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RC826  .B83  On  disorders  of  dige 


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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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Fis.  50. 


-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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