excreted in much the 
same way as sugar would have been under similar circumstances. 
We find only too frequently that both doctors and patients think 
that the strength is sure to be kept' up if a sufficient quantity 
of beef-tea can only be got down ; but this observation, I think, 
raises the question whether beef-tea may not very frequently be 
actually injurious, and whether the products of muscular waste 
which constitute the chief portion of beef-tea or beef-essence 
may not under certain circumstances be actually poisonous. For 
although there can be no doubt that beef-tea is in many cases 
a most useful stimulant, one which we find it very hard indeed 
to do without, and which could hardly be replaced by any other, 
yet sometimes the administration of beef- tea, like that of alcoholic 
stimulants, may be overdone, and the patient weakened instead 
of strengthened. In many cases of nervous depression we find 
a feeling of weakness and prostration coming on during digestion, 
and becoming so very marked about the second hour after a meal 
has been taken, and at the very time when absorption is going 
on, that we can hardly do otherwise than ascribe it to actual 
poisoning by digestive products absorbed into the circulation. 
From the observation of a number of cases I came to the con- 
clusion that the languor and faintness of which many patients 
complained, and which occurred about eleven and four o'clock, 
was due to actual poisoning by the products of digestion of 
breakfast and lunch; but at the time when I arrived at this 
conclusion I had no experimental data to show that the products 
of digestion were actually poisonous in themselves, and only within 
the last few months have I seen the conclusions to which I had 
arrived by clinical observation confirmed by experiments made in 
the laboratory. Such experiments have been made by Professor 
Albertoni of Genoa, and by Dr. Schmidt-Mtihlheim in Professor 
Ludwig's laboratory at Leipsic. 

Professor Albertoni has found that peptones have a most 
remarkable action upon the blood, completely destroying its 
coagulability in dogs, while they have little power in this respect 
over the blood of rabbits or sheep. The number of species upon 
which he experimented is limited, so that he cannot as yet draw 
the conclusion with certainty that peptones prevent the coagula- 
tion of the blood in carnivora and not in herbivora, although, so 
far as experiments go, this conclusion seems probable. He and 
Dr. Schmidt-Miihlheim independently made the discovery that 



* 



248 INDIGESTION AND NERVOUS DEPRESSION. 

peptones prevented the coagulation of the blood in dogs, and the 
latter, under Ludwig's direction, has also investigated their action 
upon the circulation. He finds that, v^hen injected into a vein, 
they greatly depress the circulation, so that the blood-pressure 
falls very considerably; and when the quantity injected is large, 
they produce a soporose condition, complete arrest of the secretion 
by the kidneys, convulsions, and death. From these experiments 
it is evident that the normal products of digestion are poisons 
of no inconsiderable power, and that if they reach the general 
circulation in large quantities they may produce very alarming, 
if not dangerous, symptoms. 

Such experiments as this open up a new and very wide field 
of inquiry, which is likely to prove of very great practical import- 
ance. We have hitherto been accustomed to reckon all peptones 
as identical, by whatever digestive ferment they were formed, 
and to look upon it as a matter of slight moment whether 
albuminous foods introduced into the digestive canal were dis- 
solved by the stomach or by the pancreas, although it is quite 
possible that the peptones differ as much from each other as 
different kinds of sugars. It is a matter of wonder, also, that 
at the present moment, although the digestive processes have 
been so carefully investigated, we know very little of the uses 
of the sucms entericus. Notwithstanding the great extent and 
evident importance of the intestine, and the large quantity of 
fluid which it is able to secrete : all that we find regarding the 
action of this secretion in such a book as Foster's Physiology is 
that " the statements with reference to its action are conflicting. 
Probably it has no direct action on either fats or proteids, but is 
amylolitic in some animals, though not in all. Succus entericus 
has also been said to change cane- into grape-sugar, and by a 
fermentative action to convert cane-sugar into lactic acid, and 
this again into butyric acid, with an evolution of carbonic acid 
and free hydrogen." The reason why experiments on the action 
of intestinal juice have given such an apparently unsatisfactory 
result is that they have been chiefly tried on such kinds of 
food as we are accustomed to put into our mouths. Now the 
intestinal juice is not intended to act upon such substances : its 
place is to finish the digestion begun by the other juices ; and 
when experiments with intestinal juice are tried upon foods which 
have previously been subjected to the action of the other digestive 
fluids, positive, and not negative, results ai'e obtained. Thus, for 



LIMITATION OF DIGESTIVE PROCESSES. 249 

example, it was stated by Kiihne, in his lectures at Amsterdam 
in 1868-9, that though intestinal juice would dissolve raw 
albumen and fibrine, it would not act at all upon them if 
boiled ; but if the boiled albumen or fibrine were first subjected 
to the action of pancreatic juice for a short time, the intestinal 
juice would afterwards dissolve them much more quickly than 
it would even in a raw condition. The action of digestive 
ferments is just beginning to find a practical application in 
medicine, and sometimes, undoubtedly, they are of very great 
service ; but unless their action is investigated more thoroughly 
than it has been up to the present, it is just possible that we 
may by-and-by find that the digestive ferments, like all other 
powerful agents, may do much harm as well as much good. 
Hitherto we have been accustomed to regard the phases of 
digestion, gastric digestion, pancreatic digestion, and intestinal 
digestion, as almost separate processes, any of which we might 
increase indefinitely without doing any harm to the patient. We 
forget the relation which each bears to the other ; and yet such 
a relation undoubtedly exists, for we find that when pepsine is 
mixed with bile it is precipitated and rendered inert. Further 
transformation of foods by the gastric juice is thus arrested as 
soon as the chyme leaves the stomach. And well it is that this 
should be so, for if the pepsine was not rendered inert it 
would destroy that pancreatic ferment (trypsin) which acts on 
albuminous substances, and thus interfere with digestion by it. 
How far this prolonged peptic digestion and impaired pancreatic 
digestion of albuminous substances has to do with the production 
of poisonous digestive products in cases where the quantity of bile 
poured into the intestine is deficient it is at present impossible 
to say, but it is a condition which ought to be kept in mind in 
all cases where there is deficiency of bile in the intestine, and 
the advisability of nourishing the patient by farinaceous food is 
constantly to be considered in these cases. 

And now comes the question. How is it that in healthy con- 
ditions of the intestine peptones do not pass into the general 
circulation, and are therefore unable to exert any poisonous 
action upon the nerve-centres ? This question is one which we 
cannot at present answer quite satisfactorily. 

Usually the peptones disappear from the portal blood before 
it reaches the general circulation. Indeed, Ludwig and Schmidt- 
Mtihlheim found that even in the portal blood, before it reaches 



250 INDIGESTION AND NERVOUS DEPRESSION. 

the liver, very little if any peptone is to be found. They have 
not succeeded in discovering where the peptone undergoes 
change. Plosz and Gergyai, and also DrosdorfF, have discovered 
peptone in the blood of the portal vein, and Plosz and Gergyai 
have been led, by their experiments, to regard the liver as the 
seat of the transformation of peptones. In consideration of the 
more recent experiments of Ludwig and Schmidt- Miihlheim, 
we caunot entirely adopt the view of these authors, though it 
is nevertheless possible that they are to a certain extent right, 
and that the liver, to some extent at least, serves the purpose 
of preventing any peptones from getting into the general cir- 
culation, which may have escaped transformation in the portal 
blood before reachiDg it.-^ 

And now, having run over in this cursory manner some points 
connected with digestion and with the functions of the liver, we 
come back to the question of why it is that the mental woi-ker 
becomes depressed, irritable, melancholy, and, it may be, stupid and 
forgetful, after a few months' work, although every part of his 
body may be organically healthy, and a month's holiday may be 
sufficient to restore every organ to perfect functional activity ? 
One reason, no doubt, may be that his systematic overwork may 
produce a diminution in the energy-yielding substance of bis 
nerve-centres, just as we see that a certain amount of atrophy 
occasionally occurs in overworked muscles. But this does not 
seem very probable. It seems mucb more likely that they cease 
to act in the normal way because during each day's activity a 
certain amount of waste product is formed which is not perfectly 
removed during the hours of rest. 

All throughout the body we have most elaborate arrangements 
for removing waste products. In the muscles, for example, we 
find that the fascia which surrounds them forms a regular pump- 
ing arrangement, the two layers of which it consists being 
separated from each other at each muscular relaxation, and 
pressed together at each contraction.^ ' The lymph and the 
waste products which it contains are thereby actually pumped 
out of the muscle at each contraction, and sent onwards into 
the larger lymph-channels, so that the muscular action itself 
removes the waste products (p. 332). At the same time we find 

^ ^ch.m\At-lsLa}x\\iQ\v[i, Anhiv filr Anatomie ibnd Physiologic; Physiologisclic Abth, 
1 & 2 Heft, 1880, p. 33. Albertoni, Ccntralblatt f. d. medicinischen Wissensohaften, 
1880, p. 577. ^ Ludwig and Genersich, p. 53, Ludwig' s Arbeiten, 1870. 



CIRCULATION OF CEREBROSPINAL FLUID. 251 

that the movement of the muscles of the leg, for example, will also 
pump out the blood from the veins, sending it upwards from the 
feet, and pressing it upwards to the body.-^ 

Again, we find that in the abdomen and thorax we have 
pumping an-angements, whereby any excess of the serous fluid 
which bathes the intestines and lungs is pumped out of the 
peritoneal pleural cavities by the action of respiration. The two 
layers of the central tendon of the diaphragm and of the pleura 
here form pumping arrangements similar to the fascia in the leg. 

The brain and spinal cord, being inclosed in rigid cases, have 
no pumping arrangements in immediate connection with them, 
but the circulation of the cerebral spinal fluid in them is probably 
effected also by the movements of the thorax and abdomen. The 
cavity of the arachnoid and of the cerebral ventricles is not only 
continuous with similar cavities in the spinal cord, but also witb 
the lymph-space surrounding the choroid with the interior 
chamber of the eye, and even with the lumbar lymphatics; and 
Professor Schwalbe has succeeded in injecting these parts by a 
single insertion of the nozzle of his injecting syringe into the 
arachnoid. His observations have been confirmed and extended 
by Althann.2 The experiments of Quincke have shown that 
during life a current exists in the cerebral spinal fluid both from 
above downwards, and from below upwards.^ The cause of this 
current is, in all probability, the respiratory movements. We 
have, indeed, in the brain and spinal cord, a condition not unlike 
that which exists in the fasciae covering muscles, where the 
muscular substance during its contraction presses the flexible inner 
against the unyielding outer layer of the fascia, and thus produces, 
in the space between them, a pumping action. The skull and 
vertebral canal would correspond to the hard layer of fascia ; and 
the brain and cord, which, as we know, expand and retract during 
the movements of respiration, when a part of their bony case is 
removed, will have a similar pumping action upon the cerebral 
spinal fluid to that of the muscle upon the lymph jn the fascia. 

In the case of the brain and the cord there will be, in addition, 
a pumping action produced by the very circulation of the blood in 

1 Braune, Bar. der Sachs. Gcscll. d. TViss., 1870, p. 261. 

2 Althann, vide Virclww's Jahreshericht, 1872, p. 156. 

3 Several authors, as Axel Key aud Retzius (Nordisk medicinsh ArTciv., 1870, II, 
1, 13—18; Centralblatt fur Mcdicinischa Wissenschaften, 1871, p. 514); Quincke 
(Reichert'sund Du Bois Bcymond's Archiv, 1872, 153 — 177; Centralblatt fur Med. 
Wissen., 1872, p. 898.) 



252 IXDIGESTIOX AXD NERVOUS DEPRESSION. 

them, the alternate expansion and dilatation, corresponding to the 
heart's beats, having a similar effect to that produced by the respir- 
atory movements. As stimulation of the brain causes dilatation of 
its vessels, and increases the flow of blood through them, mental 
action of itself not only attracts more blood to the brain, but pro- 
vides to some extent for the removal of waste products. The 
movements induced by the cardiac pulsations are not so extensive 
as those caused by the respiratory movements or by muscular 
exertion, and therefore, when the brain is overworked, and the 
respiration and muscular movements are underworked, the cerebral 
nutrition will be diminished by the imperfect removal of waste 
from its substance. But if, in addition to this, the cerebral cells 
and fibres are actually poisoned by the circulation within the 
vessels which supply them, of noxious substances due to imperfect 
digestion or assimilation, matters will become very much worse. 

We have already seen how much the liver has to do with such 
a condition. Now, while the brain is being taxed to its utmost, 
the worker generally gets but very little exercise. The conse- 
quence of this is, that although the respiratory movements still go 
on with regularity, and the pressure of the diaphragm upon the 
liver at each respiration presses the bile more or less out of the 
liver, yet the pressure thus exerted is very much less than would 
be the case if the individual were making occasional vigorous 
efforts during which the breath was held, and the muscles of the 
abdomen put into action, as, for instance, in springing from boulder 
to boulder on the moraine of a Swiss glacier. So long as the 
brain-worker is exceedingly careful what he eats, so that no excess 
of bile is formed, and is fortunate enough to escape duodenal 
catarrh, so that no impediment, however slight, prevents the flow 
of bile into the intestine, he may get along perfectly well ; but if 
he be unfortunate enough to get what is commonly known as cold 
in the stomach, or unwary enough to irritate the mucous mem- 
brane of his stomach or duodenum by wines or spirits, the case is 
at once altered, for now the swollen mucous membrane of the 
duodenum tends to close the orifice of the bile-duct, or the con- 
gestion may even extend up to the duct itself. Thus an impedi- 
ment, however slight it may be, is opposed to the exit of bile from 
the liver. The pressure under which the bile is secreted, as I 
have already said, is very small, and there being no extra pressure 
put upon the liver by the diaphragm and abdominal muscles, 
instead of the bile being at once forced out of the bile-capillaries 



PURGATIVES VERSUS STIMULANTS. 253 

it will remain in them, causing more or less congestion, and now 
follows a whole series of disagreeable results. The bile, which 
may be looked upon as a waste product of the liver, not being 
removed, the other functions of the liver are disturbed. Assimil- 
ation becomes imperfect, we find lithates appearing in the urine ; 
the circulation in the liver itself may be altered, and thereby the 
whole circulation in the stomach and intestines may be impeded, 
for it must be remembered that all the blood from the stomach 
and intestines has to pass through the liver before it again reaches 
the general circulation. Thus the individual becomes troubled 
with haemorrhoids, secretion and vermicular movement in the 
bowels are impaired, so that constipation results ; congestion of the 
stomach, with loss of appetite, impaired digestion, and flatulent 
eructations ensue, and the brain and nervous system begin to suffer 
from the accumulation in them of their own waste or the absorption 
of abnormal products of assimilation. 

Feeling weak, dull, and melancholy, the sufferer now thinks he 
ought to take meat three times a day, and perhaps during the 
intervals of his meals, to take strong beef-tea, or perhaps a glass of 
wine or a nip of brandy. Yet, in spite of all this, he becomes 
weaker, more stupid, and more melancholy ; and no wonder. He 
is simply further over-taxing his already over-worked digestive 
organs. He is piling up fuel, instead of removing ash, and 
choking the vital processes both in his digestive and nervous 
systems. What he wants is not more nutriment, but a more 
rapid removal of waste, and the change upon the adoption of a 
proper system of treatment is in many cases most marked and 
satisfactory both to the physician and the patient. 

The first thing to be done is to clear out the liver. This may 
seem to be an unscientific expression, one adapted rather to popular 
notions than in a,ccordance with ascertained facts. But this is not 
the case. In a former paper on the action of purgative medicines,^ 
I have explained the way in which certain purgatives may be said 
to have the effect of clearing out the liver, and first amongst those 
we must reckon mercurials. In the case which we have just been 
describing, five grains of blue pill may be taken at night, or 
two or three grains of calomel either alone or combined with 
extract of hyoscyamus or conium, and this should be followed next 
morning by a saline draught. As a saline we may use sulphate of 
magnesia, or Friedrichshall, Pullna, Hunyadi Janos, or Carlsbad 
1 Practitioner, vol. xii. pp. 342, 403. 



254 INDIGESTION AND NERVOUS DEPRESSION. 

water; but whichever saline we may choose, the use of one or 
other of them should on no account be omitted. One of the best 
salines is half a drachm of crystallised Carlsbad salts dissolved in 
a tumbler of hot water and drunk immediately after rising in the 
morning, and this may be used not merely in the morning after 
the mercurial, but it may also be employed every morning in cases 
where the bowels are constipated, The quantity of water is of 
considerable importance. Half a teaspoonful dissolved in a full 
tumbler is more efficacious than double the quantity of salt in half 
the quantity of water. Nor is this to be wondered at, for not only 
has the larger quantity of liquid greater power to wash out the 
intestine, but the increased amount of the water tends to increase 
the quantity of bile secreted, and this increase in bile is especially 
marked when the water is taken frequently in small quantities, as 
it is by persons undergoing the cure at Carlsbad, or who take the 
solution of Carlsbad salts at home by sipping it at intervals while 
dressing, instead of drinking it all off at once. 

Zawilski found that when liquids were taken in this way not 
only was the bile secreted in greater quantity, but under a greater 
pressure, so much so that secretion still occurred when such an 
obstruction was opposed to its exit as would usually have caused 
the bile which had already been secreted to be reabsorbed.^ 

When the Carlsbad salts are employed after the mercurial, it is, 
I think, best to take them in single large draughts immediately on 
rising, but when used by themselves the solution should be sipped 
at intervals during dressing. When used alone the Carlsbad water, 
warmed in an aitna, or by standing the tumbler in a basin of hot 
water, is perhaps even better than the salts, which represent only a 
part of the normal constituents of the water. After the liver has 
been thoroughly cleared out in this manner by a mercurial purga- 
tive followed by a saline, vegetable cholagogues, such as iridin and 
euonymin, may be employed to assist the action of the Carlsbad 
salts, when these are found to be insufficient even although they 
are taken with regularity. These cholagogues, the introduction of 
which into medicine, in this country at least, we owe to Professor 
Rutherford, are sometimes as useful, perhaps even more so than 
mercury, but as a rule I think the mercurial purgative is the best 
to begin with. Euonymin is the cholagogue most usually em- 
ployed, but iridin is really the most powerful one, and is specially 
recommended by Dr. Ptutherford. 

1 Sitzuncisbcr. der Wiener Acad., 1877 ; Mat. Nat., Abth. Bd. iv. p. 73. 



CURARE-LIKE POISONS. 255 

Instead of trying to keep up the strength, as it is termed, 
by loading the stomach with food, the exhausted brain-worker 
shoidd rather lean towards abstinence from food, and especially 
towards abstinence from alcoholic liquors. The feeling of muscular 
weakness and lassitude, which I have already had occasion to 
mention as frequently coming on about two hours after meals, 
is not uncommonly met with in persoHS belonging to the upper 
classes who are well fed and have little exercise. It is perhaps 
seen in its most marked form in young women or girls who 
have left school, and who, having no definite occupation in life, 
are indisposed to any exercise, either bodily or mental. I am 
led to look upon this condition as one of poisoning, both on 
account of the time of its occurrence, during the absorption of 
digestive products, and by reason of the peculiar symptoms — viz. 
a curious weight in the legs and arms, the patient describing them 
as feeling like lumps of lead. These symptoms so much resemble 
the effect which would be produced by a poison like curare, that 
one could hardly help attributing them to the action of a depres- 
sant or paralyser of motor nerves or centres. The recent researches 
of Ludwig and Schmidt-Miihlheim render it exceedingly probable 
that peptones are the poisonous agents in these cases, and an 
observation which I have made seems to confirm this conclusion, 
for I find that the weakness and languor are apparently less 
after meals consisting of farinaceous food only. My observations, 
however, are not sufficiently extensive to convince me absolutely 
that they are entirely absent after meals of this sort, so that 
possibly the poisoning by peptones, although one cause of the 
languor, is not to be looked upon as the only cause. A glass of 
soda-water with or without the juice of a lemon squeezed into it, 
may be slowly sipped when the feeling of weakness comes on, and 
a biscuit may be eaten along with it if desired. This will some- 
times relieve languor, but if it be found insufficient, a small cup of 
warm but weak tea or cocoa with a biscuit will act as an efficient 
stimulant, although they may be less unobjectionable than the 
soda-water. Heat is one of the most powerful of all cardiac 
stimulants, and any warm fluid in the stomach will increase its 
action ; a cup of warm water alone will do this, but it is unpleasant 
to take, and so something must be added to flavour it : a little 
claret may be used if tea disagrees, or tincture of ginger and sugar, 
or even some Liebig's extract. It is the local action of the warmth 
that we want, and in order to obtain it we may sometimes have to 



256 INDIGESTION AND NERVOUS DEPRESSION. 

put up witli the inconvenience of giving substances which will be 
to some extent injurious after their absoi'ption, such as beef extract 
or even whisky. The advice that I have given here, in recom- 
mending a glass of cold soda-water or a cup of hot tea, may remind 
one of the countryman in one of iEsop's Fables who fell into 
disgrace because he blew upon the fire to heat it, and blew upon 
his porridge to cool it. And yet the countryman was right, for 
experience had taught him that the desired result would follow his 
actions, even though he might not be able to explain the reason 
why. So we find that a draught of cold water will revive a faint- 
ing person, and hot water will have a somewhat similar effect. 
Both of them give relief by stimulating the circulation, but their 
modus operandi is different. In the case of the hot water the 
circulation is stimulated through the heart, which is excited to 
increased contraction, and thus the tension within the vessels is 
raised. In the case of the cold, the pressure is also raised, not by 
stimulation of the heart, but by the contraction of the vessels, 
especially those of the stomach and intestine. In the case of 
warmth, more blood is poured into the aorta by the excited heart, 
and where we apply cold less blood flows out of the aorta into the 
veins through the intestinal vessels, and thus it is that in both 
cases the tension is raised and the faintness removed. 

At each meal it is well for the patient to begin with the solids 
before he proceeds to the fluids, and at breakfast, instead of 
beginning the meal with a cup of tea or coffee, he should finish 
a slice of dry toast and a piece of fish, egg, or bacon before he 
takes any liquid at all. The same rule should be observed at 
lunch and dinner. The effect of this course is that the patient 
is less troubled with weight and flatulence after meals. The 
explanation of the fact probably is that the solids, entering the 
stomach first, stimulate it to secretion and movement ; whereas 
if it already contained a quantity of liquid at the time they were 
ingested they would not have this effect, and imperfect digestion 
would be the result. At dinner, wine or beer may be taken if 
the j)atient finds them agree, but in all probability he will be better 
without them. There are some brain- workers who require them, 
and must have them, but it is better for a good many others to 
avoid either wine or beer, and to take some effervescing water 
instead. Not unfrequently we hear the comj)laint that effervescing 
water is too cold, and where this is felt to be the case ginger ale 
or zoedone may be substituted, the colour of these beverages and 



EXERCISE. 257 

tlicir more pungent taste rendering tliem more grateful both to 
the eye and the pah^te of many persons. In some cases weak 
claret and water may be used, and if the water be somewhat warm 
the mixture will be better for the patients, and will not cause the 
feeling of coldness in the stomach, of which they sometimes 
complain. 

A medicine which has long enjoyed a great reputation in dis- 
order of the liver is nitro-muriatic acid, and I think this reputation 
well deserved. We do not know hoAv it acts, but in some way or 
another it does tend to improve the digestion. Ten minims of the 
dilute nitro-hydrochloric acid either before or immediately after 
meals, combined with some aromatic and carminative, such as 
chloroform and cardamoms or orange, and from five to ten minims 
of tincture of nux vomica where the nervous depression is great, 
is a most efficient remedy. 

But even with all this care in food and drink, with all this 
attention to what is to be taken and what avoided, with medicine 
morning, noon, and night, how are we to keep the liver in order 
without exercise ? Sometimes the patient may be able to take 
walking exercise, but when he does it is generally only for a 
short time during the day, and of so gentle a character that the 
respiratory movements are but very slightly increased, and the 
liver is hardly more stimulated by the pressure of the diaphragm 
and abdominal walls during the Avalk than it would have been had! 
the patient remained quietly at home. Time is an important 
element in many cases. Many a hai'd-worked man has his day so 
fully occupied that he cannot give up more than a quarter or half 
of an hour to exercise, and it is of importance that in this limited 
period he should get as much exercise as possible, and the best 
way to employ this brief time is by taking horse exercise. I 
believe it is to the late Lord Palmerston that we owe the saying, 
that " the outside of a horse is the best thing for the inside of a 
man," and it is very near the truth. A brisk trot for fifteen 
minutes will cause more pressure upon and stimulation of the 
liver than a lazy lounge of an hour or more. The time for this 
will depend in a great measure ujDon the engagements of the 
patient. It should not be taken immediately after a meal, and 
for most men whose days are fully occupied almost the only 
time to take it is before breakfast. A cup of milk, or a small 
cup of tea or coffee, with a piece of bread and butter or a biscuit, 
may be taken just before starting, and then the regular breakfast 



258 INDIGESTION AND NERVOUS DEPRESSION. 

will be taken with greater appetite and better digestion after the 
exercise is over. 

By careful attention to the removal of waste products, and to 
the prevention of absorption of poisonous substances from the 
intestine, by regulation of the diet, regulation of the bowels, and 
exercise, in the ways just mentioned, I believe that the nervous 
exhaustion and depression from which brain-workers suffer may be 
greatly diminishedj even though it may not be entirely prevented. 



ATHOPIA AS AN ANTIDOTE TO POISONOUS 
MUSHROOMS. 

{From the 'British Medical Journal,' November lUh, 1874.) 

It is, perhaps, not very generally known that one of the most 
perfect instances of antagonism with which we are acquainted is 
the power of atropia to counteract the poisonous principle of mush- 
rooms. This principle seems to be the same, or nearly the same, 
in different species of mushroom, for they all seem to have similar 
actions. The Agaricus muscarius, A. pludloides, A. pantherinus, 
Boletus Satanas, and Bussula foeUns, all resemble one another in 
action ; but tlie effects produced by the same sort of fungus may 
vary in different individuals. They all act more or less on the 
intestinal canal and heart, and apparently also on the brain. The 
usual symptoms are uneasiness in the stomach, vomiting, purging, 
a feeling of constriction in the neck, want of breath, giddiness, 
fainting, prostration, and stupor. Sometimes the intestinal symp- 
toms are most prominent ; at other times, the cerebral ones. The 
most extraordinary action of poisonous mushrooms is upon the 
heart. The active principle of the Agaricus muscarius, or Amanita 
muscaria, was separated by my friend Professor Schmiedeberg of 
Strasburg, and named by him muscarin. The merest trace of this 
alkaloid will arrest the pulsations of the frog's heart almost 
instantaneously, and prevent it from ever beating again unless its 
effect be counteracted. But if a minute quantity of atropia be 
brought into contact with the organ, it will begin to pulsate again, 
and will go on beating for a long time. I have stopped the motions 
of a frog's heart by dropping a little dilute muscarin upon it, and 
have again made it pulsate after it had remained perfectly motion- 
less for no less than four hours. Muscarin does not stop the heart of 
mammals so readily as that of the frog, but it renders the pulse 
slower, and intermissions are sometimes noticed in cases of poisoning 
by mushrooms. A little atropia at once counteracts the effect of 
muscarin on the heart in mammals just as it does in the frog. 



260 ATROPIA VERSUS POISONOUS MUSHROOMS. 

But, besides this remarlvable effect of muscarin on the heart 
discovered by Professor Schmiedeberg, it possesses one no less 
extraordinary upon the pulmonary vessels. This I discovered some 
time ago, when experimenting with a specimen of muscarin given to 
me by my friend. He had noticed that intense dysi^noea was one of 
the most marked symptoms produced by the poison. He had not, 
however, attempted to explain it. He had observed that during the 
dyspnoea the arteries contained very little blood, and when cat 
across hardly bled at all. On considering the matter, it ajopeared 
to me that this emptiness of the arteries and the dyspnoea might be 
due to a common cause, viz., contraction of the pulmonary vessels. 
If these vessels contract spasmodically, the blood will be prevented 
from passing through them, and will accumulate in the right side of 
the heart. The right heart and veins will consequently become 
goi'ged with blood, while none will reach the left side, so that both 
it and the arteries will remain empty or nearly so (see fig. 29). 
As the blood cannot reach the lungs to become aerated, dyspnoea 
occurs ; for this may be produced as well by preventing the blood 
from reaching the air as by compressing the windpipe, and thus 
l^re venting the air from reaching the blood. This supposition of 
luine appeared to explain the symptoms perfectly; but it was only 
a supposition, and required to be tested by experiment before it 
could be regarded as having any value. I accordingly tested it in 
the following way. 

Having thoroughly narcotised a rabbit with hydrate of chloral, I 
commenced artificial respiration, and opened the thorax, so that I 
could see the lungs and the heart perfectly. It is well known that 
with due precautions animals can be kept in this condition, for an 
hour or two at least, without any change occurring in either heart 
or lungs. The animal is so deeply narcotised that it lies as if dead, 
but the heart goes on pulsating as regularly as if everything were 
in its normal condition. Both sides of the heart are equally filled, 
the vena cava is only moderately distended, and the lungs are rosy. 
While this state of things continued, I injected a little muscarin into 
the jugular vein. At once everything changed. The lungs became 
blanched, the left side of the heart became small, the right side 
swelled up, and the vena cava became greatly distended. (See fig. 
29.) After a short time,, I injected a little atropia into the jugular 
vein, and instantly ever^^thing returned to its normal condition. 
The left side of the heart regained its former size, the right side 
diminished, the distension of the veins disappeared, and the blanched 



PULMONARY CIRCULATION. 



2G1 



lungs again assumed a rosy hue (see fig. 28). This was exactly what 
I expected, and consequently I was all the more distrustful of my 
own personal observations. A little prejudice might have led me 
to exaggerate the blanching of the lungs, although the condition of 
the heart and veins was so obvious as to preclude the possibility of 
error. I accordingly got two observers who knew nothing about 
the experiment, and repeated it before them, noting down their 
observations. These agreed exactly with my own, and I thus 
became sure of my facts. 

As dyspnoea is observed after poisoning by mushrooms, both in 
animals and men, we may, I think, safely extend the results we 
have obtained by experiments on the lower animals to men, and say 





. 28. — Diagram of the normal 
pulmonary circulation. 



Y'v^. 29. — Diagram of the pulmonary 
circulation in poisoning by muscarin. 



that in them also the dyspnoea is due to spasmodic contraction 
of the pulmonary vessels. The dyspnoea, as well as the other 
S3"mptoms of muscarin poisoning, disappear in animals almost 
immediately after the injection of atropia, and, indeed, Schmiede- 
berg and Koppe describe an experiment in which the use of this 
antidote during the death-struggle completely restored a dog which 
had been poisoned by muscarin. They, therefore, recommend that 
in cases of poisoning by mushrooms, the stomach should be emptied 
and then atropia injected subcutaneously. It is a curious circum- 
stance that, in poisoning by mushrooms, tickling the fauces seems 
to prove much more efficacious in producing vomiting than the 
administration of tartar emetic. The antidote may be given by 
the mouth, either in the form of tincture of belladonna or liquor 
atropias; but Schmiedeberg and Koppe prefer subcutaneous injection 
on account of the more rapid absorption and speedy action of the 
drug, as well as the more accurate adjustment of the dose. The 
dose for subcutaneous injection should be about one-hundredth of a 
grain or about one minim of the liquor atropine sulphatis {B. P.) 
repeated if necessary until the dyspnoea is relieved. 



PHYSIOLOGICAL RESEARCHES ON THE 
NATURE OF CHOLERA. 

(Bead he/ore the British Association at Bradford, Sept. 2Zrd, 1873.) 
Printed in abstract in Reports of the British Association for 1873. 

The medicines whicli have been employed at one time or another 
in the treatment of cholera are almost numberless, and yet the 
universal dread in which this terrible disease is held, no less than 
the distinct acknowledgment of the uselessness of treatment which 
we find in medical text-books, clearly shows that the search after 
a true remedy has hitherto been fruitless. Empiricism having 
entirely failed, it only remains to be seen whether a greater means 
of success is to be attained by patient scientific research. I now 
purpose to give the outlines of an investigation which I began 
two years ago, but which circumstances have hitherto prevented 
me from completing. I should not have brought it before the 
Association in its present imperfect state were it not that I find 
a remedy, which my experiments had indicated to me as one 
likely to be beneficial, has lately been tried empirically in America 
with good results,-^ and I hope that others may be induced not 
merely to give this remedy a fair trial but to search for other 
medicines possessing properties which I am afraid this one lacks. 

The cause of cholera is now generally admitted to be a poison 
of some sort, which can be conveyed about from place to place and 
transmitted from one person to another, through the medium of 
the evacuations which either get into water and are drunk, or 
become dry and are taken into the mouth and nostrils in the shape 
of dust. Some, even yet, are inclined to hold that cholera results 
rather from peculiar atmospheric and other conditions, than firom 
the presence of a specific poison, but the fact that the disease may 
be conveyed from one infected locality to numerous others by a 
single individual, breaking out where he has stopped and passing 

1 Saunders, American Practitioner^ ^'^J^ 1873. 



EFFECTS OF CHOLERA-POISON. 263 

over those places which he has only travelled through, although 
these may present apparently identical conditions of air, sea, and 
water, shows conclusively that an outbreak of the pestilence cannot 
be due to these latter circumstances alone. Nor will the mere 
presence of the poison always produce cholera, for those who are 
exposed to contagion do not all become affected, and even those 
who have swallowed cholera stools in which the poison is supposed 
to be present in its most concentrated form have sometimes 
escaped with impunity. It would appear that two conditions are 
required, viz. : the presence of the poison and the existence of a 
proper soil for its development. In other words, it would seem that 
the poison does not produce its usual effects even when it has 
entered the system, unless the blood and tissues are in such a state 
that it can act upon them. The nature of this state we cannot 
exactly define, but its presence seems to be due in great measure 
to those conditions of atmosphere and soil which some assert 
to be the immediate cause of the disease, but which in reality 
only predispose to it. 

Without entering into this question at any greater length, I 
shall assume that cholera is caused by a specific poison acting ujDon 
an organism which has become in some way or other susceptible 
to its influence. The effects of the poison upon the body may 
be summed up in a few words. It produces irritability of the 
digestive canal, immoderate secretion from the intestines, and 
lessened circulation both through the lungs and the body. Bearing 
in mind these actions it is perfectly easy for any one to deduce from 
them all the symptoms which are observed in the state of cholera 
collapse. 

From the irritability of the stomach and intestines there is 
constant vomiting and purging. The secretion from them is so 
profuse that the whole intestinal canal is speedily washed clean 
out ; the stools are no longer feculent nor even tinged with bile, 
but consist of the secretion alone, pure and unmixed and resembling- 
rice-water in appearance. The blood is thus drained of its fluid 
parts, and the consequence of this is intense thirst, which adds 
greatly to the sufferings of the patient. The blood itself, instead 
of coursing rapidly through the vessels as it does in health, 
stagnates in the great veins of the thorax and abdomen (see 
diagram), the left side of the heart, instead of receiving from the 
lungs a full supply of well-aerated blood, which it would propel 
through every part of the body, receives only a scanty driblet 



2Gi RESEARCHES ON CHOLERA. 

wliicli leaves it almost collapsed ; the arteries wliicli proceed- to 
the body are so empty that when they are cut across hardly a 
drop of blood flows from them, and even when a tube is passed 
through the carotid artery and aorta right up to the sigmoid 
valves of the heart, as was done by Dieffenbach,^ no blood can 
be drawn from it. The warm blood from the interior of the body 
which usually circulates in the vesse^.s near the surface, imparting 
to it the plumpness, warmth, and rosy hue of health, stagnates 
in the abdominal veins and leaves the skin shrunken, pale, and 
■cold, while that in the interior of the body being no longer cooled 
by circulation near the surface, becomes hotter and hotter till the 
internal temperature of the unfortunate patient is higher than it 
usually is in high fever, though his skin and breath are cold as 
ice.^ The blood which fills the small cutaneous veins being 
no longer driven forward by fresh supplies from the arteries, 
becomes completely deoxidized and black, imparting to the surface 
a livid hue. So dark does the blood become that it assumes the 
colour of bilberry juice,^ and the colouring matter leaves the 
corpuscles and tinges the serum,* It still retains its power to 
take up oxygen and give off carbonic acid,^ but notwithstanding 
this is passes so slowly through the pulmonary vessels that only 
about one-third of the usual quantity of carbonic acid is given 
off from the lungs,'' and little oxygen being taken in there is a 
distressing feeling of want of breath. The voice at the same time 
is hoarse, low, and weak, but this seems to be simply a consequence 
of the general exhaustion of the patient. 

Such are the symptoms of cholera, all rising from disturbance of 
the circulation and excessive intestinal secretion. The remedy we 
seek must, therefore, be one which has the power of removing these 
conditions It may be thought that the only way to do this is to 
eliminate from the body the poison which is producing these results, 
and that so long as it is still circulating in the blood any remedy 
which is simply intended to counteract its effects will be adminis- 
tered in vain. But the researches of Fraser^ and others on 

1 DiefFenbacli quoted by Magendie, Gaz. Me'dicale, 1832, p. 253. 

2 GiiterLock, Virch. Arch, xxxviii. p. 30. 

3 Niemeyer, Symptomaiische Behandlung der Cholera, p. 13. 
* Parkes, on Cholera, p. 124. 

5 This is shown by its becoming red on exposure to air, Parkes Op. cH., 
p. 113. 

6 Eayer, Gaz. Med., 1832, p. 278, and others quoted by him. 

■ '' Eraser, Transactions of the Royal Society of Edinburgh, vol. xxvi. 



SEARCH FOR ANTIDOTE TO CHOLERA-POISON. 265 

antagonism have shown us that the elimination of a poison is not 
required in order to prevent its injurious or fatal action, for the 
administration of an antidote will deprive it of its hurtful power, 
and as it is with other poisons so may it be with that of cholera. 

While thinking over this subject two years ago it occurred to me 
that if any poison should possess actions similar to those of the 
cholera-poison, an antidote to it might possibly prove to be a 
remedy for cholera. It was by no means certain that it would do 
so, but still in this direction seemed to be the one in which the 
search after a cure for cholera might be prosecuted Avith the 
greatest chance of success. I therefore began to look for a drug 
which would produce the same changes in the circulation which I 
have described as occurring in cholera. These were, I believe, first 
ascribed by Dr. Parkes-^ to spasmodic contraction of the vessels in 
the lung, which prevented the blood from passing through them, 
and this opinion has found a warm supporter in Dr. George Johnson. 
It will be readily seen that almost all the symptoms can be explained 
on this supposition, though there are some, as I will afterwards 
show, which this hypothesis does not include. The obstruction to 
the passage of blood through the lungs causes breathlessness by 
keeping the blood from the air, just as readily as it could be done 
by a plug in the windpipe keeping the air from the blood. The 
left side of the heart getting little or no blood becomes empty, the 
arteries do not bleed when cut,- the surface gets shrunken and pale, 
svhile the veins get distended, and the right side of the heart is 
found, after cleatli, to be full of blood. ^ 

If, then, Dr. Parkes's and Dr. Johnson's idea regarding the arrest 
of circulation were correct, the first thing to be found was some 
druo; which would remove the contraction of the vessels in the lungs. 

Some time previously, my friend Professor Schmiedeberg, now of 
Strasburg, had discovered and islolated a new alkaloid from a 
poisonous mushroom, the Amanita 3Iuscaria. or Agaricus Muscarius, 
and had investigated its physiological action. Among other things, 
he noticed that when given to animals it caused great dyspnoea.* 
At the same time the arteries became empty so that when cut 

1 [This is an error. Parkes ascribed the symptoms to arrest of tlie circulation 
in the lung, but he appeared t) think the arrest was due to alteration in the 
b'ood, whilst Johnson ascribed it to contraction of the vessels. T. L. B., 1885.] 

2 Dieffenbach quoted by Griesinger, Virchow's Hcmdb. d. Fathol. n. 
TItercqy, Bd. II. Abt. 2, p. 327, and by Magendie, Gaz. Med., 1832, p. 253. 

3 Parkes, on CJwlera, London, 1847, p. 105. 

* Schmiedeberg and Koppe, Das Muscarin, p. 50. 



266 RESEARCHES ON CHOLERA. 

across hardly a drop of blood issued from them, the very condition 
which I have already mentioned as existing in cholera.^ From a 
peculiar action which it exerts upon the heart of the frog, and 
which is removed by atropia, he administered atropia to the warm- 
blooded animals suffering from the symptoms just described in the 
hope that it would counteract the effects of muscaria in them, just 
as it did in the frog. His anticipations were completely realized, 
and the symptoms at once disappeared after the antidote had been 
given. My friend had not thought at all of contraction of the 
pulmonary vessels as a cause of dyspnoea ; he attributed it rather 
to excitement of the nervous centre in the medulla oblongata 
which regulates the respiratory movements, and the effect of atropia 
in removing the dyspnoea greatly puzzled him, for atropia itself 
excites the nervous centre, and ought, according to my friend's sup- 
position, to have increased instead of removing the breathlessness,^ 
Although he had only a very little of the alkaloid himself, Professor 
Schmiedeberg had very kindly given me some, and as soon as the 
idea that the dyspnoea was due to contraction of the pulmonary 
capillaries suggested itself to me I proceeded to test it by experi- 
ment. I first gave a rabbit such a dose of chloral hydrate as 
completely to deprive it of all sensibility, then put a tube in the 
trachea and connected it with a pair of bellows. I was thus able to 
inflate the animal's lungs at regular intervals and keep up respir- 
ation artificially when the animal could no longer breathe itself. 
I next opened the thoracic cavity so as readily to observe the 
slightest change in the lungs or heart. Fearing lest my wishes 
should lead me in the slightest degree to make erroneous observ- 
ations, I obtained two assistants and made them tell me what they 
saw without my informing them of what I expected. In all the 
observations which we made, however, we perfectly coincided, and 
the results of my experiments being thus attested were carefully 
noted down. Our preparations being complete, I injected a little 
muscaria into the jugular vein. Scarcely was the injection finished 
when the lungs which had previously been rosy became blanched, 
the right side of the heart swelled up, the veins passing to it 
became enormously distended, and the left side of the heart almost 
empty. After allowing this state of things to continue for a short 
time, I injected a little atropia into the jugular vein — at once the 
effects of the muscaria disappeared and everything seemed again 
to present its normal appearance. The lungs again became rosy, 
1 Op. cit, p. 57. 2 02). cit., p. 56. 



MUSCARINE AND CHOLERA. 



267 



the right side of the heart and the veins contracted, and simultane- 
ously the collapsed and shrunken left side of the heart regained its 
normal fulness. 

This confirmation of my ideas regarding the cause of the dyspnoea 
induced by the administration of muscaria and the power of relax- 
ing the pulmonary vessels which atropia was thus seen to possess, 
raised my hopes regarding its usefulness in cholera. But there 
were other points relating to the action of muscaria and of atropia 
which I wished to investigate and I did not publish my results. 
Unfortunately my supply of muscaria failed me and I have been 
unable to obtain any until a month or two ago, when Professor 
Schmiedeberg made some more and kindly sent me a fresh supply, 
as soon as he had finished preparing it. Owing to other engage- 
ments I have not yet been able to prosecute my investigations, but 
hope shortly to do so. 





Tis,. 30.— ITormal. 



Fig. 31.— Contracted Pulmonary vessels. 



I have hitherto proceeded on the assumption that Parkes's and 
Johnson's theory of cholera is correct, and that the stoppage of the 
circulation is due to contraction of the arterioles in the lunws. In 
poisonmg by muscaria the right side of the heart seems to be 
almost as much distended as the great veins of the thorax and 
abdomen, and exactly the same condition is found in the post- 
mortem examination of persons who have died of cholera. But it 
is not certain that the right side of the heart is always distended 
during life even when the symptoms of cholera are present in their 
most pronounced form. Indeed it would appear that the veins of 
the intestines and the vena cava are more widely dilated in cholera 
than in muscaria poisoning, and hold so much blood that very little 
of it reaches the right side of the heart, which is therefore almost 
as empty as the left. There are several reasons for this supposi- 
tion. The first of these is that an increase in the size of the 



2G8 RESEARCHES ON CHOLERA. 

lieart is not to be detected by percussion. On the contrary it is 
smaller than usual.^ The second is that the symptoms of cholera 
are very similar to those of collapse or shock, produced either by 
mechanical violence or by the presence of a powerful irritant, such 
as arsenic in the intestines. In this condition the veins are widely 
dilated.^ The third is that nitrite of amyl has failed to be of 
service in cholera. It Avas first tried in this disease by Drs. Hayden 
and Cruise of Dublin, who administered it by inhalation. It has 
the power of dilating the arterioles throughout the body, and, as I 
have shown, in those of the lung also.^ It "ought therefore to be 
of great service in cholera, by relaxing the spasm of the pulmonary 
vessels and allowinsf the blood to flow from the riccht to the left 
side of the heart. But it is found to be practically of little or no 
use. Indeed, Drs. Hayden and Cruise found that it increased the 
sufferings of the patient by intefering with respiration. From a 
knowledge of the action of the drug upon the blood I came to the 
conclusion that it would not hinder the breathing if it were injected 
subcutaneously instead of being inhaled, and I mentioned this in 
a paper which appeared some time ago in the British Medical 
Journal^ In consequence of my recommendation Dr. Smith 
employed it subcutaneously in a case of cholera, and found as I 
expected that it did not produce any difficulty of breathing. Its 
action on the circulation, however, was very slight. After each 
injection the brachial pulse was perhaps a little broader than before, 
but even this- effect was insignificant and very transient.^ Its 
action when inhaled was perhaps a little more marked, the pulse 
becominsj somewhat stronofer and the surface a little warmer than 
before, but the improvement was but very slight.^ If the weakness 
of the pulse depends only on contraction of the pulmonary vessels, 
this result would be very astonishing, but if we suppose it to depend 
on dilatation of the great veins, this is exactly what we would 
expect. 

A fourth argument in favour of the view that there is a great 
dilatation of the abdominal veins is afforded by the results of 
the injection of fluid into the circulation. It is evident that 

1 Griesinger, VirchoVs Handb. d. Pathol, u. Therap., Bel. II. Abt. 2. 

2 See Fischer, Ueber Schok. Volkmann's Klin. Vortrage, and Brunton, 
Practitioner, Oct. 1873. 

3 Brunton, Brit. Med. Journ., Jan. 13. 1872, p. 44. * Ojx cit. 

5 Smith, Indian Med. Gaz., May 1, 1873, p. 123. 

6 Hayden and Cruise, Op. clt. 



VENOUS CIRCULATION IN CHOLERA. 2G9 

all the symptoms which I formerly attributed with Parkes and 
Johnson to arrested circulation in the lungs, and which I have 
mentioned in the beginning of this paper as proceeding from 
diminished circulation, will be produced as readily by dilatation of 
the abdominal and thoracic veins and stao-nation of the blood in 
them, as by contraction of the pulmonary capillaries. In both cases 
there will be a very small stream of blood circulating through the 
pulmonary vessels, little respiratory change in the lungs, small 
pulse, empty arteries, a cold skin, and high internal temperature. 
The only difference will be that if the circulation is arrested by 
an obstruction in the pulmonary vessels, the right side of the heart 
will be distended with blood, but if the flow is arrested by enormous 
dilatation of the veins the blood Avill stagnate in them instead of 
the heart, and thus the rioht ventricle instead of bein^ distended 
will be nearly empty, and the whole organ will be smaller than 
usual as percussion actually shows it to be. In cholera the pro- 
fuse secretion from the intestines drains away a great deal of the 
watery constituents of the blood, and attempts have been made to 
restore this by injecting saline solutions into the veins. Almost 
immediately after the injections the symptoms of the collapse 
disappeared, but returned again after a short while. Part of 
this improvement was in all probability due to the improvement 
produced by the injection in the quality of the blood, which was 
previously too thick, and needed dilution, but it seems highly 
probable that the increase in its quantity was also useful. For 
Schiff has lately found that when by means of an operation he 
produces in animals dilatation of the vessels, the introduction of 
more liquid into them will again restore the circulation nearly to 
its normal state, but in a short while the effect of this new supply 
of liquid is lost, and matters return to their former condition just 
as in cholera.^ 

From all these facts it would appear that the veins are really 
dilated,^ and if so, we must employ some remedy which will make 
them contract. 

Now there are very few experiments on the contractibility of 
veins, and hence we know very little about it. It has been found, 

1 ScliifF, LaNazoine, Aug. 9, 1872, No. 222. 

2 About two months after reading this paper before the British Association 
at Bradford, I discovered that the theory of dilatation of the veins being 
the cause of the symptoms of collapse in cholera had been propounded 
by A. Eulenburg some years ago. Wiener Med. Wochensche, 1866, Nos. 
90 and 91. 



270 RESEARCHES ON CHOLERA. 

however, that in the condition of depression or shock which follows 
severe injuries, in which the great veins are much dilated, the 
injection of digitalis has been very useful,'- and if the theory of the 
causation of cholera collapse which I have advanced be correct, it is 
likely to prove useful in cholera also. 

I do not know whether atropia has a similar action on the veins 
or not, but it has been lately tried in cholera with great success by 
Dr. Saunders, of Paducah, Kentucky.^ He writes, " In the recent 
outbreak of cholera in Paducah, I treated a number of cases by 
sulphate of atropia hypodermically — one-fiftieth to one-thirtieth of 
a grain in water — with the happiest results. The more distressing 
symptoms — vomiting, purging, cramps — were relieved almost at 
once, followed by refreshing sleep, continuing in some cases for 
several hours. I found these effects, however, to follow only when 
the atropia was used in sufficient quantities to produce the specific 
scarlatinal rash, dry throat, and dilatation of the pupils. In some 
cases the relief afforded was astonishing ; the skin grew warm, the 
pulse rose, the surface, previously clammy and shrivelled, assumed 
its natural condition, and in some instances the patient slept 
soundly for ten or twelve hours, the bowels remaining undisturbed 
during the entire time. Of course you will not understand me as 
advocating the exhibition of the atropia to the exclusion of all other 
means, especially the use of calomel, to which I attach much 
importance. In the first case in which I gave the atropia I 
combined it with morphia (one-fortieth of a grain of sulphate of 
atropia to one-sixth of a grain of sulphate of morphia), and I think 
the combination is better perhaps than the atropia alone." I have 
already mentioned that my experiments with atropia in muscaria- 
poisoning had led me to expect great benefit from its employment 
in cholera, but my hopes being founded only on a supposition, viz., 
that it would benefit the disease because the symptoms resembled 
those of the poison in some though not in all particulars, I was 
unwilling to recommend its use until I had some positive facts to 
bring forward- I accordingly wrote to a friend in India desiring 
him to try atropia in cholera, some time before I became acquainted 
with Dr. Saunders's paper. I have had, as yet, no communication 
from my friend, and it is possible that more extended experiments 
may show more clearly that, as Dr. Saunders himself observes, 
atropia alone is not to be absolutely relied on as a remedy in 

1 Wilks, Med. Times and Gaz., Jan. 16, 1864. 

2 American Practitioner, July, 1873. 



PARALYTIC SECRETION. 271 

cholera, yet the very encouraging results he has obtained by its 
use are such as to show that it deserves at the hands of the medical 
profession a careful and extensive trial. 

But any search after a remedy for cholera will be very imperfect 
if the action of any proposed medicine on the circulation alone 
is considered, and its effect on the intestinal secretion left out of 
account. For the latter is probably even more important than the 
former, and it is not unfrequently present when the changes in the 
circulation are either slight or absent altogether. I have therefore 
endeavoured to discover the action of atropia on the intestinal 
secretion. It has been found that secretion occurs in the salivary 
glands under two altogether different conditions, viz., when the 
nerves passing to them are irritated and when all their nerves have 
been completely divided. In the first case the gland only secretes 
so long as the irritation to the nerves continues, but in the second 
it goes on constantly and will continue to do so for days or even 
weeks, because the nerves have all been cut and in this way para- 
lyzed ; the secretion is known by the name of paralytic secretion. 
Several years ago M. Moreau showed ^ that the same sort of 
paralytic secretion which has been observed in the salivary glands 
takes place in the intestine, and the method of experiment which 
he employed was this : — He kept a large dog fasting for twenty-four 
hours, so that the intestines should be quite empty. He then 
chloroformed it and drew out the small intestine through an 
incision in the abdominal walls. He next tied four ligatures 
tightly round it at some little distance from each other so as to 
isolate three pieces or loops of intestine. These still remained 
attached to the mesentery, along which the vessels and nerves run 
from the spine to the intestine. Leaving everything else untouched, 
he carefully cut all the nerves going to the middle loop, and then 
returned the whole of the intestine into the abdomen, sewed up the 
wound, and left the animal to itself for several hours. On killing 
it and examining the intestine, he found that the middle loop was 
qiTite full, in fact distended like a sausage by a liquid like rice- 
water, while the other loops remaiued perfectly empty. All the 
loops had been under exactly the same conditions with the exception 
that the nerves of the middle one had been cut, and therefore this 
profuse secretion must be due to the division of the nerves. 
Professor Kiihne analyzed this secretion and also the rice-water- 
looking liquid which is secreted in cholera, and he found that their 
1 Moreau, Comjptes Bendus, 1858, p. 554. 



272 RESEARCHES ON CHOLERA. 

composition was identical, both being nothing more nor less than 
very watery intestinal juice.^ Since the effect of cholera upon the 
intestine is the same as that of dividing the nerves, we are justified, 
I think, in believing that if anything can stop the secretion in this 
experiment it is likely to have a similar effect in cholera. Now 
atropia has the remarkable power of arresting the secretion from 
the salivary glands when their nerves are irritated,^ and also from 
the sweat glands,^ rendering the mouth and skin quite dry. What 
its effect on paralytic secretion in the salivary glands is, I do not 
know, but thinking that it might possibly arrest the flow of fluid 
into the intestine, I repeated Moreau's experiment, and at the same 
time injected some solution of atropia into the vein of the animal. 
On killing it some hours afterwards, I found, somewhat to my 
disappointment, that there was fluid in the middle loop. The dose 
of atropia, however, was not very large, and I comfort myself with 
the hope that a large dose might do though a small one would not- 
Whether it does so or not I cannot say yet, for I have not been able 
to get any large dogs for several months past, and experiments on 
small ones are in this case very unsatisfactory. For in them the 
nerves are so fine that it is not easy to be certain that they have 
been all divided, and so if one should find an arrest of secretion 
after the administration of atropia, it might be simply due to 
imperfect division of the nerves and not at all to the action of the 
drug. 

Foiled in my attempts to test the remedy in this way, I had 
recourse to another plan. M. Moreau found that when three loops 
of intestine are isolated in the way I have already mentioned, and 
Epsom salts are injected into one of them without hurting the 
nerves, the effect is much the same as if the nerves had been cut.* 
I have already said that secretion may be induced in two ways, and 
it is very probable that this secretion is due to irritation and not 
to paralysis. However this may be, I tried the effect of atropia 
upon it both by injecting a mixture of sulphate of magnesia, with 
sulphate of atropia, into the intestine ; and by injecting sulphate 
of magnesia alone into the bowel, and solution of atropia into the 
veins. In both cases I used atropia in large doses, which not only 

1 Kiihne, unpublislied paper read before the Medical Society of Amsterdam, 
1868-69. 

2 Heidenhain Pfliiger's Archiv. V. p. 40. 

3 Sydney Ringer, Practitioner, Ang. and Oct., 1872. 

* Moreau, Pull, de I'Acad. Imp. de Medicine, 1870, p. 629. 



SUMMARY. 273 

dilated the puiDil of the animal's eyes till the iris became almost 
invisible, lut were, in fact, so large that we would hardly dare to 
employ proportionate ones in man for fear of causing immediate 
death. 

Notwithstanding this, they had not the slightest influence upori 
the secretion, which was quite as copious as when no atropia 
whatever was used. 

This result is disappointing and renders the use of atropia m 
cholera somewhat doubtful, for although the secretion caused by the 
sulphate of magnesia may be due to irritation, while in cholera it is 
due to paralysis of the nerves, yet if atropia cannot stop it in the 
forn:er case it is much less likely to arrest it in the latter. It is, 
however, always difficult to foretell the effect of any drug under 
particular circumstances, and so I shall not at present speculate 
on the action of atropia upon j)aralytic secretion, but shall test it 
experimentally as soon as circumstances will permit. 

The points in this paper to which I wish to direct special 
attention are — 

1. Assuming Parkes's and Johnson's theory to be correct, and the 
impeded circulation in cholera to be really due either in whole oi- 
in part to obstruction in the pulmonary vessels, my experiments 
with atropia in muscaria-poisoning show that it is likely to prove 
beneficial to a certain extent in cholera, and since it has been found 
en.pirically to be useful in this disease, it ought to receive a fair 
trial at the hands of the medical profession. 

2. The fact that the right side of the heart is not dilated during 
life in cholera patients, as well as the uselessness of nitrite of amyl 
which dilates the pulmonary vessels, show that Parkes's and 
Johnson's theory is imperfect, and that one of the most important 
pathological conditions in cholera collapse consists in dilatation 
of the thoracic and abdominal veins. Any remedy which is to 
be useful in cholera must have the power of counteracting this 
condition, and the administration of digitalis in cholera collapse 
may be viseful. 

3. The profuse secretion from the bowels in cholera is due to 
paralysis of some of the intestinal nerves, and a remedy which will 
arrest it is still a desideratum. 



ON POISONS FORMED FROM FOOD, AND THEIR 
RELATION TO BILIOUSNESS AND DIARRHCEA. 

{^ The Practitioner,'' vol. xxxv., Aiig., Sept., and Oct., 1885.) 

" What is one man's meat is another man's poison " is a wise 
saying, embodying the observation of many generations, probably 
indeed of many centuries. It is only within the last few years 
that we have begun to discover the true relationship between food 
and poison, through a number of researches which have been made 
in the last ten years, and especially in the last five, on the pro- 
duction of poisonous alkaloids from various sorts of food by 
putrefaction or even by simple digestion. Every now and again 
we meet with cases of individual idiosyncrasy, in which particular 
foods produce quite exceptional symptoms. Thus I know a lady 
in whom a single strawberry causes the face to swell up until the 
eyes become almost closed (p. 349). But in addition to these very 
exceptional cases, we meet with numbers of people — we might 
almost say classes of people — to whom certain kinds of food are 
more or less injurious. Milk and eggs are two of the most valuable 
foods we possess, and in cases of sickness where the patient is 
unable to take solid food, or in typhoid fever, where farinaceous 
foods, however easy of digestion, are, sometimes at least, injurious, 
milk and eggs are invaluable. Yet both milk and eggs appear to 
be more or less injurious to many healthy persons, and have the 
evil reputation of being bilious. If we inquire more precisely what 
is meant by this term we find that these foods are apt, when taken 
at all freely, to produce sensations of discomfort which are referred 
partly to the digestive and partly to the nervous system. Some- 
times these sensations appear within one or two hours after taking 
the particular food which disagrees ; at other times they may not 
appear until its use has been continued for several days. For 
example, one person, an hour after taking eggs or milk, feels an 



POISONOUS ACTION OF EGGS. 275 

unpleasant taste in the mouth, general malaise, and a frontal head- 
ache. In others, after eggs have been taken for two or three days 
together, the appetite becomes impaired, the intellect appears less 
clear, the conjunctiva slightly yellowish, headache may occur, and 
the discomfort may culminate in an attack of vomiting or diarrhoea, 
or both. The vomiting and diarrhoea are sometimes, though not 
always, preceded by constipation ; and both eggs and milk, on account 
of their constipating quality, are popularly known as "binding." 

In some sensitive persons eggs do not merely produce the 
symptoms of so-called biliousness, but act as violent poisons. A 
well-marked instance of this kind I have seen in a friend of my 
own, who was attacked with violent vomiting and purging when- 
ever she happened to take even a very small quantity of egg- 
So sensitive was she, that on one occasion she was persuaded to 
eat a small portion of cake by the assurance that it contained 
no egg. Unfortunately the statement was -incorrect, and even the 
small piece of cake produced the usual symptoms of poisoning by 
eggs in her. In such a case as this the effect of the food as a 
poison appears to depend on the individual who takes it. With 
certain articles of food, which occasionally produce poisonous 
effects, these effects may be due in some instances to the indivi- 
dual Avho takes them, but in others to changes in the articles of 
food themselves. Thus cucumbers and melons are apt to bring on 
diarrhoea, which may be due in some cases to a peculiar sensitive- 
ness of the persons who eat them, but in other cases the disagree- 
able consequences may ensue from an accidental development of 
purgative principles in the fruits themselves. There appears to be 
a tendency to the formation of purgative substances in all plants 
belonging to the natural order Cucurbitacece, of which the cucumber 
and melon ai'e members. In the colocynth and elaterium plants 
the purgative properties acquire a high development, and even the 
cultivated melons and cucumbers appear sometimes to show a 
tendency to reversion in the same direction, and to acquire pur- 
gative properties more or less strong. In the case of animal food 
we find that poisonous properties are apt to appear either from 
particular modes of cooking, or from commencing decomposition. 
Thus, meat which has been baked in a pie, without a hole in the 
crust by which to ventilate it, is more apt to disagTee than the 
same meat boiled or roasted. Meat Avhich has been kept until it 
has become high, or fish which has become tainted, is also very apt 
to produce symptoms of poisoning. 



276 FOOD AND POISON. 

Till within the last few years we have been very much in the 
dark regarding the causes of the different phenomena just men- 
tioned, viz. : the tendency of milk and eggs to produce biliousness, 
or to be actually poisonous to certain persons, and of nitrogenous 
food such as meat, fish, or cheese to act as poisons when putre- 
faction has commenced, or of farinaceous food such as rye and 
maize to become poisonous when attacked by fungi. Even yet a 
great deal remains to be done before the subject is thoroughly 
cleared up, but so much has been done by recent researches that 
it may be useful to give their results shortly and to indicate the 
bearing of these results on the pathology of disease, and more 
especially on the pathology of biliousness and diarrhoea. The 
cardinal fact which results from all these researches is that 
albuminous, or perhaps to speak more correctly proteid, substances 
which are themselves foods may be split up so as to yield poisons. 
This decomposition is usually originated by various species of low 
organisms, and especially of bacilli, but it may be effected by the 
digestive ferments of the healthy body. The poisons formed by 
the decomposition of proteid bodies such as albumen, fibrine, and 
gelatine vary not only according to the particular body which is 
decomposed but to the particular organism or ferment which sets 
up decomposition, and according to the temperature at which it 
occurs and the length of time that it continues. Some of the products 
of the decomposition of proteid bodies are poisonous, others are 
innocuous. Amongst the poisonous bodies we find various degrees 
of activity, some being but slightly poisonous, while others are 
most virulent. When these poisonous products are separated from 
each other and isolated, they may remain unaltered and retain 
their properties for a length of time, but, when mixed together, 
they are apt to undergo further decomposition and become inert. 

In order to make it easier to remember and understand these 
different changes, 1 may perhaps be allowed to use a very homely 
comparison between the food we eat and the utensils we employ 
at our meals. Albuminous food will ordinarily do us no harm, 
although a large quantity of it eaten at once may mechanically 
produce uncomfortable distension of the stomach. The glass 
tumbler or earthenware plate that we use in taking our food or 
drink are also safe to handle, and will do no harm unless they 
strike with exceptional violence against some part of the body. 
But this holds good for albumen and for our utensils only while 
they remain whole, though the nature of the wholeness is different 



SPLINTERS— MECHANICAL AND CHEMICAL. 277 

in the two cases, being chemical in that of albumen and mechani- 
cal in that of the utensils, Wlien the tumbler or plate is broken 
across, the sharp edges may render them liable to cut the fingers, 
but the pieces may be put together with cement and they again 
become useful as before. When the chemical molecules of which 
albumen is composed are broken up in the process of digestion 
into peptones, these molecular fragments become dangerous, and 
peptones, when injected directly into the jugular vein, act as 
powerful poisons, producing loss of coagulability of the blood, 
fall of blood pressure, and death. But in the healthy body the 
peptones, formed by the digestion of albuminous matters in the 
digestion, do not enter the general circulation. Like the broken 
plate they appear to be cemented again into the kind of albumen 
known as globuline, during their passage through the portal vein 
and the liver. But it is not when the tumbler is merely broken 
in half, or albumen simply decomposed into peptones, that the 
fractured products are most dangerous. It is when the tumbler 
is broken into splinters that the pieces are most likely to produce 
serious injury; it is when albumen has been split up so as to yield 
organic alkaloids that the products of its decomposition are most 
poisonous. Amongst the broken glass we may find several pieces 
which have no sharp points and little, if any, sharp edge, so that 
they will be almost innocuous, while others may have a point and 
edge as sharp as a dagger, and capable not only of producing injury 
but of destroying life, and amongst these sharp pieces we may find 
some which are much more dangerous than others. In like 
manner amongst the products of decomposition of albumen we 
find some which are innocuous and others which are poisonous, 
and ainongst the poisonous we find various degrees of virulency. 
If we select from amongst the splinters of glass one with a sharp 
point and edge and lay it aside by itself, it may retain its danger- 
ous qualities unimpaired for years ; but if we leave it to be shaken 
about amongst the rest, and still more if we continue the very 
process of striking by which the splinter was at first formed, its 
point will be broken, its edges blunted, and it will become once 
more harmless. Similarly the poisonous products of albuminous 
decomposition when isolated may retain their properties unim- 
paired, but, if allowed to remain together, and still more if exposed 
to the continuous action of the putrefactive process by which they 
were at first formed, they undergo further change and aoain 
become innocuous. On this account the products of the decom- 



278 FOOD AND POISON. 

position of albuminous matters vary much in their poisonous 
properties according to the time during which decomposition has 
gone on. At first they are only slightly poisonous, later on they 
become intensely jDoisonous, but at a later stage still their poison- 
ous qualities disappear, and they become more or less innocuous. 

it is evident that the splinters of glass will vaiy according to 

the kind of glass, mode of striking it, and the force which we 

employ. If we break a large soda-water tumbler we will get 

longer, stronger, and more dangerous fragments than if we break 

a wine-glass, but the force which would splinter the wine-glass 

might simply crack the tumbler, and that which would split the 

tumbler into dangerous splinters might crush the wine-glass into 

harmless fragments. In the same way we find that the nature of 

the albuminous material influences the nature of the products of 

putrefaction. Wlien putrefactive bacteria are sown on the flesh 

of .mammals, the substance they produce is an exceedingly active 

poison, neurine, while they produce when sown upon fish another 

poison differing chemically from neurine although closely allied to 

it and resembling it also in physiological action. This poison, 

muscarine, is very interesting, inasmuch as it had only been 

obtained from a plant, the Agaricus muscarius, or fly-fungus, until 

it was discovered by Brieger to be a product of the decomposition 

of fish. Brieger has also found that the typhoid bacillus, when 

cultivated in peptone, forms no poison, but when cultivated in 

meat jelly or meat infusion it forms two poisons which he has not 

yet isolated completely. One of these causes salivation, diarrhoea, 

and paralysis ; the other causes violent and exhausting diarrhoea. 

The importance of an exact knowledge of the substances which are 

produced by the decomposition of various foods by the action of 

typhoid bacilli on them is obvious. The plan of treating typhoid 

fever by an exclusively milk diet has probably saved many lives, 

but our use of this plan is to a great extent empirical. We do 

not fully know why it is successful, and although we may suppose 

that it is because the milk is non-irritating and does not irritate 

the intestinal ulcers, that is probably only a part of the truth. 

For milk may, and sometimes does, form very hard clots, which 

may pass through a great part of the intestine undigested, and as 

we see in children may actually be voided in this condition. 

Farinaceous food on the other hand is chiefly digested by the 

saliva and pancreatic juice before it reaches the lower part of the 

small intestine, and even if it did pass over the ulcerated surface 



ELECTRICITY AND FERMENTATION. 279 

ought to do no harm by its meclianical action. Acting on tliis 
idea I have sometimes given starchy food in typhoid fever, but in 
a few trials it seemed to cause a rise in temperature, and I there- 
fore abandoned it. If the effect of food in typhoid fever is a 
purely mechanical one upon the ulcerated intestine, calfs-foot 
jelly ought to be tolerated ; but if the typhoid bacilli decompose 
gelatine so as to produce alkaloids having a violent purgative 
action, the jelly will be very injurious. 

The temperature at which the putrefactive processes occur 
greatly influences the rapidity with which the albuminous sub- 
stances split up, and the nature of the products which they yield. 
When the temperature is low decomposition occurs slowly, but does 
so quickly when it is high. It is probable that it may be much 
modified by other factors, such as the quantity of moisture in the 
albuminous substance itself, or in the atmosphere generally; and 
also by electrical atmospheric conditions, such as those which occur 
before or during a thunder-storm, for it is an old observation that 
meat as well as milk often becomes tainted during the electrical 
conditions wdiich are popularly expressed by the term "thunder in 
the air." The difference between the products of decomposition in 
hot and cold weather is illustrated by the alkaloids obtained from 
decomposing maize in summer and winter. The alkaloid which it 
yields in winter has a narcotic and paralysing action ; but when it 
decomposes during summer it yields, in addition to this alkaloid, 
another one which has a tetanising action somewhat like strychnine. 
As the putrefactive processes go on more quickly during summer 
albuminous substances become poisonous much sooner than in 
winter, and again lose their poisonous properties more quickly by 
the progress of decomposition. As putrefaction may go on to a 
certain extent after the introduction of food into the intestinal 
canal, and will probably from the higher temperature and greater 
moisture go on even more quickly than outside, it is evident that 
poisons may be formed from the part eaten, and produce dangerous 
symptoms, while no poison can be found in the remaining parts of 
the same food. This is perhaps of special importance in regard to 
milk when used as a food for infants. Milk may apparently be 
quite sweet at the time it is given, and yet it may be really " on 
the turn," as the term is. When swallowed by the infant it may 
rajjidly become sour, and disagree, while a portion of the same milk, 
especially if kept cool, may appear to continue sweet for some 
hours afterwards. It is highly probable that not the least advan- 



280 FOOD AND POISON. 

tage possessed by milk drawn directly from the breast, over that 
given by a bottle, is that the former is free from bacteria with 
which the latter is apt to be contaminated. Both may appear to 
be equally sweet when administered to the child, but the organisms 
present in the baby's bottle will continue their action after the 
milk has been taken, and render it liable to produc-e vomiting and 
purging, which, as we shall presently see, are symptoms of poisoning 
by putrefactive alkaloids. 

The risk of contamination is much greater when a bottle with a 
long tube is used, for the bacteria readily find a lodgment in it ; and 
it is to be remembered that not only do the bacteria present in the 
milk at the time it is swallowed continue to decompose it in the 
stomach, but they continue to multiply, so that if even a few are 
present in the milk when it is taken they may within a short time 
multiply greatly, and produce extensive changes in the food if they 
find conditions favourable to their growth in the intestinal canal. 

I have already mentioned that even the primary products of 
albuminous decomposition by digestive ferments such as peptones 
are poisonous. But Brieger has lately shown that pepsine will 
split up albuminous substances still further, so that by digesting* 
fibrine with artificial gastric juice he has obtained an alkaloid to 
which he has given the name of peptotoxine. 

The bitter taste which appears during the digestion of meat, or 
of milk artificially, is suggestive of the formation of some alkaloid, 
but I do not know whether Brieger has ascertained this bitterness 
to depend on the presence of an alkaloid or not. Of late years the 
use of digestive ferments, and of artificially-digested foods, has 
become so common that a study of the products of albuminous 
decomposition is becoming of extreme practical importance, for it is 
possible that digestive ferments, like other powerful agents, may be 
edged tools, and capable of doing harm as well as good. 

When we consider how many conditions influence the nature of 
the products of albuminous decomposition we cannot be astonished 
to find that very different substances have been attained by different 
experimenters. The chemical operations required to isolate the 
different products are so complicated and laborious that most 
experimenters have been satisfied with obtaining extractiform 
bodies, and have not attempted to crystallise them. But without 
obtaining them in a crystallised form one cannot be sure that they 
are pure, and the recent investigations of Brieger are therefore of 
great importance, because he not only obtained several products of 



PROD UCTS OF ALB UMINO US DECOMPOSITION. 281 

decomposition in a crystalline form, but has subjected them to 
organic analysis, and thus ascertained their chemical composition. 
The products of decomposition, or, as returning to the illustration 
we have already used, what we may term the splinters into which 
the albuminous molecule breaks up, are partly poisonous and partly 
innocuous. One fragment, as we may term it, wliich Brieger has 
got from flesh, is a substance called neuridine, which is innocuous, 
another, neurine, which is poisonous. From decomposing fish 
he has obtained a third substance, muscarine, which is more 
poisonous still, and two other substances, ethylenediamine, which 
is also poisonous, and gadinine, which is innocuous. 

Besides the substances which Brieger has got from decomposing 
flesh, fish, and cheese, in which decomposition has been artificially 
induced, he has obtained from human corpses, a different set of 
bodies, one of which he calls cadaverine, and the other putrescine, 
which are feeble poisons, and two others which are produced 
later and are more powerful poisons, causing paralysis and 
death. 

In addition to the alkaloids obtained by Brieger, a number of 
poisons have been got by other workers from decomposing articles 
of food or from dead bodies, and even from portions of healthy 
animal bodies. Although these may perhaps not have been got 
in the same state of purity, nor have had their chemical constitution 
so well defined as Brieger' s, they are still of great interest and 
importance. It is evident that when putrid substances are intro- 
duced into the body we must be careful to distinguish hetween the 
effects produced by the poisonous products of albuminous decom- 
position and those of the bacteria themselves, for the bacteria after 
their introduction may act upon the blood and tissues, and form 
poisons within the body itself even though none were present in the 
matter injected. Kerner appears to have been the first to suspect 
the formation of alkaloids by the decomposition of albumen, 
and in 1820 he pointed out the resemblance between the 
symptoms of poisoning by sausages and by atropine. He made 
experiments upon animals, and appears to have thought at first 
that an alkaloid was present in the poisonous sausage, but after- 
wards he forsook the idea and regarded the fatty acids as the 
poisonous agent. 

The researches of Magendie and Gaspard on the effects of decom- 
posing organic substances were important, but rather as affording 
a starting-point to researches on the effects of low organisms on 



282 FOOD AND POISON. 

the animal body than on the effect of chemical poisons produced in 
the putrefaction. 

In 1856 Panum showed that the inflammatory change which occurs 
in the intestinal mucous membrane of animals poisoned by putrid 
matter is not due to the microbes contained in it, but to a chemical 
poison which remained unaltered when its aqueous solution was 
boiled for a long time. His conclusion that the poison contained 
in putrid matter was of a chemical nature was confirmed by C. 0. 
Weber, Hemnier, Schweninger, Stich, and Thiersch. 

Bergmann and Schmiedeberg isolated a crystalline poison from 
decomposing yeast, to which they gave the name of sepsine. 

Bence Jones and Dupre found a substance resembling quinine in 
the liver. 

Zuelzer and Sonnenschein obtained both from macerated dead 
bodies and from putrefied meat infusion small quantities of a crys- 
talline substance which exhibited the reactions of an alkaloid and 
had a physiological action like atropine, dilating the pupil, paralys- 
ing the muscular fibres of the intestine, and increasing the rapidity 
of the pulse. 

Rorsch and Fasbender obtained from dead bodies a substance 
which had properties like digitaline, but which was not crystalline. 
Gautier obtained from putrefied proteid substances, and also 
from the secretions of living beings, alkaloidal bodies having a 
poisonous action. But the greatest impulse to the study of 
putrefactive poisons was given by Professor Selmi of Bologna, 
whose researches were unfortunately too soon brought to a close by 
his death. To alkaloids formed by the decomposition of proteid 
substances he gave the name of ptomaines, by which they are now 
known. It was at first supposed that these differed in their 
nature from organic alkaloids formed by vegetables, and various 
reactions were given to distinguish between them. Recent re- 
searches appear to show that this distinction can no longer be 
maintained, and that both animal and vegetable alkaloids are 
similar in their chemical constitution, and are both products of 
albuminous decomposition, I have already mentioned Brieger's 
discovery that an alkaloid psptotoxine is formed during the digestion 
of fibrine by artificial gastric juice. Pellicani has found a poison in 
the suprarenal capsule, and sometimes ptomaines may be obtained 
from the flesh of healthy animals. It is, therefore, probable that 
poisonous alkaloids are continually being formed in healthy men and 
animals by the decomposition of albumen in the intestinal canal 



POISONS AND ANTIDOTES. 2S3 

during the process of digestion, or in the blood and tissues generally 
by the metabolism which occurs during the functional activity. A 
considerable portion of these alkaloids is in all probability destroyed 
in the body, but some are excreted in the urine and fiBces, from 
both of which powerful poisons have been extracted. 

It used to be an old saying that nature never provided a poison 
without providing an antidote, and the fact that the dock leaf and 
the nettle usually grow together is often pointed to as an illustra- 
tion. In the case of poisonous alkaloids there seems to be a good 
deal of truth in this saying, for various poisonous alkaloids which 
have an antagonistic action to each other appear to be produced by 
albuminous decomposition. It has not yet been ascertained how 
far the symptoms of poisoning from decomposing fish, flesh, or 
sausages, or from the retention of morbid products of the organism 
itself, such as we see in cases of ursemia, depend upon a single 
poison or on a mixture of poisons. It seems, hi:-wever, very 
probable, that in many such cases we have more poisons than one, 
and that the comparative absence of symptoms in seme cases may 
be due to one poison counteracting another. Brieger has found 
that two of the most important alkaloids produced by putrefaction 
are neurine and muscarine; and to these may be added a thuxl 
substance, choline. Choline is obtained by boiling bile, brain, or 
yolk of egg, with baryta, and gets its name of choline from its 
having first been obtained by treating bile in the way just 
mentioned. It has for some time back been considered to be 
identical with neurine, but Brieger has been led by his recent 
researches to regard choline and neurine as two ditferent bodies, 
though very closely allied in their chemical constitution. By 
oxidising choline, obtained either from bile or from yolk of egg, 
with strong nitric acid, Schmiedeberg and Harnack have prepared 
artificial muscarine, which is almost, though perhaps not c[uite, 
identical with that which is found naturally in a poisonous mush- 
room (the Amanita mnscaria). iRecently Boehm has subjected 
choline and muscarine to a careful examination, and while he finds 
that their action is somewhat the same in kind, it varies in degree; 
muscarine being very much stronger than choline, and having a 
marked action on the heart of the frog which choline lacks. 
Artificial muscarine differs also to a certain extent fi'om natural 
muscarine, inasmuch as the artificial alkaloid possesses a paralysing 
action on the ends of motor nerves, somewhat resembKng that of 
curara, while the natural muscarine^ if it possesses this action at all. 



284 FOOD AND POISON. 

has it only to a slight extent. With small doses the effects of 
artificial and natural muscarine are almost identical, and it is only 
when the dose is large that the paralysing action upon the motor 
nerves of the artificial muscarine becomes evident. It may be 
said that all three bodies — choline, neurine, and muscarine — have 
a similar action, but choline is much weaker than the other two. 
The lethal power of neurine is nearly ten times, and that of arti- 
ficial muscarine fifty times, as great as that of choline. The most 
marked symptoms which they produce are salivation, diarrhoea and 
vomiting, dyspnoea, paralysis, and death. They seem to stimulate 
the secretion of glandular organs, because along with salivation 
there is also a flow of tears, and the secretion of bronchial mucus 
is rendered abundant and fluid, as is shown by the occurrence of 
abundant moist rales within the chest. The dyspnoea, however, is 
not entirely due to abundant secretion of bronchial mucus in the 
lutjgs, because even in frogs choline produces a peculiar alteration 
of the respiration and dyspnoeic movements. 

Muscarine and neurine produce in frogs a complete arrest of the 
cardiac pulsations, the heart stopping in diastole;^ but this cannot 
be regarded as the cause of the dyspnoea, because the respiratory 
movements in frogs are not dependent on the circulation in the 
same way as they are in warm-blooded animals. In mammals ^ mus- 
carine and neurine render the beats of the heart slow and w^eak, but 
do not usually arrest the cardiac pulsations, so that the heart is com- 
monly found to be beating after death has occurred. The dyspnoea 
produced by muscarine has been attributed by Schmiedeberg to 
excitement of the respiratory centre in the medulla oblongata ;3 
but I am inclined to think that in all probability contraction of the 
pulmonary vessels may have something to do with it; for one of 
the most marked points about the action of muscarine, neurine, 
and choline, is the extraordinary effect of atropine as an antidote 
to them. In animals poisoned by any of these three substances 
the subcutaneous injection of atropine stops the salivation, arrests 
the diarrhoea, and removes the dyspnoea. It also prevents death 
from these poisons, but only within certain limits : for if the dose 
be very great, the animals may still die. More especially is this 
the case with choline and artificial muscarine which paralyse the 
ends of the motor nerves, because the curara-Uke action is not 

^ Brieger, Ueher Ptomaine, pp. 26 and 34. 

2 Brieger, Op. cit, pp. 29 and 34. 

3 Schmiedeberg and Koppe, Pas Mii,scarin, p. 50. 



TJRJSMIA. 285 

counteracted by atropine, but is perhaps rather increased, atropine 
itself having also the power of paralysing the motor nerves when 
given in large doses. The effect of muscarine and neurine on the 
heart is also removed by atropine. It is possible that atropine 
removes the dyspnoea by destroying the effect of these drugs upon 
the heart and thus allowing the circulation to go on freely again, 
Yet as 1 have mentioned in a former paper, the injection of mus- 
carine causes the lungs to become pale, while the subsequent 
administration of atropine makes them regain their normal rosy 
colour, and I am inclined to attribute the dyspnoea produced by 
muscarine, partly at least, to contraction of the pulmonary vessels, 
and to regard the dilatation of these vessels by atropine as one of 
the reasons at least why this drug removes the dyspnoea. 

Although, as I have already said, we do not as yet know that 
ptomaines, having a physiological action like atropine, are generated 
in the intestines or in the tissues, at the same time as muscarine, 
nem'ine, or choline, it appears quite possible that such may be the 
case, and that we may have symptoms occurring which are due 
either to the mixture of two alkaloids or to the preponderance of 
one or other. A case of uraemia which I saw a few days ago was 
strongly suggestive of poisoning by a mixture of atropine and 
muscarine. The secretion of urine had completely stopped, the 
skin, eyes, and mouth were all dry, the pupil was somewhat dilated, 
the pulse was beating at the rate of about 130, the mouth was 
held constantly open, and the breathing was laboured and gasping, 
but air entered abundantly into the lungs, and there was no 
secretion of bronchial mucus. All these are symptoms such as we 
find from poisoning by atropine, but in two respects the symptoms 
resembled those produced by muscarine, for the skin was pale 
instead of being scarlet as in belladonna poisoning, and when 
cups w^ere ajoplied over the region of the kidneys in order to restore 
if possible the renal secretion, very little blood flowed from the 
incisions (cf. pp. 255, 256). 

I have already mentioned that Zuelzer and Sonnenschein have 
obtained from putrefying meat infusion, a substance having the 
chemical reactions and physiological effects of atropine ; and some 
such alkaloid appears to occur frequently in poisoning by sausages, 
so that in a case of sausage poisoning at Wildbad in 1793 the 
medical man who treated the case came to the conclusion that 
some one either through carelessness or design had put belladonna 
into the sausage. 



285 FOOD AND POISON. 

In anotlier case of sausage-poisoning described by Dr. Kaatzer, 
a family ate some smoked sausage at their mid-day meal; in half 
an hour afterwards they became unwell, with feelings of languor 
fatigue, and drowsiness, yet with such dryness of the mouth that 
they were unable to sleep, and were obliged to be constantly 
ddnkinof. In addition to this, the father had obstinate vomitino-. 
Next day the dryness of the throat was so mux;h greater they could 
hardly swallow, and the sight became affected. On the third day. 
the symptoms were worse, the pupils were widely dilated, there 
was double vision, dryness of the mouth and of the nose, and when 
bread was chewed it was ejected again from the mouth as dry as 
when it was put in. Next day the child of twelve years old died 
with symptoms of oeilema of the lung; and the father, though 
much affected, could not weep as his lachrymal secretion was 
paralysed. The father and mother gradually improved, but on 
the fourteenth day of the poisoning there was still complete 
paralysis of accommodation. In all of them, just as in the case of 
uraemia which I have just mentioned, there Wcis paleness instead 
of redness of the face — a symptom which I am disposed to regard 
as possibly indicating the presence of a muscarine-like poison, in 
addition to one like atropine. 

In other cases of sausage-poisoning additional symptoms have 
been noticed, which point to the existence of a muscarine-like poison 
also. These are the presence of diarrhoea, alternating with con- 
stipation, and of colic. The pulse also is sometimes slow, small, 
and almost imperceptible — a condition which is typically that of 
muscarine poisoning, while in atropine poisoning the pulse is rapid 
from the complete paralysis of the inhibitory fibres in the vagus 
which the poison produces. 

It is possible that instead of there being two or more poisons 
having a partly antagonistic action there may be only one having 
an action resembling atropine in some respects and muscarine in 
others. In some cases of poisoning by fish the symptoms have 
been those of poisoning by atropine, viz., dryness of the mouth, 
difficulty in swallowing, weight of the limbs, paralysis of the 
superior and inferior recti and of the oblique muscles of the eyes, 
as well as ptosis and paralysis of accommodation, dilatation of the 
pupil and double vision. The pulse was, however, not quickened 
as it is in poisoning by pure atropine.-^ V. Anrep ^ states that he 

1 Schreiber, Berlin. Jclin. TFochenschr. 1884, xxi. pp. 162, 183. 

2 V. Anrep, Vratch, 1885, p. 213, abstracted in London Med. Bee, 1885, p. 271. 



ANTIDOTES TO PTOMAINES. 287 

has isolated an alkaloid from poisonous fish, which produces 
similar symptoms to those just described as caused by fisli itself, 
and Vaugiian^ has obtained from poisonous cheese an alkaloid 
which he calls tyrotoxicon which produces symptoms similar to 
those caused by cheese or by fish. If the alkaloid should turn out 
to be perfectly pure we should be obliged to regard them as having 
an action similar to atropine in many re; pects, but differing fnmi 
it in respect to their action on the pulse. When we remember, 
however, how many vegetable alkaloids previously supposed to be 
pure have been recently shown to be mixed with others having a 
perfectly opposite action, we may still regard it as probable that 
the symptoms of poisoning by sausages, fish, &c., may in many 
cases be due to a mixture of alkaloids. 

In cases of poisoning by a ptomaine having a purely atropine- 
like action, the treatment indicated, which has also been adopted 
in at least one case, is the administration of physostigma either by 
application to the eye, or, perhaps still better, by subcutaneous 
injection. In cases, however, where the symptoms are of a mixed 
character, our knowledge of the combined effects of the poisons is 
sufficient at present to enable us to decide with certainty whether 
medication of this sort would be useful or injurious in any given 
case, although we may try that alkaloid as a remedy which will 
tend to remove the most prominent or distressing symptoms. It is 
evident that if an atropine-like poison is present in the body at 
the same time with choline, neurine, or muscarine, in sufficient 
quantity to antagonize them, the effects of those latter poisons will 
hardly be observed, although they may possibly evidence their 
presence by producing diarrhoea alternately with constipation. 
But if they are present alone, they may be expected to pro- 
duce salivation, vomiting, purging, and collapse, according to the 
quantity which is taken into the system. 

Where the symptoms are markedly those of a muscarine-like 
poison, we may try atropine as a remedy; and in one case lately it 
seemed to me to do good. A servant girl had taken at dinner some 
fried liver, and ten hours afterwards siie was seized with vomiting 
and puiging, which lasted the whole night. I saw her next 
morning and gave her some bismuth and soda, but the vomiting 
continuing I gave her fifteen drops of tincture of belladonna, and 
there was no vomiting afterwards. Of course this single case is 
quite insufficient to found a treatment upon, but I think that the 
1 Vuiiglian, Betroit Lancet, Aiigiist 1885, p. 60. 



288 FOOD AND POISON. 

administration of belladonna or atropine may be worth a trial in 
cases of poisoning by articles of food where the symptoms are those 
of muscarine or some allied poisons. 

Four alkaloids which Brieger has isolated from cadavers, viz., 
neuridine, cadaverine, putrescine, and saprine, have no marked 
physiological action ; but he has isolated from human cadavers in 
an advanced stage of decomposition two alkaloids having a very 
powerful physiological action. One of these, when injected into 
guinea-pigs or rabbits, appeared to affect the intestine alone, and to 
have no action on any of the other organs. It caused an enormous 
increase in the peristaltic action, which lasted for several days, and 
the continuous diarrhoea led to extreme weakness of the animals. 

Another alkaloid, which he terms mydalein, has a still more 
marked physiological action, and one which is of great clinical 
interest, inasmuch as we find amongst the symptoms a rise of 
temperature. IXo one who has watched cases of acitte disease, 
such as pneumonia, can have failed to see how a rise of tempera- 
ture sometimes coincides with the occurrence of constipation, and 
is removed by opening the bowels. In the case of such an acute 
disease as pneumonia, one has hitherto been unable to say 
definitely why constipation should produce this rise of tempera- 
ture, but it seems not improbable that it may be due to the 
absoiption from the intestine of some ptomaine. In his work on 
Purgative Medicines also, Hamilton says that in cases of typhus 
fever the administration of an antimonial remedy " was beneficial 
only when it moved the belly. In this case the faeces were black 
and foetid, and generally copious. On the discharge of these, the 
low delirium, tremor, floccitatio and subsultus tendinum which 
had prevailed were abated ; the tongue, which had been dry and 
furred, became moist and cleaner j and a feeble creeping pulse, 
acquired a firmer beat." 

The action of mydalein is according to Brieger perfectly specific 
in its nature. When a very minute quantity of it is injected into 
guinea-pigs or rabbits the under-lip in a short time becomes moist, 
the nasal secretion becomes more abundant, and a copious secretion 
of tears occurs. The pupils then become dilated, the vessels of 
the ear become much injected, and the rectal temperature rises 
from 1° — 2° C. The pupils gradually dilate to the maximum and 
cease to react to light. The coat of the animals becomes staring 
and sometimes they tremble ; gradually the secretion of saliva 
diminishes, the respiration and pulse, which at first were very rapid. 



ACTION OF MYDALEIN. 289 

become slower, the temperature falls, the ears become paler and 
the animals recover. During the action of the poison the animals 
show a tendency to sleep, and the peristaltic action of the intestine 
is increased. When larger doses are injected into guinea-pigs, even 
although they are still under half a centigramme {-i^ of a grain), 
their action is exceedingly violent and always fatal. The secretion 
of all organs composed of involuntary muscular fibre becomes 
exceedingly profuse; and the saliva becoming mixed with the 
intestinal discharges, the animals constantly lie in a puddle, 
especially as the power of motion is impaired ; exophthalmos occurs 
and the dilated pupils are difficult to examine on account of the 
profuse lachrymal secretion. When the action of the poison has 
attained its maximum the animals fall down, first the hind legs 
and then the fore legs becoming paralysed ; fibrillary twitchings are 
visible in various groups of muscles, and the respiration becomes 
more and more violent and gasping. Sometimes the animal makes 
a sudden upward spring, raising its head and gasping for air ; then 
it sinks down again and lies in its excrement, making slight 
defensive movements with its legs. The temperature gradually 
siuks, the movements become slighter and slighter, and finally the 
animal dies. On post-mortem examination the heart is found 
standing still in diastole and the bladder and intestine are con- 
tracted, but there is nothing else abnormal. In cats mydale'in 
caused dilatation of the pupil ; profuse secretion of tears, saliva, 
and sweat, vomiting and diarrhoea : to these succeeded paralysis 
first affecting the hind-legs and then the fore-legs, occasionally 
convulsive twitchings, laboured breathing, coma, and death. On 
post-mortem examination the heart was found standing still in 
diastole, the intestines contained a little thin fluid secretion, and 
the mucous membrane was injected. This alkaloid is, as I have 
akeady said, very interesting from the rise of temperature which it 
produces; but we do not as a rule find all the symptoms here 
described as characteristic of poisoning in animals occurring usually 
in men, either in cases of disease or in consequence of poisoning by 
decomposing food, although a number of them may occur. It is 
possible that the occurrence of some and not of others may be due 
to the occurrence in disease of alkaloids allied to mydalein, although 
not identical with it; or to the presence of two or more alkaloids 
which partially neutralise each other's effects. 

It is quite evident that it would be unjustifiable to conclude that 
because alkaloids are formed by the decomposition set up by 



290 FOOD AND POISOK 

bacteria in albuminous matters outside the body, they are there- 
fore formed constantly within the body, either in health or disease, 
however probable such a conclusion might be. But positive 
evidence that such a formation of alkaloids does occur in the 
intestine is afforded by the fact that alkaloids are found in the 
freshly voided faeces. 

That alkaloids are present in the circulating blood, is shown by 
the fact that they are separated from it by the kidneys, and are 
found in the urine. The effect of ptomaines formed in the body 
in producing disease has been investigated by Bouchard, who has 
found that the poisonous activity of human fseces is very great, 
even when they are quite healthy, and a substance obtained 
from them by dialysis, produces violent convulsions in rabbits. 
Bouchard considers that the alkaloids formed in the intestine 
of a healthy man in twenty-four hours would be quite sufficient to 
kill him if they were all absorbed and excretion stopped. When 
the functions of the kidneys are • impaired, so that excretion is 
stopped, uraemia occurs : and to this condition Bouchard would 
give the name of stercorsemia, because he thinks it due to alkaloids 
absorbed from the intestines. The nervous disturbances which 
occur in cases of dyspepsia, and of dilatation of the stomach, he 
thinks are due to nothing else than poisoning by ptomaines. 
Lepine and MoUifere describe the case of a man suffering from 
intestinal constriction, who suddenly became ill and died in two 
days Avitli all the symptoms of atropine poisoning, redness of the 
skin, delirium, dryness of the throat, extreme dilatation of the 
pupils with loss of reaction to light and rise of temperature. 
There was nothing to show that the patient had taken atropine 
or belladonna, and Ldpine and Molliere consider that he died from 
jDtomaines formed in the bowel and absorbed from it. They 
found in the contracted intestine a fiecal mass having a particularly 
bad smell, and they think that it was the source of the poisoning.^ 
There seems to be little doubt that the amount of ptomaines 
formed in the body in disease is greater than it is in health ; and 
very probably they are of a different character, possibly varying 
with the disease. According to Lepine and Guerin the poisons 
contained in the urine in diiferent diseases differ in their physio- 
logical action. The extract obtained from the urine in cases of 
typhoid produced in frogs increased reflex action and death after 
three hours, the heart being usually found in a state of diastole. 
1 Lyon Med., No. 42, 1884. 



CHEMICAL VACCINATION— TYPHOID BACILLUS. 291 

In cases of pneumonia the urine had a similar action, except that 
the heart was found in a more or less contracted state, varying 
with the severity of the case from which the urine had been 
obtained.! One author has gone so far as to consider that 
the immunity which one attack of an infective disease confers 
against a subsequent one, is due to alteration in the body, not by 
bacteria, or other low organisms, but by a chemical substance 
which they produce ; and he has proposed to afford protection 
against the disease by cultivating the bacteria artificially and 
inoculating mth the poison which they produce without the 
bacteria themselves. This does not seem a very promising method 
of treatment, but we are likely to obtain most useful information 
regarding the proper diet in disease, and especially in cases of 
intestinal disease, by observations on the nature of the poisons 
which bacteria produce when cultivated in different kinds of food. 

This investigation has been begun by Brieger, who found that 
the typhoid bacillus, although it grew well in peptone, appeared 
to form no alkaloids from it — at least he was unable to obtain any. 
When he cultivated it in beef-tea, however, he obtained as a 
product of decomposition an exceedingly small quantity of ptomaine, 
which had a marked peculiarity in its action, namely, that after 
death from it the heart was found constantly in a state of systoKc 
contraction, whereas most of the other alkaloids obtained from 
putrefying substances, such as muscarine, tend to produce stoppage 
of the heart in diastole. This alkaloid when given to guinea-pio-s 
caused slight salivation and increased rapidity of respiration ; later 
on the animals lost control of the muscles of the extremities and 
trunk, although there was no definite paralysis of the muscles 
themselves. The pupils became dilated and no longer reacted to 
light, salivation was profuse, and there was constant diarrhoea; the 
respiration and pulse became slower, but sometimes the animals 
did not die until after twenty-four or forty-eight hours. On ]3ost- 
mortem examination, in addition to the systolic contraction of the 
heart already mentioned, hyperaemia of the lungs was found, but 
the other organs were pale. The intestines were firmly contracted, 
and their walls were pale. Most of the alkaloids which have been 
obtained by the decomposition of albumen appear to belong to the 
muscarine type, and to have a tendency to cause diarrhoea, although 
some appear to belong rather to the atropine type, which, to a 
certain extent, counteracts the effects of muscarine. 
1 Lyon Med., No. 24, 188i. 

XT 2 



292 FOOD AND POISON. 

No alkaloid having a well characterised chemical formula appears 
as yet to have been isolated from cholera stools, but Nicati and 
Eietsch i have produced choleraic symptoms in animals by cultiva- 
tions of the comma bacillus from which the bacilli themselves had 
been removed ; and somewhat similar results were obtained several 
years ago by Lewis and Douglas Cunningham with cholera stools, 
in which any organisms present had been destroyed by boiling. 
In view of the extraordinary activity of some of those alkaloids, we 
cannot wonder at the violent symptoms which sometimes occur after 
the use of tainted meat, nor even at the extraordinary poisonous 
action of eggs in some persons. It is probable that the diarrhoea 
and vomiting which are produced by tainted meat, are due to the 
poison formed from the albuminous substance of the meat, by low 
organisms, either before it has been consumed, or by decomposition 
in the intestinal canal itself. In most persons eggs are harmless, 
but the yolk of eggs contains, in considerable quantity, lecithin 
from which choline may be readily formed; and if we suppose 
that in certain individuals choline, or perhaps even muscarine, is 
formed from eggs during digestion, we can readily see why this 
useful article of diet should prove to such persons a violent poison. 
It is more difficult to say why milk should, in some persons, prove 
poisonous. Milk also contains lecithin, but in small quantity ; and 
all we can say about it at present is that, in some individuals, a 
poison is probably formed from it, which causes it to disagree. 

But even when milk and eggs do not cause any immediate 
disturbance of the digestive functions, they sometimes produce, 
when taken for several days together, a condition which is generally 
termed biHousness. It is rather hard to define this condition, 
inasmuch as the term is an elastic one and includes a number of 
symptoms. Amongst them may be said to be a tendency to eruct- 
ation and acidity with an appetite which sometimes is very good, 
sometimes is bad, and sometimes is capricious. These symptoms 
may depend upon the condition of the stomach itself, but they 
may also be due to derangement of the liver, for all the venous 
blood from the stomach must pass through the liver on its way 
to the general circulation, and any obstruction to the hepatic 
circulation will produce venous congestion of the stomach and 
consequent disturbance of its functions. But these symptoms are 
* Com;pt. rend., xc. 928. 



BILIOUSNESS AND JAUNDICE FROM POISON. 293 

not nnfrequently accompanied, or succeeded after an interval of a 
day or two, by others which point more distinctly to the liver 
itself, such as slight frontal headache, a sallowness of complexion, a 
faint yellowish tinge of the conjunctiva, and a bitter taste in the 
mouth. These are usually attributed to the presence of biliary 
matters in the blood, the colour of the face and conjunctiva being 
attributed to bile pigment, and the bitter taste in the mouth to bile 
acids. But bile acids are not so very bitter — they are rather bitter- 
sweet, and healthy bile has no bitter taste, so that it seems that the 
bitterness in the mouth may, with more probability, be attributed 
to some alkaloid circulating in the blood, and excreted by the 
salivary glands. Along with this condition we sometimes find that 
the stools are pale, and then the explanation of the symptoms is 
easy, for we at once conclude that there is a catarrhal condition 
of the stomach and duodenum, and that the swollen mucous 
membrane presents a mechanical obstacle to the flow of bile from 
the liver. The pressure of bile in the biliary passages is thus 
increased, and absorption occurs. This explanation seems so satis- 
factory that we hardly care to look for another. But it is quite 
possible that it is not the true one. The real cause may be that 
the bile has become so viscid that it will not flow through the 
ducts, and even when the tendency to secrete such thick bile has 
passed away, the viscid bile already formed may plug the ducts 
and cause the jaundice to continue, even though the mucous mem- 
brane of the ducts and duodenum should be healthy. Moreover, 
we sometimes find that instead of the stools being paler than usual 
they are darker than usual, and it seems rather hard to say why we 
should have more bile than usual passing out into the intestine, and 
at the same time have bile absorbed into the blood. But here we 
gain much information from observations on the action of poisons. 
Schmiedeberg noticed that toluylendiamine, a substance belonging 
to the aromatic series, produced jaundice ; and the action of this 
substance has been further investigated by Stadelmann. Their 
observations show that this poison causes increased destruction 
of blood corpuscles in the liver, with increased formation of bile. 
At first all the constituents of the bile, both the solids and the 
water, are increased, so that a greater quantity of bile is secreted ; 
but as the action of the poison goes on the solids are excreted in 
greater quantity than the water: and so along with a great 
increase in the biliary solids secreted, the bile itself becomes more 



294 FOOD AND POISON. 

and more viscid, until at length it will not flow through the bile 
ducts, and thus absorption and jaundice takes place — although 
there is no mechanical obstacle to the passage of the bile into the 
duodenum. The first stage of the action of this poison corresponds 
to the condition of biliousness with excess of bile in the stools. 
It is possible that the second stage may correspond to so-called 
catarrhal jaundice, especially in epidemics, though it is also possible 
that the usual explanation of the causation of catarrhal jaundice 
may be in many cases the correct one. 

It is proboble that other bodies belonging to the aromatic 
series have also a considerable action on the biliary secretion, 
for salicylate of soda is a powerful hepatic stimulant, greatly 
increasing the secretion of bile. Unlike toluylendiamine, however, 
it greatly increases the water of the bile, and renders it thinner 
instead of more viscid. We do not as yet know what the action 
of the aromatic compounds formed in the intestine is upon the 
secretion of bile, but we know that a number of aromatic com- 
pounds are formed in the body and are excreted in the urine. 
These bodies are formed both in health and disease, and carbolic 
acid occurs in the urine of healthy men. It becomes much 
increased when the peristaltic movements of the intestine are 
interfered with;^ and occurs also in much larger quantity than 
normally in some cases of infective disease, such as diphtheria, facial 
erysipelas, pyaemia, and scarlet fever.'^ So far as I know toluyl- 
endiamine has not been obtained as a product of albuminous 
decomposition ; but another substance having, like it, the power 
of producing intense jaundice has been got from lupine seeds. 
Sheep fed upon these seeds frequently die, and one of the most 
marked symptoms is intense jaundice. From these seeds Kiihne^ 
extracted a substance to which he gave the name of ictrogen ; and 
this substance has been further purified by Arnold and Schneide- 
miihl, who give it the name of lupintoxin. It does not appear to 
be an alkaloid ; but rather a substance of an acid nature, but 
what its exact chemical nature is, has, so far as I know, not been 
exactly ascertained. 

Along with biliousness we frequently find headache, and many 
severe headaches associated with vomiting are popularly known 
as bilious headaches. Modern pathology is inclined to regard the 

1 Sa]kowski iind Leube, Lehre mm Earn, p. 143. 

2 Brieger, Weitere Untersicchungen uber Ptomaine, p. 70. 

3 Quoted by Robert, Schmidt's Jahrh., 1884, cciv. p. 13. 



BILIOUS HEADACHE AND INTESTINAL ALKALOIDS 295 

so-called bilious headaches as rather of nervous than of hepatic 
origin, and no doubt they frequently originate in mental conditions 
such as worry and overwork, and also in defective vision. Still, 
we are but very imperfectly acquainted with the links which 
connect excessive worry with pain in the head and vomiting : and 
I think it is probable that here, as in many other cases, popular 
opinion is based to a certain extent upon truth. Lately, during the 
epidemic of cholera in Spain, we have heard the same cry raised as 
in the Middle Ages, that the wells were poisoned, and the popular 
belief of the Middle Ages coincides with the result of modern 
scientific research in pointing to contaminated water as the source 
of disease, although the poisoning is due to the ignorance or care- 
lessness which allows sewage to enter the wells, and not to the 
direct introduction of poison by design. Similarly popular belief 
in regard to headaches is, I think, not entirely mistaken in giving 
to them the term " bilious," for while they may originate in the 
central nervous system, the hver may play a not unimportant part 
in their actual production. In the case of a lady who consulted 
me a short time ago, I was a good deal struck by her observation, 
that she was always better after the vomiting although she brought 
up no bile whatever, and she was puzzled to know how the mere 
action of vomiting could do good. Her observation to a certain 
extent corresponds with my own experience, and I am inclined to 
believe that the relief experienced after the vomiting may be due, in 
part at least, to the emptying of the gall ducts by the compression 
which the liver undergoes between the diaphragm and the abdominal 
walls in the act of emesis. The pressure under which bile is 
secreted is normally very low, and it is easy to see that if the bile 
should from any reason be more viscid than usual, mechanical 
pressure would be exceedingly useful, by tending to press the 
viscid bile, along with any alkaloid it may contain, out of the 
liver into the duodenum, and thus to prevent its re-absorption. 

I do not mean to accuse the bile of being the primary factor 
in the production of bilious headache. I should be inclined to look 
upon it more as an accessory, and to attribute the symptoms rather 
to the presence in the bile of some alkaloidal substance which, on 
passing into the general circulation, gives rise to vascular disturb- 
ance and headache. 

We must look to further observations upon the nature of the 
alkaloids formed by putrefaction ; upon the effect of typhoid and 
other bacilli, on milk, eggs, beef-tea, and other foods used in 



296 FOOD AND POISON. 

typhoid fever, to a more exact investigation of the alkaloids 
formed in the intestine and found in the fseces and urine, and to 
experiment upon the action of aromatic substances formed in the 
intestine upon the liver, for further knowledge which may aid us in 
treating disease, but enough has been already done to show what 
important effects on the animal body are in all probability pro- 
duced by the alkaloidal products of albuminous decomposition. 



INTEODUCTORY REMARKS ON THE STRUCTURE 
AND FUNCTIONS OF THE KIDNEY. 

(' The Practitioner,' vol. xxvii., August, 1881.) 

The progress of physiology and histology in recent years has been 
so rapid that it is difficult for men engaged in practice to keep 
up with it, and in addition to this difficulty there is yet another, 
viz. that the great majority of men are unable to retain, unim- 
paired, the knowledge which they have at one time acquired, 
unless they are constantly refreshing their memories. Thus it 
may happen that men who have been for a length of time engaged 
in practice may not be acquainted with the points in the histology 
of the kidney which have been discovered of late years, and tliat 
others, who have learned these, may have forgotten them. In 
order to save such practitioners the trouble of referring to special 
text-books on histology, I have thought that a few notes on the 
histology of the kidney may not be amiss. 

The function of the kidney is to separate from the blood the 
products of nitrogenous waste, as well as excess of salts, and 
various soluble substances which may have passed into the circu- 
lation. These are excreted in the form of a watery solution 
which is the urine. The blood which is to be purified passes to 
the kidney through the renal artery, and returns, purified, from it 
by the renal vein, and the products of waste pass out through the 
ureter. These structures enter into or pass out of the kidney at 
the hilus. The whole organ is covered by a closely-applied fibrous 
coat, which in the healthy kidney can be readily stripped off. 
The kidney may be looked upon as a large filtering apparatus, 
and the funnel into which the filtrate drains is the ureter. The 
upper end of the ureter is expanded so as to form the pelvis, and 
into this funnel-like dilatation the filtering apparatus of the kidney 



298 



STRUCTURE OF THE KIDNEY. 



projects in the form of small pyramids called the medullary pyra- 
mids, or the pyramids of Malpighi. The parts of the pelvis which 
lie between these are termed the calyces, or infundibula. The 
substance of the kidney itself consists of two parts — the cortex 
and the medulla. The medullary part has been' again subdivided 
into the boundary layer or marginal layer, and the papillary layer. 



Boundary 

layer of 

medulla. 
Papillary 

portion of 

medulla. 

Transverse sec- i 
tion of tubules f 
in boundary f 
layer. ) 

Fat of renal J 
sinus. t 



Transversely ^ \rgs^i, 
cotirsing me- >• i^ff"' 
dullary rays. ) 



Artery. 



Artery, 




Labyrinth. 

1 Medullary rays or 
\ pyramids of Ferrein 



MEDXrilA. 

Papilla -with calyx 
or infundibulum 
at each side. 
COBTEX. 



Ureter. 
Renal artery. 



Fig. 32. — Longitudinal section through the kidney. 

Henle.) 



(Modified from Tj'son, after 



When a section of the kidney is made, the cortex is seen to be of a 
light red colour, and of a granular appearance. It is on an average 
a little less than a quarter of an inch in width, and dips inwards 
into the medullary part, so as to divide the pyramids from each 
other. These prolongations of the cortex are called the columns 
of Bertin. The pyramids are darker in colour than the cortex, 
but striated instead of granular. The apex of the pyramid, 
to which the name of papilla has been given, projects into the 
pelvis, while its base is in contact with the cortex. The stria? 
radiate from the apex to the base. These strise indicate the 



MEDULLARY PYRAMLDS. 



299 



course of the urinary tubules and of the blood-vessels. The 
ajDical portion or paj^illary portion of the pyramids is somewhat 




Cortex. 



Boundary or marginal layer. 



Papillary layer. 



Fig. 33.— Horizontal section of kidney of dog (after Ludwig) : — h, fasciculi of urinary 
tubules prolonged as medullary rays ; m, into the cortex ; i, blood-vessels ; 
c, cortex proper, with glomeruli. 

lighter in colour than the basal portion, and in it the striae are 

y Cortex. 




. Border layer. 



\ Papillary layer. 



Fig. 34.— Diagram of the course of the uriniferous tubes, showing what parts of 
them occur in each layer of the kidney-substance. 

chiefly urinary tubules, the openings of which may be seen on the 
papilla. In the basal part of the pyramids, or boundary layer, the 



300 STRUCTURE OF THE KIDNEY. 

strise are not uniform, but run in alternate bands, and tbese bands 
indicate that this part of the pyramid is no longer uniform in 
composition like the papillary portion. The difference between 
the papillary and boundary layers is due partly to the presence of 
blood-vessels in much larger number in the medullary layer, and 
partly also to the uriniferous tubules being now no longer uniform 
in character. This want of uniformity is due to the presence in the 
boundary layer of portions of the urinary tubules which have come 
down into it from the cortical layer, and, after forming in a bend 
or loop, return back to the cortical layer before finally redescend- 
ing. To these portions the name of Henle's loops has been 
given. In the medullary layer both tubules and blood-vessels 
have a straight course, and thus give a striated appearance to the 
kidney structure. 

In the cortical substance both the renal tubules and the blood- 
vessels have a convoluted course, and the blood-vessels form 
numerous tufts which give a granular appearance to the cortical 
substance. This arrangement is seen in Figs. 33 and 34. 

But the cortex is not entirely granular. It consists of alternate 
bands of granular and striated substance (c and m. Fig. 33). The 
striated bands, to which the name of medullary rays or pyramids 
of Ferrein has been given, are composed of straight uriniferous 
tubules, surrounded by a longitudinal meshwork of capillaries, 
Figs. 30 and 32. These straight tubules consist partly of collecting 
tubes on their way to the papilla, partly of the ascending and 
descending parts of Henle's loops, and partly of certain convoluted 
tubules, which instead of forming Henle's loops pass straight down 
towards the papilla (Rose). To the granular bands (c. Fig. 33), 
consisting of convoluted tubules and vessels, the name of labyrinth, 
or cortex proper, has been given. 

The vessels of the kidney are large in proportion to the size 
of the organ, and it is to be borne in mind that instead of the 
arteries subdividing near the hilus, as one might imagine, and then 
running out towards the cortex, they run outwards between the 
pyramids as far as the inner surface of the cortex before they 
divide (Fig. 35). At the junction of the cortical with the medullary 
substance of the kidney the arteries divide and subdivide, forming 
arches between the cortical and medullaiy parts. From these are 
sent off branches, some running outwards towards the surface, and 
some inwards towards the pelvis. Those running outwards ace 
termed interlobular arteries, and those running inwards are called 



BLOOD-VESSELS OF THE KIDNEY. 



SOI 



t^e arterice recfce. From the interlobular arteries branches are 
oiven off which, after a short course, break up into cajDillary tufts 



STELLATE VEINS. 

rs 



luterlobular vein. 



Interlobular vein. 
Interlobular artery. 

Glomerulus. 



i 



T Glomerulus. 



Interlobular vein. 



Venous bundles. 



Bundles of venules. 



il 



Vasa recta. 1 



Interlobular artery. 
Interlobular vein. 



ArterisB rectje. 
Interlobular vein. 
Interlobular artery 
Artprife rectse. 

Arterial bundles. 



Bandies of arterioles. 



Venous plexus around the 

apices of the pyramids. — 

Fig. 35. — Diagram of the blood-vessels in the kidney (after Ludwig). 

or knots known by the name of Malpighian tufts or glomeruli. 
The branch going to the tuft is called the afferent artery (va, Fig. 
36), and the branch going from it, the efferent artery (ve, Fig. 36). 



302 STRUCTURE OF THE KIDNEY. 

The efferent artery, almost immediately after its exit, breaks 
up into a capillary mesh-work (Figs. 30 and 32), spreading around 
and among the tubules. From these capillaries the blood is 
collected by small rootlets which anastomose to form the inter- 
lobular vein, which runs backwards parallel with the interlobular 
artery. The vasa recta lie between the uriniferous tubules, running 
parallel with them. They partly form loops like Henle's urinifer- 
ous tubules in form, and partly break up into capillaries, forming 
an elongated mesh-work from which veins arise, and run back 
parallel with the arteries (Fig. 35). 




Fig. 36. — Mah^igliian glomerulus, va is tlie afferent vessel which springs from the 
interlobular artery ai, and breaks up to form the glomerulus ; ve is the eiferent 
vessel which conveys the blood from the glomerulus. 

The kidneys, as we have already said, are a filtering apparatus 
for the separation of water and soluble matters from the organism. 
But they are not simply filters, for they have to remove certain 
substances while they retain others, and to remove those in different 
quantities and different proportions according to the wants of the 
organism. There is, then, in the kidney, one part which seems to 
be devoted to pure- filtration, namely, the glomeruli, and another 
whose function is secretion, viz., the uriniferous tubules. The 
vessels of the Malpighian tuft are surrounded by a capsule, from 
which a long, excretary tube leads (Fig. 37). The tuft of vessels 
may be compared to a porous filter, and the capsule to a funnel, in 
which the filter lies, and which drains away the filtrate. It has 
been supposed by Ludwig that the secretion of urine is chiefly a 
process of filtration, the fluid which drains out of the vessels into 



MALPIGHIAN TUFTS. 



503 



tlie capsule of the Malpighian body, containing all the elements of 
the urine, and that the change which this fluid undergoes in its 
passage down the uriniferous tubules is simply one of concentration, 
a considerable portion of the water and some of the solids being 
re-absorbed by the epithelial cells lining the tubule. It has now 
been shown, however, by Heidenhain, that this view is not quite 
correct, and that the fluid excreted by the Malpighian tuft is to a 
great extent water, with, perhaps, a few salts, while certain solid 
ingredients are excreted by the epithelium of the tubules. The 




Fig. 37. — Diagram showing the relation of the Malpighian body to the uriniferous 
ducts and blood-vessels (after Ludwig). m, medullary ray or pyramid of Ferrein ; 
6, labyrinth or portion of cortex with tortuous tubules ; ai, interlobular artery ; 
va, afferent vessel ; gl, glomerulus ; ve, efferent vessel ; zv, venous twig ; vi, 
interlobular vein. 

tubules, as might be expected from their complicated function, 
possess a somewhat complicated structure. They nqt only vary 
in width at different parts of their course (Fig. 38), but the 
epithelium lining these different parts is also different. From the 
capsule surrounding the Malpighian tuft, often known as Bowman's 
capsule, the tubule passes off. At first it forms a constricted 
portion or neck, then it becomes dilated and very tortuous, and 
runs more or less transversely towards the adjacent medullary ray. 
It is known at this point by the name of the proximal convoluted 
tubule. It now runs downwards and is called the spiral tubule of 
Schachowa. It next becomes greatly constricted, and runs in a 
straight course down through the boundary layer, into the papillary 
layer, and here, bending suddenly upon itself and forming Henle's 
loop, it turns back and again ascends into the cortical layer. The 



304 



STRUCTURE OF THE KIDNEY, 



descending part of this loop is very narrow and straight. The 
ascending limb of the loop is more dilated and -winding, and 
becomes more or less spiral. As it ascends it becomes wavy, then 
irregular in outline (irregular tubule), and again dilated and 



straight part of collect- \ 
iag tube. t 

Wavy part of ascending ( 
limb of Henle's loop. \ 




Spiral part of ascending 
limb. 



Henle's loop, descending 
and ascending limbs. 



Collecting tube, 



Large collecting tube, or 
duct of BeUiiu. 



straight part of collecting tube. 
-- ) Intermediary segment or distal 
convoluted tubule. 
CORTEX. 
IiTegular tubule. 

Proximal convoluted tubule. 



Wavy part of ascending limb. 
Constriction or neck. 
Spiral tubule. 

Malpighian tuft surrounded by 
Bowman's capsule. 



Spiral part of ascending limb of 
Henle's loop. 



BORDER LAYER. 



Henle's loop, first thick portion 
of ascending limb. 



Henle's-loop, 
PAPILLARY LAYER. 



Fig. 38. — Diagram of the course of the uriniferous tubes (after Klein). 



convoluted. This second dilated or convoluted part is called the 
intermediary segment, or distal convoluted tubule. Beyond this 
the tube again becomes constricted, and joining with others, forms 
a collecting tube. This in its turn joins with others to form the 



EPITHELIUM OF THE TUBULES. 



305 



large collecting tube, or tube of Bellini, which opens into the 
pelvis at the papilla. The epithelium lining these different parts 



i - - G/ OM^RUL US 




Fiff. 39. — Diagram showing the relation of uriniferous tubes and blood-vessels. 



is, as I have already said, varied in structure. The cells covering 
the glomerulus and lining Bowman's capsule are squamous, those 
of the proximal convoluted tubule are short polyhedral, columnar, 
or club-shaped. In the spiral tubule they are also polyhedral, and 
have a tendency to fibulation. In the descending limb of Henle's 
loop they are flattened, in the ascending limb polyhedral, but 
flattened and fibulated. In the irregular tubule they vary accord- 
ing to the thickness of the tube, and are polyhedral, pyramidal, or 
short columnar. The distal -convoluted tubule has a structure 
exactly like that of the proximal convoluted tubule. The collect- 
ing tubes have transparent polyhedral cells whose size varies 



306 STRUCTURE OF THE KIDNEY. 

according to that of the tubules. Around the tubules is a net-work of 
capillaries (Figs. 37 and 39), the blood in which plays, no doubt, a 
very important part in the processes of secretion which occur in 
the various parts of each tubule. Between the tubules there is a 
net-work of lymph spaces, which communicate freely with each 
other^ as well as with the lymphatics on the surface of the kidney, 
and those which issue from the hilus along with the blood-vessels. 
Between the tubules and the vessels, also, a small amount of 
connective tissue is found, and a number of small nerve filaments 
derived from the renal plexus and the smaller splanchnic nerve 
accompany the final branches of the arteries. 



SYMPTOMS, PATHOLOGY, AND TREATMENT OF 
ALBUMINURIA.^ 

{'The Practitioner,' tol. xv., Nov. and Dec, 1876.) 

A VERY large proportion of the patients that medical men in 
large towns are called upon to treat present symptoms of anemia or 
want of blood. 

They are pale and washed-out-looking, their whole appearance 
being apt to recall the blanched look of a washerwoman's hands, 
and when we examine the gums and the inside of the lips, or pull 
forward the lower eyelid, and look at its inner surface, we find that 
all the mucous membranes are paler than in health. 

When we come to question the patients, we find that they 
complain of the very symptoms which we might a priori predicate 
from the condition of the blood. As it is frequently convenient 
to be able to tell the patient what he or she feels, we will run over 
in order the symptoms of which persons suffering from anaemia 
usually complain. First of all, the use of the blood is to nourish 
the tissues generally, and the muscles among the rest. If the 
blood be defective either in quantity or quality, the tissues will be 
insufficiently nourished, the muscles will be unable to do their 
ordinary work, and the patient will complain of being weak and 
easily fatigued. 

Secondly, the blood has to act as a carrier of oxygen from the 
lungs to the tissues. All muscular work, all secretion from glands, 
in fact we may say, every process of life is a process of combustion. 
Whenever the supply of oxygen fails the work is lessened, and at 
length stopped entirely, just as the exclusion of air would extinguish 
the fire in a furnace, and bring to a complete stand-still the engine 
to which it furnishes the motor power. 

Now the combustion in the body goes on at a great distance 
1 Eead before the AbemetMan Society at St. Bartholomew's Hospital. 

X 2 



308 ALBUMINURIA. 

from the outer air, and it would stop for want of a sufficient supply 
of oxygen were it not for the bsBmoglobin of the blood. The 
hsemoo'lobin is the red colouring^ matter of the blood, and is con- 
tained in the red corpuscles alone. When they are deficient it is 
deficient, and its chief function and theirs is to act as a carrier of 
oxygen. It takes up this gas in the lungs, carries it to the tissues, 
and then gives it up to them. At each breath that a man takes 
he saturates a quantity of the haemoglobin in the blood-vessels of 
his lungs with oxygen, and then on it goes to his muscles to keep 
up combustion in them. If he is running, leaping, rowing, or using 
his muscles much in any way whatever, they must get more oxygen 
than when he is sitting or lying, and in order to give them as much 
as they need he must breathe much often er than usual. By doing 
this, a healthy man can get enough oxygen to enable him to make 
great exertions, and if his work is only moderately hard he scarcely 
feels that his breathing is different from usual. But if he unfortun- 
ately happens to have a quantity of fluid in his chest, so that one 
lung can only expand to half the size it ought to do, he cannot 
take in the proper quantity of oxygen at each respiration. He is 
therefore obliged to breathe oftener, so as to make up for the small 
quantity of air that he can take in each time, and so a moderate 
exertion will make him puff and blow like a healthy man after a 
hard run. 

Now, exactly the same thing takes place when a person has too 
little hsemogiobin and red blood corpuscles as when he has too 
little available lung tissue. It is easy to see this. If a man has 
only half the quantity of h£emoglobin in his blood that he ought to 
have, it can only take up about half the amount of oxygen that it 
ought to do, and there is not much to choose between this condition 
and the case where only one lung is working, and thus giving only 
half the proper quantity of oxygen to the blood. If the blood only 
takes half the right quantity of oxygen, it is much the same as if it 
only gets half the right quantity. 

Thus it is that ansemic persons are short of breath, and if they 
go quickly up-stairs, they puff and blow so that they cannot 
speak when they get to the to^D, and, in short, they are incapable 
of any great exertion. 

Thus the first symptom of anoemia, not to mention the pallor, is 
muscular weakness ; the second is shortness of breath. 

The third symptom, or set of symptoms, refers to secretion. 
As I have already said, secretion is a process of oxidation 



SYJIPTOJLS OF Ay.EMJA. 309 

as mucTi and perhaps even more than muscular contraction. 
Ludwigi and Spiess found that the saHva secreted by the sub- 
maxillary gland of a dog was actually 1|° C. warmer than the 
blood of the carotid artery, and of course to heat the saliva in 
tliis way there must be very active combustion going on in the 
gland during the process of secretion. To supply the oxygen 
required for this combustion, the arteries of the glands are found 
to dilate, and torrents of bright-red oxygenated blood rush rapidly 
through them. Nor is this process confined to the salivary glands 
alone. The stomach, the pancreas, and probably also the intes- 
tines, all get a copious supply of arterial blood during the process 
of secretion, and although a rise of temperature indicative of 
active combustion has not been demonstrated to take place in 
them during the act of secretion, it is in the highest degree 
probable that these other glands resemble the salivary ones in 
this respect. Seeing, then, that oxidation plays such an important 
part in secretion, we could hardly expect that it would go on 
briskly^ any more than that the muscles would work easily, when 
the blood is poor in haemoglobin, and the supply of oxygen which 
it ought to convey to the glands is consequently deficient. 

Now the whole process of digestion depends on secretion, and 
if the sahvary glands and pancreas do not secrete properly, the 
starchy part of the food will not be rendered soluble; if the 
stomach does not pour out gastric juice, the albumen and fibrin 
will not be digested ; and if the pancreas is not working, the fats 
will pass out unchanged. And even when these organs do their 
work after a fashion and succeed in digesting the food at length, 
yet if they secrete their appropriate juices in small quantity the 
food will be only slowly digested. It will then undergo partial 
decomposition in the intestine instead of being rapidly dissolved, 
and will give rise to the formation of gas in the intestines with 
all its attendant discomforts. The symptoms of this condition are. 
— there is no appetite, the food lies heavy at the stomach, and 
there is frequent belching of gas which often brings up with it 
particles of undigested food or sour burning liquids. There is 
often nausea, sometimes retching, or vomiting. The bowels are 
sometimes very loose and at others very confined. 

We may thus add to muscular weakness and shortness of breath 
a third symptom of anaemia, viz. dyspepsia. 

Having thus found that the muscular, respiratory, and digestive 
1 Ladwig's Physiolocjie, vol. ii. p. 341. 



310 ALBUMINURIA. 

functions are all impaired by ansemia, we naturally inquire how 
the nervous system gets along. The brain cannot work without 
oxygen any more than the muscles ; indeed it requires a still more 
constant supply than they, and when we direct our attention to 
it we find that it enjoys no exemption from tbe general debility. 
Deficiency of motor power manifests itself in languor, listlessness, 
and laziness, while the sensory functions evidence their disturbance 
by giddiness, drowsiness, headache, weight in the head, throbbing 
of the arteries, neuralgic affections, and numberless odd nervous 
symptoms, which lead medical men who are themselves suffering 
from ansemia to believe that they have all sorts of mischief going 
on within their brain-pan, until a little quassia and iron removes 
their symptoms and allays their apprehensions. 

We come lastly to the circulation, and we find that it too 
suffers, so that although we have put it last, one of the symptoms 
connected with it sometimes attracts our attention more than all 
the others together. This symptom is cedema or swelling from the 
presence of fluid in the cellular tissues. 

How does this fluid come to be there ? During life there is 
a constant exudation of fluid from the blood-vessels, and after 
this has done its work by affording nutriment to the cells of which 
these tissues are composed, it is again absorbed, partly by the 
veins and partly by the lymphatics. In health the exudation and 
absorption balance each other, and so there is no accumulation of 
fluid in the tissues; but whenever the exudation becomes too 
rapid, or the absorption becomes too slow, such an accumulation 
takes place. Yfhen it occurs in the tissues it is called cedema; 
when in a large lymphatic space, better known perhaps by its 
more common name of serous cavity, it is termed dropsy. 

Now absorption has been shown by Goltz to dej^end very much 
on the vaso-motor nerves.^ When these are acting powerfully, 
absorption takes place rapidly; when they are acting slightly, 
absorption takes place slowly. 

Deficient action of these nerves also causes fluid to be poured 
out more I'apidly from the vessels,^ as well as to be absorbed more 
slowly. Thus any weakness of the vaso-motor system tends to 
produce oedema in a double fashion, and to such weakness we 
may probably ascribe the oedema we meet with in ansemia. It 

^ Pfliiger's ArcMv., vol. v. p. 33. 

^ Ranvier. Eecherches Exjiei'imentales sur U Production de VCEdomc, Comptcs 
rendus, 1869. 



CAUSES OF ANEMIA. 311 

is quite evident that if tlie oedema is dependent on deficient 
re-absorption, we shall find it most marked in those parts where 
the circulation in the veins and lymphatics is most languid — i.e. 
in the feet and ankles ; and this is indeed what we do find in 
oedema depending on venous obstruction ; but when it depends on 
excessive exudation also, it may be found wherever the tissues are 
loose, as in the lower eyelid and scrotum. In health the vaso- 
motor nerves keep the arterioles throughout the body more or 
less contracted, and thus prevent the blood which the heart 
pumps into the aorta from running out quickly into the veins. 
They thus keep the arteries always well filled and fairly on the 
stretch, so that the heart cannot stretch them still more by empty- 
ing itself into them, without using a fair amount of force. But 
when the vaso-motor system gets weak, it no longer keeps the 
arterioles up to their work, and in consequence they occasionally 
dilate and let the blood through them more quickly than they 
ought. The arteries consequently get partially emptied; the 
heart can pump all the blood into them with almost no exertion, 
and so it sometimes seems as if it did not know what to do with 
its superabundant energy, and works fast and loose like the 
driving-wheel of a locomotive on a piece of greasy rail. Another 
symptom of anaemia is^ therefore, ^al23itation. 

We may now at last count up on our fingers the symptoms of 
anemia, not reckoning, but always bearing in mind, the pallor of the 
patient. We have (1) muscular weakness; (2) shortness of breath; (3) 
dyspepsia ; (4) weakened nervous system, both sensory and motor ; 
(5) weak circulation leading to palpitation, and oedema or dropsy. 

All the varied symptoms included under these five heads may, 
as we have seen, be caused by anaemia, though we must not 
forget that some of them may be present without anaemia. For 
example, an individual may come complaining of dyspepsia, 
though a single glance at his plethoric countenance shows you 
that no want of blood is the cause, but rather gourmandizing 
and gluttony above the powers of even the most healthy stomach 
to sustain. But supposing we have all the symptoms included 
under the five heads just given, and the pale face and blanched 
mucous membranes leave no doubt on our minds as to the pre- 
sence of ansemia, we have next to ask what is the cause of it, 
in order that, instead of trying to remedy one symptom by itself 
and another symptom by itself, we may stiike at the root of the 
disease and remove the ana3mia on which they all depend. 



312 ALBUMINURIA. 

There are two ways in which a man may come to want money ; 
(1) he may not get enough to supply his daily wants, either from 
laziness or misfortune ; or (2) he may lose what he has either by 
being extravagant and squandering until poverty compels him to 
tighten his purse-strings — steadily living above his income, and 
thus losing his fortune by degrees ; or by rashly speculating, and 
thus losing a great part of it at one stroke. 

And just so it is with the blood. We use up some of it every 
day to keep our tissues in working order; and unless this loss 
were regularly compensated by the food we eat our blood would 
soon be too much reduced in quality, if not in quantity, to sustain 
life. For be it remembered that a proper quantity of blood will 
not nourish the tissues if its quality be deficient, any more than 
an ounce of copper will pay a man's debts when they amount to an 
ounce of gold. Whenever, then, this nourishment, which is daily 
received into the blood, is insufficient to supply the daily ex- 
penditure on the tissues, anaemia will, in a greater or less degree, 
be sure to follow. It does not very much matter whether the 
supply of food taken into the mouth is insufficient, or whether 
imperfect digestion prevents assimilation. Dyspepsia, then, by 
lessening the appetite, and rendering the digestion of such food 
as is consumed less perfect than it ought to be, has much the 
same effect as partial starvation, and is one cause of ansemia. 

But ansemia we have already seen to be a cause of dyspepsia ; 
and thus the one aiding the other they go on from bad to worse, 
in a vicious circle, unless something interferes to break it. 

The cases of ansemia which I would liken to the spendthrift are 
those of chlorotic girls where the aucemia really seems to depend 
on some of the organs or tissues using up the blood in a way they 
have no right to do, and thus squandering the precious fluid with- 
out getting any good from it, and indeed without one's being able 
to see where it has gone, unless the deep-red colour of the urine 
one gets in such cases on the addition of nitric acid to it may be 
taken as an indication that more than a fair share of the haemo- 
globin of the blood has undergone some mysterious transformation, 
and found too ready a way of escape through the kidneys. 

Anaemia may also be a consequence of sudden and considerable 
losses of blood, such as those which occur in menorrhagia, or from 
bleeding piles, which not unfrequently drain away the vital fluid 
and sap the patient's strength, ere ever he be aware of the mischief 
which is going on. 



ANEMIA FROM ALBUMINURIA. 313 

Important as these causes of ansemia are, there is yet another 
no less important, and in which the drain is still more constant, 
although in it one may not see the blood actually leave the body 
while still retaining its well-known colour. 

This cause to which I wish especially to direct your attention is 
albuminuria. 

In it the blood is constantly losing one of its most important 
constituents, the albumin, which leaks through the kidneys along 
with the urine, and thus runs to waste instead of remaining in the 
body and ministering to its nutriment. Although the serum- 
albumen thus lost is not a constituent of the red blood corpuscles 
yet the deficiency in it seems in some way to affect them, and their 
numbers diminish, possibly, though we cannot say with certainty, 
because they cannot get the albuminous constituents of their 
haemoglobin in requisite quantity. For it must be remembered 
that the haemoglobin, or colouring matter of the blood, which plays 
such an important part in the oxygenation of the tissues, consists 
of an albuminous substance, globulin, and a non-albuminous sub- 
stance, hsematin. There are regulating arrangements in the body 
which keep all its different parts in mutual harmony and 
dependence on one another, so that, as St. Paul said long ago, 
" if one member suffer, all the members suffer with it," and if one 
part is starved, the other parts frequently, if not always, suffer 
privation with it. The serum-albumin being, then, deficient in 
the blood, it is not at all astonishing that the albuminous con- 
stituent of the colouring matter should also be below par. 

The symptoms of albuminuria are, therefore, those of anaemia, 
and we often suspect the presence of the disease from the mere 
look of the patient before we have addressed a question to him or 
applied a single instrument of physical diagnosis. There is not 
only paleness from the general want of blood, but there is a greater 
tendency to oedema than in other forms of anaemia, so that the face 
is not only pale, but puffy, pasty, or doughy looking, with a 
tendency to swelling about the lower eyelids. The ankles and 
shins are frequently cedematous and pit on pressure, and there may 
also be accumulations of fluid in one or other of the serous cavities. 
These appearances in a patient at once arouse a suspicion of 
albuminuria, and we proceed to test them by examining the urine. 
In a state of health this secretion should be absolutely free from 
albumen. We detect the presence of this abnormal constituent in 
two ways : 1st, By boiling ; and, 2nd, by adding nitric acid. On 



314 ALBUMINURIA. 

boiling urine containing albumin, coagulation takes place, and 
accoaxling to the quantity present we have either a faint haze 
giving an opalescence to the liquid, a heavy coagulum, or any inter- 
mediate condition between these two. There are some fallacies 
in this test, however, which require attention, for ignorance of them 
may lead us to imagine that there is no albumin when it is really 
present, or to fancy it there when the urine is completely free from 
it. The first fallacy is that serum-albumin forms compounds both 
with alkalis and acids, to which the names of alkali-albumin and 
acid-albumin have been given respectively. Now neither of these 
compounds are coagulated by heat, and although serum-albumin 
itself is readily coagulated by boiling, yet if acids or alkalis are 
present when we begin to heat it, ths very warmth of the liquid, 
as we gradually raise its temperature, causes the albumin to com- 
bine with the acids or alkalis and form acid-albumin, or alkali- 
albumin. Thus it may happen that by the time we reach the 
temperature at which the albumin should be precipitated it is no 
longer present in its original condition, its combiaations being 
already complete. 

Thus, if the urine be very strongly acid, or very strongly alka- 
line, we may get these compounds formed,, and thea heat produces 
no coagulation, although albumin is present. We therefore 
ascertain the reaction of the urine by means of litmus paper 
before applying heat. As the tissues of the body are all alkaline, 
it is very unlikely that the urine Avill contain so much free acid as 
to produce acid-albumin, and indeed such a condition is almost 
nev(ir found except in persons who have been taking large quan- 
tities of mineral acids.^ In such a case we would add sufficient 
alkali merely to neutralise the acid before we boiled the urine, 
but this is so rarely necessary that we generally disregard this 
source of error. Excessive alkalinity, however, is not so uncommon, 
and we very frequently have to add a few drops of acetic acid to 
the urine so as to render it slightly acid before boiling. 

This addition of acid, however, serves a double purpose, and not 
only enables us to detect the albumin more certainly when it is 
present, but prevents us from mistaking other things for it when 
it is absent. 

In some urines alkaline phosphates or carbonates are precipi- 
tated by heat and may be mistaken for albumin, but a drop or 
two of acetic or nitric acid prevents their precipitation, or if added 
^ Stockvis, Sur V Albiuninurie, p. 3. 



TESTS FOR ALBUMIN. 315 

after they have already been thrown down dissolves them again 
and causes the urine which they have clouded to become clear 
again. 

It is thus evident that heat alone without acid is an insufficient 
test for albumin. Nitric acid coagulates albumin and causes a haze 
or coagulum just like heat, but nitric acid alone without heat is 
also unsatisfactory and may be deceptive. If the urine contain 
a large quantity of urea, the nitric acid may cause the formation of 
a crystalline precipitate of nitrate of urea, which is, however, but 
rarely mistaken for albumin. But if urates be present in large 
proportion, one is much more likely to fall into error, for the nitric 
acid drives out uric acid from its combinations with soda or potash, 
and free uric acid being much less soluble than urates a precipitate 
is formed which is much more likely than the urea one to be mis- 
taken for albumin. A little heat now applied to the urine causes 
either urea or uric acid to redissolve, and the urine clouded by 
them to clear ; but it has no effect on the haze or coagulum 
produced by albumin. 

In testing for albumin, then, the best method of proceeding is 
to allow three or four drops of nitric acid to trickle down the side 
of the test tube containing the urine. If no haze appears we may 
conclude that the urine is free from albumin.^ It won't do to 
pour in acid until the test tube is half full, for it is possible that if 
only a little albumin is present it may be converted into acid- 
albumin and dissolved by the concentrated acid. If a cloudiness 
appears we must not at once conclude that it is due to albumin, 
but must warm the urine over a spirit lamp. If it is really 
albuminous the opacity will remain, but if the cloud is due to uiea 
or uric acid it will disappear. 

So much for the symj)toms of albuminuria, which are paleness 
and pastiness of the face, a tendency to oedema and dropsy, 
complaints of weakness, shortness of breath, dyspepsia, nervous 
symptoms, and, I may add, occasionally palpitation, associated with 
the presence of serum-albumin in the urine. 

The next thing we have to do is to inquire how the albumin 
which we find in the urine gets there, and in order to do this we 
must take a glance at the structure of the kidney. 

The function of this organ is to separate the products of tissue 
waste and any excess of Avater which may be present in the blood, 
but at the same time to prevent anything that is of use to the 
^ Stockvis, S'ur l' Aliuminitric, p. 4. 



316 ALBUMINURIA. 

economy from passing through. When we wish to separate two 
substances, one of which is insoluble and the other soluble, in the 
laboratory, we use a filter, and we have in the kidney an apparatus 
for filtration. When we wish to filter rapidly we use a number of 
filters at once, so as to increase the surface of filtering paper, and 
if we are in a great hurry we help the fluid through by means of 
pressure, generally that of the atmosphere, as in a Bunsen's pump. 
In the kidney we have something similar, for the renal artery 
inside the kidney divides into branches, which break up into knots 
of small vessels, thereby increasing their surface enormously ; and 
the renal artery is extremely wide, so that there is always a con- 
siderable pressure on these little vessels compared with what there 
usually is on small vessels generally. And just as a filter is put in 
a funnel which collects and conveys away the filtrate, so these 
bunches of arterioles or glomeruli, as they are called, are enclosed 
in a little bag or capsule which collects the urine as it exudes 
through them. But the urine, as it filters through, contains a 
number of salts which may be utilized in the body, and more water 
than the organism can well afford to lose. Therefore, before it is 
excreted it passes through a long winding tube lined with epithe- 
lium and dilated at two points, while it is narrow at two others. 
Thus the fluid finds a difiiculty in getting through rapidly, and lies 
for a while in the dilated parts of the tube, so that the epithelial 
cells which line them have plenty of time to absorb the superfluous 
water and the salts, which may again be utilized. But what are 
the cells to do with this water and salts ? How are they to get 
rid of them ? They do so by giving them up to the veins, which 
form a plexus all round these tubes, and absorb and convey away 
into the general circulation all that the celJs remove from the 
tubules. It is thought by many, and with great probability, that 
the cells lining the tubules do not merely absorb from the tubules 
the water and salts which they give up to the veins, but that they 
also take from the veins various products of tissue waste, especially 
urea, and excrete them into the tubules. Between the tubules 
and veins are lymph spaces, in which both they and the arteries 
lie, and this fact I wish you specially to remember, as it is of great 
importance. We may, if we like, look on the kidney as a sac 
containing lymph, in which the arteries, tubules, and veins are all 
imbedded, though they are packed so thickly together that we 
hardly recollect that there is any lymph space there at all; just as 
when we stuff a lot of tow into a pan of water so as to fill it, we 



SIZE OF MOLECULES— DIFFUSION. 317 

see only the fibres of the tow and forget that they are lying 
imbedded in water, which fills all the interstices between the fibres. 
This will be more evident if we look at the right-hand side of the 
accompanying diagram (Fig. 39, p. 305), in which the tubules, 
arteries, and veins, thickly crowded together as they are, may be 
fairly compared to the closely-packed fibres of a bundle of tow, 
while all around them is lymph. At the left-hand side of the 
diagram the capillaries have been omitted so as to show the course 
of the tubules more plainly. Now, ordinarily, the glomeruli do not 
let out any albumin, though they allow water, salts, urea, and such 
like crystalline products to filter out, or possibly it might be more 
correct to say diffuse out, seeing we have fluid on the outside as 
well as inside of the arterial twigs instead of air on the outside as 
in ordinary filtration. But filtration and diffusion seem to be 
merely varieties of the same process, if we accept the experiments 
of Moritz Traube.^ The molecular weight of a body seems, accord- 
ing to him, to represent the size of a single molecule, and a body 
with a low molecular weight, and consequently with a small-sized 
molecule, will pass through the minute pores of an animal or 
vegetable membrane when the big molecules of a body which has a 
large molecular weight would stick on their way. Thus you know 
that Graham divided bodies into crystalloids and colloids, because 
crystals when dissolved generally diffuse easily, while bodies which 
do not crystallize hardly diffuse at all. But hgemoglobin, the 
colouring matter of the blood, forms beautiful crystals, and yet it 
does not diffuse, a fact which seems difficult to explain unless we 
adopt Traube's hypothesis, and then it is as plain as possible. 
Most crystals have a low molecular weight, but hgemoglobin has 
an enormous one, its formula, according to Preyer, being C1200 Hgeo 
N154 F2 Sg O354, so that its giant molecules are simply too big to get 
through the pores of a membrane. 

Now serum-albumin, as I have said, does not diffuse through 
the kidney, but white of eg^ does, and whenever we inject white 
of egg under the skin it ajDpears again in the urine, and the same 
is the case if a man eats more eggs than he can digest. A single 
raw &gg drank before a race is popularly said to give a man wind, 
but I have heard of a man who, when about to run a race, instead 
of one, drank eleven eggs, with the result that, instead of improving 
his wind immensely as he expected, he could not run at all. I 
have little doubt that if his urine had been examined albumen 
1 Centralhlatt /. d. mcd. Wissenschaften, 1866, p. 97. 



318 ALB UMINURIA . 

would have been found in it. AVhen eggs are injected into the 
rectum also, part of the albumen sometimes remains undigested, 
but is absorbed and passes out in the urine. Another sort of 
albumin discovered by Bence Jones, and named after him, passes 
into the urine in the same way as white of egg.^ 

From these facts, judged in the light of Traube's hypothesis^ it 
would almost seem that the molecular weight of white of egg and 
of Bence Jones's albumin is less than that of serum-albumin, and 
that they filter through while the latter is retained. But though 
the arterial twigs in the glomeruli may allow white of egg to pass^ 
they do not appear ever to allow serum-albumin to exude even 
under the greatest pressure, unless indeed they should happen to 
burst altogether, and then not only the albumin, but the blood 
corpuscles also get out into the urine. The reason for this belief 
is that even when we tie the aorta below the renal arteries, and 
thus raise the blood pressure enormously in the glomeruli, not a 
particle of albumin appears except, as I have already said, it comes 
along with blood.^ 

But the veins are very different from the arteries in this respect, 
and a slight increase of the blood pressure within them is sufficient 
to produce albuminuria. We can easily fancy this when we take 
a glance again at the structure of the kidney. The tubules are 
surrounded by lymph, which probably exudes from the capillary 
net formed by the artery after leaving the glomerulus. So long as 
the veins are ready to absorb this lymph matters go on smoothly, 
but whenever the pressure inside the venous radicles is increased 
by any obstruction in front, the case becomes very different. The 
lymph cannot get back into the arteries because the pressure in 
them is too great, it cannot get into the veins for a similar reason, 
the lymphatics do not seem to be able to carry it all off, and the 
easiest way of escape is into the tubuli uriniferi, and so out it goes, 
carrying with it the albumin it contains, and thus producing 
albuminuria. 

Thus any obstruction to the return of venous blood from the 
kidneys is one of the causes most certain to produce albuminuria. 
Let us, therefore, follow the course of the renal veins so as to see 
where any obstruction is likely to occur. First, there may be a 

1 The only practical apx)iication to whicli a knowledge of this kind of albuminuria 
may be turned is that, if you are feeding weak patients with enemata of eggs, the 
appearance of albumen in the urine may not be at all an indication of kidney-disease, 
and researches on this point would certainly be of service to the profession. 

2 Stockvis, Sur V Albuminxorie. 



CARDIAC DISEASE AND ALBUMINURIA. 319 

tumour pressing on the renal veins themselves or on the vena cava, 
and this at once reminds us that a pregnant uterus may be a 
temporary cause of albuminuria. But except from this physiological 
tumour, we find comparatively few instances of pressure on the 
veins, and, omitting tumours of the liver, the first cause of 
obstruction we come to is the heart. "Whenever the right side 
of the heart becomes dilated, and the tricuspid valve incompetent, 
each cardiac systole drives some of the blood back into the veins, 
and thus leads to serious congestion of the kidneys. A common 
cause of albuminuria, therefore, is heart disease. 

But tricuspid disease is rare as a primary lesion, and incompetence 
of this valve is generally secondary to affections of some of the 
other cardiac orifices, such as the mitral or aortic. 

As it is more common in cases of mitral disease, we will consider 
this first. You will often find patients who have loud mitral 
murmurs without a trace of albuminuria. So long as the right 
side of the heart is tolerably strong, it can hold its ground even 
against the increased pressure it has to overcome, and it is not 
until it begins to get weak that it relaxes and dilates before 
the internal pressure until the tricuspid valves no longer 
suffice to close the enlarged orifice, and regurgitation conse- 
quently takes place. The same is the case in aortic disease, only 
the pressure there has first to overcome the left ventricle and 
dilate the mitral orifice before it can begin to perform the same 
operation on the right ventricle and tricuspid valve. Thus it is 
that venous congestion and albuminuria do not so readily follow 
aortic as mitral disease. 

But any obstruction to the flow of blood through the lungs will 
produce more or less congestion of the kidneys, and thus lead to 
albuminuria, although it would appear that the obstruction must 
be pretty considerable before this symptom appears. Thus we do 
not find albumen in the urine in every case of pulmonary derange- 
ment ; but Dr. Parkes has found it temporarily present in con- 
siderable quantities in acute pneumonia.^ In cholera too, where, 
as is usually believed, the pulmonary vessels contract spasmodic- 
ally, so as to prevent the blood from flowing through them, we 

^ I am inclined to think, however, that there must he a weakening of the vaso-motor 
nerves to the renal veins as well as obstruction to the circulation in the lungs, for I 
have seen a case of great dilatation of the right ventricle and tricuspid incompetence 
where no albumen appeared in the urine, notwithstanding the great pressure to which 
the blood in the renal veins must have been subjected by the backward flow from the 
ventricle. 



320 ALBUMINURIA. 

would expect albuminuria to be present, and so it is — indeed, some 
have said that the only reliable diagnostic sign between true 
cholera and other diseases simulating it is the presence of albumin 
in the urine. If we could produce a similar spasm of the pul- 
monary vessels reflexly, we would expect a similar result ; and Dr. 
George Johnson has observed a phenomenon which may possibly 
be due to this cause.^ Sometimes after bathing albumin apjDears 
in the urine of perfectly healthy persons. Now I dare say we 
have all felt the peculiar constriction about the chest and difficulty 
of breathing when we walked up to the chest into cold water. We 
have no proof, so far as I know, that this is due at all to contrac- 
tion of the pulmonary vessels, and I only suggest it as a possibility ; 
but if these vessels should contract under the influence of an 
impression conveyed to them reflexly from the nerves of the skin 
we can at once understand why albumin should appear in the 
urine in such cases. 

One great cause of true albuminuria, then, is venous congcsfAon. 

The next cause has to do, not with the vessels, but with the 
tubules. When inflammation of the kidney has occurred, and the 
epithelium lining the tubules undergoes degeneration and peels 
off, leaving the walls of the tubules bare, there does not seem to 
be any reason why the lymph which surrounds them should not 
filter into them instead of going into the veins ; and practically We 
do find that when the tubules are in this condition the urine is 
albuminous, just as we would expect. 

Having already trespassed too much on your patience, I cannot 
enter here into the different kinds of kidney disease in which 
albumin occurs, but I would like to say a word ere closing on the 
question of treatment. 

We have seen that venous congestion causes albuminuria, and 
will of course increase it, even v/hen it depends on denudation of 
the tubules. Arterial congestion does not cause albuminuria; but 
if much blood is flowing through the arteries of the kidney .there 
will be more in the veins than if the circulation was less, and 
consequently arterial congestion, by increasing the pressure in the 
veins, may aggravate albuminuria abeady present, although it does 
not produce it. 

The first indication for treatment then is, remove the venous 
obstruction if you can. The second is, lessen the flow of blood to 
the kidneys by drawing some of it elsewhere. 

1 Brit. Med. Journ., Dec. 6, 1873, XJ- 664. 



TREATMENT OF ALBUMINURIA. 321 

The venous obstruction depending on pregnancy will cease at 
the time of parturition, but it may be diminished by the prone 
position, while that depending on cardiac disease may be lessened 
by the use of such drugs as digitalis, which causes the heart to 
contract more forcibly, and by thus diminishing its orifices may 
render its valves once more competent,^ 

The second indication is fulfilled by warm clothing, warm baths, 
and diaphoretics, wdiich draw the blood to .the skin ; and by 
purgatives, which cause a greater flow of it towards the intestines. 

The third indication is to lessen the anaemia, which results from 
the drain of albumen, and of itself produces so many distressing 
symptoms and injurious effects. 

This indication is fulfilled by the adLxiinistration of iron, which 
increases the number of blood-corpuscles, and at the same time 
diminishes the loss of albumen through the kidney. I will not at 
present attempt to explain how it acts, for this is matter of suppo- 
sition, and others may be prepared with a more probable hypothesis 
than I can offer. 

The special points to which I have tried to draw^ attention in this 
paper are — 

(1) The sj-mptoms of albuminuria are those of anaemia, viz. — a 
pale and pasty complexion of the patient, who, on inquiry, tells 
you that he is weak, that he is short of breath, and suffers from 
dyspepsia and nervous weakness ; that you may observe oedema of 
the legs, and you find albumin in the urine. 

(2) The modes of detecting albumin. 

(3) The causation of albuminuria. 

a. Spurious albuminuria due to wdiite of egg, or albumins 

other than serum-albumin. 
1). True albuminuria, in wdiich serum-albumin appears in 

the urine, and which is due to venous congestion o¥ 

disease of the tubules, 
(•i) The treatment of albuminuria. 

^ Digitalis has also a direct action on the renal vessels, which it causes to contract 
when given in large doses. Brnnton and Power; Proceedings of Roy. Sac, Ko. 153, 
1874. 



AKSEXIC IN ALIBUMINURIA."^ 

(* The Practitio-iur' for June 1877.) 

Albuminuria has been divided by Gubler into two sorts, false 
and true. False albuminuria, according to binj, consists in the 
admixture of pus, or of blood, wiih the urine. I, however, am 
inclined to extend the significance of the term false albuminuria, 
and include iu it all those cases where an albuminous body other 
than serum-albumin occurs in the urine. False albuminuria would 
thus include not only those cases where pus or blood occurs in the 
urine, but those in which the so-called Bence Jones's albumin, 
egg-albumin,^ and jDossibly paraglobulin make their appearance. 
Under ordinary circumstances albuminous bodies do nor ditiuse 
through animal membranes, but it has been shown by Bernard, 
Pavy, Stockvis, and others that albumin of eggs will pass out 
through the kidneys, while the albumin of blood does not do so 
under similar conditions. Bernard, it is true, believed that serum- 
albumin jDassed through the kidneys in much the same way as 
egg-albumin when it was injected into the circulation; but 
Stockvis, having repeated Bernard's experiments, showed that 
the serum-albumin only apj)eared in the urine when the experi- 
ments had been imperfectly performed, and the injection had 
interfered with the proper circulation of the blood in the veins, 
thus causing venous congestion of the kidney itself. Egg-albumin 
and Bence Jones's albumin he found to be excreted by the 
kidneys, not only when they were injected into the blood, but 
when they were introduced under the skin or in large quantities 
into the rectum.'^ In the two latter cases the interference with 

^ Read before the Medical Society of Loudon. 

2 To distinguish between the entke -white of egg or albumen and egg-albumin, 
which is its chief but not its only constituent, the former is spelt with an e and the 
latter with an i, 

2 Stockvis. Over resorjnie en Assimilatie van het als vocdsel gcmcttigd emit 1&72, 
and Maandblad voor Natuarwetenschai^^jen, 2dc Jaargang, No. 6, bk. 95, 



TRUE AND FALSE ALBUMINURIA, 323 

tlie circulation was obviously not the cause of tlie appearance of 
albuminuria. It seems curious that one sort of albumin should 
pass through the vessels of the kidney, while another should be 
retained, and the only feasible explanation of it seems to be that 
the molecule of the different albumins varies in size. For the 
passage of substances in solution through membranes has been 
shown by Moritz Traube to resemble very much the passage of 
powdered matters through a sieve.^ When the particles of the 
substance are too large to pass through the meshes of the sieve 
they ai'e retained, but when they are too small they pass through. 
Thus almost all crystalline substances readily diffuse through 
animal membranes, and Graham divided bodies, according to their 
diffusibility, into crystalloids and colloids. But there is one marked 
exception to the rule that crystalline bodies diffuse, and this is 
the colouring matter of the blood, haemoglobin. This substance 
differs from most other crystalline bodies in possessing a very liigh 
molecular weight, and the molecule is therefore, in all probability, 
very large. Traubc's hypothesis at once explains this curious 
exception to Graham's law, and renders it probable that liEsmoglobin 
does not diffuse simply because its molecule is too large to pass 
through the pores of ordinary membranes. We may apply this 
hypothesis to explain the appearance of albumin in urine after the 
injection of white of egg under the skin, and its absence after 
a similar injection of serum-albumin. If we suppose that the 
molecule of egg-albumin is smaller than that of serum-albumin, 
we can readily understand that after being absorbed from the 
subcutaneous cellular tissue, and carried by the blood to the 
kidneys, it may pass through the vessels into the urine^ while the 
larger molecule of serum-albumin will be retained. 

The facts regarding false albuminuria are, that egg-alburnin, 
and other albumins such as Bence Jones's albumin, pass out 
through the vessels of the kidney without any alteration in the 
structure of the organ, or interference with the circulation of the 
blood through it, while serum-albumin will not pass out. 

True albuminuria consists in the passage of serum-albumin, 
which is a normal constituent of the blood, into the urine. It 
depends either upon alterations in the structure of the kidney, 
or interference with the circulation through it, or upon both. It 
has been supposed that great increase in the pressure of blood 
within the renal glomeruli will cause albumin to appear in the 
1 CcntralhlcM d. incd. JFiss. 1866, p. 97. 

T 2 



324 ARSENIC IN ALBUMINURIA. 

urine, but the experiments of Stockvis appear to disprove this 
supposition.^ He found that no increase in the arterial pressure, 
either generally throughout the body, or in the kidney alone, 
would produce it. He raised the general pressure by compressing 
the aorta and other large arteries, and he raised the pressure in 
the kidney itself by dividing the vaso-motor nerves of the organ 
so that the renal arteries dilated and allowed much more blood 
than usual to pour into the kidney. In neither case did he find 
any albuminuria, but the result was very different when he 
interfered at all with the venous circulation of the kidney. An 
obstruction to the return of the blood through the renal veins was 
sufficient to cause albuminuria. Thus it came on when the renal 
veins were tied, when the vena cava was plugged, or when the 
movements of the heart were interfered v/ith by a small caout- 
chouc ball passed down the jugular vein into the I'ight ventricle, 
or when quantities of fluid were injected quickly into the jugular 
vein. It is to the venous obstruction caused by such injections 
that Stockvis attributes the albuminuria observed by Bernard 
after the injection of ordinary serum into the vein. 

Pathologically we find albuminuria occurring from venous 
congestion, in cases of thrombosis of the vena cava, in mitral 
disease, and in emphysema whenever the right ventricle begins 
to yield and allow regurgitation into the veins. There is, however, 
another cause of venous congestion which at first si^dit would 
appear likely to have an effect exactly opposite to that which 
it actually produces. This is obstruction to the flow of blood 
through the renal artery. When this artery is ligatured, or when 
the circulation through the kidney is stoi^ped by the action of 
drugs upon it, we find albumin appearing in the urine after the 
secretion has been re-established. One would expect to find the 
kidney pale, and ananuic after ligature of the artery, but, on 
performing this experiment, Brown-Sequard found that the kidney 
was deeply congested, the reason of this being that the veins had 
lost their contractile power, and the blood had consequently flowed 
backwards into them from the larger venous trunks. We may 
indeed, form a good conception of the condition by noticing the 
difference between the paleness of the hands when they are first 
exposed to cold and the congested blueness which follows a longer 

^ Stockvis, Sur V Albuminurie and Qudqucs 3f)ts a propos cle la Brochure de M. 
le Profcs'ieur Corrcnti relative a V Albuminurie. Jowrii. piMie p. I. Soc. Hoy. d. 
Sciences med. et iiat. de.Bruxcllcs, Reprint. 



RELATION BETWEEN URINE AND ALBUMIN. 325 

exposure. Venous congestion then is the cause of albuminuria 
depending on alterations in the circulation. In embolism of the 
kidney the result as respects a part of the organ will be the same 
as what we find in the Avhole organ after ligature of the renal 
artery, and the albuminuria depending upon euibolism may be 
exjjlained in the same way. 

The second cause of true albuminuria is alteration in the 
structure of the kidney, and these alterations may affect the 
vessels and tubules or the connective tissue stroma in the which 
they are embedded. In the waxy kidney the vessels are affected 
and the structure of their walls is changed. It seems not improb- 
able that the altered structure of the vessels may permit the 
serum- albumin to transude through them in somewhat the same 
way as the vessels in their normal condition permit the transudation 
of egg-albumin. In desquamative nephritis we may suppose that 
the albumin finds its way into the uriniferous tubules, because the 
epithelial lining which might have prevented its passage has been 
more or less removed. Even in cases where the albuminuria 
depends upon organic disease of the kidney, the quantity of 
albumin present in the urine varies with the condition of the 
circulation. As a rule it is less during the night and greater 
during the da^^ We find too, generally, that a relation subsists 
betAveen the quantity of urine and the proportion of albumen 
present in it. When the urine is copious the proportion of 
albumin is less; when the urine is scanty albumin is usually 
increased. Now it has been shown by Ludwig and Max Hermann 
that the quantity of urine increases with the pressure of blood in 
the renal glomeruli, so that, other things being equal, contraction 
of the arterioles just at their exit from the Malpighian capsules 
will increase the pressure in the glomeruli, and augment the 
secretion of urine. At the same time their partial contraction 
will probably diminish the pressure in the capillaries, will probably 
lessen the quantity of the lymph exuding from them into the 
connective tissue, and will thus lessen the leakage of albumin 
into the uriniferous tubules. Probably this is the reason why the 
albumin is usually diminished when the urine is increased, but 
at any rate the fact is that increased secretion does indicate 
increased pressure in the glomeruli, and increased secretion is 
usually, though not always, associated with diminution in the 
albumin. 

I will now relate the case which I wish to bring before you, 



326 ARSENIC IN ALBUMINURIA. 

and will afterwards return to tlie bearing of what I have already 
said upon its pathology. 

R, A., aged S3, analytical chemist. Short, slight, fair-haired, 
sallow complexion, thin. With the exception of being liable to 
headaches after exertion, he was apparently healthy until ten 
years ago. He then noticed a tendency to become very easily 
tired after any exertion. About a year after this (1868) he 
wished to insure his life, but was rejected on account of the 
medical officer of the insurance company having discovered 
albumin in his urine. He then consulted two medical men, who 
gave him strychnine in doses of about -—-th of a grain. This 
immediately stopped the albumin, but brought on violent head- 
aches and sickness. The albumin at this early stage was only 
present during the summer months. It came on with work and 
disappeared with rest. In the winter it was absent, except during 
one or two severe frosts. 

In the following summer it returned in large quantities, and 
he was advised by his medical man to go to the seaside (Margate 
and Ramsgate) for the three hot months, to take hot sea-baths, 
and to abstain from all exertion. 

Though the albumen ceased, the patient's strength diminished 
very much. On his return to London the weather was cooler 
and he rapidly improved, so as to be able to return to work. In 
1870 the albumen returned more persistently, so he was again 
recommended by a medical man to take a sea-voyage. He went 
to the Cape of Good Hope ; leaving in June and arriving in 
November, very little, if at all, the better for the trip. This 
might be due to his ignorance of the care required in selecting 
the proper food. He stayed six weeks at the Cape, then came 
back. On his return he tried pancreatic emulsion, and for two 
or three days it was very successful and stopped the albumen, but 
after that time it brought it on worse than ever. He then tried 
the skim-milk treatment for three months. It was very successfid 
at first, but he lost weight rapidly, and the albumin gradually 
reappeared during the last two weeks of the treatment. On 
discontinuinor it the albumin returned. 

In 1872 he was again recommended to take another and longer 
voyage, and take care of his diet on the way and after his arrival. 
He had now found that fatty food always brought on albumin, 
and that meat taken in the morning had a similar effect, but 
he could take meat with impunity for supper. He now went 



EFFECT OF MEAT, FAT, AND TIME OF DAY. 327 

to Australia and New Zealand for nearly three years, leaving in 
October 1872, and returning in June 1875. During the greater 
part of this time phosphates were very abundant, and although 
albumin was generally completely absent, it came on whenever 
he exerted himself much. His strength also did not increase 
much. On one occasion he took a prescription containing quinine 
and phosphoric acid, which almost immediately caused albumin 
to appear in considerable quantities, and it was some time before 
it again disappeared. After his return in June 1875, he still 
remained in statu quo. 

I saw him for the first time in January 1876. No oedema; 
the heart and lungs were healthy ; liver normal ; appetite poor ; 
subject to acidity and headache. On inquiry I found that the 
albuminuria was brought on by exertion either mental or bodily 
in the morning, by fats such as butter, or by meat for breakfast. 
After midday he could do work, and could take fat and meat 
without bringing on the albumin. The quantity of albumin 
was always greatest when the urine was scanty, and least when 
the urine was abundant. When he engaged in his work during 
the forenoon albumin did not come on immediately after break- 
fast, but began to appear about eleven and remained until about 
two. When he did not work the albumin did not come on at 
all. He suffered much from acidity, especially in the morning. 
The remarkable fact that meat and fats caused albumin to 
appear, and that by rigid adherence to a farinaceous diet he 
could completely get rid of the albumin, led me to think that 
his albuminuria might be connected with imperfect digestion, and 
I accordingly gave him nitro-muriatic acid before meals. This 
lessened the acidity, and diminished, but did not completely 
remove, the albumin, so that I supposed the kidneys to be also 
in fault. 

The quantity of albumin, as I have already mentioned, was 
always greatest when the urine was scanty, and least when the 
urine Avas abundant. This seemed to indicate to me that the 
albumin came either from the venous radicals in the kidney, 
or else from the lymphatic spaces in the connective tissue. I 
therefore attempted to act upon the arterioles of the glomeruli, 
and increase the secretion of urine by means of digitalis. The 
exjDeriments made by Mr. Power and myself had shown us that 
this drug has a special action upon the vessels of the kidney, 
and, by giving it in small doses, I expected to contract the 



328 ARSENIC IN ALBUMINUUIA. 

arterioles of tlie glomeruli, and thus while increasing the urine 
to diminish the jjressure in the capillaries and veins, and lessen 
or remove the albr.men. I intended, in fact, to produce by the 
drug the condition in which the patient had already found there 
was less albumen. 

Two drachms of the infusion three times a day diminished 
the albumin, but lowered the action of the heart and interfered 
with digestion. After reducing the dose and finding that still 
the digitalis disagreed, I stopjoed it after it had been taken for 
a fortnight. 

There was no history of S3^philis, but thinking that the alter- 
ative action of mercury might be beneficial, I tried small doses 
of Hydrarg. c. Creta, but without any beneficial result. I next 
tried quinine and sulphuric acid, but this brought the albumin 
in large quantities into the urine, doubled it in fact, within 
twenty-four hours, just as it had done before. 

As he had found benefit from pancreatic emulsion for a day 
or t^YO on a former occasion, I advised him to try it again, and 
to stop it after two days so as to prevent the increase of albumin 
which its continued use had previously induced. The first dose, 
however, made him worse, and it was accordingly stopj)ed. My 
attemjjts to act upon the vessels of the kidney having been futile, 
and my random treatment with mercury and quinine having 
also been useless, I determined to try to act upon the secreting 
structures of the kidney, and accordingly gave arsenic, which has 
a considerable action upon tissue change, and also appears to 
possess a special affinity for epithelial structures. 

The patient accordingly took 3 \x\ of Fuwler's solution at meal- 
times. Almost at once the albumin disappeared, and the 
j)atient was able to do much more work than usual without 
brino-ino; it back. After giving this for a while I thought that 
as phosphorus is nearly allied to arsenic the hypophosphites 
might have a similar action, and accordingly gave him 5 gi-s. of 
hypophosphite of soda three times a day. This disagreed with 
his stomach and increased the albumin. He then returned 
to Fowler's solution again, and the albumin disappeared. On 
stopping the medicine the albumin came back, but the liquor 
sodse arseniatis stopped it. 

On again thinking over the pathology of the case it seemed 
to me probable that the albumin was derived in great measure, 
from the intestinal canal, and was due to imperfect digestion of 



ALBUMINURIA FROM IMPERFECT DIGESTION. 329 

albuminous substances Avliich were absorbed from the intestine, 
and excreted in the urine in much the same way as white of 
eon- would have been if the person had swallowed several raw 
ef;-p"S at once. As the pancreatic juice first converts cojigulated 
albumen into a soluble form before finally digesting it, it seemed 
probable that imperfect pancreatic digestion was the cause of the 
albuminuria. The failure of the pancreatic emulsion to do good 
might have been due to the fat causing acidity of the stomach. 
The chyme being too acid would prevent the pancreatic juice 
from acting, and Avould thus make matters worse, I therefore 
gave pancreatine without the fat, so as to increase the pancreatic 
digestion without increasing the acidity of the stomach, and this 
has stopped the albumen also. He has, however, only been 
takincc this for a short time, so that I do not know what the result 
will ultimately be. 

I am inclined to regard the case I have described as due at 
least in part to imperfect digestion. I am uncertain whether the 
kidneys have anything to do with it or not. There is no history 
of nephritis, and the close connection between the digestion 
which is weak in the forenoon and stronger in the afternoon, 
the acidity of stomach, and albumin in the forenoon, and the 
want of these in the evening, seem to point to digestion as the 
chief cause of the albuminuria. I have not seen any casts, but I 
have not examined the urine frequently for them. The albuminous 
body which appears in the urine is probably not serum-albumin, 
because it only coagulates between 175° and 180'' F., while the 
albumin in a case of chronic Bright's disease which I tested for 
the purpose of comparison coagulated at 140° F. The point of 
coagulation varies somewhat according to the amount of urea and 
uric acid present in the urine, but this variation will hardly account 
for the difference of more than 30° F. between the coagulating 
points of the albumen in these two urines. 

The points which I wish especially to bring forward are : — 
1. The intermittence of the albumin and its connection with 
the digestion ; 2. The absorption of albuminous matters from 
the intestine as a cause of albuminuria — a cause recognized 
indeed in several text-books, but often ignored in practice ; 3. 
The utility of arsenic as shown in this case ; 4. The possible 
use of pancreatine; 5. The effect of quinine in increasing the 
albumin. 



ON THE PATHOLOGY OF DROPSY. 

(' The Practitioner,' vol. xxxi., Sept. 1883.) 

Dropsy is an accumulation of fluid in the lympli spaces. 
These lymjih spaces may either be small, as in the subcutaneous 
cellular tissue, and in the substance of organs ; or they may be 
large, as in so-called serous cavities, the peritoneum, pericardium, 
pjleura, &c. 

In the normal condition, these Ijnxiph spaces are only moistened 
with lymph, whereas in dropsy they may contain it in great 
quantities. 

The question before us, viz. the ^ioXholo'gy of drojDsy, is 
simply : How has the lymph come to accumulate in these lymph 
spaces ? Supposing that we have a cistern furnished below with 
two exit pipes which together are much larger than the supjoly, 
it will never become full, although the supply pipe should be 
running night and day {vide Fig. 40). The water rushing into it 
mav wet its sides, but will do nothing more. If we close the 
exit pipes completel}^, however, the cistern will soon fill, and, if 
we close them only partially, the rapidity with which it fills 
will depend upon the extent to which we close the exit pipes 
and open the supply pipe, or in other words, it will depend 
upon the relation between the quantity running in and the 
quantity running out in a given time. This is exactly what we 
find in the case of the lymph sjDaces : these are the cisterns, 
the arteries and capillaries are the supply pijDes, the veins and 
Ivmphatic vessels ai'e the exit pipes. In health the lymph 
spaces are merely moistened with lymph, because, although, 
constant or nearly constant exudation of lymph is taking place 
into them from the capillaries, it is at once carried away by the 
venous radicles and by the lymphatic vessels. In the illustration 
just given, I have spoken of the cistern as having two exit pipes. 



REMOVAL OF LYMPH BY LYMPHATICS. 331 

which together are much larger than the supply pipe, but I might 
have spoken of tbem as being of unequal size, and of one of them 
alone being much larger than the supply pipe, althougli the other 
may not be so. For not only can the venous radicles and lymph- 
atics together carry away all the lymph which is poured out into 
the lymph spaces ; the venous radicles alone are sufficient for this 
purpose, so that even when the flow of lymph is entirely stopped 
by ligature of the lymphatics, no accumulation of fluid in lymph 
sjoaces may occur. ^ The lymphatics also may to a great extent 



Fig. 40. — Diagram of the relations of the lymph spaces, and vessels. 

remove the fluid from the lymph spaces when the veins are 
obstructed. Thvis, as Ranvier and Cohnheim have observed in 
the dog, and as I have found in the cat, ligature of the inferior 
vena cava may sometimes produce no oedema whatever in the 
limbs. This is supposed by Cohnheim to bo due chiefly to the 
establishment of collateral venous circulation. 

But on this point I do not feel disposed entirely to agree with 
him, inasmuch as the veins of the surface in my observations 
were not dilated to the extent that one would have imagined, 
and I am inclined rather to believe that the prevention of 
oedema wa,s due in a great measure to increased action of the 
lymphatics. 

' Cohnheim's Patltulogy, second edition, vol. i. p. 4S5. 



332 PATHOLOGY OF DROrSY. 

Ligature of the veins at once increases the lymphatic stream, as 
seen in experiments upon animals. When a cannula is inserted 
into a lymphatic vessel in a clog, the lymph flows in small quan- 
tities in slowly succeeding drops with long intervals between. 
But when the chief vein of the district from which the lymph is 
supplied is ligatured the lymph flows much more quickly. This 
may be due partly to the quantity poured out from the capillaries 
being increased in consequence of the ligature of the vein, but I 
think We can hardly imagine that it is. not in a great measure due 
also simply to the lymph, which would have been poured out in 
any case, passing away by the lymphatics when it could no longer 
be taken up by the veins. It is probable that the proportion of 
lymph which is removed from the lymph spaces by the veins and 
lymphatics varies in different individuals. 

Ludwig noticed that strong, short-haired dogs 3ueld much lymph. 
Now if we pat a long- and a short-haired dog we are at once 
struck with the difference in the feeling of the muscles. In short- 
haired dogs the muscles are usually hard and well defined, feeling 
like solid lumps under the skin. In long-haired dogs on the 
contrary they are soft. We notice similar differences in men, 
some men have very hard muscles, others very soft. This 
difference does not appear to affect the muscular power, because it 
has been found that some of the strongest men are those with soft 
muscles ; and Klihne has shown that the contractile substance of 
muscle may be regarded as semifluid. The difference between the 
two sets of muscles lies, not in the muscular substance, but in the 
fascia by which it is surrounded. In some it appears to be much 
more developed than in others, and where it is thick it gives to 
the muscle a feeling of hardness. Now this fascia is a pumping 
arrangement (vide Fig. 41) by which the lymph is drawn out of the 
muscle and is passed onwards into the lymphatics. It consists of 
two layers, between which are lymph spaces ending in lymphatic 
vessels. Each time that the muscle contracts, the inner layer is 
pressed against the outer and forces the fluid onwards into the 
lymphatic vessel. Each time that the muscle reUxes, the inner 
layer tends to fall away from the outer, and thus the lymph from 
the muscle readily finds its way into it. In the very act of 
muscular contraction, then, the products of waste are washed out 
of it by the fresh lymph which flows through it. 

This difference in the development of the muscular fascia 
appears to me, although upon this point I should like to sjDeak 



LYMPH rUMPS. 



333 



with great reservation, to coincide witli differences in the tend- 
encies to muscular as distinguished from aHicular rheumatism. 
\\'"here the muscles are soft from thinness of the fascia, it lias ap- 
peared to me that the tendency to muscular rheumatism is greater, 
whereas persons with hard muscles and firm fasciae have appeared to 




Pig. 41.— Injected lympli spaces from the fascia lata of the dog, after Ludwig and 
Sch\^'eigg.a--Scidel, Lymijlujrfusse dzr Fccscicn unci Schncn. The injected s^jaces 
are black in the figure. 

me to have a greater tendency to articular rheumatism. This is 
what one might expect, because, if by over- exertion, irritant pro- 
ducts of waste should be formed in the muscle, they will tend 
rather to remain there when the fascia is soft, and give rise to 
muscular pain ; while in those whose fascia is hard, they will be 
removed from the muscle, but may possibly give rise to inflam- 
mation in the joints. This point is, I think, worthy of further 
attention ; and careful observations on it might give us valuable 
data in regard to the true origin of rheumatism, 

111 the case of the large serous cavities also, we have other 

limping arrangements. In the central tendon of the diaphragm 

{lide Fig. 42) vv^e have two layers which are alternately pressed 




Fi'T. 42.— Section of central tendon of the diaphragm. The injected lymph spaces, 
h and h, are black. At/ the walls of the space are collapsed. After Ludwig and 
Schweiffcrer-Seidel, Lymph gefdnse dcr Faacicn 'and Schncn. 

too-ether and separated by the movements of respiration, so that 
they pump the lymph fjom the peritoneal cavity in much the same 



33 i 



PATLIOLOGY OF DROPSY. 



way as the fascioe remove it from the muscles. This is well seen 
by connecting the trachea of a dead rabbit with an apparatus for 
artificial respiration, removing the lower part of the body and 
hanging the thorax up with the head downwards. A solution of 
Prussian blue or other injecting fluid is then poured over the lower 
surface of the diaphragm, and the ajDparatus for artificial respir- 
ation set in motion. Before long the Prussian blue is jjumped into 
the lymjDh sjaaces of the diaphragm, wdiich then exhibit a beautiful 
blue network. 

Similar conditions to those in the diaphragm and muscles are 
to be found in the costal pleura {vide Fig. 43). Besides these 
pumping arrangements in the muscles and in the serous cavities 
by wdiich the flow of lymph is accelerated, actual rythmical 




Fig. 43. — Section of pleura. The lymph spaces appear black in the figure. 
Ludwig and Dybkowsky. Ludwig's Arbeiten, 1866. 



After 



pulsation has been observed in the lymphatics and the mesentery 
of guinea-pigs, but has not been found in other mammals 
or man. 

We find, however, that there are other conditions which aid the 
flow" of lymph. This flow naturally depends upon the difference 
of pressure at the two ends of the vessels, and it will be increased 
by anything raising its pressure in the tissues, or anything accelerat- 
ing its exit from the lymphatics into the veins. Two things which 
diminish the pressure in the veins and aid the flow of lymph 
into them, are the inspiratory action of the thorax and the diastolic 
suction of the heart. The effect of the inspiratory action of the 
tliorax is readily seen wdien one tries to blow up a fire, for the 
violent respiratory exertions there required appear to ]3ump either 
the blood or lymph from the brain and by reducing the pressure to 
cause giddiness. 

When these two things are imperfect, e. g. wdien the right side 
of the heart is incompletely emptied, and still more when there is 



REMOVAL OF LYMPH BY VEINS. 335 

tricuspid regurgitation, so tliat the veins ave full, a marked 
hindrance will be presented to the flow of lymph. Tlie flow will 
also be diminished by emphysema, in which, the chest being 
already barrel-shaped and incapable of much further expansion, 
the inspiratory suction will be diminished. 

To recapitulate shortly the conditions which cause the flow of 
lymph, we may say its flow depends upon the difference of pressure 
between the two ends of the lymphatic vessels. It is increased by 
the pressure being raised in the tissues and lowered in the vena 
cava, and it is retarded by opposite conditions. Where the 
relations of the tissues are such that it might accumulate unduly 
in the lymphatic spaces, as in the muscles or the serous cavities, 
there are arrangements for pumping it out of those spaces and 
driving it into the lymphatics, so that it enters the peripheral 
extremities under pressure. The conditions which will interfere 
with the flow of lymph are : {a) want of muscular action ; (&) want 
of inspiratory action of the thorax ; (c) diminution of the diastolic 
suction of the heart, and (cl) positive pressure in the veins. 

We now come to consider the part taken by the veins in 
removing lymph from the lymjih spaces. This, as I have already 
said, appears to be very great, much greater than that of the 
lymphatics, for when a cannula is placed in a lymphatic vessel 
the flow, as I have already said, is slow, but if the vein of the 
district be tied, the flow becomes increased to an extent far more 
than double what it originally was. The objection may be raised 
that this great increase is not merely due to the absorption which 
would usually have taken place from the lymphatic spaces into 
the veins having been arrested by the ligature, but that it is really 
due to the exudation of lymph from the capillary blood-vessels 
into the spaces being greatly increased. 

It is, I should think, probable that both of these factors take 
part in the increase, although it may be rather hard to say precisely 
how far the increased quantity of lymph which flows from the 
lymphatics after ligature of a vein is due to increased transudation 
or diminished absorption. 

There is, however, a point which seems to indicate not only 
that the veins have much absorptive power, but that they tend to 
reabsorb especially the watery constituents of the lymph, for oede- 
matous lymph contains only from 2 to 3 per cent, of solids, while 
the lymph which flows from a vessel when the veins are oj)en 
contains from 4 to 5 per cent. This difference of composition 



330 PATHOLOGY OF DROPSY. 

appears to me to point strongly to reabsorption of water from the 
lymph by the venous radicles, while the solids tend to find their 
way onwards through the lymphatics. 

The flow of blood in the veins, like that of the lymph, depends 
upon difference of pressure in the peripheral and central ends of 
the vessels. In the upper part of the body this is aided by 
gravity, but in the lower parts it is counteracted by gravity. The 
weight of the longer column of blood in the veins of the body and 
leg would, to a great extent, prevent the circulation in' the veins of 
the feet were it not aided by muscular action, which presses it 
onward in much the same way as it does the lymph ; and how 
powerfully muscular action does so has been known for centuries 
to every barber, who provided his patient with a pole to grasp 
before letting blood from the arm. 

It is aided also to a certain extent by the respiratory action of 
the thorax and the diastolic relaxation (?) of the heart. In saying 
"diastolic relaxation" of the heart, I have followed Cohnheim in 
the recent edition of his Lectures on General Fatliology, but I am 
not quite certain that it would not be more correct to say the 
" systole " of the heart, because, as Briicke has pointed out,^ the 
pericardium may be looked upon as a sort of bell-jar, the walls of 
which, though elastic, are kept more or less rigidly in j^osition by 
the apposition of their outer surface to the lungs. Each time 
that the ventricle contracts and drives the blood into the aorta, it 
tends to cause a vacuum in the pericardial space, and thus tends 
to draw the blood from the vente cavee into the auricle. 

The conditions which interfere with the flow of blood in the 
veins are then : (a) want of muscular action, (h) want of movement 
in the thorax, and (c) feeble action of the heart, no matter whether 
v/e look upon the systole or diastole as being the active power 
in sucking the blood onwards from the veins. 

More important still as causes of complete arrest in a vein are 
{(l) pressure upon it from without or (c) plugging within. 

We have now considered what we termed at first the two exit 
pipes of the cistern, the veins and the lymphatics. Not only the 
two together, but either the one or the other separately, appears 
in the normal condition to be able to remove the lymph which is 
poured out into the tissues from the blood-vessels, and thus to 
prevent any accumulation from taking place. 

^ I quote from a lecture I heard liim deliver to his cla^s ia Vienna in the winter 
session, 1867-68. 



EXUDATION OF LYMPH. 



337 



Dropsy then does not occur except we have increased outflow of 
l3aii23h into the tissues in addition to an interference with its 
removal by the veins or lymphatics. 

We have now to consider the conditions which affect the supply 
pipe in the illustration with which we commenced, or, in other 
words, the conditions which increase and diminish the exudation 
of lymph from the capillaries into the lymph spaces. The first of 
these is iii creased supply of blood from dilatation of the arteries 
supplying a part. 

I have already mentioned that, in Ranvier's experiment of tying 
the vena cava in a dog, the mere stoppage of the venous circula- 
tion does not always produce oedema of the legs, the lymph which 
is exuded from the capillaries being removed either by collateral 



Vaso-motor. 

NERVES i' 



ARTERIES 




Fig. 44. — Diagram of Ranvier's expei'iment. 

venous circulation or by the lymphatics. The case, however, is 
usually different when, in addition to the ligature of the vena 
cava, the sciatic nerve is divided on one side. In consequence of 
the division the vessels dilate, more blood pours into the limb, 
more lymph is exuded into the tissues, and the limb with a 
divided nerve swells up enormously, while the other remains of its 
normal size, although the venous circulation is equally arrested in 

z 



/ 



338 PATHOLOGY OF DROPSY. 

"both. That this accumulation of Ijmpli in the tissues of the leg is 
due to paralysis of the vaso-motor and not of the motor nerves of the 
limb is proved by dividing on the one side the motor roots of the 
sciatic and on the other the vaso-motor roots. When the sciatic 
trunk is divided, there is of course both a vaso-motor and motor 
paralysis in the limb, because the vaso-motor and motor nerves 
have been alike divided, and we get the oedema therefore coincid- 
ing with the paralysis in the limb; but when we get the motor 
roots of the sciatic divided and the vaso-motor intact we no lono-er 
have the paralysis and the oedema coinciding. The limb on that 
side where the motor roots have been divided is paralysed, but, the 
vaso-motor roots being intact, it retains its normal size. On the other 
side, where the vaso-motor roots are divided while the motor roots 
are intact, the power of motion is retained, but the limb becomes 
cedematous. The supply of lymph to the tissues is evidently 
so much increased by division of the vaso-motor nerves and conse- 
quent dilatation of the arteries, that the partially obstructed efferent 
vessels, veins and lymphatics, can no longer carry the lymjoh 
away, and oedema occurs. Sometimes a very slight obstruction is 
sufficient to j)roduce oedema when there is vaso-motor weakness. 
This one may sometimes observe in one's own hands. Usually we 
may walk about for a whole day without feeling the least tendency 
to swelling in the hands, but every now and again, in a hot sultry 
day, when there appears to be thunder in the air and we feel limp 
and languid, we may notice that, after walking about for a while 
with the hands hanging by the side, the fingers swell to a certain 
extent, and there may be not only difficulty in drawing on one's 
gloves, but the fingers may be so distinctly swollen as to be 
slightly stiff in trying to bend them. Here we have not complete 
vaso-motor paralysis, but only ]3aresis from the effect of the atmo- 
spheric conditions on the vaso-motor nerves, j^et the consequence 
is that the exudation of lymph being increased the slight inter- 
ference with venous and lymphatic return, caused by the position 
of the limbs, and aided perhaps by a slight ^jressure of the 
clothing, is sufficient to produce oedema. 

This, at least, would be the explanation if we were to consider 
increased exudation of lymph from the blood-vessels as due only 
to dilatation of the arteries and interference with venous or 
lymphatic flow. As we shall see shortly, however, there is probably 
another factor, viz. changes in the capillaries themselves. 

As a contrast to the ready production of oedema in the arm 



EFFECT OF ALTERED QUALITY OF BLOOD. 339 

by simple dependent position, aided perhaps by a slight constric- 
tion of the clothes and by atmospheric influences, we may take 
the difficulty with which it occurs under certain experimental 
conditions. 

Frequently, as Ranvier has shown, ligature of the vena cava 
with accompanying section of the vaso-motor nerves of a limb will 
cause great oedema ; but this is not always the case. For Cohn- 
heim has observed in dogs, and I have myself found a number of 
years ago in the cat, that simultaneous ligature of the vena cava 
and section of the sciatic does not always produce oedema. I was 
very much struck by this in one experiment which I made, for in 
it, although the vena cava was tied and the sciatic divided in one 
leg, I could notice almost no increase in the size of either limb. 
At the same time, as I have akeady mentioned, the veins on the 
surface of the limb where the sciatic had been divided were not 
much swollen, so that I am inclined to believe that a great part 
of the lymph effused from the capillaries was removed by the 
lymphatics. 

The readiness with which oedema sometimes occurs with very 
slight alterations in the circulation, and at other times does not 
occur although the alterations in the circulation are very great, 
shows us that there are other factors of very great importance. 
These factors are the condition of the blood and the state of 
nutrition of the capillary vessels. It is possible that those two 
conditions really resolve themselves to a great extent, if not 
entirely, into one, and the main factor is the condition of the 
capillary vessels. This must necessarily depend to a considerable 
extent on the condition of the blood. It would, however, be going 
too far to exclude the condition of the blood from direct influence 
on the transudation of lymph, and allow it only an indirect action 
through its effect on the walls of the capillary vessels. 

There can, I think, be little doubt that the quality of the blood 
itself alters the quantity and quality of the lymph exuded, just as 
differences in the quality of the fluid that you pour upon a filter 
will affect the quantity and character of the filtrate. But in 
filtering we find that with many fluids the filter will allow filtra- 
tion to go on for a length of time, while with others it is speedily 
choked and allows neither fluid nor solid to pass. In the process 
of filtration the filter becomes altered, and thus the quantity and 
quality of the filtrate depend not only on the condition of the 
filter as originally used, but on the quantity and quality of the 

z 2 



340 PATHOLOGY OF DROPSY. 

fluid to be filtered, and also on the changes which the filter 
undergoes during the process of filtration. 

One of the most ordinary forms of dropsy is the slight oedema 
\vhich we notice in the legs of persons suffering from ansemia. 
There may be no cardiac disease, the lungs may be quite healthy, 
there may not be the slightest interference with the flow of blood, 
either through the lymphatics or veins, and yet we find dropsy 
occurring in the legs ; the lymph passing out in such quantities 
from the blood-vessels that the veins and lymphatics are unable 
to remove it. It occurs in the legs and not in the other parts of 
the body, because in the upright position the circulation in the 
veins and lymphatics is opj)osed by gravity. In the production of 
the oedema here we have probably several factors: there is first the 
watery condition of the blood ; next the condition of nutrition of 
the capillaries ; and in addition we probably have a tendency to 
vaso-motor paresis, for the anaemia lessens the nutrition of the 
tissues generally, and the vaso-motor centre suffers with the rest. 

The occurrence of cedema in the hands when hanging by the 
sides on a sultry day shows us how very slight an interference 
with the venous circulation may be sufficient to produce oedema 
under certain conditions. Usually, hoAvever, some interference 
with the venous or lymphatic flow may be noticed, but there is 
one case in which oedema may be produced without any apparent 
interference with either the veins or lymphatics. This occurs in 
the case of the tongue, for Ostroumoff has found that Avhen the 
lingual nerve is irritated, not only do the vessels of the tongue 
dilate, but the whole side of the tongue swells up and becomes 
oedematous. This might be looked upon as proof positive that 
mere dilatation of the vessels may cause oedema, but such a con- 
clusion would be premature. We must bear in mind that when 
we irritate a vaso-dilating nerve we not only make the vessels 
dilate, but we very probably alter their structure for the time 
being and render exudation from them more easy. 

Claude Bernard's beautiful experiments on the submaxillary 
gland have taught us that, when the chorda tympani is irritated, 
the arteries going to the submaxillary gland dilate so much that 
the blood rushes through them, and through the capillaries that 
connect them with the veins, in a rapid stream, so rapid that if 
the vein be punctured the blood issuing from it is no longer dark, 
but bright and arterial, and instead of trickling out of the vein in 
slow drops, it jets from it as if from an artery. When this experi- 



RELATION OF SECRETION TO LYMPH SUPPLY. 341 

rnent is performed on a normal animal, at the same time that the 
artery dilates the secreting cells of the gland begin to form saliva, 
which pours in a stream from the duct during the continuous 
irritation of the nerve. The secreting cells do not take the 
material from which they form the saliva directly from the blood, 
they receive it indirectly from the lymph spaces which surround 
the alveoli. Into these spaces the lymph exudes from the blood, 
and from it as from a reservoir the cells take up the materials 
they ^s'ant ; indeed these spaces will so far act as a reservoir that 
we may cause the cells to secrete saliva even after the head has 
been separated from the body, if we take care to fill the lymph 
spaces with lymph previously by tying the veins of the gland and 
renderings it to some extent oedematous before cutting off the 
head. During irritation of the chorda tympani, then, the secreting 

Vksseia orGiAA/o 




Fig. 45. — Diagram of a salivary gland. 

cells of the submaxillary gland take up lymph very rapidly from 
the lymph spaces which are adjacent to them, and pour it out in 
the form of saliva. Quickly as they take up the lymph, however, 
it is still more quickly poured out from the blood-vessels, so that 
during the continuance of the irritation we not only have a stream 
of saliva pouring out from the salivary duct, but we have a con- 
siderable increase in the amount of lymph which pours out from 
the cervical lymphatics. This observation, as well as most of the 
knowledge that we possess in regard to the flow of lymph and the 
fundamental facts of secretion in general, we owe to Ludwig. In 
this experiment we have the lymph which exudes from the vessels 
carried away by two, perhaps three, channels, viz., the secreting cells 
of the gland, the lymphatics, and probably also, to some extent, the 
veins. \Yhen we obstruct one of these channels by injecting into 



312 PATHOLOGY OF DROPSY. 

the salivary gland a solution of quinine, or dilute hydrochloric 
acid, more lymph is poured out from the arteries than the lymph- 
atics and veins together can carry away, and the gland becomes 
cedematous. 

A very remarkable change occurs in the results of this experi- 
ment when we administer a dose of atropine to the animal. If we 
irritate the chorda tympani after poisoning by atropine, the vessels 
dilate as before, the veins become full, and the current of blood 
in them becomes rapid, but not a drop of saliva is secreted by the 
cells. 

We are usually in the habit of assuming that the chorda tym- 
pani contains two sets of fibres, one of which goes to the secreting 
cells and another to the vessels ; the one set stimulates the glands 
to functional activity, and the othei* causes the vessels to dilate. 

We usually explain the effect of atropine by saying that it 
paralyses the peripheral ends of the secreting nerves in the cells of 
the gland ; but if this were the only explanation, we ought to have 
a result very much like what we get by injecting a solution of 
quinine into the gland. We ought to have the gland either be- 
coming cedematous, or the flow of lymph in the lymphatics passing 
from the gland should be enormously accelerated ; the lymph 
which exudes from the vessels ought either to be carried away 
rapidly by the efferent vessels, or should accumulate and jDroduce 
oedema, but neither of these results occurs. Heidenhain has found 
that the gland does not become cedematous under these circum- 
stances, and the flow of lymph through the cervical lymphatics is 
not accelerated. Now I have already mentioned that under 
normal conditions, even when the gland is forming large quantities 
of saliva, and thus removing a quantity of the fluid poured out 
from the vessels, we have an increased flow of lymph occurring 
during irritation of the chorda tympani nerve. I can see then no 
other way of explaining the fact that after poisoning by atropine 
it does not produce either secretion of saliva or increased flow of 
lymph from the lymphatics, than by assuming that the atropine 
has so altered the vessels as to prevent the exudation of lymph 
from them into the lymph spaces at the same time that it has 
allowed the arteries to dilate ; for we know that the secreting cells 
of the gland are still able to form saliva because irritation of the 
sympathetic nerve will cause secretion even after the power of the 
chorda tympani to cause secretion has been completely paralysed. 
I should not be prepared at present to deny that the chorda 



EFFECT OF DRUGS ON EXUDATION OF LYMPH. 343 

tympaui lias fibres which stimulate the secreting cells to increased 
action. 

But what I wish to insist upon here is that in all probability 
atropine has an action upon the vessels of the gland which has 
hitherto been entirely overlooked. Yet such an action as I have 
mentioned is one of the greatest practical importance, because 
if we are able through the action of our drugs to prevent the 
exudation of lymph from the blood-vessels into the lymph spaces, 
it will enormously increase our power to prevent or to lessen 
dropsy. 

In a remarkable research upon the action of drugs on the 
heart and vessels, Dr. Gaskell showed that dilute acids cause 
relaxation of the muscular substance both of the heart and 
blood-vessels, while dilute alkalies have an opposite effect, aiid 
cause contraction. He showed also that certain drugs resemble 
acids in their action, while others resemble alkalies. Thus 
muscarine, the poisonous principle of mushrooms, tends like 
acids to cause relaxation of the ventricle and dilatation of the 
blood-vessels, while atropine has an opposite effect, and resembles 
alkalies in its action. 

Dr. Cash and I have repeated Dr. Gaskell's experiments on 
the effect of acids and alkalies on the vessels. This action is 
tested by killing a frog and then keeping up the circulation in 
it artificially, by connecting the aorta with a vessel containing 
diluted blood or saline solution. As the pressure is constant, 
the rapidity with which the fluid flows out of the veins affords 
a measure of the dilatation or contraction of the vessels. We 
have observed that not only do the vessels dilate under the 
influence of acids added to the circulating fluid, so that the 
liquid pours much more readily out of the veins than before, 
but that the walls of the vessels themselves appear to become 
much more permeable, so that the tissues tend to become 
oedematous. 

Under the influence of alkalies the vessels contract, the flow 
of fluid out of the veins becomes scanty, and no oedema is 
observed in the tissues. This experiment affords, I think, a 
clue to the changes in the vascular walls which give rise to 
dropsy, although much research will still be necessary before our 
knowledge on this subject is either complete or accurate. 

In regard to the action of acids and alkalies upon the vessels, 
however, we may obtain useful information fi'om the effect 



344 PATHOLOGY OF DROPSY. 

of experiments on the submaxillary gland. I have already 
mentioned that atropine, which Gaskell found to act upon the 
vessels like alkalies, appears to arrest the flow of lymph from 
the blood-vessels into the lymph spaces, so that the secretion of 
saliva is entirely arrested, while the flow of lymph through the 
lymphatics is certainly not increased, nor yet does the gland 
become oedematous, although the blood-vessels are fully dilated. 
As I have said, moreover, by injecting a solution of quinine 
or dilute hydrochloric acid into the duct of the gland, the 
secretion of saliva is stopped, but here the gland becomes 
oedematous. These facts seem then to indicate that the acid 
has increased the tendency to exudation of lymph from the 
blood-vessels. 

I may again shortly recapitulate what we have now gone over, 
as to the general sources of dropsy, and then proceed to say a few 
words regarding particular kinds of dropsy. 

Shortly, then, dropsy depends on the quantity of lymph effused 
from the blood-vessels being greater than the veins and lymph- 
atics can carry away. This may depend either upon obstruction 
to the veins and lymphatics, or excessive exudation from the 
blood-vessels. The veins and lymphatics in the normal condition 
are able, however, to carry away so much more fluid than is 
effused from the capillaries, that, unless the obstruction to them 
is very great indeed, no oedema occurs so long as the capillaries 
are in their normal condition. 

In almost all cases of dropsy, then, we may consider that the 
capillaries are so altered as to allow a greater amount of trans- 
udation. The exact nature of the alteration we do not at present 
know ; but such experiments as we have on the subject tend to 
show that acids, or substances having an action upon the vessels 
similar to that of acids, may have very much to do with this 
efi"ect. 

The forms of dropsy may be divided either according to their 
supposed causation or to their seat. 

From their causation they maybe divided into dropsy of passive 
congestion, hydrsemic dropsy, and inflammatory dropsy. 

These may again be subdivided into cardiac dropsy, hepatic 
dropsy, anaemic dropsy, renal dropsy, scarlatinal dropsy, according 
to the tissue on the affection of which the dropsy appears to 
depend. 

Another class of dropsies are nervous dropsies, and it is perhaps 



CLASSIFICATION OF DROPSIES. 345 

at the present moment rather doubtful how these dropsies are 
produced, and how far they are dependent on changes m the 
chx-ulation of blood in the part affected, and how far on alterations 
in the permeability of the vascular walls. 

In dividing dropsies according to their seat we have general 
cedema, ascites, hydropericardium, pleuritic effusion, hydrocele, and 
effusion into joints. 

In regard to the particular dropsies I shall say only a few words, 
as, in questions of this sort, if we can settle the general causation 
of any condition^ the application of it to particular instances is 
easy. 

I have mentioned that sometimes, even in health, the mere 
weight of the column of blood in the arms, and j)erhaps slight 
constriction by the clothes on a sultry day, may produce shght 
oedema in the hands. A similar condition is noticed in the legs 
in oedema, and it is not unfrequently very marked in cases of fatty 
heart. Indeed, the occurrence of oedema in the legs when the 
urine is normal, and no cardiac murmur is to be heard, is, I think, 
a very important point in the diagnosis of fatty heart. 

"VVe find it also markedly in the legs where the venous flow is 
obstructed in consequence of emphysema or mitral disease. In 
such cases the effect of the greater pressure of blood in the venous 
radicals in producing oedema is well shown by its disappearance 
when the patient has been lying down. That even in such cases, 
however, the permeability of the capillaries has much to do with 
the production of oedema is shown by the fact that every now and 
again we meet with persons who are suffering from great emphysema 
and excessive interference of the venous circulation, and yet little 
or no oedema is to be noticed. A sudden change in the condition 
of the patient, and one too attended by a relief of the general 
symptoms, may cause oedema to appear. 

I was much struck with a case of this sort which I saw a year or 
two ago. An old woman was suffering from chronic bronchitis with 
emphysema, the lungs were choked with mucus which she could 
not expectorate, her face was becoming rapidly more and more 
livid, she was apparently at the point of death, and yet there was 
but very slight oedema in the legs. I gave her an emetic of 
ipecacuanha with the effect of greatly relieving her, clearing the 
lungs, and removing the lividity, but the day afterwards the 
oedema in the feet was very well marked. This shows that eveii 
in those cases the permeability of the capillaries has much to do 



346 PATHOLOGY OF DROPSY. 

with the production of dropsy, although such cases are generally 
ascribed almost entirely to venous obstruction, and this obstruction 
has no doubt a great deal to do with their causation. 

Another form of oedema is that which occurs in connection with 
albuminuria — or perhaps it might be better to say, with Cohnheira, 
in the earlier stages of albuminuria. For Cohnheim divides the 
dropsies which occur in albuminuria into two classes : the first, 
which occurs in the earlier stages, is due to changes in the per- 
meability of the vessels, allowing a more rapid exudation of fluid 
from them. The dropsy which occurs in the later stages, and 
which affects the serous cavities as well as subcutaneous cellular 
tissue, he regards as due to passive congestion, secondary to changes 
in the heart. 

The first form, then, of albuminuric dropsy, which affects only 
the subcutaneous cellular tissue, differs from the dropsy of passive 
congestion not only by being confined to the subcutaneous tissue, 
but in affecting different parts of it. In the dropsy of passive 
congestion the parts which swell are those which are most dependent, 
such as the feet and legs ; but in the dropsy of albuminuria the 
parts affected are those where the cellular tissue is loose, such as 
the face. The dropsy of albuminuria is usually ascribed to a more 
watery condition of the blood, but Cohnheim shows that this alone 
is not sufficient to produce oedema. So long as the capillaries are 
in a healthy condition, they do not allow more exudation to take 
place when the blood is rendered watery by the intravenous 
injection of a large quantity of dilute saline solution than they do 
when the blood is in its normal condition. But when the capillaries 
have become altered by inflammation, which renders them more 
permeable than usual, the effect of any alteration in the concen- 
tration of the blood is at once manifest. The dilute blood, although 
it does not pass through healthy capillaries more easily than the 
concentrated blood, exudes through the altered capillaries very 
much more rapidly than the normal blood, as is shown by the much 
greater quantity of lymph which is poured out from the vessels of 
the inflamed limb of a dog, when its blood is diluted by the injection 
of a large quantity of saline solution into the veins. This experiment 
shows us that, although alterations in the composition of the blood 
will not produce oedema when the vessels are healthy, yet, when 
the vessels are already altered by disease, a diluted condition of the 
blood tends greatly to increase the oedema ; and we thus obtain to 
some extent an explanation of the good effects of diuretics and 



INDEPENDENCE OF VASCULAR DILATATION. 347 

purgatives in dropsy ; for these remedies, by removing water from 
the body, will lessen the dilution of the blood. 

The ready occurrence of oedema in scarlet fever, and as a con- 
sequence of a sudden chill, is ascribed by Cohnheim to increased 
]3ermeability of the vessels due to inflammatory changes in them. 
No doubt he is to a great extent right, and the oedema occurs 
chiefly in consequence of changes in the vessels, but we must try 
and find out more particularly what the changes are if we are to 
learn much regarding the rational treatment of oedema. The term 
injiammatory does not help us — at least, does not help us much. 
We must tiy and find out whether we can bring the changes in 
the vessels into direct connection with the action of drugs. 

Now one of the most striking forms of dropsy is probably the 
intense oedema which is said to occur to the natives of the West 
Coast of Africa, or in Europeans resident in some hot climates in 
consequence of sudden wetting. This comes on suddenly in the 
absence of cardiac disease, aud in the absence of albuminuria. 
Now in hot climates the skin secretes much sweat, and this sudden 
cedema is just what we would expect if stoppage of the functional 
activity of the sweat glands were to occur without a corresponding 
arrest of exudation from the vessels. In poisoning by belladonna 
or atropine, as we have seen, the secretion of saliva is arrested, but 
the exudation from the vessels of the salivary gland is also dimin- 
ished. We have no similar experiments regarding the action of 
atropine upon the vessels of the skin, but probably a similar action 
occurs in regard to the lymphatics of the skin, for we know that 
atropine arrests the secretion of sweat in almost exactly the same 
way as it arrests the secretion of saliva. 

In consequence of the diminished exudation from the vessels, 
we find no oedema occurring in the salivary gland after poisoning 
by atropine, although the vessels are much dilated, nor do we 
find any oedema occurring in the skin under similar conditions, 
even although the cutaneous vessels may be so much dilated that 
the patient poisoned by atropine presents an erythematous flush all 
over, like one suffering from scarlet fever. In scarlet fever, also, 
the secretion from the skin appears to be diminished or arrested, 
for the skin is dry and has a pungent feeling, which is probably 
due to the want of cooling by evaporation. But at this time there 
is no oedema. The skin is red, the vessels are fully dilated, the 
secretion from the sweat glands is probably completely arrested, 
and yet there is no oedema. But we can readily see that, if the 



348 CEDEMA FROM POISONS FORMED IN INTESTINES. 

vessels should by any means become readily permeable before the 
sweat glands had resumed their function, we should at once have 
all the conditions for acute oedema. 

We can readily see, also, that the blood-vessels will be more 
readily acted upon by any substance which is circulating in the 
blood than the sweat glands would be, for, in order to act upon the 
sweat glands, any substance must first pass through the vessels 
into the lymph spaces adjacent to the sweat glands, and then be 
taken up by the secreting cells. 

If therefore any substance should either be absorbed from the 
intestinal canal, or be formed in the tissues of a patient suffering 
from scarlet fever, which will cause permeability of the capillaries 
without stimulating secretion of the sweat glands, we would expect 
oedema to occur. Now it would almost appear that certain abnor- 
malities, either in digestion or in tissue change, precede the oedema 
of scarlet fever and the albuminuria which accompanies it, for here, 
I think, we must look upon the albuminuria and the oedema, not 
as dependent uj)on one another, but as consequences of one common 
cause, which probably is the presence of something in the blood 
which acts as a poison upon the tissues already predisj^osed to its 
action. Now Dr. Mahomed found what he regards as a pre- 
albuminuric stage of scarlet fever, in which he noticed a peculiar 
reaction of the urine, which gave a blue with guaiac. If the 
patient was left alone when this action was noticed, albuminuria 
came on, but if a brisk purgative was at once administered, the 
abnormal condition passed awa}" and no injury resulted. 

The osdema of scarlet fever is usually considered to be due to some 
chill, but we do find cases in which the utmost care has been 
taken, and where we cannot trace any distinct history of a chiU, 
and yet oedema occurs. A chill may, no doubt, not only induce 
changes in the circulation, but may induce changes in the aliment- 
ary canal, and in the tissues generally, by which substances may 
be formed which, after their absorption into the blood, may increase 
the permeability of the v^essels. But I think, at the same time, 
we must keep our eyes oj3en to the possibility of such substances 
being formed even without any exposure. 

The phenomena which occur in urticaria are, I think, instructive 
in regard to the possible causation of dropsy by poisons circulating 
in the blood, for there we frequently find that after the ingestion 
of certain articles of diet the skin becomes bright red, the capillaries 
dilated, and what are really spots of local oedema occur. These 



URTICARIA—SUMMARY. 349 

may be very limited, or they may be extensive, as in the case of a 
lady of my acquaintance in whom a single strawberry will produce 
such intense urticaria that the face swells up and the eyes become 
almost closed by the accompanying oedema. 

Now in urticaria the round white swellino-s resemblino- the 
effects of the sting of a nettle suggest the idea that they arise from 
some point in the centre, and it seems not improbable that the 
originating point is a sweat gland. Both in urticaria and in the 
sudden oedema occurring after a chill in hot climates, I am inclined 
to regard the sweat glands as playing an important part, and 
paralysis of the secreting power as a cause of oedema, not only 
because the fluid effused from the blood-vessels ceases to be drained 
away from them, but also because it seems to me not improbable 
that, although the secretion is not fully elaborated, such changes 
may occur as will produce acid in the secreting cells. Normally 
this will be carried away in the sweat, but if retained it may react 
upon the capillaries in the same way as Cash and I have found in 
our experiments, and thus increase the amount of fluid poured out 
from them. 

I have preferred in this paper on the pathology of dropsy, to 
deal most at length with the particular points which seem to me 
most likely to lead us to a rational and successful treatment. 

Again to recapitulate. Dropsy consists in the accumulation of 
lymph in small lymph spaces or large serous cavities. The accumu- 
lation is caused by more lymph being poured out from the vessels 
than can be removed by the lymphatics and -veins. Obstruction 
to the lymphatics and veins will rarely produce dropsy unless the 
quantity exuded from the capillaries is greater than the normal. 
The exudation from the capillaries is increased by changes which 
occur in them. These changes are classed generally by Cohnheim 
under the name of injiammatoo-y. This designation is too vague 
to give us any guide to treatment, and I have tried to point out 
that the increased permeability of the vessels is probably due to 
an alteration in them. It may be produced by acids circulating 
in the blood, as in the experiments of Cash and myself; by acids 
applied to them from without, as in Ludwig's experiment with 
the submaxillary gland; or by acids, or poisons which act like 
acids, absorbed from the intestinal canal, or formed in the tissues 
themselves (cf. p. 274). 



350 PATHOLOGY OF DROPSY— APPENDIX. 



APPENDIX. 

Since I wrote tliis paper I have become acquainted witli some 
facts whicli seem to me to support the views regarding the action of 
acids which I have advanced. Tlirough the kindness of Professor 
Hans Meyer of Doi^pat, I have received an Inaugural Dissertation, 
written, under his direction by Jacob Feitelberg, on the action of 
various j)oison.s upon the acidity of the blood. In this paper the 
author shows that a number of poisons have the power of increasing 
the acidity of the blood. They appear to do this by diminishing 
oxidation, as it is found that, along with an increase of acid, w^hich 
chiefly appears to be sarcolactic acid in. the blood, the carbolic acid 
in it is lessened. One drug which has this power in a marked 
degree is arsenic, as we know one of the common symptoms of 
arsenic poisoning is an osdematous condition of the eyelids. This 
effect of arsenic on the amount of acid in the blood seems to me to 
afford a ready explanation of the oedema which it produces. 



ON THE ACTION AND USE OF DIURETICS. 

{'Practitioner,' TOL. xxxil., A-piil and May, 1SS4.) 

The part which water plays in the animal body is a very 
important one. Not merely does it form by far the greatest part 
of the body itself, constituting no less than 59 per cent, of its 
weight, but the life of ail the tissues is essentially dependent 
on its presence in them. "Without water no vital function can 
go on. In the dry climate of Egypt wheat has been preserved 
unchanged since the days of the Pharaohs, without the slightest 
tendency to growth having occurred until it was moistened ; and 
when rotifer animalculse are dried up they will fly about as dust 
devoid of any appearance of life, until they are again put into 
the water. In the complicated organism of the human body 
the same thing occurs, though to a much less extent. We cannot 
have any one of the tissues completely desiccated, otherwise it 
would, like the rotifer, lose all its vital functions, but, unlike it, 
would not regain them when a fresh supply of water was brought 
to it. Diminution of water to a certain extent may be endured 
by the tissues without injury, but it will diminish tissue change 
in them, while increase of water will augment it. When much 
water is drunk, as certain experiments have shown, the tissue 
change is increased to such an extent that the body must rapidly 
waste, and the necessity for more food to supply them is indicated 
by the ravenous appetite which is induced, as well as by the loss 
of body weight which occurs when the aj)petite is not gratified. 
Not only does water increase tissue change, it removes the waste 
products produced more rapidly than usual, and, indeed, the effect 
of water-drinking upon the body, in increasing tissue change and 
removing the waste products, may be compared to raking out the 
ashes from a fire, and at the same time making it burn more 
brightly. All the water drunk must find its way out of the body 



352 ON THE ACTION AND USE OF DIURETICS. 

again by one channel or another. Some of it passes off through 
the lungs, and a little by the bowels, but the greater proportion 
passes through the skin and kidneys. The action of these organs 
is compensatory. 

It is difficult to estimate precisely how much is excreted by 
the skin, but probably it may be taken at about two-thirds of 
the quantity eliminated by the kidneys. When the skin is active 
the kidneys have, consequently, less work to do, and when the 
secretion from the skin is sluggish, the kidneys must secrete all 
the more. Some years ago, while making experiments upon the 
urinary secretion, I found that on the sudden occurrence of a cold 
day after a succession of warm ones, the amount of urine secreted 
was very nearly doubled. One reason of this compensatory 
function of the skin and kidneys probably is that the secretion 
in both, like the secretion in other glands, depends to a great 
extent on the supply of blood going to them. When the supply of 
blood is greater, the secretion is also increased. On a Avarm day, 
or when the body is exposed to external warmth, the vessels of the 
skin dilate, and the cutaneous glands are freely supplied with 
blood. The application of cold to the surface of the body, on the 
contrary, causes the cutaneous vessels to contract, and thus more 
blood is driven to the internal organs — the kidney amongst the 
rest. 

The utility of this an-angement is obvious, for although the 
skin has an excreting function complementary to that of the 
kidneys, its chief function is that of regulating the temperature 
of the body. When the temperature rises either in consequence 
of active muscular exercise or from any other cause, the vessels 
of the skin dilate, and if the temperature of the external air be 
lower than that of the body, heat is lost by radiation. The blood 
returns cooled from the cutaneous capillaries to the internal organs, 
and thus the temperature is again brought down to the normal. 
But even when the temperature of the external air, instead of being 
lower, is higher than that of the body, the skin still acts as a 
cooling aj)paratus by means of the evaporation of sweat. The 
quantity of heat which is changed into potential energy in the 
process of converting liquid water into gaseous steam is very gieat. 
Five and a half times as much heat are required to convert boiling 
water into steam as to raise the same amount of water from the 
freezing to the boiling point. The immense loss of heat occasioned 
by the evaporation of the perspiration is so great that in negroes 



THE SKIN AS A REGULATOR OF TEMPERATURE. 353 

on the west coast of Africa it has been noticed that the skin, while 
perspiring profusely, is as cold as marble, and Sir Charles Blagdon 
observed that in a room with a temperature of 128° F. his side 
felt quite cold to the touch. The skin cooled by perspiration 
therefore acts even with a high external temperature as a refriger- 
ating apparatus to the blood, and prevents the temperature of the 
body from rising too high. When the external temperature is low 
the vessels of the skin contract so that little blood circulates 
through them, and loss of heat by conduction or radiation or by 
perspiration is, to a great extent, prevented. It is evident that 
on a hot, dry day, with active exertion the loss of water by the 
skin must be considerable, and sometimes work must be done with 
but a limited supply of water to drink. At the same time the 
products of waste must be removed, and under such circumstances, 
although the skin excretes a very large quantity of water, it 
excretes but a small quantity of solids. The kidneys are thus put 
to a great disadvantage. They have still to excrete the solids: 
they can only do so when these solids are in a state of solution, 
and yet if they excrete the usual amount of water while more than 
usual is being thrown off from the skin, and, perhaps, less than 
usiial is being drunk, the proper proportion of water in the body 
will rapidly be reduced below the normal, and its functions seriously 
disturbed. In order to prevent this there seems to be an arrange- 
ment in the kidney whereby water is retained after it has served 
its purpose of washing the solids so far through the kidneys that 
they can be afterwards eliminated without it. The products of 
tissue waste must be removed in a state of solution from the part 
of the kidney where they are excreted, and yet sometimes provision 
must be made for the water by which they are washed out being 
retained in the body. The urine in mammals and amphibia is 
liquid ; in birds and reptiles it is semi-fluid or solid, yet the solid 
constituents are removed in solution from the urinary tubules, and 
the water in which they are dissolved is afterwards absorbed. 

In cold weather, on the other hand, the vessels of the skin are 
contracted, there is little or no perspiration, and yet it may so 
happen that the individual is obliged to live on food containing a 
large proportion of water. This difficulty must also be met, and so 
in the kidney we have a provision for the removal of water without 
solids. 

We may say then that the kidney has a threefold function : — 
1 st, that of excretion of waste products ; 2ndly , a provision for the 

A A 



354 ON THE ACTION AND USE OF DIURETICS. 

removal of excessive water; and Srdly, an arrangement for tlie 
retention of water in the body by its re-absorption, after it has 
washed out the waste products. On looking at the kidney we 
find three structures which seem to be connected with these three 
functions, viz. : (1) convoluted tubules with epithelial cells, which 
in all probability are the chief structures for excreting waste 
products ; (2) the malpighian corpuscles for excreting water along 
with some solids; and (3) usually one or more constrictions in the 
tubule which may serve the purpose of preventing too rapid exit 
of the water, and thus allow time for its re-absorption in cases 
where its retention is desirable, as for example on a hot day and 
when the supply of drinking-water is very limited. 

The process of secretion in the kidney was regarded by Bowman 
as consisting of the filtration of water from the vessels of the 
glomeruli into the tubule, and the excretion of waste products by 
the epithelium lining the tubule. Ludwig, however, came to look 
upon it rather as a process of filtration and re-absorption ; a dilute 
solution of urea and salts being, according to him, poured out from 
the malpighian corpuscles and gradually concentrated by the 
absorption of water in its passage along the tubules. This theory 
had so many facts in its favour that it was for a good while 
exclusively adopted, but latterly Heideuhain in an admirable series 
of experiments has shown that substances like indigo are certainly 
excreted by the ej)ithelium of the tubules. At the same time 
Hiifner has shown by a comparison of the structure of the kidney 
in fishes, frogs, tortoises, birds, and mammals, that the form of the 
tubules closely agrees with that required for the re-absoi^ption of 
w^ater in each case. Fishes have a low blood-pressure, and so the 
resistance in the kidney requires to be small in order to allow of 
the secretion of urine. Living as they do in water, they do not 
require any apparatus for its retention in the body. In them 
therefore the tubule is short and wide, and destitute of any con- 
striction which would retard the outflow of fluid. In frogs there 
must be ample provision for the retention of water in the body, as 
evaporation takes place freely from their skin. In them we find, 
as we might expect, that the tubule, and especially the contracted 
part of it, is very long. In tortoises no evaporation from the skin 
can take place, and in them the contracted part of the tubule is 
short. This renders it probable that, while the ideas advanced by 
Bowman and supported by Heidenhain are in the main true, the 
re-absorption of water on which Ludwig lays so much stress is also 



ABSORPTION IN THE URINARY TV BULKS. 355 

a most important factor in the secretion of urine under different 
circumstances. 

But it is not only rendered probable by the facts of comparative 
anatomy ; it appears to be proved by direct experiment. Pdbbert ^ 
has extirpated the medullary substance of the kidney in the 
rabbit while leaving the cortical substance. He h&s thus succeeded 
in collecting the urine as it is excreted by the malpighian cor- 
puscles before it has passed through Henle's loops, and has found 
that the urine secreted by the cortical substance alone is much 
more watery than that which is secreted by the entire kidney, a 




Fig. 46. — Diagram showirig tlie form of the urinaiy tubules in different classes of 
animals, after Hiifner. 1. Fish. 2. Frog. 3. Tortoise. 4. Bird. 5. Mammal. 
The letters have the same significance in each. a. Capsule of the glomerulus. 
6. Convoluted tubule, c. Loop. d. Collecting tube. ?6 in 2 indicates the trans- 
verse section of the ureter. 

fact which appears conclusively to prove that water is actually 
re-absorbed, and the urine rendered more concentrated, during its 
passage through the tubules in the medullary substance. 

In the frog and triton the arrangement of the kidney is such as 

to allow of a much more complete investigation of the different 

factors in secretion than in mammals, because in amphibia the 

glomeruli which separate the water and the tubules which excrete 

" 1 Pdbbert, FircJiow's ArcMv, July 1883, p. 189. . " 

A A 2 



356 



ON THE ACTION AND USE OF DIURETICS. 



the solids receive tlieir blood supply to a great extent independ- 
ently. The glomeruli are supplied by branches of the renal artery. 
The tubules are supplied b}'' a vein which proceeds from the 
posterior extremities, and entering the kidney, breaks up into a 
capillary plexus bearing a somewhat similar relation to the renal 
tubules, to that which the portal vein bears to the lobules of the 
liver. It is therefore called the portal vein of the kidney. 

The arterial circulation in the glomeruli is not entirely distinct 
from the venous portal circulation round the tubules, for the 
efferent arteries of the glomeruli unite with the portal capil- 
laries, and, moreover, arterial twigs also pass directly from the 
renal artery into the capillary venous plexus. Still the two 
systems are so far distinct that Nussbaum has been able to 
ascertain with considerable exactitude the part played by each in 

Branch of renal artery. 

Afferent artery to the glomerulua. — 

Connecting branch. 

Artery passing directly to the") 

plexus (corresponding to one >■ 

of the arterias rectfe). ) 

Glomerulus with efferent artery. 



Union of arterial and venous ' 
branches to form the plexus. ] 

Poital vein of the kidney. 
Urinary tubule. 




Abdominal vein. 

Small branch connecting the 
efferent artery from the glome- 
rulus directly with the abdo- 
minal vein. 



Fig. 47. 



-Diagram of the circulation in the kidney of the newt. 
from Nussbaum. 



Modified 



secretion. By ligaturing the renal artery he destroys the func- 
tional activity of the glomeruli, and by ligaturing the portal vein 
of the kidney he destroys that of the tubules. By injecting a 
substance into the circulation after ligature either of the artery 
or the vein, and observing whether it is excreted or not, he 
determines whether it is excreted by the glomeruli or the tubules. 
In this way he finds that sugar, peptones, and albumen pass out 
through the glomeruli exclusively^ for they are not excreted when 
the renal arteries are tied. Albumen, however, only passes out 
through the glomeruli when an abnormal change has already 
occurred in the vascular wall ; as, for example, after the circulation 
has been arrested for a while by ligature of the renal artery. 
Indigo- carmine, when injected after ligature of the renal arteries, 



BLOOD-SUPPLY OF TLIE GLOMERULI AND TUBULES. 357 

passes into the epitlielium of the tubules, but it does not give rise 
to any secretion of water, so that the bladder is found empty. 
Urea, on the contrary, is not only excreted by the tubules after 
ligature of the renal artery, but carries with it, in the process of 
secretion, a considerable quantity of water from the venous plexus, 
so that the bladder becomes partially filled. 

The excretion of water, therefore, takes place in a double 
manner : it passes out through the glomeruli when the renal 
arteries are free, and it passes out from the venous plexus along 
with urea, even although the renal arteries are tied. 

In the kidneys of the higher animals and of man the glomeruli 
and the tubules do not receive blood from two entirely different 
sources, but there is an arrangement somewhat similar to that just 




Fig. 48. — Diagrammatic sketch of the hlood-vessels in a mammalian kidney. From 
Schweigger-Seidel, Die Niercn, Halle, 1865, o is an artery ascending into the 
cortical substance of the kidney, p is a branch from it which divides into two 
branches, q and P. q breaks up at once into a number of twigs. Pis the afferent 
artery to a glomerulus (s) of the lowest row. t is the afferent vessel of the glomerulus ; 
it divides into two branches, one of which {u) ascends towards the cortex, whilst 
the other {v) descends towards the medulla. 

described ; for the plexus surrounding the tiibules does not receive 
blood only from the efferent vessels of the malpighian corpuscles, 
it gets blood also directly from the renal arteries. 

There are three channels by which the blood may pass from the 
renal arteries into the venous plexus without going through the 
glomeruli. 

The first is the inosculation which takes place between the 
terminal twigs of the renal artery and the venous plexus on the 
surface of the kidney directly under the capsule (stellate veins, 
Fig. 35, p. 301). 

The second channel is formed by small branches given off 



358 ON THE ACTION AND USE OF DIURETICS. 

directly by the interlobular arteries or by the afferent arteries before 
they reach the glomeruli.^ The former of these may be regarded 
as corresponding to the artery which passes directly to the plexus 
in the newt, and the latter to the branch connecting it with the 
afferent artery (Fig. 48). These arterial twigs are found not only 
near the surface of the kidney, but also in the deeper layers of the 
cortical substance.^ 

The third and most important channel is afforded by the arterise 
rectai, which spring from the branches of the renal artery at the' 
boundary between the cortical and medullary substance and pass 
into the medulla, where they form a plexus with elongated meshes 
surrounding Henle's loops and the collecting tubules. Near their 
origin the arterise rectse inosculate with the venous plexus 
surrounding the convoluted tubules (Fig. 49, p. 359). 

Through these three channels it is possible for blood to reach 
the secreting structures of the kidney and there get rid of urea, 
salts, &c., without losing water by its passage through the 
glomeruli. On the other hand, if these vessels contract, while 
the size of the renal artery and the pressure of the blood within it 
remain unaltered, more blood will be forced into the malpighian 
corpuscles, and thus the quantity of water excreted will be 
increased. At the same time the contraction of the arterise 
rectse will probably diminish absorption from the tubules, and thus 
the quantity of water excreted will be increased in a twofold manner. 

Circumstances modifying the Secretion of Urine. — The experi- 
ments of Ludwig and his pupils have shown that the amount of 
urine secreted depends very closely upon the pressiire of blood 
in the malpighian corpuscles, or, to put it more exactly, on the 
difference of pressure between the blood in these corpuscles and 
the pressure within the tubules. For if the ureter be tied so that 
the pressure of urine in the tubules is increased, the secretion is 
greatly diminished, and even arrested, although the pressure of 
blood in the renal artery be high. 

A somewhat similar effect to that of ligature of the ureter is 
produced by ligature of the renal vein, for the blood accumulating 
in the venous plexus surrounding the tubules compresses them so 
as to prevent the flow of urine throiigh them. A similar condition 
may occur from cardiac or pulmonary disease obstructing the venous 
circulation. 

1 Ludwig, Handworterhuch d. Physiol., v. E. "Wfigner, Bd. 2. 

2 Schweigger-Seidel, Die Nieren, p. 67 ; Heidenhain, Hermann's Handbuch d. 
riajdologic, vol. v. Th. I. p. 293. 



FACTORS IN THE SECRETION- OF URINE. 359 

But unless in exceptional circumstances which alter the pressure 
within the tubules, such as compression of the tubules by con- 
gestion of the venous plexus, as in cardiac disease, impaction of a 
calculus in the ureter, or pressure on the ureters by dropsical 




Artcriae rcctse. 



Vciife rectffl. 



Fig. 49. — Diagram of the tubules and vascular supply of the kidney. On the left is 
a tubule alone, in the middle is a tubule along with the blood-vessels, ou the right 
are blood-vessels only. 

accumulations or tumours, the rapidity of the secretion of urine 
depends on two factors: — (1) arterial pressure in the glomeruli; 
and (2) the composition of the blood. 

The pressure of blood in the glomeruli may be raised — • 

(1) by increase of the arterial tension generally, 

(2) by increased tension locally. 

Thus the effect of cold winds and cold baths is probably due 
chiefly to their power of contracting the vessels in other parts of 
the body, and thus driving more blood into the renal artery, and 



360 ON THE ACTION AND USE OF DIURETICS. 

increasing the pressure in the glomeruli. In some pathological 
conditions also we find the blood pressure high, and the secretion 
of urine abundant. This occurs, as a general rule, in persons 
suffering from cirrhotic or contracting kidney, in -vvhom the pulse 
is generally tense, and the blood pressure high, although in these 
cases also the high blood pressure is probably not the only factor 
in the increased secretion. 

Such a general increase may be brought about by greater action 
of the heart, or by contraction of the b'ood-vessels in other vascular 
areas, such as the intestines, muscles, or skin, by nervous stimula- 
tion, exposure to cold, or the action of drugs. 

The pressure may be increased locally by dilatation of the renal 
arteries, e.g. from section of the vaso-motor nerves, or possibly 
stimulation of vaso-dilating nerves. 

In addition to such increase of pressure in the glomeruli by 
increase of blood supply to them, we must not, however, forget 
the possibility of increased pressure in them by contraction of 
the efferent vessels leading from them, as well as of those arterial 
twigs (arterige rectre) which pass directly to the venous plexus 
surrounding the tubules, and which form no inconsiderable part of 
tlie vascular supply of the kidney. 

Alterations in the size of the renal vessels were formerly 
ascertained simply by exposing the kidney and observing its 
colour, contraction of the arteries being associated with paleness, 
and dilatation with redness of tlie organ. A much more exact 
method has been introduced by Roy, who incloses the kidney in a 
capsule filled with oil and connected with a registering apparatus. 
When the vessels dilate, the kidney increases in size, and 
diminishes when it contracts, so that the alterations can be readily 
recorded on the same revolving cylinder on which the general 
blood pressure is registered by the manometer. 

The pressure of blood in the glomeruli may be diminished 
generally — 

(1) by failure of the heart's action, or 

(2) by dilatation of vessels in larger areas, as the intestines, 
muscles, and skin. 

The pressure of blood in the glomeruli may be diminished 
locally by contraction of the renal arteries, or of the afferent 
branches to the glomeruli. 

The heart's action may fail from many causes, which have 
already been discussed more particularly. 



NER VO US S UPPL Y OF THE KIDNEY. 2 G 1 

Dilatation of the vessels in the skin, intestines, &c, may be 
caused by exi30sure to warmth, by the action of drugs, or by 
paralysis due to nervous injury. 

Section of the splanchnics or of the spinal cord causes paralysis 
of the renal arteries and ouQ-ht, therefore, to increase the secretion 
of urine. This does occur, though not invariably, when the 
splanchnics are divided ; but section of the spinal cord, by 
paralysing the intestinal and other vessels, lowers the blood 
pressure so much that the supply of blood to the kidney is not 
only much below the normal, but is so small that the secretion of 
urine is generally almost completely arrested. 

The nerves of the kidney consist of a number of small branches 
running along the renal artery and containing a number of ganglia. 
When these nerves are cut the vessels of the kidney dilate ; when 
they are stimulated the vessels contract. A number of these fibres 
pass to the kidney from the spinal cord through the splanchnics. so 
that when the splanchnics are cut the vessels of the kidney usually 
dilate, and when they are irritated, they contract. 

The whole of the nerves, however, do not pass through the 
splanchnics, for stimulation of a sensory nerve, of the medulla 
oblongata, or of the spinal cord in the neck, will cause contraction 
of the renal vessels after both sj)lanchnics have been cut, and 
section of the splanchnics does not always cause the renal vessels 
to dilate. 

The nervous centre for the renal arteries is probably, like 
the chief vaso-motor centre for the body generally, in the 
medulla oblongata ; but in all probability there are also sub- 
sidiary centres in the spinal cord and in the solar and mesenteric 
plexuses. 

The reason for supposing these latter centres to exist is, that 
stimulation of the jDeripheral end of the sjolanchnic, divided 
at its passage through the diaphragm, causes contraction of both 
kidneys, and the vessels of the kidney of the side opposite to 
the stimulated nerve commence to contract later than that on 
the same side. A delay like this in the action of the stinmlus 
means that it has not acted directly, but through the medium 
of ganglia. 

When the splanchnics are divided, the vessels of the kidney 
sometimes dilate and the kidney increases in size; a profuse 
secretion of urine may take place, which quickly increases to a 
maximum and remains for a considerable time. This, however, 



362 ON THE ACTION AND USE OF DIURETICS. 

is not a constant effect, and not unfrequently the vessels do not 
dilate, and the kidney, instead of increasing, diminishes in size. 
This is what to a certain extent might be expected, inasmuch as a 
section of the splanchnics causes dilatation of the intestinal vessels 
and lowers the blood pressure, and thus diminishes the supply of 
blood to the kidney. 

When a puncture is made in the medulla oblongata in the 
floor of the fourth ventricle, profuse secretion also occurs, but 
this differs from that caused by section of the splanchnics, in 
being preceded by slight diminution, in rising rapidly to a 
maximum, and then rapidly falling. These characters seem to 
show that it is due to irritation of some vaso-dilating mechanism^ 
rather than to any pai-alysis. 

Stimulation of the vaso-motor centre in the medulla oblongata 
by venous blood, or by drugs such as strychnine or digitalis, has a 
twofold action on the kidney, for it tends to cause contraction not 
only in the vessels of the kidney, but in those of other parts of the 
body. The effect on the kidney is thus a complicated one, for the 
contraction of the intestinal and other vessels by raising the blood 
pressure tends to drive blood into the kidneys at the same 
time that the contraction of the renal arteries tends to keep it out. 
"When the renal nerves are cut, the renal vessels no longer oppose 
the entrance of blood, and therefore the renal vessels dilate very 
greatly when the vaso-motor centre is stimulated ; but when the 
renal nerves are intact the result is a varying one, for sometimes 
contraction of the renal vessels may be so great as to prevent the 
entrance of blood into the kidney, however high the general blood 
pressure may rise ; at other times the general high blood pressure 
may be able to dilate the renal arteries in spite of any resistance 
they may offer. These different conditions may occur subse- 
quently to one another; and this stimulation of the vaso-motor 
centre may cause contraction of the renal vessels succeeded by 
dilatation, or vice versa. Thus Mr. Power and I found that on 
injecting digitalis into the circulation of a dog the blood joressure 
rose, but the secretion of urine was either greatly diminished or 
ceased altogether. Here it is evident that the renal vessels had 
contracted so much as to prevent the circulation through the 
kidney, notwithstanding the rise which had taken place in the 
blood pressure. After a Avhile the blood pressure began to fall, 
and then the secretion of urine rose miich above its normal, 
' Heidenhain, Hermann's Eanclbuch d. Fhysiologie, vol. v. Th. 1, p. 366. 



BLOOD PRESSURE AND URINARY SECRETION. 3G3 



showing that the general blood pressure was then able again to 
drive the blood into the kidnej'S.^ 

Similar observations were made by Mr. Pye and myself with 
regard to erythrophloeum, and the accompanying curves show well 
the result of the mutual action of rise in blood pressure and con- 
traction of the renal arteries upon the secretion of urine. It will 
be noticed that at first the blood pressure rises more quickly than 
the secretion of urine, the circulation through the kidney appear- 
ing to be opposed by the renal arteries. This ojDposition is then 



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-Curves showing the effect of eiy thropWceum upon the blood pressure and 
secretion of urine. From Phil. Trans., vol. 167. 

overcome, and the secretion of the urine rises more quickly than 
the general blood pressure. The renal vessels again appear to 
contract, so that the urine diminishes while the blood pressure 
rises still further. We have next oscillations due first to one 
factor and then to the other being predominant; and then, when 
the blood pressure rises to its maximum, we find that the urine 
is at its minimum, the secretion of urine again rising as the 
blood pressure falls. 

A good deal of discussion has arisen regarding the mode of 
action of digitalis, and it has been stated by many to act as a 
diuretic only in cases of heart disease, and to have no diuretic 
action in health. In my own experiments, however, I found that 
it acted as a very marked diuretic even in health, and the explan- 
ation of this discrepancy may possibly be that, in my own case, the 

* Iloyal Society's Proceedings, No. 153, 187i 



364 ON THE ACTION AND USE OF DIURETICS. 

normal blood pressure was low, whereas in the others it was 
probably much higher; but I am uncertain regarding the true 
explanation, though I am certain of the fact. 

By causing increased secretion of water through the kidneys 
diuretics may increase the concentration of the blood and thus 
produce thirst, or cause absorption of water from the intercellular 
tissue or serous cavities in dropsies. In my own experiments on 
digitalis I weighed all my food and measured all my drink for 
nearly six months, taking exactly the same quantity every day. 
After producing profuse diuresis by a large dose of digitaline (sixty 
milligrammes in two days), such thirst ensued that I was forced to 
take a quantity of water to allay it.^ 

Mode of Action of Diure.tics. — From what has already been said, 
it is evident that diuretics may act in several ways. They may 
act: 

(A) On the circulation in the kidney, raising the pressure in the 
glomeruli. 

(1) Locally («) by contracting the efferent vessels, or the arterial 
twigs which pass directly to the capillary plexus ; (5) by causing 
dilatation of the renal arteries, and thus increasing the supply of 
blood to the kidney. This they may do also in more ways than 
one, for they may either paralyse the vaso-motor nerves of the 
kidney, or act on vaso-dilating mechanisms. 

(2) They may raise the blood pressure generally by causing the 
contraction of vessels in other parts of the body. 

(B) Other diuretics may act on the secreting cells of the tubules, 
and may increase bijth the amount of water and the amount of 
solids excreted by them. 

Diuretics have been by some classified as stimulating and 
sedative ; and the sedative class agrees very closely with the one 
which we have just indicated as acting on the kidneys through *the 
circulation. 

From what has been said of the action of diuretics it is evident 
that we may hope to do much more by combining them, than by 
using them singly. Thus we see that digitalis, instead of acting as 
a diuretic, may completely arrest the renal circulation, and stop the 
secretion altogether. If, however, we can combine it with some- 
thing which will produce dilatation of the renal vessels, while the 
general blood pressure remains high, we shall greatly increase the 

1 The experiments were made in 1865 and published in part in my thesis on 
Digitalis, with some Observations on Urine. London: Chui'chill, 1868. 



ACTION OF NITRITES. SC5 

circulation tbrougli the kidney, and obtain the desired result. 
Experiments in regard to this were made by Griitzner with nitrite 
of sodium. He found that this substance increased the secretion 
of urine when the blood pressure was reduced to a minimum by 
curara; and he found that it also had this effect when the blood 
pressure was raised by imperfect respiration. When the vaso- 
motor centre was excessively stimulated however, by allowing the 
blood to become very venous, the nitrite of sodium no longer 
produced any increase of secretion. 

All nitrites have an action on the blood-vessels more or less 
alike. All of them cause the arterioles to dilate either by an 
action ou their muscular walls or on the peripheral terminations of 
vaso-motor nerves. One of the commonest diuretics is spiritus 
setheris nitrosi, which contains nitrite of ethyl. Sometimes this is 
combined with acetate of ammonia as a diaphoretic, sometimes 
with digitalis, broom, or spirit of juniper, as a diuretic. We have 
already seen that the action of the skin and of the kidneys are 
complementary, so that if we increase the secretion from the one 
we tend to diminish that of the other. At first sioht then it mio-ht 
appear curious that we should use the same drug to increase the 
secretion of both. Yet there can be little doubt from clinical 
experience that nitrous ether is useful for both purposes, and the 
reason of its utility at once becomes evident when we remember 
that it is strictly neither diaphoretic nor diuretic, but its action is 
simply that of dilating the vessels, and consequently allowing the 
blood to flow freely in whatever direction it may be determined by 
other conditions. If by combining it with digitalis we can dilate the 
renal arteries while those of the other parts of the body remain 
contracted, it is evident that we shall obtain a much freer flow of 
urine than we could by the administration of digitalis alone. 

If instead of a diuretic like digitalis, which acts chiefly through 
the blood-vessels, we combine spirits of nitrous ether with salts of 
potassium, which act on the secreting structure, it is evident that 
we are likely to obtain from the increased circulation in the kid- 
neys caused by the nitrites a much more plentiful secretion than 
the potassium salts alone would have produced. 

The mode of action of diuretics may perhaps be rendered clearer 
by the following table. At present the data we possess are insuf- 
ficient to allow us to classify diuretics with absolute certainty 
according to their mode of action, yet I think the accompanying 
table may be fairly said to represent our present knowledge of the 



366 



ON THE ACTION AND USE OF DIURETICS. 



subject, its imperfections being indicated by the number of notes 
of interrogation which the table contains. 

TABLE SHOWING THE PROBABLE MODE OF ACTION OF DIURETICS. 

r Digitalis. 



rOenerally 



Raise arte- 
rial pres- 
sure 



j Increased action of the heart- by alcohol. 

( Contraction of vessels in intestine and throughout the body. 



Locally in 
kidney... 



I Erythrophlcenm. 
I Strophanthus. 
■! Squill. 
I Con-vaUaria. 
I Strychnia. 
CCold to surface 

fBy action on vaso-motor ) ? The same as in 

'Contract efferent vessels or centres. ( preceding list. 

arteria recta so as to raise j 

pressure in glomerulus and ■<, f? Broom. 

lessen absorption in tu- I By local action on vessels or | ? Turpeutino. 

bules, or both. | nei-vous structures in the < ? Juniper, 

i I. kidney itself. j ? Coioaiba. 

I \J Canthaiides. 



LDilate afferent vessels 



I" Paralyse vaso-motor nerves or ( Nitrites. 
•< involuntary muscular fibre. < AlcohoL 
(. Stimulate vaso-dilating nei-4'es (? Urea.* 



Act on the se- 
creting nerves, ( 
or secreting . 
cells of the i 
kidney itself. ' 



Increase water excreted. 



Increase solids excreted. 



( Urea. 
\ Caffeine. 

f Liquor potassae. 

( Potassium acetate, &a. 



• When a current of blood is passed artificially through an excised kidney, the stream is much 
accelerated by the addition of urea. Abeles, Silz-B:r. d. ic. k. ]Vieyier Akad. Bd. 87, Abt, 3, April, 
1S83. 

It not infrequently happens that one is able to understand a 
hypothesis more clearly when it is put in a diagrammatic form, 
and that one can thus perceive more readily the particular points 
in which it may be erroneous, even if true in the main. I there- 
fore subjoin a diagram of the circulation and secreting apparatus 
of the kidney to show the parts which are probably affected by 
difl'erent diuretics : — 

Afferent vessels. (?) Dilated by nitrous i _. "^^^/ 

ether, potassium nitrite ' .^^7 

l 

Efferent vessels. (?) Contracted by digi- j ar a f 

talis, strychnine, erythi-ophloeum, squill. ( ~--M——M-Li 

Tubules. (?) Stimulated by urea and potao- , --mm ^ — ^> 

slum nitrite, acetate, <fcc. Caffeine, tur-J 
pentine, cantharidine (?) Paralysed by') 
curare (?) 

I 

Fig. 51. — Diagram to show the parts of the secreting apparatus of the kidney which 
are probably affected by different diui'etics. 

Uses. — Diuretics may be emplo3^ed either for the purpose of 
removing water or solids from the body. They are used : 




USES OF DIURETICS. 3G7 

1st, to remove the excess of fluid met with in the tissues and 
serous cavities in cases of dropsy. 

2nd, to hasten the removal of injurious waste products and 
poisonous substances from the blood. 
3rd, to dilute the urine. 

In cases where the accumulation of fluid depends on venous 
congestion, as for example in cardiac dropsy, those. diuretics which 
act on the general vascular system, like digitalis, strophanthus, 
squill, or erythrophloeum, are most efficient because they tend to 
remove the cause of the dropsy, as well as to assist the absorption 
and excretion of the fluid already effused. 

When the dropsy depends on the disease of the kidneys or liver, 
other diuretics should either be given instead of, or along with, 
digitahs or squill, even in cases of cardiac disease. Where digitalis 
or squill are not proving efficacious, the addition of a little blue 
pill greatly assists their action, though it would be hard to say in 
what way it does so. 

In dropsy depending on kidney disease, decoction of broom, and 
oil of juniper, and nitrous ether, are amongst the most reliable 
diuretics, and copaiba in hepatic dropsy. 

Diuretics are used to increase the secretion of solids in febrile 
conditions, and in cases of kidney disease where the excretion of 
waste products is deficient, and their retention threatens to prove 
injurious. In such cases, nitrate and bi-tartrate of potassium, 
turpentine, and juniper, and caffeine are useful. 

Diuretics are also used to increase the proportion of water in the 
urine, and thus to prevent the solids being deposited from it and 
forming calculi in the kidney or bladder ; or even to dissolve again 
concretions which have been already formed. 

Water is perhaps the most powerful diuretic we possess, although 
fewer experiments have been made with it upon animals than with 
the others. The diuretic action of water drunk by a healthy man 
is very marked, and it appears impossible to explain its elimination 
by a mere increase in blood-pressure, whether general or local. It 
has, as we have remarked, the power of increasing tissue change, 
and thus multiplying the products of tissue waste which result 
from it, but it removes those waste products as fast as they are 
formed, and thus, by giving rise to increased appetite, provides 
fresh nutriment for the tissues, and thus acts as a true tonic. In 
persons who are accustomed to take too little water, the products 
of tissue waste may be formed faster tlian they are removed, and 



368 ON TEE ACTION AND USE OF DIURETICS. 

thus accumulating may give rise to disease. If water be freely 
drunk by such persons, the products of waste will be removed, and 
health maintained or restored. Thus many gouty persons are 
accustomed to take little or no water except in the form of a small 
cup of tea or coffee daily, besides what they get in the form of wine 
or beer. In such people a large tumbler of water drunk every 
morning, and especially with the addition of some nitrate or 
carbonate of potassium, will prevent a gouty paroxysm. Still 
more numerous, possibly, is the class of people who rise in the 
morning feelins^ weak and lanoruid, more tired, indeed, than when 
they went to bed. Now fatigue may be regarded as the imperfect 
response of muscles and nerves to stiuiuli, and such an imperfection 
in their action may be due either to their imperfect nutrition or to 
the imperfect removal of the products of their waste. Many such 
people are well fed, they sleep soundly, and it seems almost impos- 
sible to believe that the fatigue which they feel in the morning 
can result from imperfect nutrition, more especially as one finds 
that after moving about, the languor appears in a great measure 
to pass off. It seems to me that this languor must depend upon 
imperfect removal of the waste products from the body, as we 
know that the secretion of urine in healthy persons is generally 
much less during the night than during the day. I am therefore 
in the habit of advising such people to drink a tumbler of water 
before oroingf to bed in order to aid the secretion of urine and 
elimination of the waste products during tlie night. In some 
cases, though not in all, the result has been satisfactory, and 
possibly might have been still more so had I added to the water 
the bi-carbonate and nitrate of potassium which, as I have already 
mentioned, is so useful in cases of gout. 

Lately a plan of treating gout by draughts of water at intervals 
during the day has been a good deal employed and is in many 
cases successful. As an example of this I subjoin the diet used 
along with this treatment by a medical friend of mine who has 
been a martyr to gout, but who feels himself perfectly well as long 
as he adheres strictly to this course of diet : — ■ 

7.30 A.M. Ten fluid ounces very hot water. 

8 A.M. Breakfast: Equal parts of weak tea and milk, a small 

quantity of white sugar, a slice of fat bacon without a strip 

of lean, bread and fresh butter. 
1 P.M. Milk pudding, rice, sago, tapioca, macaroni, or blanc mange, 

and small biscuits with butter, ten fluid ounces hot water. 



HOT WATER 12^ GOUT AND GRAVEL. 369 

4 to 5 p.:m. Ten fluid ounces hot Avater. 

G P.:Nr. Dinner: White fish or fowl (usually boiled), greens, bread, 

no potatoes, claret seven fluid ounces. 
8 to 9 P.^r. Ten fluid ounces hot water. 
11 P.M. Ten fluid ounces hot water. 

If he indulges either in meat or game, or drinks copiously of 
claret, or omits one or two glasses of hot water, he feels gouty and 
gravelly next day. It is obvious that by this plan of treatment, in 
which the ingestion of nitrogenous food is most strictly limited, at 
the same time that every facility is given for the elimination of 
the products of nitrogenous waste by the large quantities of hot 
water drunk in the course of the day, the accumulation of waste in 
the tissues ought to be most effectually prevented. 

Adjuvants to Diuretics. — As the amount of urine secreted 
depends upon the difference in pressure between the blood in the 
glomeruli and the urine in the tubules, it is evident that any 
pressure on the tubules, whether caused by obstruction of the 
ureter by a calculus, by the mechanical pressure of dropsical 
accumulations in the abdomen, or by distension of the venous 
plexus in the kidney itself, will tend to lessen the secretion of 
urine. Consequently we sometimes find that in such cases 
diuretics fail to act until the pressure has been relieved by 
paracentesis in cases of dropsy, or the venous congestion lessened 
by the use of a brisk purgative, or by cupping over the loins. 

If the venous congestion be very great, as in cases of mitral 
disease or of chronic bronchitis with emphysema and dilated heart, 
bleeding from the arm may be advantageous or even imperatively 
necessary. In dilated heart and in mitral incompetence the action 
of digitalis on the heart itself, strengthening its action and 
enabling it more effectually to pump the blood out of the venous 
into the arterial system and thus to reduce venous congestion, will 
aid its action upon the kidneys. 



B B 



INDEX. 



Abdomixal circulation in cholera, 269 

Abdominal muscles in vomiting, action 
of, 166 

Abernethian Society, papers read be- 
fore, 113 note, 307 note 

Absorption, in intestines,16; in urinary 
tubules, 354 ; of alcohol, 150 ; of 
digestive ferments, 227 ; of fat, 9 ; 
part of digestion, 5 ; through skin, 5 

Acacia, emulsion with cod-liver oil, 
134 

Acetic acid in stomach, 241 

Acid-albumin, 314, 315 

Acid from food, 33 : fruits, 63 ; in- 
creased in gastric juice, 33 note 

Acidity, 28, 32, 64 ; and cough, 40 ; 
of gastric juice in fever, 180 

Acids, effect of, on heart and vessels, 
343, 350; in headache, 109, 198 

Action of Infused Beverages on Fej^tic 
Digestion, J. W. Fraser, referred 
to, 64 note 

Activity of man maintained by com- 
bustion, 3 

Adam's diet table, 62 

Adipose tissue. See Fat. 

Adviser, quoted, 56 

uEsoiJS Fables, quoted, 256 

Afferent nerves, which excite vomit- 
ing, 171 

African West Coast, oedema on, 347 

Agaricus muscarius, 265, 278 ; other 
varieties, 259 

Air swallowed, as a cause of flatulence, 
29, 30 ; before vomiting, 167 

Albertoni, Professor, on the action of 
peptones, 247 

Albini, observations on bile, 201 

Albrecht, on convulsions and dental 
caries, 94 

Albumin, action of pancreatic juice 



on, 14 ; detection of, in mine, 313 ; 
hydration of, 8 ; precipitated by 
alcohol, 142 ; by ipacacuanlia, 178 
7iotej by tartar emetic, 178 ; varie- 
ties, 37 

Albuminoids in stomach, 12 

Albuminous tissues, action of mercury 
on, 232 

Albuminuria, 35, 246, 356 ; arsenic 
in, 328 ; case of, 326 ; cause of 
anemia, 313 ; causes of, 324 ; effect 
of meat, fat, and time of day, 327 ; 
elateriura in, 208 ; from imperfect 
digestion, 829 ; summary, 329 ; 
symptoms of, 315 ; temporary, 36, 
66 note-, 243, 317 ; time and place, 
322 ; treatment of, 320 

Albuminuric dropsy, 346 ; headache, 
111 

Alcohol, 41, 69, 121, 366 ; absorption 
of, 150 ; and cold, 159 ; as a cause 
of gastric catarrh, 153 ; as a food, 
153 ; as a poison, 161 ; as a stimu- 
lant, 157 ; action on heart, 149 ; 
skin, 141; stomach, 143 ; coagulates 
albumin, 142; coma from, 148 ; effect 
on amoeboid movements, 150 ; on 
circulation, 147 ; on diarrhoea, 143 ; 
on motor ganglia of heart, 163 ; in 
mental processes, 154 ; on muscles, 
154 ; on the pulse, 158 ; on red 
corpuscles, 150 ; on temperature, 
158 ; food or poison, 140; in Arctic 
regions, 159 ; in fever, 151 ; oxida- 
tion of, 152 ; physiological action 
of, 152 ; reasons for drinking, 140 ; 
reflex action of, 147 ; summary of 
effects of, 163 

Alkali-albumin, 314 

Alkalies, eft'ect on heart and vessels, 
343- in headache, 109, 198 

B B 2" 



372 



INDEX. 



Alkaloids, from maize, 279 ; from 
putrefaction, 281 ; in the blood, 
290 ; in cholera stools, 296 ; in 
fseces, 290 ; in urine, 290 ; relation 
to albumin, 13. See also Ptomaines. 
Aloes, 72, 186, 188, 191, 208 
Alteratives, action on ferments, 228 ; 
meaning of term, 223 ; mode of 
action of, 225 ; resemblance to 
nutritives, 225 ; summary, 232 
Althann, 251 
Alum in vomiting, 176 
Amanita muscaria, 265, 283 
American cure for drunkeimess, 57 
Ammonia salts in urine, 75 
Ammonium bromide in dyspepsia, 67; 

chloride in liver disease, 73 
Amoeboid movements, effect of alcohol 

on, 150 
Arnyl nitrite, 232 ; in cholera, 268 
^nffimia, causes of, 311 ; from albu- 
minuria, 313; headache of, 109 ; in 
migraine, 85 ; of brain in intoxi- 
cation, 161 ; symptoms of, 307 
Anaesthesia from destruction of hip- 

pocampal convolutions, 98 
Anaesthetics in dental cases, 96 
Animals, over-eating in, 68 ; fat in, 

129 
Anrep, V., 286 
Anstie, Dr., on alcohol, 152 
Anti album ose, 9 
Antidotes, 283 
Anti-emetics, action of, 165 
Antimony, 232 ; in typhus, 288 
Antipeptone, 9 
Antiseptic, bile as an, 15 
Anxiety during meals, effect of, 50 
Apnoea, 168 
Apomorphia, 177, 179 
Appetite, 68; and palate, 71 ; excitants 
of, 117, 144 ; indulgence of, 61 ; in 
gastric indigestion, 22 ; rebellion of, 
62 
Arctic regions, alcohol in, 159 
Arnold on lupintoxin, 294 
Aromatic bodies, 13, 44 
Arsenic, 144, 223, 232 ; in albuminuria, 

322, 328 ; in skin diseases, 225 
ArterifB rectse, 301 
Arterial pressure and albuminuria, 

318, 324 
Asclepiadin, 177 

Ashanti campaign, alcohol in, 157, 158 
Asthma, 39 ; treatment of, 76 
Astigmatism and headache, 48, 76, 
107 



Astringents in diarrhoea, 143 

Atmospheric conditions and cholera, 
262 

Atonic dyspepsia, 126 

Atropin, effect in cholera, 270 ; in 
headache, 77 ; in muscarin poison- 
ing, 259, 266, 284 ; in mushroom 
poisoning, 259 ; in ptomaine poison- 
ing, 287 ; efi'ect on heart and vessels, 
343; on intestinal secretion, 371; 
on pupils, 273 ; on secretion, 342 ; 
on secretion of saliva and sweat, 
347 

Austrian peasants, diet of, 146 

Bacillus, comma, 292 ; tubercle, 66 ; 

typhoid, 278, 291 
Bacteria in digestion, 277 
Bandaging in sea-sickness, 177 
Bantingism, 136 
Barium nitrate, diffusion of, 8 
Bathing, albuminuria after, 320 
Baudot, Dr., on alcohol, 152 
Bauer, observations on fat, 131, 137 
Beaumont, Dr., on Alexis St. Martin, 
22, 26, 27, 63, 74 ; on appetite, 60 ; 
on digestion, 115, 116, 118, 119, 
120, 122, 126, 147 note; Fhysioloyy 
of Digestion, quoted, 117 
Beef-tea, 247 
Beer, 63 
Beeswax, 181 

Begbie, Dr. Warburton, on albumin- 
uria, 36 ; on intermittent pulse, 76 
Beklemming, 30 
Bell, Sir Charles, 196, 198, 199 
BiUadonna, 287 
Bellini, tube of, 305 
Bence-Jones, 282 ; on an alkaloid in 
the liver, 44, ' Bence - Jones 
albumin,' 318, 322. See also 
Hemialbumose. 
Bennett, Dr. Hughes, 38; on oils, 134 ; 

on tuberculosis, 132 
Bergmann, 282 
Bernard, experiments referred to, 117, 

144 note, 172, 200, 206, 322, 340 
Bertin, colunms of, 298 
Bile, absorption and excretion of, 185, 
205 ; action of, 14 ; as an antiseptic, 
15, 54 ; as a muscular poison, 46 ; 
eli'ect of fasting on, 186 ; effect on 
diffusion, 134 ; excretion of metals 
by, 201 ; in the blood, 184, 246 ; 
physiology of secretion of, 245 ; 
tastelessuess of, 44, 245 ; vomiting 
of, 182 



INDEX. 



373 



Biliary congestion, 123 ; matters in 
cod-liver oil, 134 

Bilious headache and alkaloids, 295 

Biliousness, 22, 23, 27 ; condition of 
stomach in, 119 ; emetics in, IHI ; 
fasting- in, 203 ; from mill?: and eggs, 
292 ; pathology of, 73, 276 

' Binding ' quality of milk and eggs, 
275 

Binoxide of manganese, 69 

Biuz on ferments, 207 

Bird, Dr. Golding, on Urinary 
Deposits, 47 

Bismuth, 69, 124 ; in vomiting, 174 

'Bitter as gall,' 245 ; taste of bile, 44, 
245 ; taste in jaundice, 46 ; taste of 
digested proteids, 280, of peptones, 
13 

Bitters, 68. See also Vegetable bitters. 

Black bread, 6 

Black draught, 74 

Blagdon, Sir Charles, 353 

Bleeding, 369 

Blindness in toothache, 89 

Blisters, 176 

Blondlot, 172 

Blood, corpuscles, action in absorp- 
tion, 16 ; action of alcohol on, 150 
in cholera, 264 ; in urine, 322 
pressure and urinary secretion, 363 
pressure after purgation, 208 j states 
and dropsy, 339 

Blood-vessels, action of nitrites on, 365 

Blue pill, 74, 3G7 

Bocci on alkaloids in urine, 43 

Bodily strain, 113 

Body compared to concentric cylin- 
ders, 4 

Boehm on choline, 283 

Boerhaave on digestion, 115 

Bolting food, 60 

Borborygmi, 28, 67 

Bouchard on ptomaines, 290 

Bouillaud on oedema, 218 

Bowels, constipation of, 72 

Bowman, 354 

Bowman's capsule, 305 

Brahmin bull of India, 129 

Brailey, Dr., 107 

Brandy, 71 ; action on mouth and 
stomach, 143 ; as an excitant of 
appetite, 144 ; action of, 147 

Braune, 251 note 

Bread as a peptogen, 19 ; at breakfast, 
35 ; at dinner, 20, 21 ; black, 6 

Breakfast, glj'cosuria after, 35 

Brieger on alkaloids, 13, 71, 283, 288 ; 



on albuminous decomposition, 281 ; 
on the typboid bacillus, 291 ; on 
muscarin, 278 ; on mydalein, 288 ; 
on peptotoxin, 43 

Brissaud, 155 

British Association, paper on cholera, 
read before, 262 

British Medical Association, report of 
the Edinburgh Committee on the 
secretion of bile, 184, 187, 204 

Brodie, Sir B., on alcohol, 148 

Broncliitis, emetics in, 182 

Broom, 367 

Brown-Sequard, on the kidney, 324 

Bruce, Ur. Mitchell, on ' heart wind,' 
29 

Briicke, on ^ligestion, 116 ; on fer- 
ments, 206; on the pericardium, 336; 
on pepsine, 327 

Brunton, Dr. Lauder, as casualty 
physician at St. Bartholomew's 
Hospital, 72, 108; at Edinburgh 
Infirmary, 109 ; ]iapers by, referred 
to, 181, 268 ; Action of Alcohol, 70 
note; Action of Purgative Medicines, 
227, 253 ; Indigestion as a cause of 
NervoiLS Depression, 42 note, 47 ; 
Inhibition, Central and Fo'ipheral, 
155 note; On Diabetes, S5 note ; On 
Digitcdis, 44 note, 246 note, 364 
note; On Headache, Neurcdgia, and 

* other Nervous Diseases connected 
with the Teeth, 48 note; on one 
cause of death during chloroform 
narcosis, 95 ; Pathology and Treat- 
ment of some forms of Headache, 48 
note ; The Influence of Stimulants 
and Narcotics on Health, 56 note, 
70 note ; The Influence of Tempera- 
ture on the Mcunmalian Heart, and 
on the Action of the Vagus, 158 
note 

Brunton, Dr. Lauder, and Dr. Cash, 
343, 349 ; and Dr. Power, 244 oiote, 
321, 327, 363 ; and Mr. Pye, 363 ; 
and Dr. Pye Smith, 41 note; papers 
or experiments by, referred to. 

Buchheim, Dr., 147 note, 223; on 
emetics, 177; on bile, 186 ; on pur- 
gatives, 189 ; on calomel, 205 

Budge, Dr., 166 note, 168, 172 note, 
174, 175, 179 

Buffalo, 129 

Bunsen's pump, 316 

Butter, 51, 133 

Butyric acid, as a poison, 121, 146, 
181, 198. 214, 242 



374 



INDEX. 



Cabbage, flatulence produced by, 38 ; 

oxaluria from, 38 
Cadaverine, 281, 288 
Caffeine, 64, 65, 367 
Caffeon, 65 

Calomel, 74, 189 ; in cholera, 270 
' Calomel stool^^,' 186, 205 
Camel's hump, 129 
Canada, the habits of the lumberers 

of, 159 
Canines, decayed, with headache, 106 
Cantliarides, 36G 
Capillaries, unhealthy, and oedema, 

339, 346 
Carbo-hydrates, in food, 6; action of, 7 
Carbolic acid, in toothache, 83, 100, 

199 ; in urine, 294 
Carbonic acid, in cholera, 264 ; in 

stomach, 28 ; in intestines, 31 
Cardamoms, 257 
Cardiac orifice, in heartburn, 34 ; in 

vomiting, 166, 167 
Caries, dental, and toothache, 86 
Carlsbad -water and salts, 73, 84, 137, 

253, 254 
Carminati, on digestion, 115 
Carminatives, 68, 107 
Carpenter's Physiology, 144 note, 172 

note 
Carter, Mr., 107 

Casein of milk, and vegetable casein, 9 
Cash, Dr., 343, 349 
Casper, 94 note 
Castle, Mr., on convulsions and dental 

caries, 94 
Castor-oil, 189, 196, 200 
Catarrhal jaundice, 294 
Catching cold after a purgative, 229 
Central and peripheral pain, 99, 102 
Cerebellum, congestion of, in intoxi- 
cation, 162 
Cerebral centre for movements of jaw, 

92 
Cerebral circulation, 57 ; and consti- 
pation, 157 
Cerebri tis, 174 
Cerebro-spinal fluid, 251 
Charcoal in flatulence, 68, 215 
Cheese at dinner, 21, 121 
Chemical nature of putrid poison, 

282 
Chemical vaccination, 291 
Chloral, 231 
Chloride of ammonium, in liver disease, 

75 
Chloroform, 257 
Chlorosis, 312 



Cholagogues, 254 ; is mercury one ? 

204 
Cholera, albuminuria in, 319 ; bacillus, 

41, 292 ; nature of, 262 ; poison, 

262 ; summary, 273 ; susceptibility 

for, 262 ; symptoms, 263 
Choline, 283, 292 
Chorda tympani, 341 
Choreic movements during dentition, 

93, 94 
Christmas dinners, 186 
Chyme, 13 
Circulation, in brain, 57 ; affected by 

posture, 156 ; in kidney, 356 ; in 

liver, 23, 122 ; in rectum, 34 ; of 

cerebro-spinal fluid, 251 ; of lymph, 

250 
Citrate of potash, 76 
Claret at meals, 257 
' Clearing out the liver,' 253 
Clothing versus fat, 129 
Cobra poisoning, 239 
Cocoa, 65 ; nut, 121 
Cocoatina, 65 
Cod-liver oil, mode of administering, 

134 ; in cough, and phthisis, 135 
Coffee, constituents of, and their 

action, 65 
Cohnheim, 199, 331, 339, 347 ; Lectures 

on General Pathology, referred to, 

336 
Colchicura, in gout, 231 
Cold, and alcohol, 159 ; and amount 

of urine, 359 ; and muscular activity, 

128 ; effect of, on headache, 104 
Colic, 34 ; poultices in, 211 
Colin, on trismus, 92 
Collecting tubules, 305 
Colloids, 317, 323 
Colocynth, 275 
Colon, action of aloes on, 186 
Coma, alcoholic, 148 
Combe, Dr., on appetite and palate, 

61 
Combustion of tissues, 3, 138 
Comma bacillus, 292 
Common salt, in epilepsy, 231 
Congestion, in migraine, 85 ; of liver, 

216 ; of stomach and intestines, 26, 

27 ; of spinal cord in infantile 

paralysis, 93 
Constipation, 71, 72 ; and cerebral 

circulation, 197 ; and neuralgia, 

199 ; and otalgia, 199 
Constitutional walks, 75 
Constriction, sense of, 30 
Consumption. See Phthisis. 



INDEX. 



375 



Contem2)orary Beview, quoted, 70 note 

Continental cookery, 55 

Contraction of vessels, reflex, 96 

Convallaria, 366 

Convoluted tubules, 300, 304 

Convulsions in case of dental caries, 
94 

Cookery, as a fine art, 18 ; as a moral 
agent, 65; bad, 54 ; lecture on sick 
room, 135 ; schools of, 55 

Cooking, man as a cooking animal, 1 ; 
early methods of, 2 ; in stone age, 2 

Co-ordination, loss of, in intoxication, 
161 

Copaiba, 367 

Copper sulphate, 177 

Cord-like arteries in migraine, 85 

Cortex of kidney, 298 

Cough in indigestion, 40; in tooth- 
ache, 89 

Coughing and vomiting, 166 

Courses at dinner, order of, 19 

Coxe, Dr. J., 61 note 

Cragie, Practice of Physic, referred 
to, 173 

Craving for alcohol, 56 

Crepitations, 28 

Croton oil, 188, 189 ; experiments on, 
191, 192 ; in neuralgia, 197 ; in 
sciatica, 197 

Croup, emetics in, 182 

Cruciferte, 39 

Cruise, Dr., on cholera, 268 

Crystallisation and diffusion, 8 

Crystalloids, 317, 323 

Cucumbers, 275 

CucurbitaccEe, 275 

Cunningham, Dr. Douglas, on cholera, 
292 

Cupping, 369 

Curara, 13, 366 ; curara-like poisons, 
255 ; in portal circulation, 202, 
swallowed, 16 ; efEects of, like 
indigestion, 42 

Cyclamin, 177 

Cylinders, body compared to con- 
centric, 4 
Czermak on vagus, 30, 158 note 

Darwin, on indigestion, 47 
De Witt, Dr., 89 
Deafness witii toothache, 89 
Debility, headache of, 109 
Decomposition of albumen, 281 
Deglutition, on action of vagus, 11 
Dehydration of sugar, 16 ; of peptones, 
16, 35 ; in the liver, 35 



Delphinia, 177 

Dental irritation, 94, 95, 107 

Dentistry as a moral agent, 56 

Dentition, diarrhaa during, 95 

Depletion, 176 

Depressant action of purgatives, 229 

Depression, caused by indigestion, 

233 ; mental causes of, 67 
Dessert, 21 

Dextrin as a peptogen, 19 ; formed in 
duodenum, 14 ; in stomach, 12 ; 
by saliva, 12 
Diabetes and glycosuria, 35 
Diaphoretics in albuminuria, 321 
Diaphragm, in connection with vomit- 
ing, 166 ; central tendon, 333 
Diarrhoea, during dentition, 95 ; use 
of astringents in, 143 ; pathology 
of, 276 
Diastatic ferment in saliva, 10 
Diastolic relaxation of heart, 336 
Dictionnaire cles Sciences Medicales, 

referred to, 182 note 
Dieffenbach, on cholera, 264, 265 

note 
Diet of Jews, 62 ; for dyspeptics, 63; 
diet table, 62 ; of the Austrian 
peasantry, 146 
Diffusion, 8, 36, 322 ; aided by bile, 
14, 134 ; and filtration, 317 ; rela- 
tion of molecular weight to, 8, 317 ; 
of peptones, 12 ; of haemoglobin, 
8 ; in causation of albuminuria, 8 
Digestibility of beef, mutton, fish, 

and chicken, 20 
Digestion, comprising solution and 
absorption, 5 ; intermediate pro- 
ducts of, 8, 9 ; imperfect, causing 
albuminuria, 329 ; physiology of, 1, 
115; primary and secondary, 9; 
poisons resulting from, 47 ; sum- 
mary, 131 ; strong and weak, 5, 49 
Digestion and Secretion, Part III. of 

Sanderson's Handbook, 1 note 
Digestive disorders, treatment of, 49 
Digestive ferments in blood, 228 
Digestive tonics, 214 
Digitalis, 215, 366, 367 ; as a diuretic, 
363 ; effect on renal vessels, 321 
note; in albunrinuria, 321, 327; in 
collapse, 270 ; in oedema, 220 
Digitalis, 245 
Digitalis, on, by Dr. Lauder Brunton, 

referred to, 364 
Dilatation of pupil in megrim, 103, 

105 ; of vessels by alcohol, 160 
Dinners, City Company, 18 ; English 



37Q 



INDEX. 



and Continental, compared, 55 ; 
biliousness caused by beavy, 203 

Dinner pills, 72, 196 

Diseases of Liver, by Dr. Murchison, 
referred to, 48 

Diuretics, 76 ; adjuvants to, 369 ; 
modes of action, 364 ; table of 
modes of action, 366 ; stimulating 
and sedative, 364 ; uses of, 366 

Division of nerves, 90 

Dock leaf and nettle, 288 

Dogiel on alcobol, 147, 154, 161 note, 
197 

Dogs, long and short-baired, 332 

D'Ornellas, US note 

Drangbts causing gastric catarrh, 
124 

Drink, 4 : causes of desire for, 56 ; 
causing indigestion, 63 ; rules as to, 
at meals, 256 

Dropsy, classification of, 344 ; in 
albuminuria, 346 ; pathology of, 
330 ; summary, 344, 349. See also 
(Edema. 

DrosdorfE, 250 

Droutb or thirst, 56 

Duckworth, Dr. Dyce, on malaria, 
182 ; on oxaluria, 229 

Ductus choledochus, ligature of, 185, 
203 

Dumarquay on sewer gas, 240 

Duodenum, action of mercury on, 186 

Dupre, Dr., on alkaloids, 45 ; on 
alcohol, 162 ; on poisons, 152 

Duroy on alcohol, 151 

Dj'bkowsky, figure after, 334 

Dj'spepsia, atonic, 126; due to defec- 
tive teeth, 95 ; emetics in, 181 ; 
genital disorders in, 67, 68 ; in 
anemia, 309 ; ptomaines in, 290 ; 
symptoms, 42 

Dyspeptics, diet of, 62 

DyspncBa, 168 ; from muscarin poison- 
ing, 260, 284 ; in antemia, 308 ; in 
mushroom poisoning, 261 

Ear disease and headache, 107 ; in 
connection with the teeth, 89 

Eau-de-Cologne, action of, on the 
skin, 141 

Eberle, on digestion, 115 

Ebstein, on flatulence, 31 

Education of taste, 18 

Eggs, causing albuminuria, 37 ; as 
food, 274 ; as poison, 275 ; action 
of, on the digestive functions, 292 ; 
used by athletes, 317 



Egypt, dry climate of, 351 
Egyptian tombs, paintings on, 114 
Elasticity of liver, 25 
Elaterium, 189, 275 ; in albuminuria, 

208 ; experiment on, 193 
Electricity and fermentation, 279 
Emaciation, case of, 77 
Embolism of kidney, 325 
Emetics, Buchbeim on, 177 ; classes 

of, 177 ; effect of, on liver, 295 ; in 

bronchitis, 182, 345 ; in croup, 

182 ; in dj'spepsia and biliousness, 

181 ; in epilepsy, ague, and hysteria, 

182 ; in lead poisoning, 182 ; in 

typhus, 182 ; in gall stones, 182 ; 

injection of, into circulation, 168, 

177 ; uses of, 180 
Emotion and appetite, 67 ; effect on 

vagus, 30 
Emotional dyspepsia, 67 
Emphysema, oedema in, 345 
Emulsion of cod-liver oil, 134; of 

fats, 9 ; produced by pancreatic 

juice, 14 
Entero-hepatic circulation, 181, 201 
Entero-salivary circulation, 201 note 
Epidemic jaundice, 74 
Epidermis, 4 
Epilepsy, during second dentition, 

94 ; emetics in, 182 ; use of common 

salt in, 231 
Epithelium of alimentary tract, 5 ; 

of uriniferous tubules, 305 
Eructations, 28, 126, 181, 198 
Erythematous patches in stomach, 

123 
Erythrophloeum, 363, 366, 367 
Esau and Isaac, 65 
Esbach, on cabbages, 39 ; on oxalic 

acid, 39 
Esrnarch, 39 
Esquimaux' food, 54 
Ether in flatulence, 68 ; as a stimulant, 

69 
Ethylenediamine, 281 
Eulenberg, 269 note 
Euonj'min, 254 
Evaporation of alcohol, 141 
Ewald, Dr., on eructations, 31, 32, 241 
Excessive food, 121 
Excitement, effect of, on appetite, 66 
Exercise, before dinner, 66 ; effect on 

heart, 155 ; on liver, 252 ; necessity 

for, 252, 257 ; Lord Palmerston on, 

75 ; injudicious, 66, 75 
Exertion, results of, 29 
Exostosis in Czermak's neck, 30 



INDEX. 



377 



Exudation of lymph, causes o£, 337 ; 

effect of drugs upon, 343 
Eyelids, twitching of, 91 
Eyes, in connection with biliousness 

and lieadache, 77, 106 ; in connection 

with the teeth, 89 
Eye-teeth, 90 

Face, flushed, 154 

Fsecal accumulation, 71 

Faintness, causes of, 41 

False teeth, 51 

Fano, G., 16 note 

Farinaceous food, 278 

Fasbender, 282 

Fascise, as lymph pumps, 231, 250, 
332 

Fasting in biliousness, 26, 186, 203 

Fat and Bloody and Uoiv to make 
them, by Dr, Weir Mitchell, referred 
to, 77, 130 _ 

Fat necessary in diet, 6, 51 ; emulsion 
of, 9 ; fine division of, necessary for 
digestion, 133 ; formation of, 131 ; 
in blood, 129, 131 ; in cocoa, 65 ; in 
muscles, 129 ; in nervous system, 
130 ; in stomach, 14 ; how to eat, 
133 ; pancreatic juice, action on, 
14; sources of, 130; versus clothing, 
129 

Fatigue, 65 

Fatty degeneration, 137 

Fatty heart, 138 

Fatty heart, oedema in cases of, 345 

Fauces, tickling, 72 

Fayrer, Dr., 159 

Febrile headache, 108 

Feeding bottles, 280 

Feeding, necessary attention to, 50 

Feitelberg, J., 350 

Fermentation and electricity, 279 

Ferments, action of, 227 ; action of 
alteratives on, 228 ; absorption of, 
227 ; in connection with fever, 207 ; 
in saliva, 10 

Ferrein, pyramids of, 303 

Ferrier, Dr., researches, quoted, 92ij 
98, 162 ; on sea-sickness, 175, 177 

Fever, gastric juice in, 180 ; ferments 
in connection with, 207 ; headache 
in, 108 ; scarlet, 348 ; use of alcohol 
in, 151 

Fifth nerve, in connection with the 
sympathetic, 102 ; with the vagus, 
95 _ 

Filtering apparatus in kidney, 302, 
316 



Fischer, 268 note 

Fish as food, 20 ; kidney in, 354 

Fistulse, biliar}^ 185, 203 ; gastric, 10 ; 
intestinal (Thiry), 190 

Flannel bag JEor poultices, 211 

Flatulence, causes and effects, 28 ; 
Ebstein and Zeckendorf on, 31 ; 
intestinal, 31 ; Kolbi and Ruge on, 
31 ; produced by cabbage, 38, 39 

Flea-bites, localisation of, 99 

Fliess, on paralysis during dentition, 
93 

Flint, Dr. Austin, on diet, 58 ; on 
palate and appetite, 61 

Flourens, on intoxication, 161 

Fontanelles, changes seen in, during 
suction, 11 

Food, action of, 4; reflex action of, 
4 ; proportions of (Eanke), 6 ; 
courses, 19 ; comparative digesti- 
bility of, 20, 52 ; oxalic acid in, 
38 ; importance of surroundings, 
55 ; experiments of Reaumur and 
Spallanzani on, 115 ; salt as, 226 ; 
on poisons formed from, 274 ; mole- 
cular disintegration of, 7 

Foster, Dr. Michael, on Succiis enteri- 
ciis, 248 

Fothergill, Dr. Milner, case related 
by, 159 

Fran9ois Franck, 155 

Eraser, 64 notes, 184 note, 264 

French meat, 20 ; peasantry, diet of, 6 

Friction, in the wet sheet, 216 

Friedriclishall water, 253 

Frog, kidney in, 355 

Frontal headache, due to ej'e con- 
ditions, 106 ; treatment of, 108 

Frontal sinuses, 107 

Fruits, as food. 63 

Funny bone, ICO 

Gadinine, 281 

Gaine, case recorded bj', 92 

Uall-stones, formation of, 74 ; emetics 

in, 182 
Galvano-cautery, 107 
Gamboge, experiment with, 194 
Game, 53 

Gamgee, Dr, A., 217 note 
Ganz, 147 note 

Gargles, used in vomiting, 174 
Garrod, Dr., on the liver, 48 ; on 

gout, 231 
Gas, composition of, in intestines, 31 ; 

in stomach, 28; secreted by mucous 

membrane, 29 ; from food, 29 



378 



INDEX. 



Gaskell, Dr., on the action of drugs on 

the heart, 343 
Gaspard, 281 
Gastra]gia, in gout, 76 
Gastric catarrh, 123 ; caused by tea, 

65 _ 
Gastric fistula, case of, 10 
Gastric indigestion, 22 
Gastric irritation, 121 
Gastric secretion, 26 ; action of, 12 ; 

action of bitters on, 214 
Gastric tonics, 68, 214 
Gastritis, 123 

Gastro- salivary circulation, 200 
Gautier, researches of, on poisons, 282 
Gee, Dr., on apomorphia, 179 
Gelatine, in typhoid fever, 279 
Genersich, 250 note 
Genital disorders, and dyspepsia, 67 
Gergyai, 250 
Germain, on trismus, 92 
Gianuzzi, 166 note 
Giddiness, replacing headache, 48, 76, 

106 
Gilbert, experiments on fat, 131 
Ginger ale, 256 
Globulin, 16 

Glomeruli, blood pressure in, 360 
Gluttony, 311 
Glycogen, formed from peptones, 16 ; 

from sugar, 16 ; in liver, 243 ; in- 
creased by ammoniacal salts, 75 
Glycosuria and diabetes, 35, 136 ; 

anxiety as a cause of, 67 ; gouty, 

136 
Gmelin, 115 
Goltz, 220, 310 
Gout, 42 ; action of water in cases of, 

368 ; use of potash in, 230 ; use of 

colchicum in, 231 
Gouty dyspepsia, 76 
Gowers, Dr., on hemoglobin, 222 
Grabbing food, 59 
Graham on diffusion, 8, 317, 323 
Gravel, water as a cure for, 368 
Greeks, idea as to the liver among 

the, 45 
Green, W. E., on biliary fistula, 44 
Green stools from calomel, 186, 205 
Gregory's mixture, 223 
Greve, 180 note 
Griesinger, 268 note 
Griitzner, on sodium nitrite, 365 
Gubler, 178 note; on albuminuria, 

322 
Gu^rin, 290 
Guillot, 200 



Gumboils, 89, 92 
Gums, 51 

Guterbock, 264 note 
Gymnastics, 75 

Habitual constipation, 72 

Hack, Dr., on megrim, 107 

Haemoglobin, formula (Preyer), 317 ; 
functions of, 308 ; indifEusibility of, 
317, 323 ; in connection with iron, 
222 

Hsemorrhoidal veins, 34 

Hsemorrhoids, 34. See also under 
Piles. 

Hall, Dr. De Havilland, 45 note 

Haller's Physiology, 115 note 

Hamilton's Purgative Medicines, 
quoted, 288 

Hammond, Dr., 152, 153 note 

Hands, condition of, at dinner, 153 

Harnack on apomorphia, 179 ; on 
choline, 283 

Harley, Dr. George, 150 

Haustus, Acidi Mtro-hydrochlorici, 
108, and note 

■ CalumbcB Alkalinte, 108, 125, 

and note 

' Magnesise Sulphatis, 108, a7id 

note 

• GentianEe cum Eheo, 125, and 

note 

Hayden, Dr., on cholera, 268 

Headache, 48, 98 ; after straining the 
eyes, 106 ; due to alkaloids, 295 ; 
to constipation, 71, 197 ; to indiges- 
tion, 108, 242; to bad teeth, 84, 
100, 101 ; to nose disease, 107 ; 
causes of, 76, 108, 111 ; of fevers, 
108 ; situation of, dependent on 
tooth affected, 105 ; treatment of, 
76 ; treatment varying with situa- 
tion, 198 

Health, dependent on tissue change, 
removal of waste, supply of new 
material, 3 

Healthy stomach and appetite, 117 

Heart, action of alcohol on, 149, 157; 
action of alkaloids on, 41 ; action 
of atropia and muscaria on, 259 ; 
albuminuria in disease of, 319 ; 

■ after removal from body, 238 ; ia 
indigestion, 41 

Heartburn, 33, 121, 126 

' Heart-wind,' 29 

Heidenhain, experiments and observa- 
tions of, referred to, 147 note^ 243, 
272 note, 303, 342, 354, 362 note 



INDEX. 



379 



Heincken, on otalgia, 199 

Helmont, on vomiting, 170 

Hemialbumose, 9, 12 ; in urine, 12, 37 

Hemipeptone, 9 

Hemmer, on putrid poison, 282 

Henle, figure after, 298 

Henle's loops, 300, 303, 355 

Henoch, on infantile paralysis, 93 

Hepatic stimulants, 74, 294 

Hepatitis, 176 

Hermann, Max, 168 ; on tartar emetic, 
179 ; on urine, 325 

Hewetson, Bendelack, work on head- 
ache, referred to, 77 

Hewson, on oedema, 219 

Higgins, Mr., 107 

High game, 54 

Hippocampal convolutions, 98 

Hippocrates, 115 note 

Histoire de ma Vie, George Sand, 
quoted, 45 

Holidays, necessity for, 233 

Holland, Lady, 46 note 

Hooper's Physician^s Vade Meciim, 
173 

Horse exercise for torpid livers, 75, 
257 

Hot tea, 65 

Hot water in gout, 76, 368 ; in gravel, 
368 

Hiif ner on ferments, 206, 227 ; on 
the kidney, 354 

Hump of camel and other animals, 129 

Hunger, causes of, 117 

Hunyadi Janos, 353 

Hutchinson, Mr. Jonathan, on blind- 
ness in toothache, 89 

Hydration in digestion, 7, 8, 12 

Hydrochloric acid in gastric juice, 
115 ; effect of salivary secretion 
on, 342 

Hydrocyanic acid, 124, 174, 176, 239 

Hydrogen, in intestine, 31 

Hyperassthesia of oesophagus, 64 ; of 
stomach, 33, 58, 175 

Hypochondriasis, 45, 47 

Hypophosphites in albuminuria, 328 

Hysteria, galvanism in, 182 ; pain in, 
99 

Hysterical flatulence, 31 

Icelander's food, 54 
Ictrogen, 294 
Idiosyncrasy in food, 274 
Image, Dr., 78, 110 
Imperfect digestion causing albumin- 
uria, 329 



'Impression on the nervous system,' 
182 

Improper food, 121 

Incisors, decayed, causing headache, 
106 

Indigestible food, 5 

Indigestion, 5 ; definition of, 5 ; 
symptoms of gastric, 22 ; in rela- 
tion to piles, 34 ; cough in, 40 ; 
beginning in stomach, 27 ; begin- 
ning in liver, 28 ; headache in, 48 ; 
treatment of, 68 ; as a cause of 
nervous disorders, 242 

Indigo, indol allied to, 15 

Indol, produced by bacteria, 15 

Infantile paralysis, 93 

Inferior dental nerve, division of, 90 

Inferior maxillary nerve, division of, 
90 

Inflammation, heat and cold in, 210 ; 
poultices in, 211 

Injection of egg albumin, albuminuria 
after, 318, 322 

Insanity due to bad teeth, 96 

Inside and outside the body, 4 

Inspiration, efEect on flow of lymph, 
334 

Intemperance and food, 56 ; water 
sipping as a cure for, 57 

Interlobular arteries, 301 

Intermediate products of digestion, 8 

Intermittent pulse, causes of, 41; 
treatment of, 76 

Intervals during meals, 60 

Intestinal flatulence, 31 

Intestinal juice, action of, 15, 248 

Intestinal secretion in cholera, 271 

Intestines, the action of alkaloids on, 
41 ; action of fruits on, 63 ; action 
of purgatives on, 208 ; gas in, 31 

Intoxication, 41, 161; double vision in 
cases of, 162 ; Leslie Stephen on, 
quoted, 163 

Inunction of mercury, 5 

Iodide of Potassium. See Potassium, 
Iodide. 

Iodides, excretion and reabsorption 
of, 122, 199 

Iodine., in cod-liver oil, 134 ; Bernard's 
observations on, 200 

Ipecacuanha, 177 ; in bronchitis, 345 

Iridin, 254 

Iron, eliminated by bile, 201 ; in 
atonic dyspepsia, 156 ; in relation 
with haemoglobin, 222 ; as a tonic, 
222 ; in treatment of albuminuria, 
221 



380 



INDEX. 



Irregular tubule, 304 

Irregularity of meals, 5 

Irritation, artilicial, of intestinal 
mucous membrane, 196 ; of stomach 
by glass rod, 117, 144 ; of the brain 
in connection with vomitingj 173 

Irritants of stomach, 121 

Isaac and Esau, 55 

Isaiah, 67 note 

Jalap, 223 ; experiments with, 191 
Jalapin, experiments with, 194 
Jaundice, 46; catarrhal, 294 ; causes of, 

67, 74 ; epidemic, 74 ; from lupine 

seeds, 294 ; from poisons, 293 ; 

produced by worry, 67 
Johnson, Dr. George, on cholera, 265, 

320 
Johnson (the swimmer), attempt to 

cross the Channel, 128 
Jones, Dr. Bence. See Bence-Jones, 

Dr. 
Juniper, 367 ; oil of, 367 

Kaatzee, Dr., on sausage poisoning, 
285 

' Keeping out the cold,' 159 

Kerner, on alkaloids, 281 

Key, Axel, 281 note 

Kidneys, comparative anatomy of, 
354 ; circulation in, 300, 316, 356 ; 
embolism of, 325 ; functions of, 
297 ; in gout, 42 ; nervous supply 
of, 361 ; purgatives in disease of, 
208 ; structure of, 298, 316, 354 ; 
threefold function of, 353 

Klein, figure after, 304 

Knee-joint, loose cartilage in the, 170 ; 
pain in, from disordered sexual 
functions, 99 

Kneeling posture, 156 

Kobert, 294 note 

Koecker, on deafness in toothache, 
89 

Kohler, on bitters, 215 

Kolbe, on flatulence, 31 

Koppe, 285 note, 284 note, on mush- 
room poisoning, 261 

Kronecker, Professor, on SAvallowing, 
11 ; on the vagus, 30, 63; on the 
division of fat, 53, 133 ; on muscular 
contraction, 218 

Kiihne, 198 note, 249 ; on intestinal 
juice, 15 ; on purgatives, 189 ; on 
the pancreas, 243 ; on rice-water 
stools, 271; on ictrogen, 294; on 
muscles, 332 



Labtrinth in kidney, 300 

Lacteals, action of, in absorption, 150 

Lallemaiid on alcohol, 151 

Landois, Human Physiology, 31 note 

Large intestine, action of aloes on, 
161 

Laryngeal pain from bad teeth, 87 

Lassitude, in anemia, 310; in dys- 
pepsia, 42 ; in indigestion, cause of, 
255 ; in women, 42 

Lawes and Gilbert's experiments on 
fat, 131 

Laycock, Professor, on appetite, 62 

Lead poisoning, 200 

Leared, Dr., 121 

Lecithin, 292 

Lederer, on convulsions and tooth- 
ache, 94 

Lehmann, on glycosuria, 35 

Lepine, on ptomaines, 290 

Leube, on albuminuria, 36 ; on diges- 
tion, 58 

Leucin, 15 ; in stools, 205 

Levick, on choreic movements in den- 
tition, 94 

Lewis, Dr., on cholera, 292 

Liebig. on alcohol, 151 

Liebig's extract, 265 

Liebreich, on chloral, 231 

Life insurance statistics of albumin- 
uria, 36 

Limitation of digestion processes, 249 

Lingual nerve, division of, 90 nUe. 

Linseed poultices, 211 

Liquids, action of, 5 

Liquor Potassse, 366 

Lithates in urine, 230, 244 ; alternation 
of, with oxalates, 229 

Liver, the, as a gatekeeper, 16, 34, 
45 ; circulation in, 23 ; elasticity of, 
25 ; action on poisons, 17, 34 ; 
efiect of malaria on, 28 ; Greek ideas 
of, 45 ; action of acids on, 75 ; of 
mercury on, 184 ; biliary function 
of, 202 ; functions of, 245 ; effect 
of nitro-hydrochloric acid on, 257 

Lobster, 145 

Localisation of impressions, 99 

Longet, 179 

Low spirits, and dyspepsia, 45 

Lower, on cedema, 218. 219 

Ludwig, 222, 247, 249, 260, 255, 302, 
325 ; on peptones, 17, 43, 197; figures 
after, 299, 303, 333, 334 ; on .saliva, 
309 ; on the muscles, 332 ; on the 
flow of lymph, 341 ; on the kidney, 
354 ; on urine, 358 



INDEX. 



381 



Lungs, tlie, in connection with diges- 
tive disorders, 40 

Lupine seeds, as a cause of jaundice, 
294 

Lupintoxin, 294 

Lussana, 185 note, 201, 202 note; on 
malaria, 182, 207 

Lympli, amount of, in proportion to 
muscular development, 332 ; circu- 
lation of the, 250 ; removed by 
veins, 335 ; supply of, and secretion, 
341 

Lymph pumps, 231, 280, 332, 333 

Lymph spaces, 330 ; relation of, to 
vessels, 330 

Lymph stream, and respiration, 334 ; 
and blood strtam in veins, 332, 
335 

Machine, man compared to a, 6, 49 

iVlagendie, 204 notej on vomiting, 
165 note, 166, 178, 179 ; on organic 
decomposition, 218 ; on division of 
the inferior maxillary nerve, 90 

Magnesium sulphate, 124, 223; experi- 
ments with, 191, 194 

Mahomed, Dr., 208 ; sphygmographic- 
tracings by, 209 ; on scarlet fever, 
348 

Maize, alkaloids from, 279 

Malaria, 28, 29 ; emetics in, 182 ; 
purgatives in, 207 

Malherbe, M., on lead poisoning, 200 

Malpighian glomeruli, 301, 316, 357 

Malpighian pyramids, 258 

Malpighian tufts. See M. glomeruli. 

Man as a cooking animal, 1 j as a 
machine, 6, 49 

IManassein, 180 

Manege movement, 179 

Manganese binoxide, 69 

Marey, 155 ; on mastication, 10 

Marsh gas in intestines, 31, 241 ; in 
eructations, 31 

Massage, 77 

Masseters, spasm of, 92 

Mastication, 9, 49 ; reflex effects on 
stomach and circulation, 10 ; imper- 
fect, 49, 95 

Mathieson, discovery of apomorphia 
by, 179 

McNaught, Dr., on acidit}', 33 

Meals, irregularity of, 5; solitary, 51 ; 
order of courses at, 256 

Meat diet, Eanke on, 132 

Meats, structural differences in, in 
relation to digestibility, 52 ; cook- 



ing of, in connection with poison 

symptoms, 275 
Medulla oblongata, centres in, 169 ; 

puncture in, 362 ; stimulation of, 

362 
Medullary and cortical parts of the 

kidney, 298 
Medullary rays, 298 
Megrim. See ^Migraine. 
Melancholy, 45, 246 
Melons, 275 

Melseus, on lead poisoning, 200 
Membranes, compared to atomic 

sieves, 8 
Memoir of the Rev. S. Smith, 46 note 
ileningitis, vomiting in, 174 
IMenorrhagia, 312 
Mental processes, effect of alcohol on, 

154 
Mental strain, 113 ; results of, 250 
Mercury, action on duodenum of, 186; 

alterative action of, 232 ; as an 

antiseptic, 74 ; as a cholagogue, 

74, 204, 253 ; as a purgative, 229 ; 

in albuminuria, 328 ; in biliousness, 

184; in headache, 224 ; inunction 

of, 5 
Mesenteric nerves and vomiting, 173 
Mesmeric state, 170 
Metabolism, effect of alcohol on, 151 
Metals, eliminated by bile, 181, 201 
Meyer, 147 note; on poisons, 350 
Microbes. See Bacilli. 
Microzymes and jaundice, 74 
Middle ages, theory of cholera in, 

295 
IVligraine and astigmatism, 107 ; and 

toothache, 84 ; cured by the use of 

spectacles, 107 ; Du Bois Reymond 

on, 103 ; pathology of, 103 
MHk, as a food, 274, 292 ; in typhoid 

fever, 278 ; souring of, 279 
Mitchell, Dr. Weir, on fat and blood, 

130 
Mitral disease, albuminuria in, 319 
Mixed diet necessary, 6, 132 
Moderation, at meals, 21 ; in the use 

of alcohol, 70 
Modern life, high pressure of, 233 
Molars, decayed, and headache, 105 
Molecular weight and diffusion, 317, 

323 
Molecules, absorption of, 9 ; action of, 

36 
Moleschott's Untersuclmngen, 166 

note 
Molhere, on ptomaines^ 290 



382 



INDEX. 



Moral agent, cookery aa a, 55 ; 

Gregory's powder as a, 223 
Moreau, experiments of, referred to, 

191, 195, 208, 271, 272 
Morgagni, 191 
Morphia, combined with atropia in 

cholera, 270 
Moser, on the bile, 201 
Mosler, 186 note 
Motor ganglia of the heart, effect of 

alcohol on the, 163 
Mouth, action of alcohol on the, 

143 
Mucous membrane, of stomach, 26, 

27 ; the action of food on, 4 ; action 

of charcoal on, 68 
Mucus in stomach, 26, 68; secretion 

of, 146 
Muffins, 51 

Miiller, Johannes, on digestion, 115 
Murchison, Diseases of the Liver, 48 
Muscae volitantes, 110 
Muscarin, action of, 259 ; on pul- 
monary vessels, 260 ; experiments 

with, 267 ; production of, 278 ; 

from fish, 281 ; artificial, 283 ; 

action of, 284 ; from eggs, 292 ; 

effect on heart and vessels of, 343 
Muscle fibres, arrangement in meats, 

20 
Muscles, effect of alcohol on, 154 ; 

condition of, 332 
Muscular exhaustion, 237 ; weakness 

in antemia, 308 
Mushrooms, poisonous, 259, 265, 283, 

343 ; remedies, 261 ; atropia as an 

antidote to, 259 
Mustard, 177 
Mutton fat, 51, 134 
Mydalein, 288 

Nap, after or before dinner, 60 

Naphthilamine, 15 

Napkins at meals, 55 

Narcosis, vomiting in, 169 

Nasse, 220 

Nausea, excited reflexly, 54 ; in con- 
stipation, 197 ; in gastric indiges- 
tion, 22 ; produced by iri'itation of 
the stomach, 26, 144 

Necessity for oxygen, 236 

Negroes, source of fat in, 131 

Nephritis, 325 

Nerve-centres, effect of mastication 
on, 10 ; sensitiveness of, 23 

Nerve of intestinal tract, 4 : of kidney, 
361 



Nervous disorders, and indigestion, 
242 

Nettle-stings, 349 

Neucourt, F., on neuralgia, 86, 87 

Neumann, on alcohol, 151 ; on dif- 
fusion of fat, 134 

Neuralgia, in connection with the 
teeth, 83, 86, 87 ; nature of, 99 ; in 
constipation, 199 j use of croton oil 
in, 197 

Neuridine, 281, 288 

Neurine, 278, 281, 284 

New beer, 122 

New bread, 51 

New material, 3, 4 

New York, statistics of albuminuria 
in, 36 

Newbigging, on sciatica, 197 

Nicati, on cholera, 292 

Nicotine destroyed in liver, 17 

Niemeyer, 264 note 

Nitrate of urea, 315 

Nitric acid test for albumen, 315 

Nitrite of amyl. See Ainyl, nitrite. 

Nitrite of ethyl, 365 

Nitrites, action of, 365, 366 

Nitrogen in stomach, 28 ; in intestines, 
31 

Nitro-hydrochloric acid, use of, in 
biliousness, and headaches, 75, 224, 
230, 257, 327, 365 

Nitro-muriatic acid. See Nitro-hydro- 
chloric acid. 

Non-bitterness of bile, 44, 245 

Nose disease and headache, 107 

Noxious gases in the intestine, 240 

Nussbaum, on the kidney, 356 ; figure 
after, 356 

Nutrition of capillaries and dropsy, 
339 

Nux Vomica, 68, 126, 222, 257 

Odontological Society's transactions, 
48 note 

CEdema, after wetting, 347 ; from 
poisons formed in intestine, 348 ; 
in anaemia, 310, 340 ; in Bright's 
disease, 313; in debility, 217; in 
scarlet fever, 347 ; local, in urticaria, 
348 ; pathology of, 218 ; sudden, 
347 

Oesophagus, action of, in vomiting, 
116 ; irritation of, 33 ; hypergesthesia . 
of, 64 ; sensitiveness of, 32 

Olein, 130 

Optic thalamus, wound of, 179 

Orange, 257 



INDEX. 



383 



Ostronmoff, on division of the lingual 

nerve, 340 
Otalgia, 199 

Outside and inside the body, 4 
Ovarian nerves, and vomiting, 173 
Over-eating, in animals, 59 ; in man, 

59 
Oxalate of lime, in urine, 38, 47 
Oxalic acid, and uric acid, relation of, 

39 
Oxalic acid, sources of, 39 
Oxalnria, 38, 47, 229 
Oxidation, eiBEect of alcohol on, 151 

Paasch, on teething cough, 88 
Paducah, cholera in, 270 
Palate and tongue as gate-porters, 18 
Palmerston, Lord, on horse exercise, 

75,257 
Palmitine, 130 
Palpitation, 29, 311 
Pancreas, the, Kiihne quoted on, 243 
Pancreatic emulsion in albuminuria, 

328 
Pancreatic ferment in fseces, 208 

note ; in urine, 228 
Pancreatic secretion, action of, 14 
Panum, 158 notej on putrid poison, 282 
Papain, 54 
Pap aw fruit, 54 
Papin's digester, 227 
Paracentesis, 369 
Paraglobulin in urine, 322 
Paralytic secretion, 271 
Parapeptone, 12 

Parkes, Dr., on albuminuria, 36 ; on 
alcohol, 157; on cholera, 264 note, 
265 ; on colchicum, 231 ; on pneu- 
monia, 319 
Pastry, evils of, 132 
Pathogenese der Baiichtympanie, 31 

note 
Pathology of acute indigestion, 125 ; 
of asthma, 40 ; of biliousness, 73, 
276 ; of diarrhoia, 276 ; migraine, 
85 
Paul us Aegineta, 115 note 
Pavy, Dr., on albumin, 322 
Pea-soup causing flatulence, 30 
Peasantry, Austrian, diet of, 146 ; 

French, diet of, 6 
Pellicani, on poisons, 282 
Pehis of ureter, 297 
Pepsine, discovery of, 116 ; in 

muscles, 206 ; in urine, 227 
Peptogens, 19 
Peptones, as poisons, 17, 43, 247, 255, 



277, 280 ; as a source of glycogen, 

16 
Peptones, formation of, 9 ; formed in 

duodenum, 14 ; in portal blood, 249 ; 

in stomach, 12 
Peptonisation, artificial, 12 
Peptonuria, 35, 37, 244 
Peptotoxin, 13, 43, 280, 282 
Percussion, painful in toothache, 87 
Pereira's Materia Medica, 188 note, 

213 
Pericardium, as a bell-jar, 336 
Peristalsis, quickened by purgatives, 

188 
Perrin, on alcohol, 151 
Perspiration, the condition of the skin 

in, 353 
Pharynx, irritation of the, 40 
Phenol, 44 

Phosphates in urine, 314 
Phosphorus, 232 
Phosphorus poisoning, 137 
Phthisis, caused by pastry-cooks, 132 ; 

cod-liver oil in, 136 ; vomiting in, 

176 
Physiological ashes, 237, 351 
Physiology of digestion, 115; of 

kidney, 354 
Physiology of Digestion (Beaumont), 

quoted, 117 
Physiology of Digestion (Combe), 

quoted, 51 
Piles, 34, 216, 253, 312 
Pilocarpin, 239 
Piotrowsky, 158 note 
Playfair, Dr. William, on massage, 77 
Pleasure in work, 112 
Plethora causing headache, 109 
Pleura, 334 

PIosz, on peptones, 250 
Pneumonia, albuminuria in, 319 ; 

tartar emetic in, 180 
Pointis, on toothache, 88 
Poison and food, 274 
Poisoned wells, 295 
Poisoning by mushrooms. See Mush- 
rooms. 
Poisons and antidotes, 283 
Poisons, destroyed by the liver, 17 ; 

excreted by the liver, 17 ; formed 

in intestines causing oedema, 348 ; 

from proteids, 276 ; resulting from 

digestion, 47 
Pork as food, 121 
Pork fat, 134 
Porpoise oil to lubricate skin used by 

Webb, 128 . - 



384 



INDEX, 



Portal circulation, 24, 122. See also 

Entero-hepatic circulation. 
Position of Lead affecting circulation, 

155 
Position of headaclie, treatment vary- 
ing w-ith, 108 
Posture and vomiting, 175 
Potasli in gout, 230 
Potassium acetate, 366 

bitartrate, 188, 3G7 

bromide in dyspepsia, G7, 124 ; 

in intermittent pulse, 76 ; in 
vomiting, 175, 176 

• carbonate, 368 

citrate, 76 

ferrocyanide, diffusion of, 8 

iodide as an alterative, 223 ; in 

gout,76,2ol; inheadacbe,110 

• nitrate, 367, 368 

nitrite, 366 

permauganate, 238 

Potatoes, 51 

Poultices, how to make, 210 ; for 

abdomen and chest, 211 
Power, Dr. D'Arcy, 1 note, 144 note; 
on temporary albuminuria, 37 ; on 
digitalis, Sol note, 362 
Pregjiancy, albuminuria in, 319 
Premature labour, 176 
Presbyopia and giddiness, 107 
Preyer, on hemoglobin, 317 
Pribram, 147 note 
Prognosis in albuminuria, 36 
Propeptone, 12 

Propylene, in cod-liver oil, 134 
Proteids, action of pancreatic juice 
on, 14; digestion of, 9 ; in stomacb, 
12 ; proportion of, 6 ; poisons from, 
276 
Prout, 208 note; on digestion, 115 ; 
Stomach and Renal Diseases, re- 
ferred to, 184 note 
Prussian blue, injection of, 334 
Pseudo-albuminuria, 37 
Ptomaines, 13, 281 ; in cheese, 287; 
in circulation, 4l ; in dyspepsia, 
290 ; in fish, 287 ; in sausage poi- 
soning, 285 ; in uremia, 285, 290. 
See also Alkaloids. 
PtyalLn, in saliva, 199 ; in urine, 199 
Pullna water, 196, 253 
Pulmonary vessels, the action of mus- 

caria on, 260, 266 
Pulse, effect of alcohol on, 158 ; effect 
of cold on, 104 ; in digestive dis- 
orders, 41 ; intermittent, 41 
Pulverisation, assisting solution, 7 



Pupil, the, condition of, in migraine, 
103, 105 

Purgatives, 71, 123, 181 ; depressant 
action of, 229 ; effect on ill temper, 
223 ; effects on, 188 ; experiments 
on, 150 ; in albuminuria, 321 ; in 
biliousness, 205 ; in headache, 108 ; 
in kidney disease, 208 ; in lead 
poisoning, 182 ; in scarlatinal ne- 
phritis, 348; in toothache, 88 ; mode 
of action of, 189 ; sunnnary of 
modes of action, 208 ; versus stimu- 
lants, 253 

Pus in urine, 322 

Putrefaction in iutestinf s, 15 ; poisons 
resulting from, 282 ; prevented by 
bile, 15 ; temperature in relation 
to, 279 

Putrescine, 281, 288 

Pye, j\lr., on erythrophlceum, 303 

Pye Smith, Dr., 41 note 

Pj'lorus, action of, 13, 29 

Pyrexia, alcohol in, 151 

Quassia, 144 ; and iron mixture, 110 
Qiievenue, 251 

Quincke, on cerebro-spinal fluid, 251 
Quinine, 44, 221 ; effect on salivary 

secretion, 342 ; in albuminuria, 327, 

328 

Eadziejewsei, 208 note; on bile, 186; 
on purgatives, 189, 190, 205 

Eanke, on diet, 6, 132 

Kanvier, 310 note; on exudation of 
lymph, 337, 339 ; on oedema, 218, 
331 

Payer, 264 note 

Keabsorption of ferments, 206 

Ee action, of bile, 14 : of gastric juice, 
discovery, 115 ; of gastric juice, 12 ; 
of gastric juice in catarrh, 22, 29 ; 
of gastric juice in fever, 180 ; of 
intestinal contents, 15 ; of pancre- 
atic juice, 14 ; of saliva, 12 ; of 
urine, 314 

Eeading during meals, 51 

Eeaumur, on food, 115 

Eebellion of appetite, 62 

Eectum, circulation in, 34 ; piles, 34, 
216,252, 312 ; poisons injected into 
the, 34 

Eed blood corpuscles, action in absorp- 
tion, 16 ; reflex effect of alcohol on, 
150 

Eeflex blindness, 89 

Eeflex diarrhoea, 95 



INDEX. 



385 



Reflex effects of nlcoliol, 147 ; of 
emetics, 180 ; of foor], 4 ; of mas- 
tication, 10; of suction, 11 

Reflex vomiting, 170 

Regularity of bowels, 72 

Reiclimann, on acidity, 33 note 

lieliition of skin and kidneys, 352 

Relish of food important, 214 

Removal of irritants, 123 

Removal of lymph by veins, 335 

Removal of waste, 3, 237 

Renal nerves, section of, 362 ; vomit- 
ing in relation with, 173 

Renal portal system in frogs, 356 

Renal vein, ligature of, 358 

Respiratory action of mucous mem- 
branes, 28 

Respiratory and vomiting centres, 
relation of, 169, 179 

Rest before dinner, 66 

Restaurants, dirty, 55 

Retching, 166 

Retzius, 251 note 

Reymond, Du Bois, 31 note; on head- 
ache, 104 ; on niigraine, 85, 86, 103 

Reynolds, Dr. Russell, on epilepsy 
during dentition, 94 

Rheumatic headache, 110 

Rhubarb, producing oxaluria, 38 

Ribbert, on the kidney, 355 

Rice-water stools, 263 ; analysis of, 
272 

Ricliet, on mastication, 10 

Richter, on toothache, 87 

Rietsch, on cholera, 292 

Right side of heart in cholera, 267 

Rigor mortis, 53 

Ringer, Prof. S., 143, 272 note; 
Iheraj-ieutics by, 188 note 

Roberts, Dr. W., on oxaluria, 48 

Rohmann, F., 75 note 

Rohrig, on bile, 204 

Rolando, fissure of, 92 

Rombei-g, on infantile paralysis, 93 

Rorsch, on poisons, 282 

Rose, 300 

Rowing as an exercise, 75 

Roy, on the size of the kidney, 360 

Ruge, on flatulence, 31 

' Running down,' 234 

Russell, Dr., on cod-liver oil, 134 

Rutherford, Prof., Yi2note; on chola- 
gogues, 254 

St, Bartholomew's Hospital, Pharma- 
copoeia, 170 notej Reports, 37 
note ; 48 note 



St. Paul, and Timothy, 70 ; on the 

interdependence of parts of the 

body, 313 
St Martin, Alexis, case of, 22, 26, 27, 

63, 116, 118, 119, 123, 124 
Salathe, on reflex effects of suction, 

11 
Salicylate of soda. >S'eeSoda, salicylate. 
Saline waters, as purgatives, 72 
Salines, importance of, 253 
Saliva, action of, 10 ; action of bitters 

on, 214 ; as an excitant of gastric 

secretion, 12 ; reflex secretion of, 

30 ; secretion in anternia, 309 ; 

secretion before vomiting, 167; 

tenacity of, 30 
Salkowski, 36 note, 294 note 
Salt, action of, 7 ; as a food, 226 ; as 

a remedy in epilepsy, 231 ; desire 

for, 62 
Salts, Carlsbad. See Cailsb^id salts. 
Sand in dyspepsia, 69 
Sand, George, on melanchoIy,45 
Sanderson's Handbook fur the Phijsio- 

logical Laboratory, 1 note 
Sandwich, how to make a, 63, 133 
Sanguinarin, 177 
Saprine, 288 
Saunders, Dr., 262 note; on cholera, 

270 
Sausage poisoning, 281, 285 
Savage, Dr., 96, lu7 
Savory, Mr., on strychnia, 35 
Scarlet fever, oedema in, 347 
Schachowa, 303 
Schiflf, on digestion, 19, 166 note, 167 

note, 269 ; on ferments, 206 ; on 

dim vision after section of nerves, 

90 ; on the liver, 185, 202 
Schmidt, on intestinal secretion, 190 
Schmidt-Miihlheim, on peptones, 17, 

43, 247, 249, 250, 255 
Schmiedeberg, on alcohol, 150 ; on 

choline, 283 ; on jaundice, 293 ; on 

muscarine, 258, 284 ; on nmshroom 

poisoning, 265 ; on poison, 282 
Schnaps, 67 
Schneidemiihl, 294 
Schreiber, 286 note 
Schuler, 67 note 
Schulinus, 152 

Schwalbe, on cerebro-spinal fluid, 257 
Schwann, on digestion, 116 
Sclnveigger-Seidel, figures after, 333, 

356 
Schweninger, on putrid poison, 282 
Sciatica, croton oil in, 197 

c c 



386 



INDEX. 



Scotfc, 186 note 

Scybala, 196 

Sea-sickness, cause 176 ; Dr. Ferrier's 
prescription for, 175 

Secretion and reabsorptionof digestive 
ferments, 242 ; copious, with certain 
purgatives, 195 ; effect of atropin 
on, 272 ; in anasrnia, 308 ; paralytic, 
271 ; related to lymph supply, 341 

Seegen, 16 notej on diabetes, 137 

Seicliitz waters, 196 

Selmi, Prof., on ptomaines, 282 

Senator, on butyric acid, 146 ; on 
gastric catarrh, 197 ; on sulphuretted 
hydrogen, 47, 241 

Senna, 208 note 

Sensations, unaccountable, 239 

Sepsine, 282 

Serpent's venom in portal circulation, 
16, 202 

Serum albumin, and white of egg 
compared, 37 ; in urine, 322, Bee 
also Albuminuria. 

Sewer-gas, 47 ; in lungs, 214 ; gas 
in intestines compared to, 215 ; 
Dumarquay on, 240 

Sexual power in osaluria, 47 

Shakespeare, on sorrow, 67 

Sherry, 71, 145 

Shortness of breath in dyspepsia, 39 

Sick Headaches and Defective Bight 
(Hewetson), referred to, 77 

Sick-room cookery, 135 

Siebert, 179 

Siegen, on ferments, 207 

Sierra Nevada, Dr. Fotbergill in, 159 

Sieveking, Dr., on lead-poisoniug, 200 

Sight affections in migraine, 86 

Sipping, stimulant effects of, 11, 21, 
57 

Skin, action of alcohol on the, 141, 
159 ; action of cold on the, 159 ; as 
an excretory organ, 352 ; as a 
regulator of body temperature, 252 ; 
use of arsenic in disease of the, 225 

' Sluggish liver,' 184 

Smith, Dr., on cholera, 268 

Smith, Sydney, on dyspepsia, 45 

Soda salicylate, 74, 110, 294 

Soda sulphate, experiments with, 191 

Soda-water and indigestion, 255 

Sodium chloride in epilepsy, 231 

Solids, action of, on the mucous mem- 
brane of the alimentary tract, 5 

Solomon, King, on hurry, 59 

Solution, assisted by pulverisation, 
7 ; part of digestion, 6 



Sonnenschein, Dr., 282, 285 

Sore-throat and toothache, 105 

Soup as a peptogen, 19 

Sour wines, 63 

South Kensington, examination at, 14 

Spallanzani, on digestion, 115 

Spasm of nuisseters, 92 

Spectacles as a cure of migrairie, 107 

Spencer, Herbert, on nervous eneigy, 
246 

Sphygmograms before and after the 
application of cold to the arm, 
104 ; after purgation, 209 

Spiess, on saliva, 309 

Spinal cord, section of, 361 

Spiral tubule, S03 

Spiritus uEtkeris Nitrosi, 365, 367 

Splanchnics, section of, 361 

Spleen, effect of malaria on, 28 

Splinters, mechanical and chemical, 
compared, 277 

Squills, 366, 367 

Stadelmann, on jaundice, 293 

Starch, action of pancreatic juice on, 
14 ; hydration of, 8 

Starving treatment, 60 

Steak, tough and tender, 53 

Stearine, 130 

Stephen Leslie, 162 

Stercor^mia, 290 

Stich, on putrid poison, 282 

Stille's Therapeutics., 188 note 

Stimulant effects of alcohol, 157 

Stimulants at meals 21, 256 ; before 
meals, 21 ; hepatic, 74 ; place and 
power of, 69 ; versus purgatives, 
253 

Stinudants and Narcotics (Anstie), 
referred to, 153 

Stimulation of stomach, reflex effect 
on saliva of, 30 

Stimuli of gastric secretion, 26 

Stirling, Dr., 31 note 

Stokvis, 314 note, 315 note, 318 note; 
on hemialbumose, in urine, 38 ; on 
albumin, 322, 324 

Stomach, action of air on, 29 ; action 
of alcohol on, 144, 145 ; coughing 
caused by acidity of, 40 ; excitation 
of mucous membrane of, 172 ; fats 
in, 14 ; formation of gas in, 31 ; 
composition of gas in, 28 ; con- 
gestion of, 26, 27, 147 note; con- 
dition of, in biliousness, 119; in 
hunger, 117 ; in vomiting, 106 ; 
hypersesthesia of, 33 ; respiration 
in, 28 ,• movements of, 13 ; tea. 



INDEX. 



3S7 



coffee, {iTifl cocoa, action of, on, 

144, 145 ; weak, 6 
Stomach-cough, 40 
Stools, after taking iron, 205 ; after 

taking mercury, 186, 205 ; in 

biliousness, 73 
Strawberries, as food, 03 ; as poison, 

274 
Strieker, 204 note 
Stropbanthus, 366, 307 
Strychnia, 126, 306 ; as a tonic, 220 ; 

taste of, 13 
Stuffing a patient, 58 
Subbotin, on fat, 130 ; on alcohol, 152 
Subcutaneous fat as a protection 

against cold, 128 
Submaxillary gland, Barnard's experi- 
ments on, 340 
Subnitrate of bismuth, 09 
Succus entericus, 15, 248 
Suction, stimulant effects of, 11 ; of 

thumb in children, 11 
Sudden death in gout, 42 
Suet dumplings, 51 
Sugar formed in mouth, 10 ; in urine 

{see Glycosuria) ; injection of, 35 
Sulphur in cruciferous plants, 39 
Sulphuretted hydrogen, action on 

urates, 39 ; in eructations, 32, 75, 

181, 198 ; in intestines, 31, 39, 240, 

241 ; in sewer gas, 47 ; in stomach, 

29 ; in urine, 198 
Sulphurous acid, effect on plants, 241 
Supply of new material, 3 
Swallowed air, 167 
Swallowing, 1 1 ; action on vagus, 11 ; 

frequent, 36 
Sweat glands, part played by, in 

urticaria and sudden oedema, 349 
Sweet taste after chewing bread, 10 
Switzerland, drink in, 57 
Syme, Prof., on lead poisoning, 200 
Sympathetic system and fifth nerve, 

relations of, 102 
Syphilitic headache. 111 

Table d'hote, advantages of, 00 
Tactile sensibility, cerebral centre of, 

98 
Tainted food, 275 
Talma, Professor, on acidity, 33 
Tandon, Prof. Moquin, 1 note 
Tannin in tea, 04 
Tartar emetic, 144, 177 
Taste, the education of, 18 
Taste of peptones, strychnine and 

other alkaloids, 13 



Tastelessness of bile, 44, 245 

Tea, 03, 255 ; constituents of, 04 ; 

cause of acidity, 04 
Teeth, bad, 51, 76 ; as a cause of 

headache, 48, 76 ; in connection 

with deafness, 89 ; with dyspepsia, 

95 ; Avith insanity, 96 
Teeth, false, 51 
Teetliing cough, 88 ; paralysis during, 

93 
Teetotal associations, 55 
Temper, effect of good cookery on, 19 
Temperature of body, effect of 

alcohol on, 158 ; effect of niydalein 

on, 288 ; effect of purgatives on, 

207 
Temporary albuminuria, 30, 06 note, 

243, 317 
Temporary indigestion, treatment of, 

122 
Tender points in headache, 100, 110 ; 

in neuralgia, 84 
Tension of the eye in headache, 109 
Thiersch, on putrid poison, 282 
Thirst produced by diuresis, 364 
Thiry, experiments on purgatives, 190, 

191 
Thudicum, 152 
'Thunder in the air,' 279 
Tic doloureux, 197 
Tickling the fauces in mushroom 

poisoning, 261 
Tiedemann, 115 
Timothy and alcohol, 70 
Tissue change, 3 

Tissue lymph, action of tonics on, 218 
Toast, 51 

Toluylendiamine, 74, 293, 294 
Tone, want of. 215 
Tongue, 26, 27 ; action of alcohol on, 

144 ; as a gate-porter, 18 ; in gastric 

indigestion, 22 
Tonics, 68 ; action of, 213 ,• digitalis 

and strychnia as, 220 ; in neuralgia, 

87 ; vascular, 217 
Toothache, 83, 88 
Tortoise, the kidney in, 354 
Tracing of circulation in the brain, 155 
Tracings, sphygmographic. ^Seesphyg- 

mograms 
Training o± palate, 58 
Transference of pain in migraine, 86, 

102 
Traube, Moritz, on diffusion, 8, 317, 

323 
Treatment of cholera, 270 ; of epilepsy 

by common salt, 231 ; of frontal 
C C 2 



388 



INDEX. 



headache, 108 ; of digestive dis- 
orders, 68, 122 ; of vomiting, 174 

Tricuspid disease, albuminuria in, 319 

Tricuspid regurgitation, 335 

Triton, the kidney in, 355 

Trypsin, 249 ; papain compared to, 54 

Tubercle bacillus, 66 

Tuberculosis, causes of, 132 

Tubules, uriniferous, 299 

Tumours of brain, 174 

Turpentine, 307 

Tweedy, Mr. John, 107 

Twitching of the eyelid, 91 

Typhoid bacillus, 278, 291 ; epidemic, 
240 

Tvplius, emetics in, 182 ; headache 
"in, 109 

Typical English meal, 6 

Tyrosine, 15, 186 ; in stools, 205 

Unaccountable sensations, 259 

Urasmia, case of, 285 ; ptomaines in, 
290 

Urea, as a diuretic, 366 

Ureter, 297 ; ligature of the, 358 

Uric acid, 315 ; effect of colchicum 
on, 231 ; in relation to oxalic acid, 
38 

Urine, abnormal products in, 35. See 
a^so Albuminuria, Glycosuria, Oxal- 
uria, Peptonuria, Pus in urine, etc. 
Carbolic acid in, 294 ; circumstances 
modifying the secretion of, 358 ; 
ferments in, 227 ; hemialbumosc 
in, 12, 37 ; plij'siology of secretion 
of, 222, 355 ; poisons in, 290 ; rela- 
tion of quantity to amount of albu- 
min, 325 ; relation of amount to 
blood pressure, 363 

Urticaria, causes of, 348 

Uterine dyspepsia, 67 

Uterine nerves in relation to vomiting, 
173 

Vaccination, chemical, 291 

Vagus, action in intermittent pulse, 

41 ; effect of irritation of, 30 ; in 

connection with the fifth nerve, 95 ; 

result of cutting, 238 ; vomiting in 

relation to the, 173 
Valerian in headache, 110 
Valleix, on neuralgia, 87 
Valsalva, on oedema, 219 
Vascular conditions in migraine, 85, 

102, 103 
Vascular dilatation, independence of, 

347 



Vascular tonics, 217 
Vaso-dilating mechanism, 362 

Vaso-motor centre, position of, 221 ; 
action of digitalis on, 215 

Vaso-motor changes and secretion of 
urine, 360 

Vaso-motor disturbances in migraine, 
85, 86, 102 

Vaso-motor effects of strychnia, 221 

Vaso-motor nerves, paralysis of, in 
relation to exudation of lymph, 219, 
338 

Vaughan, Dr., on alkaloids, 287 

Vegetable bitters, 68, 125, 214 

Vegetable casein, 9 

Veins, causes of blood flow in, 336 ; 
hindrances to blood flow in, 330; 
in absorption, 150 ; in the removal 
of lymph, 335 

Velvety skin, produced b^' alcohol. 
150 

Venous congestion, as a cause of albu- 
minuria, 318, 320, 324 ; of stomach 
and intestines, 26 

Veratria, 177 

Viands at meals, order of eating, 256 

Viper venom swallowed, 16 

Visceral nerves and vomiting, 173 

Viscidity of bile, 74 

Voit, on the formation of fat, 131 ; on 
fatty degeneration, 137 

Volatile oil in tea, 64 

Volatile oils, use of, in flatulence, 68 

Vomiting, from irritation of the stom- 
ach, 20, 172 ; in biUousness, 204 ; 
in gastric indigestion, 22 ; in men- 
ingitis, 174 ; in phthisis, 176 ; in 
strangulated hernia, 173 ; mechan- 
ism of, 168 ; nervous mechanism 
of, 168; physiology of, 165; pro- 
duced by blow on the testicles, 170 ; 
produced by joint affections, 170 ; 
reflex excitation of, 170 ; vagus 
nerve in relation to, 173; visceral 
nerves in relation to, 173 ; summary 
of action of drugs on, 183 ; treat- 
ment of, 174 

Vomiting centre, 169 ; connection of, 
with respiratory centre, 169, 179 

Vulpian, on purgatives, 191, 192, 208 

Waejith in headache, application of, 
104 

Wasmann, on pepsin, 116 

Waste, removal of, 3, 4 

Water, as a diuretic, 307 ; as a stimu- 
lant, 11, 57 ; in gout, 230, 368 ; in 



INDEX. 



389 



gravel, 3G9 ; part played by, iu the 

body, b51 
"Watering of tlie mouth, 54 
Watson, Practice of Fhyslc, referred 

to, 173 
Waxy disease of the kidney, 325 
Weak stomach, 6 
Webb, Captaiu, the swimmer, 128 
Weber, Otto, ou butyric acid, 146, 

181, 198, 242; on putrid poison, 

282 
Weight in epigastrium, feeling of, 

145 
Weir-Mitchell, Dr., 135 ; Fat and 

Blood, and How to make tliem, 

b}', referred to, 77, 130 
West Indies, use of papaw in, 54 
Whiskey, 71 

White of egg, injection of, 37 
Wholth or health, derivation of, 2 
Wildbad, sausage poisoning at, 285 



Wilkinson's Ancient Ecjijptians, re- 
ferred to, 114 

Wilks, Dr., 270 note 

' Windy spasms,' 124, 199 

Wine, action of, 63, 69 ; efEect on 
heart, 153 

Winternitz, Professor, on heat and 
cold applied in headache, 103, 210 

Wittich, Von, on ferments, 227 

Wood's syringe, 192 

Yak of Tartary, 129 
Yeast plant, 41 

Zawilski, 75 notej on bile, 254 

Zebu, the, 129 

Zeckendorf, on flatulence, 31 

Zinc sulphate, 177 

Zoedone, 256 

Zuelzer, on poisons, 282, 285 

Zymogen, 243 



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