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Dicious Circles 






Plate i. Concurrent Circles. 

Vicious Circles 



JAMIESON B. HURRY, M.A., M.D. (Cantab.) 

Author of " Poverty and its Vicious Circles," 
Etc., Etc. 

Mitb ^lustrations 






Iboc Opu0 

preface to the Jfiret Ebition. 

HIS MONOGRAPH represents the first at- 
tempt to deal systematically with Vicious 
Circles in Disease, and is offered to the 
Profession with a full consciousness of 
many shortcomings. 

Such an exploration into a new field of pathological 
enquiry needs no small circumspection. But care 
has been taken to quote freely from recognised 
authorities so that the reader will have before him 
the evidence for the propositions advanced. 

The array of Vicious Circles brought together 
appears so overwhelming in its cumulative weight as 
to justify the conclusion that such Circles play a 
role of great importance in pathology. If this view 
is correct, the subject is one which no practitioner of 
the ars medendi can afford to neglect. Its study will 
conduce to increased accuracy of diagnosis, prognosis 
and treatment. Especially in regard to treatment 
will there be gain, for full of truth is the old maxim : 
Qui bene diagnoscit bene medebitur. 

Most of the Chapters have appeared in the columns 
of the British Medical Journal, The Lancet, The 
Practitioner and the Medical Press, and I am indebted 
to the courtesy of the respective Editors for per- 
mission to reprint. My thanks are also due to many 
friends for assistance and encouragement. 

My friend Dr. Harry Campbell has kindly read 

through the proof-sheets. 

J. B. H. 

February 1st, 1911. 


Introduction . . . . . . . . . . xvii 

The Aetiology of Vicious Circles . . . . i 

The Classification of Vicious Circles . . . . 7 


The Nervous System . . . . . . . . 9 


The Cardio- Vascular System . . . . . . 35 


The Respiratory System . . . . . . 71 


The Digestive System . . . . . . 87 

The Urinary System . . . . . . . . 121 

The Sexual System 137 




Constitutional Disorders J 53 

The Eyes and Eye-lids . . . . . . 171 

The Nose . . 189 

The Throat 201 

The Ear .. . . 210 

The Skin 219 

Veterinary Diseases 237 

Plant Diseases . . . . . . . . . . 255 

The Vicious Circle as a Cause of Death . . 265 

Artificial Circles 277 

Contents xiti. 


The Breaking of the Circle by Nature . . 291 


The Breaking of the Circle by Art . . . . 301 
I. Hygienic Measures 
II. Drugs 

III. Surgical Appliances 
IV. Surgical Operations 


Conclusion . . . . . . . . . . . . 353 

Index . . . . . . . . . . . . 355 


Plate Page 

I. Concurrent Circles . . Frontispiece 

II. Circles associated with the Nervous 

System . . . . . . . . n 

III. Circles associated with the Cardio- 

Vascular System . . . . . . 37 

IV. Circles associated with the Respiratory 

System . . . . . . 73 

V. Circles associated with the Digestive 

System . . . . . . . . 89 

VI. Circles associated with the Urinary 

System . . . . . . . . 123 

VII. Circles associated with the Sexual 

System . . . . . . . . 139 

VIII. Circles associated with Constitutional 

Diseases . . . . . . . . 155 

IX. Circles associated with the Eyes . . 173 

X. Circles associated with the Nose . . 191 

XI. Circles associated with the Throat . . 203 

XII. Circles associated with the Bars . . 213 

xvi. 3Uii9tration6 

Plate Pa S e 

XIII. Circles associated with the Skin . . 221 

XIV. Circles associated with Veterinary 

Diseases . . . . 239 

XV. Circles associated with Plant Diseases 257 

XVI. The Circle as a Cause of Death . . 267 

XVII. Artificial Circles . . . . 279 

XVIII. The Breaking of the Circle by Nature 293 

XIX. The Breaking of the Circle by Hygienic 

Measures . . . . . . . . 307 

XX. The Breaking of the Circle by Drugs 315 

XXI. The Breaking of the Circle by Surgical 

Appliances . . . . . . . . 335 

XXII. The Breaking of the Circle by Surgical 

Operations . . . . . . . . 341 


VICIOUS Circle in pathology (circulus 
vitiosus, cercle vicieux, Zirkelschluss, 
circolo vizioso) is defined in Murray's 
New English Dictionary as "a morbid 
process consisting in the reciprocal con- 
tinuation and aggravation of one disorder by 
another." In other words the process represents 
such a reaction of a disorder on its cause that such 
cause is perpetuated or intensified. Cause becomes 
effect and effect cause. 

This meaning of Vicious Circle is transferred from 
its earlier use in logic where the expression connotes 
a fallacious mode of reasoning in which a proposition 
is used to establish a conclusion, and is afterwards 
proved by means of the conclusion which it has 
been used to establish. 

Although the expression Vicious Circle has been 
used by pathologists for over a century and enjoys 
the advantage of brevity, it is not altogether a 
fortunate one, conveying as it may do the idea of 
form rather than of process or action. From this 
point of view the expression " circular reaction " 
introduced by Prof. J. M. Baldwin to designate 
" a condition which keeps itself going by repro- 
ducing the conditions of its own stimulation " 
is preferable. A further advantage of this term is 
that it may be applied to reciprocally acting physio- 
logical as well as pathological processes, such a 
prefix as beneficent or injurious, healthy or morbid 
being added as required. On account of its hoary- 
antiquity the term Vicious Circle has been retained 
in the title of this Book in spite of the objection 
referred to. In the letterpress both expressions are 


xviii. iDicious Circles In 2>isea0e 

Vicious Circles play a part of immense importance 
in the mechanism of disease. They are responsible 
for the perpetuation and aggravation of morbid 
processes, for the destruction of organs, for the end- 
ing of life itself. A large proportion of all deaths 
are accelerated by the intervention of this compli- 
cation, a result which' applies as much to the 
animai as to the vegetable kingdom. 

This subject has hitherto received but little 
attention from either the zoo-pathologist or the 
phyto-pathologist. No " system of medicine " dis- 
cusses the pernicious influence of the Vicious Circle 
on the progress of disease ; no text-book of thera- 
peutics guides the practitioner in his search for the 
locus minoris resistentice, so that natura medicatrix 
may once again resume her beneficent sway. 

In the normal course of events, the reactions 
provoked in response to injury are of a kind calcu- 
lated to promote recovery. Such disorders may be 
described as self-limiting and the main task of the 
physician is to further and control such beneficent 
reactions as tend to readjustment. 

On the other hand when disease is complicated by 
injurious reactions the art of therapeutics is con- 
fronted with problems of greater complexity. 
The physician has no longer merely to deal with a 
morbid process which Nature is doing her best to 
rectify. So far as the factors that go to make up 
the pernicious sequence are concerned, her beneficent 
influence becomes maleficent. The vis medicatrix 
becomes the vis vastatrix ; the gyration must be 
arrested before recovery can take place. 

A great advantage of isolating the process of 
the Vicious Circle for separate study is that such 
isolation conduces to clearness of thought and to an 
insight into the complex processes involved. More- 
over such isolation assists in the philosophical 
grouping of a mass of facts which otherwise would 

3ntrobuction xix. 

remain membra disjecta and allows such facts to be 
arranged in their several niches of pathological 
phenomena. Specialisation is an application of the 
common-sense principle " one thing at a time," 
and is a valuable aid to research, so long as other 
aspects of a problem are not lost sight of. The 
search for such inter-dependences supplies a good 
discipline for the clinician who is encouraged to 
study disease both in its immediate and remote 
effects. The subject has also intimate relations 
with therapeutics. The deeper the insight into the 
problems of disease the clearer the vision that 
adapts remedy to disorder. Attention will be 
directed to the influence of reactions on their cause, 
a most important subject that hitherto has been 
singularly neglected. 

This Volume is mainly devoted to Vicious Circles 
in human pathology ; only brief reference is made 
to the same process as complicating diseases of 
the lower animals or of plants. But an enquiry 
into the. latter will yield some important results 
well worthy of the labour. Fresh light will be 
thrown on the problems of pathology and of rational 
therapeutics. A special emphasis is laid on the 
necessity of " breaking the Circle " in order to 
secure recovery, and instances are given to shew 
how Circles may be broken both by Nature and by 

The conception of the Vicious Circle is very 
ancient. Asclepiades (ca. 124 B.C.) probably referred 
to it when he opposed the Hippocratic " Nature is 
the healer of disease " by the dictum " Not only 
is Nature useless, but it is sometimes harmful." 
Galen (ca. 130 A.D.) gives the following illustration 
of the morbid process : 

To, Kara TU'eu/xofct TGJI> eA/cojf Suo-taTorara' \a)pl<; p.i> 
"yap TOV fttJTTew OVK a.v CKKapOapOtCrj, ft^Trovitov o cVi- 
?i' aXX'yjXcDZ' ovv aurots KV/cXeirat TO KOLKOV. 

IDictous (Tirdee in Disease 

"Ulcers of the lung are most difficult to heal ; 
for they cannot be cleansed apart from coughing, 
and by coughing they are torn further. Thus 
owing, so to speak, to a reciprocity of action, the 
disorder revolves in a circle." 1 

The subject as a whole deals with conditions in 
which Nature's attempt to cure reflects small credit 
on her provisions, and the study will be found full 
of suggestion and guidance for the philosophic 
physician. Illustrations are so helpful in visualiz- 
ing ideas that it has been thought well to introduce 
a considerable number. Especially may they be 
commended to teachers : 

Segnius irritant animos demissa per aurem 
Quam quae sunt oculis subjecta fidelibus. 

Galen Methodus Medendi, V. //., (Kiihn's ed. X., p. 360). 
The following is the Latin version : " Ulcera pul- 
monis difficillime sanantur, ut quae nee citra tussim 
expurgare possis, et si tussim excites, lacer averts. 
Itaque quasi per mutuas operas malum iis in 
orbem redit." Cf. also Neuburger, History of Medi- 
cine, I., p. 204. 

Chapter ne 


HE Vicious Circle is a morbid process to 
which all organised animals and plants 
are liable. This phenomenon is associ- 
ated with differentiation of structure 
and function, and illustrates a great 
physiological law applicable to all but the lowest 
living things. 

Throughout life there is a constant process of re- 
ciprocation taking place between the various organs 
and functions both in animals and in plants. In 
animals the nervous, the cardio-vascular, the respir- 
atory, the digestive and other systems are intimately 
associated with each other, their functional activ- 
ities being harmonised by the all-controlling nervous 
system, increased or diminished requirements in one 
direction being balanced by the necessary adjust- 
ments in another. Moreover a circulating fluid 
supplies to each organ the kind and quantity of 
nutriment required, while the waste products that 
would clog further activity are removed. 

The corresponding correlations as seen in plants 
are less obvious than they are in animals. There is 
neither an all-controlling central nervous system, nor 
a circulating nutrient fluid at all comparable with 
the blood. Nevertheless in principle the phenomena 
of correlation are the same, and are controlled by 
stimuli connecting every part of the organism. 
This applies to the shoots, leaves, cortex, cambium, 
roots, in fact to every organised structure of the 
plant, although the inter-dependences are more 

lDiciou0 (tfrdes in Dieeaee 

obvious in some cases than in others. In brief, both 
in animals and plants the vital mechanism is carried 
on by means of an ever-acting chain of complex 
interactions. 1 

Even within the limits of health there are frequent 
disturbances of the harmonious co-operation between 
various organs. These, however, induce reactions 
which restore the natural state of equilibrium. 
Only when the disturbance is so severe that rapid 
restoration is impossible does the condition become 

In disease the physiological correlations are thrown 
into confusion. Disorder in one organ frequently 
awakens disorder in other associated organs which 
in turn react injuriously on the first, so that a 
circular sequence of pathological reactions is estab- 
lished. Doubtless to some extent organs can give 
vicarious assistance to one another in difficulty and 
when the disturbance is only slight this relief may be 
sufficient to allow of recovery. 

But such assistance is of limited potency, at any 
rate in animals whose organs are worked nearly up 
to their maximum capacity. In plants, on the 
other hand, there is greater opportunity for vicarious 
activity, since there is less specialisation of structure, 
and there is always the possibility of developing 

1 With the progress of our knowledge of cellular physiology 
and pathology it may be possible to pursue the 
process of the Vicious Circle into the mechanism 
of the individual cell, which forms the basis of 
all vital processes. In unicellular organisms all 
functions are carried out in the one cell ; but 
special adaptations are so microscopic as to be in- 
distinguishable in detail. We do not know whether 
an elaborate differentiation exists in the cell, 
or whether the cell taken as a whole is able to act 
like the complex apparatus of a higher plant or 
animal which may consist of millions of cells. 

fresh organs such as roots, shoots, leaves, flowers etc. 

In both animals and plants, moreover, vicarious 
assistance often has unfortunate effects, since by it a 
second organ or set of organs is in turn involved in 
difficulties, over-taxed and perhaps deranged by the 
unusual demands made upon it. In the words of 
Mitchell Bruce " vicarious help ends in a Vicious 

In the case of the animal the process may be 
illustrated by cardiac disease which affects the 
nervous, the respiratory, the digestive and other 
systems sympathetically, while these secondary 
disorders in their turn injure the organ primarily 
affected. Thus is the circulus vitiosus established. 

In the diseased plant similar injurious inter- 
dependences are observed. A common illustration 
is afforded by root starvation, leading to an inade- 
quate supply of nutritive material to the assimilating 
leaves. Their metabolic activity is impaired and 
such impairment reacts injuriously on all other 
organs. The formation of vessels in the xylem is 
checked. The sieve or phloem tissues are less able 
to transport products of assimilation to the roots. 
Further root starvation takes place and the sequence 
of events is repeated. 

A similar concatenation of injurious factors may 
start from any other organ. If the leaves of a plant 
are so feebly illuminated that assimilation is reduced 
to a minimum, the results are far-reaching. The 
stem remains thin ; the growth of the cambium 
layer is arrested ; the supplies of nutriment passing 
to the roots are insufficient for their growth and for 
the formation of new root-hairs. Absorption of 
water and salts is interfered with, and this in turn 
further paralyses the formation of chlorophyll and 
the process of photo-assimilation. Here also is 
established a mutual causal relation between disease 
of various organs. 

IDicious Circles in disease 

There is, however, a striking difference in the 
manifestation of the morbid process in animals and 
in plants. 

In animals, owing to the higher differentiation of 
organs, numerous specific circuli vitiosi are met 
with, and additional examples are constantly being 
discovered. Thus disease of the blood provokes 
disease in other tissues, which in their turn pour 
products of perverted activity into the blood, and 
it is possible to study this endless chain of disorder 
link by link. 

Future research may yield similar results in plant 
pathology. But at present specific effects of morbid 
reactions are but little understood. On the other 
hand the general principle is in universal operation, 
manifesting itself not by specific results but by the 
production of lowered resistance to morbific agencies, 
and playing a part of great importance in the 
growth and life-history of the plant. For example, 
lowered resistance permits parasitic invasion and 
this in turn further weakens resistance. The lower 
the resistance the more rapid is the progress of the 
parasite, while, on the other hand, the rapid progress 
further lessens resisting power. 

The several organs and functions in animals and 
plants vary in the power of resisting morbific influ- 
ences. This varying liability depends on numerous 
factors, such as heredity, age, environment, nutrition 
and so forth. Hence it is that injurious circular 
reactions are more often observed in some organs 
than in others, at some periods of life than at others. 
Certain Vicious Circles are prevalent in youth, others 
in advanced life. Some organs succumb readily to 
malnutrition, others to fungus or bacterial invasion. 
There is indeed an infinite variety in the influence 
exerted by pathogenic factors and in the response 
made by the living organism and its tissues. 

Other Vicious Circles result from the reciprocal 


reaction on each other of a disorder and its symptoms. 
Of such a process numerous illustrations will be 
described in the following pages. They are especially 
common in neurasthenia. For example, some neuro- 
paths suffer from insomnia which in its turn perpetu- 
ates the neurosis. Others may be tormented by 
auto-suggested cardiac disorder which further depre- 
ciates their reserve stock of energy, and so forth, 
lyewandowsky thus refers to this group of circular 
reactions : 

" A highly injurious Vicious Circle is formed as 
a result of the increased irritability due to exagger- 
ated functional activity in neurasthenia. 1 

The two great causes of the morbid process dis- 
cussed in this Volume may then be summed up as 
disturbed correlations between organs or parts of 
organs, and secondly the injurious reaction of 
symptoms on the primary disorder. These processes 
constitute a large part of the mechanism of disease. 

There is probably no disease either in animals or 
plants in which all the reactions provoked by the 
morbific factors are either beneficent or maleficent. 
Both tendencies are simultaneously in operation and 
the result of the disease depends on the relative 
potency of those beneficent and maleficent reactions. 
Happily in the great majority of cases the beneficent 
reactions prevail and the injurious ones are insigni- 
ficant in their action or wholly obscured in their 
manifestation. Where, however, the maleficent re- 
actions are dominant the Vicious Circle comes into 
operation, leading to a perpetuation or aggravation 
of the morbid process or possibly death. Under 
yet other circumstances there may be something 
like " an equation of counteracting processes " so 
that the diseased organism remains in an approxi- 
mately stationary condition, the forces tending to 

1 Handbuch der Neurologic, V. (iv.),.p. 610. 

Dicious Circles in Dieease 

recovery being neutralised by opposite forces. Time 
must be given to allow of reparative processes to 
exert their influence and perchance gain the upper 
hand. As Clifford Allbutt puts it : " Such a Vicious 
Circle may be established that .... if recovery 
is to take place, the tension between the opposing 
forces must be released the deadlock must be 
overcome even if some considerable oscillation in 
the direction of danger have to be reckoned with." 1 
Such then appears to be the pathological basis 
of the circuit vitiosi met with in animal and plant 
diseases. This Volume, however, is mainly con- 
cerned with this morbid process as met with in 
human pathology, and we may now pass on to 
discuss this narrower operation of a general principle. 

1 Clinical Journal, III., p. 194. 



|N the Chapter dealing with ^Etiology 
the origin of Vicious Circles was attri- 
buted to a disturbance of the physio- 
logical interdependence of organs and 
tissues. That disturbance may shew 
itself in a great variety of disorders. These will 
be considered in connection with the various systems 
of the body, thus following the usual classification 
adopted in works on medicine. This arrangement 
is, however, based rather on convenience than on 
principle, since many injurious circular reactions 
are not confined to a single system, but reverberate 
far and wide ; in such cases there may be a doubt 
under which system they may most appropriately 
be grouped. 

Another classification is one based on the number 
of the circular reactions provoked by a given dis- 
order. The injurious sequence may be limited to a 
single reaction on which treatment can therefore be 
concentrated. On the other hand there may be 
multiple concurrent reactions, the effects of which 
on the primary disorder are cumulative and conse- 
quently far more difficult to arrest. Examples of 
such concurrent Vicious Circles are shewn in plate 
I. a, b, where cardiac failure and pulmonary tuber- 
culosis are shewn to be thus complicated. It 
would have been easy to indicate an even larger 
number of concurrent reactions in each of these 
disorders ; but those described will suffice to illus- 
trate the principle. 

IDicious Circles in Disease 

Some Vicious Circles are specific in their influence, 
others are non-specific. In the former case the 
primary disorder provokes a definite local reaction 
in some organ or organs which aggravates the orig- 
inal disorder ; in the latter the primary disorder 
merely lowers the power of resistance, which lowering 
perpetuates and intensifies the original condition. 
The first group is abundantly illustrated in diseases 
of man and the lower animals, while the non-specific 
forms are widely prevalent in the vegetable kingdom. 

Another classification might be based on the 
predominance of some special factor. Thus we 
might distinguish between organic, mechanical, in- 
fective, chemical or neurotic Vicious Circles, and 
numerous illustrations of each of these forms will be 
found in the following pages. 

A distinction may also be drawn between Circles 
which arise in the natural course of disease and 
those which are artefacts, i.e. dependent on social 
customs or injudicious treatment. It will be suffi- 
cient in this place merely to indicate such an aspect 
of the subject which will be discussed in a special 

The number of component factors completing a 
circular reaction varies considerably. Two is, of 
course, the minimum, but some writers have split 
up the morbid sequence into as many as eight or 
ten different components. 1 

Classifications, although useful in clarifying ideas, 
are after all of secondary importance. Each reader 
will adopt the system most helpful to himself. 

1 Halls Dally (Medical Press, 1913, I., p. 222) illustrates 
a cardio-gastric Vicious Circle comprising ten fac- 
tors ; Pickerill (The Prevention of Dental Caries 
and Oral Sepsis, p. 299) one comprising six factors. 

Chapter TTbree 


HE central nervous system is the capital 
of the human microcosm with whose 
remotest outposts the capital is, for 
good as well as for ill, in constant com- 
munication. In health the closest corre- 
lations and polarities exist between it and every 
other organ ; in disease such correlations and 
polarities are no less intimate. 

The injurious circular reactions met with in dis- 
orders of the nervous system are very numerous ; 
fresh illustrations are continually being revealed by 
the progress of research. All that can be attempted 
here is the description of some striking examples, 
which every practitioner will be able to supplement 
from his own experience. 
We shall deal in order with 

I. Functional Diseases 
II. Organic Diseases 



The commonest and most protean of functional 
disorders is neurasthenia. "In no complaint does 
it happen more frequently that the patient gets 
into a Vicious Circle, the fundamental disorder 
producing symptoms which again maintain and 


io IDfdous Circles in Biseaae 

aggravate the disease." 1 Owing to the infinite 
variety of its manifestations neurasthenia has been 
described as non morbus, sed morborum cohors, and 
in truth there is scarcely an organ or function that 
may not at one time or another be affected. In 
this disease self-aggravating factors are constantly 
present, whether the psychical or physical functions 
are involved. 2 

This characteristic of neurasthenic disorders is 
doubtless due to the lowering of the neuron thres- 
hold, owing to which an increased response follows 
a given stimulus. In other words such a stimulus 
acts more readily and more vigorously in a neuras- 
thenic than in a normal individual, and the result 
is a further lowering of the threshold. 

It will be convenient to deal first with psychical 
and then with physical disorders, although much 
overlapping is inevitable. 

(a) Psychical Disorders 

Neurasthenia is frequently associated with per- 
verted emotivity and ideation (JMatC II a). These 
perversions vary greatly in their manifestations. 
The following examples may be briefly referred to : 
irritability, anxiety, melancholia, insomnia. 3 

1 Ballet, Neurasthenia. Introduction by Campbell Smith, 
p. xxvi. 

Fuller particulars will be found in a volume entitled The 
Vicious Circles of Neurasthenia and their Treatment 
by J.B.H. 

3 The psychical state in which the individual is governed 
by ideas or emotions, which more or less persistently 
obtrude themselves on consciousness, is frequently 
termed psychasthenia. But there is no definite 
border-line separating such psychical from physical 
manifestations, and the condition will here be in- 
cluded under the term neurasthenia. 

Iftcrvous System 







plate ii. Circles aseociatcb with the 
IRervoue System. 

12 Dicious Circles in Dieease 

Irritability. One of the commonest symptoms 
of neurasthenia is an exaggerated irritability, with 
a tendency to worry about trifles which would not 
disturb the equanimity of a normal individual. vSuch 
irritability may be either intellectual or emotional, 
but in either case there is a drain on the store of ner- 
vous energy so that the condition feeds itself. In 
some persons there are unreasonable explosions of 
ill-temper, a morbid sensitiveness to the opinion of 
others, an exaggerated conscientiousness and so on. 
Indeed the symptoms are infinite in variety and 
degree, doubtless also in the tax they levy on the 
reserve resources, and in the exhaustion they cause 
of the nerve centres. 

Anxiety. A form of irritability which deserves 
special mention reveals itself by various forms of 
undue .anxiety and by the presence of phobias 
which haunt the victim and depress his vitality. 
Every phobia, associated as it is with loss of self- 
control and with auto-suggestions, intensifies its 
own cause. 

Dubois describes the condition : 

" In neurasthenia one must take into account the 
real fatigue of the nervous centres which, on the one 
hand, results directly from morbid states of mind, and, 
on the other, furnishes new food for auto-suggestions. 
Here we have the eternal Vicious Circle in which the 
neuroses travel. Their real ills give birth to their 
fears and their phobias, and, on the other hand, their 
mental representations of a pessimistic nature create 
new disorders." 1 

Spear also writes : 

" The mental state of the individual suffering from 
neurasthenia is also very important these individuals 
are usually depressed, introspective, anxious, appre- 
hensive ; mental rest is therefore very difficult to 

Psychic Treatment of Nervous Disorders, p. 180. 

IRervous System 13 

obtain. As the unconscious mental activity is just as 
exhausting as, if not more so, than conscious and 
physical unrest, a Vicious Circle is established whereby 
the nervous system is maintained in a state of 
exhaustion. It is the presence of this Vicious Circle 
that renders the establishment of a state of complete 
rest so difficult and consequently makes the cure of 
this condition doubtful and sometimes impossible. 1 

These anxiety neuroses are closely associated with 
loss of will-power. Every effort may be made to 
exert and coax the will, yet the result may be utter 
failure and the greater the effort the less the success. 
Indeed the very attempt to will may annihilate 
will-power. 2 Volition can also be readily exhausted 
by the imagination, and the process once started 
continually reinforces itself. 

Phobias are by no means confined to waking 
hours. In some forms of neurasthenia, brought on 
by war conditions, terrifying dreams have been a 
prominent symptom, associated with a low blood- 
pressure and perpetuating the exhaustion of the 
neurons. 3 Night terrors in children supply a further 

Melancholia. In other cases neurasthenia shows 
itself by profound melancholia. There is inveterate 
pessimism, and the depression further diminishes 
the already reduced nervous capital. Sufferers fre- 
quently display a tendency to continual introspec- 
tion, to an exaggeration of slight disappointments, 
and the more they brood over troubles the worse 
these appear, in harmony with the well-known 
psychological law that attention intensifies sensa- 

This form of neurasthenia may be acquired as a 

1 A Manual of Nervous Diseases, pp. 495, 505. 
" Dowse, Neurasthenia, pp. 28, 30. 
3 Lancet, 1917, II., p. 456. 

14 liMcious Circles in Disease 

result of shock or accident, especially if litigation 
is probable. The trauma may appear to be insigni- 
ficant, and yet the resulting neurosis completely 
transforms the outlook on life owing to the deep 
mental impression made by the shock. In some 
cases mischief is done through the interaction be- 
tween the mind of the patient and that of his 
physician or solicitor, i.e. through hetero-suggestion. 

Thorburn writes : 

" The patient has often heard that after the shock 
of, let us say, a railway accident, symptoms are liable 
to be progressive, to develop at remote periods and to 
endure indefinitely. In this condition of expectation of 
disaster he consults probably both his medical and his 
legal advisers. The former has often a limited experi- 
ence of traumatic neuroses ; he knows that his patient 
is and always has been an honest man ; he may have 
doubts in his own mind as to whether organic disease 
of the nervous system does not follow shock. In any 
event, he enters upon his task of relief and encourage- 
ment with a more serious aspect than he would otherwise 
assume, he takes careful note of all minor symptoms, 
and he probably has to write reports to the solicitor, 
which he is asked to make ' as strong as possible.' 
The solicitor is an even graver danger ; it is his pro- 
fessional duty to obtain the largest possible amount 
of compensation for his client, and in so doing to 
emphasize to the utmost any loss, inconvenience or 
suffering which the latter may have sustained, and 
especially to guard against the making of any settle- 
ment before all possible future inconveniences have 
been excluded. None of the people thus concerned 
have any intention to exaggerate, but each mind reacts 
upon the other, and we have established a complete 
Vicious Circle as a result of which the unfortunate 
patient tends to grow daily worse." 1 

l Proc. Royal S. of Med. (1914), VII. (ii.), (Neurological 
Section), p. 8. Cf. also Bailey, Diseases of the 
Nervous System in Cases of Accident, p. 434. 

1Ren>ou0 System 15 

Insomnia. Insomnia frequently complicates 
neurasthenia and is, in Clifford Allbutt's words, 
" generally one of the links in the Vicious Circle in 
which the victim is enchained." 1 Such sleeplessness 
results from over-excitability of the cerebral cortex, 
from a lowering of the neuron threshold which 
enables stimuli, which would be subliminal in normal 
individuals, to affect consciousness. Insomnia in its 
turn prevents the renewal of those substances which 
are used up by the discharge of energy and thus 
perpetuates itself. Again conditions which interfere 
with the repose of those brain cells which are the 
organs of conscious thought may keep in operation 
the processes of ideation, with which is necessarily 
associated some cerebral hypersemia. Ideation and 
hypersemia then react one on the other and form a 
sequence of events that torments the neuropath. 2 

Insomnia may also be due to excessive fatigue, 
to an exhaustion of the nerve centres which arrests 
the progress of repair. Such a condition is readily 
provoked in neurasthenics owing to their lower 
reserves of potential energy. The insomnia hinders 
recuperation and acts as a malignant abettor. 3 
Habitual sleeplessness is not uncommonly due to the 
cerebral neurons or vessels failing to resume their 
rhythmical quiescence at bed-time. The more the 
sufferer tries to sleep the less his success. In- 
somnia and the dread of it react upon and aggravate 
each other. Job evidently was a bad sleeper : 

" When I lie down I say ; When shall I arise and 

the night be gone ? And I am full of tossings to and 

fro unto the dawning of the day." 4 

1 Allbutt and Rolleston, System of Medicine, VIII., p. 750. 

2 Sawyer, Insomnia, its Cause and Cure, pp. 26, 27. Cf. 

also Saleeby, Worry, the Disease of the Age, passim. 
'Garrett Anderson, Encyclopedia Medica, VIII., p. 336. 
4 Ch. VII., 4. 

16 IDicious Circles in Disease 

In many cases an accumulation of toxins may 
be both cause and effect of the sleeplessness. 

Amongst other psychical manifestations may be 
mentioned vertigo, 1 anorexia, and an exaggerated 
proclivity to the repression of painful memories. 2 
All of these may perpetuate the neurosis. 

Several forms of psychical disorder are usually 
present simultaneously and the mischievous influence 
is then cumulative. In severe cases all the above- 
mentioned disorders may combine to reduce the 
sufferer to the direst misery. 

(b) Physical Disorders 

In most cases of neurasthenia local symptoms 
are present which feed the neurosis and perpetuate 
the disorder. Owing to the lowered neuron thres- 
hold peripheral impulses which would not affect 
consciousness in health evoke uncomfortable or 
even painful sensations. These disturb ideation and 
emotivity and arouse injurious auto-suggestions. The 
direction of consciousness aggravates the trouble, 
since attention intensifies sensation. 

This general principle is thus stated by Krafft- 
Ebing : 

" A true Vicious Circle is gradually developed in 
neurasthenia, in consequence of the morbid relations 
between the psychic and the somatic functions. A 
crowd of functional disorders are projected by the 
psychic condition into the extracephalic organs, and 
these in their turn react on the psychic condition, more 
especially on the emotions." 3 

1 Bing, Text-Book of Nervous Diseases, p. 411. 

- Rivers, The Repression of War Experience Lancet 1018 
L, p. 173. 

3 Nothnagel, Specielle Pathologic und Therapie, Nervositat 
und Neurasthenische Zustande, p. 71. Cf. also 
Babinski and Froment, Hysteria or Pithiatism, p. 65. 

IRervous System 17 

These physical or somatic disorders present a 
great variety in form and severity ; but as a rule 
the sufferer tends to magnify a molehill into a 
mountain and adheres obstinately to his erroneous 

It is not necessary to discuss these local dis- 
orders in any great detail since this has already 
been attempted in another volume ;* but the pic- 
ture would be incomplete without some reference 
to the more important local reactions. These are 
not, as a rule, limited by hard and fast lines. The 
interlocking gears are so complex that disorder 
awakens echoes in all directions with endless 
secondary reverberations. The following examples 
must merely be regarded as typical of many others. 

Cardiac Neuroses. No functional disorders 
arouse greater anxiety than those connected with 
the heart. Even when trivial in themselves they 
may arouse a confident belief in a speedy exitus. 
Imaginary heart disease is said to be even commoner 
than organic heart disease, and supplies a good 
illustration of how the dread of a disease may pro- 
voke corresponding subjective sensations. 

The sequence of events is somewhat as follows : 
the fear of heart disease awakens auto-suggested sen- 
sations in the cardiac region producing tachycardia, 
extra-systoles with palpitation, and an intermittent 
pulse. The associated sensations then arouse distress 
and terror, which in their turn further disturb the 
cardiac action. 

Such attacks are especially common at night and 
may be caused by nightmare, reducing the neura- 
sthenic person to a condition of utter misery. Even 
fatal syncope may result. 

x The Vicious Circles of Neurasthenia and their Treatment, 
by J.B.H. 

i8 IDidous Circles in 2>ieea0e 

Andre-Thomas describes the condition : 

" Not only may neurasthenia give rise to cardiac 
disorders and anxieties, but cardiac anxieties may 

also give rise to neurasthenia Emotions, kept 

alive by fear, aggravate the symptoms or create fresh 
ones. Thus the patient becomes involved in a Vicious 
Circle which persists until he can be convinced that 
there is nothing amiss with his heart." 1 

Dubois draws attention to the same correlations 
and points out that the expression " spiral " is in 
many respects preferable to " circle," since it more 
clearly conveys the idea of an ingravescent condi- 
tion : 

" The patient may attribute the beginning of his 
illness to some psychic disorder, such as an imaginary 
evil that worries and frightens him. Or, conversely, 
he may attribute his trouble to some emotion due to 
his local disorder. In either case his illness works in 
a Vicious Circle or rather in a spiral. The local trouble 
that bothers him arouses hypochondriacal ideas and 
causes distress, followed by palpitation and gastro- 
intestinal dyspepsia which in their turn create phobias. 
These fresh disturbances then provoke other functional 
disorders or aggravate the existing ones. Hence a 
fresh source of phobias which drive the victim further 
along the spiral." 2 

Cardiopaths are frequently met with in whom the 
erroneous belief that they have heart disease excites 
an ever-present dread of illness or immediate death. 
The constant direction of the mind to the imaginary 
lesion then leads to a morbid consciousness of trivial 
sensations and to such an unwholesome regime as 
actually to make the heart feeble and flabby, so 

1 Psychotherapie, pp. 229, 230. Cf. also Lewandowsky, 
Handbuch der Neurologic, V. (iv.), p. 40. Clinical 
Lectures by German Authors (N.S.S.), (1894), p. 69. 
Practitioner, 1918, I., pp. 179,' 186, 188. 

- Volkmann, Sammlung Klinischer Vortrage (Innere Medizin, 
Nos. 137-166), 1907-1909, p. 520. 

IRervcms Spetem 19 

that at the slightest provocation it reacts on the 
neurotic condition. The exaggerated fears, like the 
sword of Damocles, over-shadow life and render 
all enjoyment impossible. Such obsessions are 
amongst the commonest complications of neuras- 

Mott thus describes them : 

" Any organ or structure which naturally or by 
habit performs its functions automatically becomes 
disordered in its functions when there is mental appre- 
hension and preoccupation regarding the performance 
of that function. Hence we can understand how a 
continued preoccupation regarding the function of an 
organ like the heart or stomach, or indeed any organ 
of the body, of the perfect action of which we 
should be quite unconscious, becomes an obsession, for 
disordered function tends to repercussion in the field 
of consciousness, causing a continual conflict between 
reason and emotion for re-adjustment. Thus a Vicious 
Circle is liable to be established owing to the inherent 
state of emotivity of the neurasthenic." 1 

Other cardiac neuroses are described on p. 53. 

Gastric Neuroses. The correlations existing 
between the nervous and the digestive systems are 
so intimate that disorder in the one readily provokes 
disorder in the other. Their importance has been 
emphasised by Mathieu and Roux : 

" There is in these cases an interlocking system of 
Vicious Circles with which the physician must be 
familiar if he wishes to understand the mechanism of 
the diseased organism, and if he wishes his treatment 
to be rational and useful." 2 

Since the various regions of the gastro-intestinal 

1 Lancet, 1918, I., p. 128. 

" I,es Cercles Vicieux dans la Pathologic Gastro-Intest- 
inale," Pathologic Gastro-Intestinale. Series I. (1909), 
p. 147. 

20 IDidous Circles in 2>isea0e 

tract have been discussed in detail in another volume, 
we may content ourselves with three examples. 

Atonic dyspepsia is one of the commonest physical 
disorders in the neuropath, cause and effect abetting 
each other. 

Cramer writes : 

" Not only do the nervous disorders provoke neurotic 
dyspepsia, but in its turn the neurotic dyspepsia 
intensifies the nervous disorder." 1 

Auto-suggestions are also very prevalent and may 
play almost as great a part as in cardiac neuroses. 
Ceaseless preoccupation with the state of the stomach 
brings gloom and discouragement which perpetuate 
the hypochondriasis. 

Membranous colitis is another disorder in which 
the local and central conditions reciprocally maintain 
each other. 

Mathieu writes : 

" In cases of muco-membranous colitis ... a true 
Vicious Circle appears often to be present. The neura- 
sthenia and the colitis react on and aggravate each 
other." 2 

And again : 

" The colitis, the pain and the nutritive disorders 
create and perpetuate the neurasthenia. The neura- 
sthenia in its turn aggravates the colitis. A Vicious 
Circle is present." 

A third example is presented by constipation, 
frequently both effect and cause of neurasthenia. 
The exhaustion of the nervous system shows itself' 
in sluggish peristalsis, and the resulting coprostasis 
in its turn depreciates the functions of the nervous 

1 Nervositat, p. 197. Cf. also Saleeby, Worry, the Dis- 
ease of the Age, p. 130. 

2 Traite des Maladies de l'Estomac et de 1'Intestin, pp. 288 

IRervoue System 21 

Striimpell writes : 

" Habitual constipation is frequently associated with 
neurasthenia, but the nature of this association is 
probably not the same in every case. Often neura- 
sthenia and constipation seem to be co-ordinate sym- 
ptoms ; sometimes existing constipation has an un- 
favourable effect upon the psychical condition of 
patients, rendering them feeble, fretful, out of sorts 
and nervous. As a rule, however, neurasthenia is the 
primary disease, and the irregularity of the bowels 
appears as a result of abnormal nervous influences or 
secondary conditions. Often the two states act in a 
Vicious Circle, each sustaining and aggravating the 
other." 1 

In other cases of neurosis there may be hyper- 
peristalsis and diarrhoea, which in turn keep up a 
state of obsession. The more the neuropath dreads 
an attack of diarrhoea the more likely is it to occur, 
and vice versa. 

Gant writes : 

" Stimuli responsible for diarrhoea may be induced 
by psychic emotions, disease of the brain, cord, general 
or local nerve mechanism, inflammation, ulceration, 
neoplasms, strictures of foreign bodies in the intestine, 
or lesions affecting it from without, or anything which 
irritates the intestinal nerve-ganglia. 

Occasionally, multiple or widely varying stimuli 
work simultaneously, so that a Vicious Circle is estab- 
lished, under which circumstances there is exaggerated 
intestinal motility, and the patient suffers deplorably 
from diarrhoea extremelv difficult to relieve or cure." 2 

1 Text-Book of Medicine, I., p. 611. Cf. also The Vicious 
Circles of Habitual Constipation, by J.B.H., Prac- 
titioner, 1915, II., p. 560. 

2 Diarrheal, Inflammatory, Obstructive and Parasitic Dis- 
eases, p. 18. Cf. also Matthieu and Roux, Pathologic 
Gastro-Intestinale, Series III. (1911), pp. 208, 230. 

22 IDidoue Circles in Disease 

Sexual Neuroses. There are numerous circular 
reactions between the nervous and the sexual 
systems, primary and secondary factors reinforcing 
each other. This applies to the entire sexual tract, 
every region of which is closely linked with the 
central nerve centres. The weakening of self- 
control so common in neurasthenia only too often 
leads to excessive self-indulgence which intensifies 
the weakness. Inmates of lunatic asylums often 
present lamentable results of such indulgence which 
is often incurable, especially where there are in- 
herited neuropathic tendencies. 
Miiller writes : 

" In neurasthenic persons of both sexes, especially 
if unmarried, there is a tendency to satisfy the sexual 
instinct by means of masturbation. Indeed it is often 
difficult to decide whether the masturbation should 
be regarded as a result or as a cause of the sexual 
neurasthenia, since a Vicious Circle has generally been 
established." 1 

Again in sensitive, highly strung women, morbid 

correlations are frequently set up by uterine or 

ovarian congestion or pain. The nervous system 

and the local disorders act and react on each other. 

As Amand Routh says : 

" We have frequently to deal with a Vicious Circle, 

with local and constitutional states so interacting that 

no real improvement is possible until both the general 

and local states receive their due share of attention." 2 

Herman and Maxwell also write : 

" In chronic pelvic pain with neurasthenia effects 
follow one another in a Vicious Circle. The patient 
feels more severely the pelvic pain because her nervous 
system is too sensitive. The persistent pelvic pain 

1 Neurasthenic, p. 181. Cf. also Hiihner, Diseases of the 

Sexual Function, pp. 4, 15, 161, 183. 

2 Allbutt, Playfair and Eden, Gynaecology, p. 737. 

IRervous System 23 

keeps her nervous system weak and sensitive and 
further weakens it." 1 

Such uterine and ovarian pain is a good illustration 
of the general relation of pain to a hypersesthesia 
of the nervous system. Bach factor intensifies the 
other and the process has much to do with the 
invalidism so often met with in highly-strung women. 
If sleeplessness is super added the symptom-complex 
is even more difficult to deal with. 

The same inter-dependences apply mutatis mutan- 
dis to neuralgia and nervous headache. 

Herman has well described the condition : 

" The great causes of neurasthenia are conditions 
which (a) cause continuous pain and (b) prevent sleep. 
The two things often form a Vicious Circle. A small 
local cause disturbs sleep, and want of sleep makes 
the nervous system over-sensitive. In proportion as 
the neurasthenic symptoms have coincided in time 
with the development of local pain, so surely may we 
conclude that the removal of the local pain and the 
procuring of sound sleep will cure the neurasthenia." 2 

Many other illustrations of somatic neuroses might 
be given, did space permit ; but enough has been 
said to indicate the facile creation of Circles where 
the neuron threshold has been lowered in neura- 
sthenia. Such reciprocal correlations indeed play 
a great part in the psychology of modern life. 


Hysteria. Hysteria differs mainly from neura- 
sthenia by the presence of an abnormal mentality 
which shows itself in increased suggestibility and 
emotional instability, combined with lowered powers 
of inhibition. In many cases some disappointment or 
other source of psychical distress has been repressed 

1 Diseases of Women, p. 73. 

2 British Med. /., 1910, I., p. 183. 

24 IDicious Circles in Disease 

and disappears from consciousness. Yet the repressed 
ideas remain latent and may break out in some form 
of mental or physical reaction which perpetuates 
the primary instability. 1 

A striking disorder which is not uncommon in 
hysterical women is that known as anorexia nervosa 
to which attention was drawn by Gull and Weir 
Mitchell (platC II. b). The condition may originate 
in some perversion of appetite or in a fear of growing 
fat or in some minor ailment which suggests the 
idea of illness and an inability to take food. 2 This 
is accompanied by an actual loss of appetite or even 
a refusal to be tempted to eat, and results in general 
emaciation. The neurosis tends to starvation ; 
the starvation feeds the neurosis. The nervous 
system is profoundly affected, the blood is impover- 
ished and the psychical functions disordered. As a 
result the sufferer becomes a bed-ridden querulous 
invalid, a burden to her family. In course of time 
the malnutrition reduces the body to a bag of little 
more than skin and bones, and a fatal issue often 
closes the scene. 

Schofield writes as follows : 

" A Vicious Circle is often kept up in these cases 
which it is absolutely essential to break. They begin, 
it may be, with loss of appetite from some slight cause . 
This . . . leads to disordered thoughts and the idea 
of disease is started. This, again, makes the appetite 
still more capricious ; the thoughts therefore get still 
worse, and so the body starves the brain and the brain 

1 Spear, Manual of Nervous Diseases, p. 472. 

2 The opposite conditions to those described in this Section 

establish physiological or virtuous Circles circuli 

virtuosi of which a large number are in constant 
operation in the normal body. Good nutrition, 
sleep, exercise, cheerfulness of disposition are all 
closely dependent on each other. 

1Ren>ou0 patent 25 

starves the body ; and the emaciated patient having, 
probably enough, first worn out her friends, sinks at 
last into her grave from sheer starvation. I have seen 
such deaths." 1 

Rayner has also described the process : 

" In diseased conditions, especially in the depressed 
emotional states, this interaction of the mind on the 
body and of the bodily state on the brain establishes 
a Vicious Cycle of nutritional disorder, which tends to 
increase and prolong the disease." 2 

Migraine. The pathology of the functional 
disorder known as migraine or hemicrania is still 
obscure, some neurologists attributing it to a form 
of nerve-storm, others to a spasm or relaxation of 
the smaller arteries or veins, others to toxaemia, 
others to increased pressure in the ventricles of the 
brain, associated with stenosis of the foramen of 

If the latter hypothesis is correct, a self -perpetu- 
ating condition is probably present which is thus 
described by Jeliffe : 

" The occasional causing of a passive or active 
hypersemia of the brain leads to hyperaemia of the 
choroid plexus. This causes a more or less complete 
plugging of the foramen of Monro, with increase of 
pressure in one or both of the ventricles. The increased 
pressure on the vessels causes more distention and more 
pressure on the walls of the ventricles ; a Vicious 
Cycle established and the migraine mounts to its height, 
until the pressure is relieved, either by a spontaneous 
reduction or by the sudden let-down in tension due to 

Serves in Disorder, p. 162. 

2 Allbutt and Rolleston, System of Medicine, VIII., p. 965. 
Dr. Rayner and other writers substitute " Vicious 
Cycle" for "Vicious Circle." The latter term seems 
preferable as implying continuity as opposed to 

26 tDicious Circles in Disease 

a shock reaction such as occurs in the act^of vomiting, 
from the use of various vaso-dilators, etc." 1 
On the other hand Adami believes the cause to 

lie in a paradoxical contraction of arteries which 

also creates a circular reaction. 

Adami writes : 

" The higher the blood pressure, the greater becomes 
the contraction of the arterioles ; the less, therefore, 
the blood supply to the tissues and the greater the call 
upon the central nervous system for more blood. 
Whether from reflex stimulation of the heart to increased 
activity in order to supply the tissues, or from direct 
automatic action of the increased aortic pressure in 
raising the intraventricular pressure, and so stimulating 
the ventricles to more forcible contraction, the blood 
pressure becomes yet higher, and, as a result, the 
arteries still further contracted. It is along these lines 
that we would explain the progressive rise of blood 
pressure and contraction of the smaller arteries in 
migraine." 2 

Further research is necessary before the pathology 
can be regarded as settled. 

Shock. Under this term may be included various 
conditions such as fainting or syncope in which 
there is loss of vaso-motor control (plate H. c). 
There may be a variety of causes including the 
administration of an anaesthetic, concussion, strong 
emotion, haemorrhage etc. During health the activ- 
ity of the vaso-motor centres is increased or dimin- 
ished, according as arterial pressure falls or rises, 
the cerebral circulation being maintained by this 
compensatory mechanism. But when this centre 
is paralysed, exhausted or inhibited by fear or other 
cause, the vaso-motor mechanism is thrown out of 

1 Osier and Macrae, System of Medicine, V., p. 710. Cf. 

also Spitzner, Ueber Migraine, p. 76. 

2 Principles of Pathology, II., p. 175. 

1Ren>ous System 27 

gear, and is weakened instead of stimulated by a 
diminished blood-supply. In severe cases the blood- 
pressure falls so much as partially to empty the 
intrinsic cardiac and cerebral vessels. Less blood 
is pumped up to the brain, and the bulbar centre 
is still further weakened. 1 The cardiac anaemia 
may also cause enfeeblement and dilation of the 
heart, and thus further interfere with the compen- 
satory mechanism. Attacks of fainting are due to 
a like interference with the vaso-motor mechanism. 
Every faint renders the bulbar centres which are 
largely controlled by self-consciousness more liable 
to loss of control over blood-pressure. 

Paroxysmal Neuroses. Rhythm plays a part of 
great importance in physiological processes, as is 
shown by the periodicity in the functions of the 
heart, the lungs, the intestines, the ovaries, the 
brain and so forth. There is economy of energy in 
such a mechanism since one stimulus does the work 
of many. 2 

Such a fundamental biological principle finds cor- 
responding expression in pathology, as may be 
illustrated by various paroxysmal neuroses. In 
such there is often an increasing proclivity to par- 
oxysm which may be acquired through mere repeti- 
tion. Bach attack from being at first an effect 

, British Med. /., 1910, II., p. 759. Cf. also Practi- 
tioner, 1910, II., p. 169. Although this explanation 
is the one usually accepted, pathologists doubt its 
sufficiency, since the vaso-motor centre is by no mean 
always exhausted in shock, and the general and 
visceral arteries may be found contracted instead of 
dilated. The question is still sub judice. British 
J. of Surgery, I., p. 114. 

2 An excellent account of rhythm in biology is given by 
Gilford, Disorders of Post-Natal Growth and Develop- 
ment, pp. 112, 123. 

28 IDictous Circles in Disease 

becomes in turn a cause. Epilepsy supplies a good 
example (plate II. d). Every fit increases the 
labile condition of the nerve centres and facilitates 
recurrence. Hence the best treatment is to break 
the habit. 

The rhythm associated with the status epilepticus 
may establish other circular reactions through the 
increasing venosity of the blood caused by inter- 
ference with the respiration. Such venosity may be 
due to the convulsions and perpetuate them until 
death closes the scene. 

A similar condition may arise from the prolonged 
convulsions which sometimes occur in general para- 
lysis. In both these disorders there are mechanical 
conditions which, as Mott points out, produce a 
Vicious Circle terminating in progressively increased 
venosity of the blood in the cortex, especially of that 
portion supplied by the carotid arteries. 1 

Allied to epileptic attacks are various forms of 
tic and habit spasms, which often persist long after 
the cause has been removed. They were attributed 
by Hunter to the "memory of the body." The attempt 
to restrain a habit spasm may be accompanied by a 
distinct mental distress, and great relief is felt when 
the rhythmic discharge has occurred. To the same 
group belong the neuroses of blushing and stutter- 

Vices of all kinds beget a craving which favours 
further indulgence. 

The familiar form of insanity known as " folie 
circulaire" also shows a strong tendency to rhythm, 
which tendency is apt to grow habitual and show 
itself on easier provocation. The initial depression 
passes through exhaustion into mania which pro- 
duces toxsemia and reappears as depression. 

1 Allbutt and Rolleston, System of Medicine, VII., p. 226. 
Cf. also Archives of Neurology, I., p. 502. 

IRervous System 29 

Paralysis of Thermotaxis. An interesting 
sequence of events may result from a weakening or 
paralysis of the thermotaxic mechanism, such as may 
follow a dangerously high or low temperature. 
For example, pyrexia may paralyse that mechanism, 
as a result of which the temperature of the body 
may rise to a fatal level. One of the commonest 
causes of such hyperpyrexia is rheumatic fever, 
in reference to which W. S. Church writes : 

" In whatsoever way the paralysis of the heat- 
regulating centres is produced, a Vicious Circle is set 
up, resulting in an over-heated condition of the body, 
and a consequent deterioration of tissue, the muscular 
tissue of the heart especially suffering." 1 

Prolonged exposure to cold illustrates the opposite 

Coma- Coma is often due to a high intra-cranial 
pressure and tends to keep up that pressure through 
the associated respiratory embarrassment. Owing 
to the lowering or abolition of the reflexes, saliva, 
food and drink often collect in the trachea, and, 
not being expelled by reflex cough, hamper respira- 
tion and cause venous engorgement, circumstances 
which aggravate the already high intra-cranial 


Organic diseases of the nervous system present 
some circular reactions of great clinical importance, 
several of which may terminate fatally. 

Cerebral Haemorrhage. Under healthy con- 
ditions there is an enormous difference between the 
blood-pressure in the cerebral arteries (ca.izo mm.Hg) 
and the intra-cranial pressure (ca. venous pressure, 
i.e. little above zero). Cerebral haemorrhage, how- 
ever, tends to raise the intra-cranial pressure to a 

1 Allbutt and Rolleston, System of Medicine, II. (i.), p. 627. 

30 IDicious Circles in Disease 

level approximating to arterial pressure, and thus 
squeezes the blood out of the vaso-motor centres, 
so as to render them anaemic (plate II. e). In 
their urgent need for blood these centres respond by 
effecting a splanchnic vaso-motor constriction, so 
great at times as to raise the arterial pressure to as 
high as 400 mm. Hg or more. 

The irony of the situation thus produced is that 
the rise, so beneficent in one respect, is apt to prove 
disastrous by starting the haemorrhage afresh or 
by increasing the flow. A further rise of intra- 
cranial pressure then results, and the whole sequence 
is repeated. 1 

Cerebral haemorrhage frequently proves fatal by 
pressure on the respiratory centre. If the patient 
survives the danger of respiratory paralysis, a 
further complication may arise and increase the 
haemorrhage. As the diffused blood lacerates the soft 
brain tissues, an enlarging cavity is formed which 
is filled with blood at nearly arterial pressure. The 
larger such a cavity grows the greater is the pres- 
sure exerted by the blood, on the principle of the 
hydraulic press, while conversely the greater the 
pressure the more does the cavity enlarge. In fact 
it is difficult to see how haemorrhage into the brain 
ever ceases, unless by pressure on the artery itself. 

If the high pressure persists for any considerable 
time, further correlations are established . The vaso- 
motor centre becomes exhausted and loses its grasp 
over the splanchnic area, which fills with blood. 
Hence results cerebral and cardiac anaemia, which 
leads to further exhaustion of the centre. 2 

Hydrocephalus. The progressive development 

^aneway, Clinical Study of Blood-pressure, pp. 142, 149. 
Cf. also Hirschfelder, Diseases of the Heart and 
Aorta, p. 46 ; Lewandowsky, Handbuch der Neuro- 
logic, III. (ii.), p. 40. 

2 Janeway, I.e., p. 160. 

IRervoug System 31 

of hydrocephalus may be due to an important self- 
aggravating process (JMatC II. f). The disorder may 
originate in some obstruction to the foramen of 
Majendie or to one of the communicating channels, 
causing fluid to accumulate in the ventricles. The 
dilated ventricles may so displace the adjacent parts 
as to increase the obstruction to which the accumul- 
ation was primarily due. For example, the cere- 
bellum and medulla may be pressed into the foramen 
magnum so as to plug that aperture. Such plugging 
in turn increases the distention of the ventricles and 
renders the condition a self -perpetuating one. In 
other cases the dilated ventricles (by compressing 
the membranes of the nerve roots) may close both 
lymphatics and veins, which closure in its turn 
leads to a greater accumulation of fluid. 1 

A similar process is observed in cerebro-spinal and 
other forms of meningitis. The foramen magnum 
is sometimes plugged by the displaced cerebellum as 
if by a cork. 2 

(Edema of the Brain. Various writers have 
called attention to the self-perpetuating processes in 
oedema of the brain. 

Treves writes : 

" Owing to the peculiar anatomical condition of the 
brain, situated as it is in an almost inexpansible cavity, 
when an oedema has once commenced, a circulus 
vitiosus is established, leading to a progressive increase 
in the oedema." 3 

Leonard Hill also writes : 

" The high blood pressure which exists in those 
capillary areas surrounding the seat of complete vascular 
obliteration will lead to increased transudation of 
fluid, since plasma may pass more easily into the brain 

1 British Med. /., 1911, I., p. 808. 

2 Carnegie Dickson, British Med. /., 1917, I., p. 454. 
3 System of Surgery, II., p. 119. 

32 lDiciou0 Circles in IDieease 

substance than the blood through the compressed 
capillaries. The transudation will take place at almost 
arterial tension, will increase the volume of the foreign 
body, and so will lead to compression of other capillary 
areas. A circulus vitiosus is thus established and the 
cerebral anaemia may spread indefinitely." 

And again : 

" In meningitis, tubercular meningitis and cerebral 
abscess, compression can arise by the accumulation of 
inflammatory exudations, by inflammatory dilatation, 
by thrombosis and blocking of vascular areas ; and 
whenever the Sylvian aqueduct and the veins of Galen 
are obliterated by intraventricular transudation. In 
all these pathological states a circulus vitiosus can be 
established leading to advancing cerebral anaemia. 
The pathological cause of ventricular hydrocephalus is 
no doubt to be found in blocking of the veins of Galen 
and the Sylvian aqueduct." 1 

Cerebral Congestion. In cases of locomotor 
ataxy and general paralysis the venous congestion 
and increased psychical activity of the neurons 
frequently react on each other, the correlations being 
probably due to the mechanical conditions favouring 
stasis in the frontal and central convolutions, and 
being especially common where syphilis has lowered 
the " durability " of the nervous "system. 
Mott writes : 

"Psychical activity will cause hyperaemia and 
congestion of the brain, and in regions where there is a 
tendency to stasis the congestion may persist, especially 
if it leads to insomnia. A Vicious Circle becomes 
established by conditions which tend, on the one hand, 
to perpetual venous congestion in certain regions, and' 
on the other hand, to increased excitability of the 
neurons ; these factors mutually interact." 2 

Physiology and Pathology of the Cerebral Circulation 

pp. 188, 197, 200. 
* Lancet, 1900, II., pp. 81, 3 ; 1913, n 1470. 

IRervoue \>0tem 33 

Other injurious circular reactions may be estab- 
lished in various conditions in which there is a rapid 
destruction of neurons. 

These Mott has also described : 

" Two conditions may mutually interact upon one 
another in the establishment of a Vicious Circle, viz. 
degenerating nervous structures, the degenerated pro- 
ducts of which accumulate and irritate the peri- 
vascular lymphatics surrounding the veins, causing a 
tendency to stasis and inflammation, combined with 
conditions which produce mechanical congestion in 
the veins ; and this reacting back on the nerve struc- 
tures leads to still further disintegration of nervous 
tissue : and thus the one vicious condition feeds the 
other." 1 

Poliomyelitis. In anterior poliomyelitis arid 
other forms of paralysis morbid correlations may 
result from a disuse of the associated muscles. 
There is in fact " a circle of reflex and trophic 
influences " affecting the whole apparatus of nerve 
cell and muscle, and reacting on one another through 
interference with the regular exchange of stimuli. 

The progress of events is well illustrated in acute 
anterior poliomyelitis when indeed two distinct 
complications may occur, one earlier in the course 
of the disease than the other. 

The first complication results from a disturbance 
of the reciprocal relations that exist between the 
tropho-motor neurons and their associated muscle- 
cells. In favourable cases the inflammation of the 
neurons of the anterior cornua rapidly subsides and 
the neurons recover more or less completely, the 
percentage of recoveries being estimated at about 
15 per cent. Recovery, however, depends not 
merely on the central lesion, but also on the main- 

1 Archives of Neurology, I., pp. 42, 179, 188, 189, 191, 501-2. 
Cf. also British Med. /., 1911, II., p. 1415. 

34 Dicious Circles in Disease 

tenance of nutrition and contractility of the depend- 
ent muscles. If these muscles remain untreated 
and disused and atrophy, they react injuriously on 
the damaged neurons which lose the stimuli which 
should reach them from the periphery, and thus 
perpetuate the disease. 

Robert Jones describes the process : 

" The muscle has wasted from disuse and become 
incapable of responding to such feeble impulses as come 
to it from an impaired nerve cell. Consequently the 
normal afferent impulses do not pass up to the nerve 
cell, because the muscular action which originates 
them is absent, and the whole reflex apparatus by 
which the spinal nerve cell and muscle react on each 

other to their mutual benefit is put out of gear 

Recovery of muscular action does not take place 
spontaneously because the whole apparatus nerve cell, 
nerve trunk and muscle are in a state of disuse 
atrophy, and continue to remain so, because the muscle, 
from its mechanical disadvantage, cannot perform its 
function of contracting, which is an essential part in the 
circle of reflex and trophic influences." 1 

In severe cases a second complication occurs. 
Owing to the pull of healthy antagonistic muscles, 
the weakened muscles associated with the central 
lesion are over-stretched, and the result is a lessened 
contractility, increased weakness and deformity. 
Over-stretching leads to weakness and weakness 
conduces to over-stretching. The muscles are thus 
rendered less and less able to supply the stimuli 
necessary for the nutrition and recovery of the 
central neurons. 2 

1 British Med. /., 1914, I., p. u66. Cf. also Hutchison 

and Sherren, Index of Treatment, p. 5ir. 

2 A good account of the similar " Vicious reflex Circle " in 

spastic paralysis is given by Tubby and Jones, 
Modern Methods in the Surgery of Paralyses, p. 215' 

Chapter Jfour 


I WING to the importance of the cardio- 
vascular system in the economy, and 
to the complexity of the vital and 
mechanical phenomena involved, the cir- 
cular reactions created by disease are 
of the highest interest. These reactions are difficult 
to classify on any scientific principle, since the 
various parts of the cardio-vascular system are so 
closely dependent on one another. Nevertheless an 
attempt at classification must be made, although 
overlapping is inevitable. 

We shall discuss in order : 

I. The Myocardium 

II. The Endocardium 

III. The Pericardium 

IV. Cardiac Neuroses 

V. The Blood- Vessels and l/ymphatics 

VI. The Blood 


Failure of Compensation. The compensatory 
changes in the myocardium, which result from 
increased resistance in the pulmonary and sys- 
temic circuits, constitute a striking example of the 
remedial adaptations of nature. In the course of 
time, however, these compensatory changes usually 
fail and end in cardiac dilatation and stasis. Hence 


36 iDicious ircle0 in SHsease 

results interference with circulation, respiration, 
digestion, absorption and elimination. The unfor- 
tunate myocardium already labouring under special 
difficulties a fronte is poisoned by the products of 
imperfect metabolism which reach it a tergo, sap its 
nutrition and intensify its weakness. 1 The vortex 
steadily increases by involving one organ after 
another, like " a circle in the water which never 
ceaseth to enlarge itself." 

The important circular reactions thus established 
may be divided into short, medium and long 
circuits. The first is concerned with the myocardium 
and its coronary vessels, the second with the myocar- 
dium and the pulmonary circulation, and the third 
with the myocardium and the peripheral circulation. 
These several reactions aggravate the cardiac failure 
(JMatC6 l> HI. a, b). All the viscera may in turn 
be thrown into disorder and aggravate the cardiac 
weakness. Thus we may have what Barie terms 
" un foie cardiaque, un poumon cardiaque, un rein 
cardiaque, une rate cardiaque," and so forth. 

A. The first organ to suffer from the heart 
failure is the heart itself, since the coronary circula- 
tion depends on systolic activity. 

West writes : 

" When the congestion travels beyond the right 
ventricle, one of the first sets of veins to feel its effects 
is the coronary. In this way the circulation of the 
whole heart is affected, and its nutrition suffers still 
more. The weakness of the left ventricle is thus 
further increased, and therefore the congestion produced 
by it, and so a Vicious Circle is established which, if 
not broken, quickly leads to a fatal issue." 2 

1 M. Bruce, Lancet, 1911, II., 2ro ; Pembrey and Ritchie, 

General Pathology, p. 283. 
-Diseases of the Organs of Respiration, I., p. 237. 

CarbicMDascular System 










(f) AN/EMIA 

Iplatc in. Circles associated witb the 
CarMo*lDascular System, 

38 IDicious Circles in Disease 

Various disorders are associated with arrhythmia. 
Such arrhythmia, on the one hand, may slow the 
circulation, thus tending to produce cyanosis by 
increasing the CO2 in the blood and diminishing 
the tone of the cardiac muscle. On the other hand, 
the long pauses increase the venous pressure, while 
the influx of venous blood under a relatively increased 
pressure, acting on a cardiac muscle whose tone is 
diminished, favours over-distention. The over-dis- 
tention by increasing the diameter of the ventricular 
chamber increases the hydrostatic pressure on its 
walls and causes the heart to work at a disadvantage. 

Hirschf elder thus represents two of " the Vicious 
Circles of the irregular heart : " l 


Permanent arrhythmia 

t 1 

Weak and irritable heart Slow circulation 

t 1 

Impaired nutrition of heart cells 


Over-filling of heart 

t 1 

Slowing of circulation < Irregularity 

In other cases progressive paroxysms of auricular 
fibrillation occur. Such paroxysms are due to the 
fact, experimentally observed, that, as Lea points 
out, "auricular fibrillation itself tends to increase 
the irritability of the auricle and so sets up a Vicious 
Circle." 2 

Diseases of the Heart and Aorta, pp. 123, 127. Cf. also 

/. of American Med. Ass., 1908, II., p. 476. 
2 Lancet, 1912, II., p. I2r6. 

CarbiotDascular pstem 39 

Other reciprocally acting processes result from de- 
generative changes of the myocardium, and the 
associated dilatation of the cardiac chambers. Since 
the strain on the walls of a sphere or spheroid in- 
creases with its circumference, the weakened and 
dilated cardiac walls yield the more under the strain 
of the systolic pressure ; the more they yield the 
greater the strain and vice versa. Dilatation begets 
dilatation. Even the fall of velocity under such 
conditions perpetuates itself. 1 

In cases of advanced myocardiac degeneration 
actual rupture of the heart may occur, followed by 
haemorrhage and rapid fall of blood-pressure. This 
fall in its turn stimulates the vaso-motor centre in 
the bulb and provokes a general vaso-constriction, 
which again raises the blood-pressure and intensifies 
the haemorrhage, thus hastening death. 

Another injurious process may be associated with 
the Adam-Stokes syndrome, i.e. the co-existence of 
extreme bradycardia and syncopal or convulsive 

Lewandowsky writes : 

" In cases of partial heart-block the condition may 
pass into one of complete heart-block, possibly owing 
to an increased frequency of the auricular contraction 
due to psychical excitement or to exertion. In such 
cases the stimuli may be insufficient, as the experi- 
ments of Erlanger have shewn (relatively complete 
heart-block). The resulting interference with the 
circulation through the brain or the medulla then 
brings on the attack. 

An extra-cardiac origin is also conceivable in cases 
where the bulbar activity is impaired owing to vaso- 
constriction or to a temporarily defective vascular 
supply i.e. where there is intermittent loss of functional 
activity of the medulla. Such a condition might in its 

'Allbutt, Diseases of the Arteries, II., p. 58. 

40 IDidous Circles in Diseaee 

turn act on the heart, and by means of a Vicious 
Circle react again through the heart on the brain." 1 

Failure of compensation is sometimes complicated 
by extreme tachycardia, the pulse-rate reaching 
250 or even 300 per minute, and the blood-pressure 
falling to as low as 50 mm. Hg. Such a low pressure 
indeed is a serious danger in itself and may lead to 
sudden death. Moreover the interval between the 
cardiac beats is so short that the ventricles can 
neither fill nor empty themselves as they should. 
These conditions perpetuate the tachycardia and 
low pressure. 

Huchard writes : 

" A Vicious Circle is created from which the sufferer 
cannot escape until his depressed arterial blood- 
pressure has been raised." 2 

B. After the myocardium itself the lungs bear 
the brunt of cardiac failure, the diminished propulsive 
and suction forces being perhaps equally injurious. 
Stasis in the lungs spells impaired aeration, and 
impaired aeration spells increased myocardial weak- 
ness. Thus there is reciprocal embarrassment in 
two of the most vital parts of the organism. 3 A 
similar embarrassment is met with in many diseases 
associated with cardiac failure, e.g. bronchitis, 
pneumonia, acute pulmonary oedema, hypostatic 
pulmonary congestion etc. 

Cardiac failure is frequently complicated by 
paroxysms of dyspnoea which tend to aggravate the 
condition. The attacks usually occur during sleep 

^andbuch der Neurologic, V. (iv.), p. 12. 

2 Maladies du Cceur et de 1'Aorte, I., pp. 16, 100. Cf. also 

Pavlov, The Work of the Digestive Glands, p 233 ; 

American J. of Surgery, 1914, II., p. n. 
3 Fothergill gives an excellent account of the pathological 

sequences in which the heart and lungs are involved. 

Lancet, 1874, II., p. 682. 

System 41 

or in the early morning when the blood-pressure is 
low, and give rise to extreme dyspnoea, tumultuous 
palpitation, acute distress, insomnia and prostration. 
Various pathological conditions may excite such 
an attack ; but broadly speaking they spring from 
cardiac inadequacy while in their turn they increase 
the inadequacy and may terminate fatally. The 
cardiac and respiratory rhythm are thrown into 
confusion and the want of harmonious action throws 
an extra strain on each of them. 

C. The third group includes the peripheral 
circulation, and especially the portal system. 1 

Barie thus describes " le foie cardiaque " : 

" The liver, whose functions are thrown out of gear 
as a result of cardiac failure, in its turn reacts on the 
heart and aggravates the venous stasis on the right 
side of the heart. Thus it comes about that heart 
failure associated with hepatic diseases (asystolie 
hepatique) gives rise to a veritable Vicious Circle, 
due to the heart and the liver alternately reacting on 
one another." 2 

Some cases of cardiac failure are complicated by 
flatulent distention of the stomach due to the 
consequential congestion of the stomach. Such 

1 Every circulus vitiosus has of course its corresponding 
circulus virtuosus. For example, the three circuits 
short, medium and long would form the following 
physiological sequences in the healthy individual : 

A. Vigorous systole : active coronary circulation : 
good nutrition of myocardium : vigorous systole. 

B. Vigorous systole : active pulmonary circu- 
lation : efficient oxygenation : vigorous systole. 

C. Vigorous systole : active visceral circulation : 
good digestion and nutrition : vigorous systole. 

2 Maladies du Cceur et de 1'Aorte, pp. 632, 771. 

42 IDickws Circles in Bieeaee 

cardiac embarrassment can actually turn the scale 
against recovery when life is trembling in the balance. 
Halls Dally who illustrates this condition diagram- 
matically gives the following as the ten component 
factors of this " cardio-gastric Vicious Circle" : 
failure of compensation : portal congestion : catarrh 
of stomach : delayed or imperfect digestion : fer- 
mentation and flatulence : raising of diaphragm : 
displacement of heart : kinking of great vessels : 
raised venous and lowered arterial pressure : cardiac 
over-strain and so back to failure of compensation. 1 
These visceral complications might be extended 
so as to include the spleen, the intestines, the kidneys 
and so forth. Indeed the entire peripheral circula- 
tion is involved. But as the same principle is at 
work further details are unnecessary ; they all go 
to show how often the heart, in the words of Allbutt, 
" falls into the Vicious Circle of doing as ill for itself 
as for other parts of the body." 2 

Cardiac Strain. Some striking circular reactions 
are met with in cases of acute dilatation due to over- 
exertion. For example, the dilatation may cause 
such weakening of the coronary circulation that the 
myocardium loses much of its contractile power. 
The result is a further diminution of the coronary 
supply, followed by still further weakening of the 
cardiac muscle. This sequence results from the fact 
that the cardiac muscle is fed by the blood which 
it circulates and is thus self-dependent. 

The dramatic death of Eucles after the victory at 
Marathon was probably due to acute dilatation. 
After racing to Athens with the good news he was 

1 Progressive Medicine (1913), III., p. 100. Cf. also Stacey 

Wilson, The Early Diagnosis of Heart Failure, p. 368. 

2 Allbutt and Rolleston, System of Medicine, III., p. 388. 

CarbicMDascular System 43 

just able to shout the words X a V T > X at / )0 / xei ', 
before he fell dead. 1 

Cardiac dilatation, according to Ehrnrooth, is 
largely due to diminished contact between the muscle 
cells since such lessened contact (in the absence of 
nerve fibres) diminishes conductivity. Stasis also 
supervenes before long, followed by exudation which 
further diminishes contact. 

Ehrnrooth writes : 

" In this way a Vicious Circle is established which 
affects the primary functions of the muscular tissues." 2 

In other cases an over-strained and weakened 
heart is associated with an abnormally high pressure. 
The slowing of the circulation due to the strain 
tends to produce anaemia of the medullary centres, 
which respond by inducing intense vaso-constriction, 
thereby driving a larger quantity of blood to the 
medullary centres. The already weakened heart is 
called upon to make a supreme effort, and the 
weaker it is the more do the imperious medullary 
centres call for blood. The cardiac weakness and 
the bulbar anaemia aggravate each other, and the 
increased arterial pressure may be kept up to the 
end in persons dying of heart failure induced by that 
high pressure. The forced draught under which 
the hydro-dynamic system is working leads to its 
destruction. 3 

Somewhat similar conditions may result from 
acute, more especially zymotic, disease, such as 
pneumonia, influenza, diphtheria and enteric fever. 
Indeed any disease that gravely diminishes the 

1 Plutarch, Opera Moralia, ed. by Didot, I., p. 425. Cf. also 
Barie, Maladies du Coeur et de 1'Aorte, pp. 612, 631. 

2 Uber Plotzlichen Tod durch Herzlahmung, p. 24. 

3 A high venous pressure may also create a dangerous 
circular reaction. Norris, Blood-Pressure, p. 20. 

44 IDictoue Circles in Disease 

cardio-motive forces may bring this morbid correla- 
tion into play. Weak systole : inadequate circula- 
tion : weaker systole represents a dangerous 
sequence. In serious attacks " there is a Vicious 
Circle of conditions which precludes all hope of 
recovery." 1 Especially is this result probable when 
the blood supplied to the myocardium is laden 
with impurities, or when there is a progressive 
accumulation of residual blood leading to increasing 
dilatation of the ventricle. Then indeed does life 
hang by a thread which may snap at any moment. 

Coronary Sclerosis. Malnutrition of the myocar- 
dium is not infrequently due to sclerosis of the 
coronary arteries, a condition which accounts for 
the sudden death of many elderly persons. After 
gradually advancing for years, the sclerosis may 
reach a stage when the lumen of the coronary 
arteries is almost blocked by degenerative changes 
so that the blood-supply to the myocardium is 
seriously curtailed. The increased resistance pro- 
duced by the sclerosis requires a more forcible 
systole, if life is to continue, whereas the systole is 
actually weakened owing to the diminished blood- 
supply, and the weakening further impairs the 
coronary circulation. At last the heart gives up 

" The insufficiency is due to the Vicious Cycle 
created by lowering the pressure in the coronary 
arteries, which occurs directly the ventricle is unable 
to maintain the required aortic pressure. Thus at the 
very time when the heart muscle requires the greatest 
supply of nutrition, the supply of blood to the myocar- 
dium lessens." 2 

1 Osier and Macrae, System of Medicine, IV., p. 125. Cf. 

also Cohnheim, General Pathology, III., p. 1416. 

2 Osier and Macrae, System of Medicine, IV., p. 31. Cf. 

also M. Bruce, Lancet, 1911, II., pp. 70, 206 ; Mac- 
Callum, Text-Book of Pathology, p. 467. 

CarMcMDascular System 45 

Angina pectoris is often associated with this 
pernicious sequence of events, the pain being 
probably due to spasm or cramp of the cardiac 
muscle which cannot obtain an adequate supply of 


The compensatory changes which take place when 
the myocardium has to meet increased resistance 
have been alluded to in the previous section. 1 Such 
increased resistance is frequently caused by valvular 
disease, and mutatis mutandis similar compensatory 
changes result. Here also in course of time decom- 
pensation follows, and gives rise to the secondary 
conditions described in connection with the failure 
of the myocardium. 

Gibson writes : 

" Sooner or later, according to its form and severity 
chronic valvular disease with compensation itself 
disposes to failure by establishing a "Vicious Circle of 
slow progressive impairment of the viscera and their 
great vital functions the lungs, liver, stomach, bowels, 
kidneys, indeed the myocardium itself." 2 

The several valvular lesions, however, may estab- 
lish special correlations which are peculiar to them- 
selves, and these are worthy of a brief consideration, 
for, as Bouillaud says : " The various diseases of 
the heart may themselves cause other diseases in 
that organ." 3 

1 Pembrey and Ritchie point out that when a hypertrophied 
heart exceeds a certain size its work is increased by 
the restrictions of the bony thorax. Thus hyper- 
trophy may mean more work and still greater 
hypertrophy. General Pathology, p. 287. 

-Text-Book of Medicine, II., p. 127. Cf. also H. Sainsbury, 
Lancet, 1917, II., p. 871. 

^Huchard, Maladies du Cceur et de 1'Aorte, III., p. 717. 

4 6 iDicioue Circles in Biseaec 

Aortic Regurgitation. Regurgitation due to 
disease of the aortic valves is, under favourable 
circumstances, compensated by hypertrophy of the 
left ventricle, which supplies the increased driving 
power necessitated by the lesion (jpIatC III. c). For 
many years the individual affected may lead a use- 
ful comfortable life, and be scarcely conscious of 
anything amiss. Sooner or later, however, the 
hypertrophied ventricle undergoes an injurious de- 
gree of dilatation. The myocardium is insufficiently 
irrigated and nourished, and the condition may 
lead to sudden death. The following is the fatal 
sequence : regurgitation, impaired coronary circu- 
lation, dilatation, weakened systole and increased 

Incompetence of the aortic valve may also result 
from disease and dilatation of the aorta, especially 
in middle and old age. This is in turn followed by 
dilatation and lessened competence. 

McKisack writes : 

" The ventricle under these circumstances usually 
becomes dilated, partly as a result of fatty and fibrous 
degeneration, and partly as the effect of mechanical 
causes set up by the defective aortic valve, so that a 
Vicious Circle is established." 1 

Occasionally an aortic valve may rupture under 
severe exertion, thus throwing a sudden strain on 
the heart for which it is unprepared. The same 
injurious sequence takes place, but as there has been 
no time for compensatory change the effects are 
more serious and instantaneous death may occur. 

Broken compensation associated with aortic 
insufficiency may also be complicated by a high 
diastolic pressure which aggravates the insufficiency. 

1 British Med. /., 1911, II., p. 1397. 

(TarbtcMDaecular Spetem 47 

Hirschf elder thus represents the correlations : l 
Cardiac weakening 


Increased cardiac effort Slowed circulation 

High blood-pressure through medulla 


Mitral Stenosis. Mitral stenosis is one of the 
commonest causes of heart failure. The nutrition of 
the auricular musculature suffers greatly and this 
hampers the flow of blood through the stenosed 

Coombs writes : 

" In a large majority of all cases of mitral stenosis 
death is due to gradual cardiac failure. The powers 
responsible for this are two. The heart and especially 
the left auricle are asked to do more work by reason 
of the valvular obstruction ; and further the gradually 
increasing venous stasis undermines the nutrition of 
the cardiac, and particularly of the auricular muscul- 
ature. An unconquerable Vicious Circle is now estab- 
lished." 2 

Mitral Regurgitation. When mitral regurgitation 
is consequent on aortic regurgitation or obstruction 
(owing to progressive dilatation of the ventricle and 
auriculo- ventricular orifice) there may be a reciprocal 
influence on each other of the aortic lesion and 
the mitral regurgitation. The cumulative result is 
usually disastrous. 

jDf the Heart and Aorta, p. 315. 
2 Rendle Short, Index of Prognosis, p. 221. 

48 IDicious Circles in Disease 

Another sequence may be associated with mitral 
regurgitation when the cusps of the valve are not 
brought tightly together, owing to want of cardiac 
tone/ A small leak may thus be transformed into 
a serious one, leading to a further diminution of 

Hirschfelder thus represents the condition : 1 
Leak at mitral valve 

1 f 

Papillary or Heart strain 

relative insufficiency " Diminished tonicity 

Tricuspid Regurgitation. Tricuspid regurgita- 
tion sometimes results from the dilatation of the 
right ventricle, secondary to mitral disease. For a 
time the reflux may relieve the overloaded ventricle, 
but its ultimate effect is to render the ventricle less 
competent to overcome the obstruction, thus tending 
to increased dilatation. 

Septic Endocarditis. In the case of septic endo- 
carditis an infective Circle may be established by 
the micro-organisms circulating in the blood. These 
microbes lead to vegetations and erosions in the 
endocardium, especially that lining the valves, and 
these vegetations throw off showers of infective 
emboli carrying infection far and wide and leading 
to further endocardial lesions. For example, the 
vegetations due to rheumatic fever are highly 
susceptible to attack by the streptococcus, pneu- 
mococcus, gonococcus or similar organisms. 

Diseases of the Heart and Aorta, p. 414. Cf. also Allbutt, 
Diseases of the Arteries, I., p. 129. 

CarfciolDascular System 49 

Valvular disease usually leaves a legacy oi mischief 
behind. The patient does not die but remains an 
invalid, the sanatio incompleta being shown by a 
disposition to relapse, by a diminished power of 
resistance to fresh attack. As a taper just blown 
out will snatch the flame from the torch that scarcely 
touches it, even so readily is the endocardiac mis- 
chief rekindled. Thus the valvular mischief and the 
lowered resistance act and react on each other, often 
ending in extensive and cumulative mischief. 

When valvular lesions occur in such persons as 
navvies or coalheavers, whose daily occupation in- 
volves severe exertion, disastrous consequences usu- 
ally follow much earlier than they would do were 
the regime of life more favourable to compensation. 
Many a premature death has occurred where poverty 
or adverse fortune has compelled a life of toil. The 
labour aggravates the heart lesion ; the heart lesion 
makes the daily task relatively, if not absolutely, 

Congenital Heart Disease. Congenital heart 
disease is usually due to imperfection either of the 
valves or of the septa caused by fcetal endocarditis. 
The malformation frequently interferes with the 
nutrition of the myocardium, thus diminishing its 
blood-supply and further impairing systolic activity. 
For example, a patent foramen ovale when associated 
with pulmonary stenosis often gives rise to reciprocal 
disorders. So long as a quiet mode of life is pursued, 
sufficient blood passes through the lungs to keep the 
blood aerated, while the remaining blood passes 
through the foramen ovale which offers less resis- 
tance. But as soon as active exercise is taken, a 
larger quantity of blood passes direct into the left 
auricle and ventricle (owing to the pulmonary 
stenosis) and thus escapes oxygenation . The con- 
sequence is a rise in venous pressure which drives 
still more blood through the foramen ovale. 

5 o IDictoug Circles in 2>igease _ 

Hirschf elder thus represents " the Vicious Circle 
of the open foramen ovale." 1 

Increased work of Heart 

i i 

Cyanosis, Asphyxia High pressure in Vena 


Passage of unaerated 
Blood into left Auricle 

In other forms of congenital morbus cordis the 
venous stasis may give rise to prolonged convulsions. 
These in their turn interfere with respiratory move- 
ments, aggravate the venosity and involve a grave 
menace to life. 

A third condition may occur in cases of congenital 
malformation associated with cyanosis. The general 
venous stagnation causes dilatation and tortuosity 
of the capillaries in the skin as well as in the internal 
organs and such dilatation increases the stasis. 2 


The pericardium is a comparatively simple struc- 
ture when compared with the heart which it envelops, 
and is not so frequently affected by injurious circular 
reactions. Nevertheless, as in the case of other 
serous membranes, there are certain reciprocations to 
which attention may be drawn. 

Slight attacks of pericarditis may be followed by 
complete recovery even when there has been some 
fibrinous exudation. After a series of attacks, 

Diseases of the Heart and Aorta, pp. 528, 539. 

2 Osier and Macrae, System of Medicine, IV., p. 335. Cf. 

also St. Thomas' Hospital Reports (1888), XVIII., 

p. 285. 

CarbiolDaecular System 51 

however, the restitutio ad integrum is generally 
imperfect. The acute attack subsides, but leaves 
behind a liability to recrudescence ; the damaged 
pericardium on slight exposure to chill or infection 
is attacked afresh, and each time the damage 
increases, until the cumulative effects may be 
prodigious. The residual lesion predisposes to re- 
currence ; recurrence aggravates the primary residual 

Pericardial Effusion. Pericardial effusions may 
be self-aggravating through interference with the 
mechanism known as the lymphatic pump, by 
means of which a constant circulation of fluid into, 
and out of, the pericardial cavity is maintained. 
This pump is worked by means of the cardiac and 
respiratory movements acting on the lymphatics 
and stomata ; owing to this mechanism the peri- 
cardial sac as a rule contains no free fluid. 

In cases of effusion the stomata are readily blocked 
by fibrinous deposits, which check the escape, and 
thus lead to an increase, of the effusion. The 
stomata and superficial lymphatics are also liable 
to be compressed, the channels of absorption being 
thus choked (JMatC III. d). 

Again the effusion impairs the cardiac move- 
ments on which depends the efficiency of the pump, 
and compresses the great vessels at the roots of the 
lungs, heart and pericardium. The circulation is 
hampered and the hampering increases the effusion. 
These reciprocally acting factors may explain why 
pericardial effusions are often very persistent. 

Fluid in the pericardium, whether resulting from 
effusion or from rupture of an aneurysm, may 
involve deadly peril when it interferes with the 
stretching of the cardiac walls which is so essential to 
the development of their energy. 

Forsyth gives the following account of a fatal 

52 IDicioue Circlee in Disease 

sequence due to this condition : 

" There can be no doubt that the pericardial effusion 
was the cause of death, and that its fatal effect was due 
to mechanical interference with the circulation. Six 
ounces of fluid were rapidly poured out around the 
heart. The strong fibrous coat of the pericardium 
was too rigid to relax for its accommodation, and a 
sac large enough to contain only the heart was now 
occupied by the heart and effusion. The result was a 
positive pressure in the pericardium leading to com- 
pression of the thin-walled vense cavae and obstructed 
return of blood to the auricles. The pulmonary veins 
shared the fate of their neighbours, and their blood 
was stemmed back until the lung capillaries grew over- 
swollen. This led to oedema of the lungs and a copious 
exudation into their alveoli of serum and even blood, 
the irritation of which stirred up violent attacks of 
coughing. The coughing raised the intra-thoracic 
pressure still higher and the diastolic filling of the heart 
became a matter of difficulty. This again aggravated 
the lung condition, and so the Vicious Circle went 
round heart, lung, lung, heart with the pericardial 
effusion for its centre." 1 

Hydro-pericardium is a frequent complication of 
heart failure and results. from general venous stasis, 
under similar conditions as does drops}^ of the pleural 
or peritoneal cavities. The fluid, if abundant, aggra- 
vates the circulatory embarrassment by interference 
with the cardiac, especially the diastolic movements, 
much as in the case of acute pericarditis just referred 
to. Such dropsical effusion often constitutes a 
terminal phenomenon. 

Gibson writes : 

" Hydro-pericardium may be said to step in as the 
closing link of a pathological chain, and once it has 

1 Clinical /., XXVII., p. 220. Cf. also Lancet, 1917, I., 
p. 292 ; Constipation and some Associated Dis- 
orders, pp. 130-1. 

(Tarfcfo-lDascular System 53 

made its appearance it unites with the other morbid 
conditions to form a Vicious Circle of fatal import." 1 


Cardiac neuroses have already been briefly alluded 
to in connection with neurasthenia (Cf. p. 17). 
But there are other circular reactions to which 
attention may be drawn. An example is some- 
times seen when a practitioner erroneously dia- 
gnoses a "weak heart" and excites in his patient 
an ever-present dread of serious illness or immediate 
death ; the injurious process is here due to hetero- 
suggestion. Sir Douglas Powell aptly illustrates 
this form of neurosis by the story of a young woman, 
once the picture of health and vigour, whose doctor 
had diagnosed a " weak heart." She had been tak- 
ing the utmost care of a healthy organ ever since, 
resting half the day, never even walking upstairs, 
until she became fat, breathless, anaemic and miser- 
able. Many months elapsed before she could be 
weaned back to her former healthy activity, if in- 
deed recovery were even then possible. 2 

A similar lamentable condition is sometimes 
brought about when excessive repose is prescribed 
after an attack of angina or some other functional 
disorder. 3 The over-rested heart grows more and 
more unequal to its task, and more and more irritable 
when extra demands are made upon it. The sufferer 
also tends to grow obese with a sluggish circulation 
which further impairs cardiac activity. 

When a neurotic temperament is associated with 
real morbus cordis, other injurious correlations may 
be established if the patient takes an unduly gloomy 

1 Diseases of the Heart and Aorta, p. 386. Cf. also Saundby, 

Old Age, p. 87. 

-Treatment in Diseases and Disorders of the Heart, p. 15. 
3 Hucliard, Maladies du Cozur et de 1'Aorte, II., p. 140. 

54 IDidoug Circles in Bt0eage 

view of his malady. Such pessimism delays com- 
pensation and must be strenuously combated. 
Frequently the physician who realises the value 
of equanimity in promoting compensation, and 
how a knowledge of the whole truth may rob a 
patient of all peace of mind may hesitate as to 
how much he should reveal. As Frantzel says : 
" Das Wissen is oft viel schlimmer als die Krankheit 

M. Bruce refers to the condition : 

" Depressing emotions contribute to failure of com- 
pensatory hypertrophy of the heart, and in this re- 
spect a Vicious Circle is formed, which can often be 
broken by judicious management." 1 

In other neurotic patients a functional disorder 
such as palpitation may start the morbid train of 
symptoms. The palpitation may be so violent as to 
cause an apprehension of sudden dissolution, and 
this apprehension in turn intensifies the palpitation. 

Arrhythmia may also give rise to a severe neurosis. 
Moreover the habit of intermitting may cause an 
exaggerated irritability of the cardiac nerve centres, 
leading to a continuance of the abnormal action 
even after the removal of the primary cause. 

Some cardiopaths are troubled with attacks of 
vomiting or cough, probably due to irritation of the 
pneumogastric nerves. Such reflex disturbances 
aggravate the cardiac trouble or may even prove 
fatal. 2 

Angina Pectoris. Angina pectoris is associated 
with such a variety of organic and functional 
disorders that it might legitimately be classified 
under several headings ; there may be myocardiac 

Principles of Treatment, p. 81. 
2 M. Bruce, I.e., p. 308. 

CarMo*lDa0cuIar System 55 

failure, valvular lesion or peripheral or central 
spasmodic neuroses. One or more of these factors 
may be present and the allocation of the precise 
share of each in the attack may be impossible. 

Morison thus describes some of the disorders 
which establish a circular reaction, but the conditions 
vary greatly : 

" vSuch agencies as cold, emotional excitement, 
reflex disturbances from various organs, and certain 
poisons, which even tobacco may prove to be at times, 
may commence the Vicious Cycle by inducing the 
peripheral spasm which finds expression in angina. 
But that such peripheral conditions, even in these 
circumstances, require the presence at the centres of 
some state or states in the majority of cases, which 
aid the peripheral resistance to find expression in pain 
is, I imagine, quite indisputable. Given a weak spot 
at the centre, capable of registering a rise of pressure 
in the vascular system, that rise may be registered as 
pain, however the increase of pressure may be brought 
about, whether by central propulsion or peripheral 
resistance. But that a patient with dissecting aneurism 
of the coronary artery, with neurotic processes active in 
the aorta and coronary system, and with a delicate and 
minute innervation of every fibre in the cardiac muscle, 
should invariably wait upon the remote periphery for 
the signal of distress is simply unthinkable, and may 
even be regarded as an opinion no longer tenable." 1 


The blood-vessels have already been referred to as 
participating with the heart in the creation of 
injurious circular reactions. It will, however, be 
convenient to describe under a special heading some 
further disorders in which they play a prominent 

1 Sensory and Motor Disorders of the Heart, p. 112. 

56 Widens Circles in Disease 

Arterio"Sclerosis. Important correlations exist 
between arterial sclerosis and cardiac hypertrophy, 
although pathologists are not agreed as to the 
precise sequence of events. At one time it was 
believed that the blood in chronic Bright 's disease 
was poisoned by the products of metabolism, which 
were retained in the body instead of excreted through 
the kidneys. To protect the tissues from being 
damaged by this vitiated blood the arterial coats 
contracted and hypertrophied so as partially to cut 
off the supply. Then the myocardium in its turn 
hypertrophied in order to propel an adequate supply 
of blood through the narrowed tubes et ainsi de 
suite. 1 

Modern pathologists, however, regard arterio-scler- 
osis as a wide-spread process affecting the arterio- 
capillary system generally, causing increased resist- 
ance to the flow of blood and compensatory 
hypertrophy of the left ventricle. These two con- 
ditions increased pressure and cardiac hypertrophy 
are progressively reciprocal, the cardiac hyper- 
trophy being a necessary physiological adaptation to 
meet the increasing peripheral resistance. On the 
other hand the resulting high arterial pressure leads 
to an increasing strain on the walls of the aorta 
and on the arterio-capillary system generally. Thus 
the arterial lesion may be both the cause and effect 
of the hypertension. 
Warfield w r rites : 

" Prolonged hypertension is not a normal state, and 
sooner or later there must result changes in the circula- 
tory system. Changes actually do occur in both the 
heart and the arteries, leading to the production of 
arterio-sclerosis and to the establishment of a Vicious 

1 H. Gilford, Disorders of Post-natal Growth and Develop- 
ment, p. 346. Cf. also Barr, British Med. /., 1905, 
I-, P- 53- 

Carbio^Dasculnr System 57 

And again : 

" The primary change is an increased tension in the 
arterioles which later leads to thickening of the coats 
of the vessels and to the other consequences of arterial 
disease. A Vicious Circle is thus established which 
has a tendencjr to become progressively worse." 1 

In the later stages of arteriosclerosis the cardiac 
hypertrophy undergoes decompensation and the 
circular reactions already described on p. 35 are 

Aneurysm. Aneurysm is frequently due to dis- 
ease of the arterial walls, which consequently grow 
weak and yield to the blood-pressure. The more 
they yield the greater the tension ; the greater 
the tension, the thinner and weaker do they become. 
The dilatation is progressive. 2 

When rupture occurs a similar reciprocation is 
established as has been alluded to in cases of rupture 
of the heart. The haemorrhage paradoxically raises 
the blood-pressure, death resulting from general 
anaemia. An illustrative case is described by Hensen 
in which an aneurysm of the descending aorta 
perforated the left bronchus and on three occasions 
gave rise to profuse haemoptysis. Careful measure- 
ments of the blood-pressure showed that while 
the pressure just before an attack was 115 mm. Hg, 
it had risen to 142 mm. a quarter of an hour later. 
The patient survived the severe attack of haemopty- 
sis, probably owing to the perforation being closed 

1 Arterio-sclerosis, pp. 87, 113, 133, 163. Cf. also Allbutt 

and Rolleston, S3^stem of Medicine, VI., pp. 60 1, 606 ; 
Barr, British Med. /., 1909, II., p. 61 ; Oliver, 
British Med. /., 1910, II., p. 1333 : Faught, Blood- 
Pressure, p. 285. 

2 If t stands for tension, r for radius, and p for blood-pressure, 

then t = rp, i.e. with a constant blood-pressure the 
tension increases with the calibre of the vessel. 

58 IDicfoud Circles in Disease 

by a clot, but died shortly afterwards from a recur- 
rence of the bleeding. 1 

Varicose Veins and Lymphatics. Another com- 
plication is associated with varicose veins, whether 
these are due to increased intra- venous pressure 
or to diminished resisting power of the vein-walls 
((Mate III. e). In either case the dilatation leads to 
increased tension, and the tension increases the 
dilatation. Incompetence of the valves constitutes 
a further aggravating factor. 

Romberg writes : 

" The venous dilatation (due to some mechanical 
obstruction) and the anatomical changes in the vein- 
walls act reciprocally on one another. Thus a circulus 
vitiosus whose pathogenesis is obscure controls the 
course of events." 2 

Lymphangiectasis stands the same relation to the 
lymphatic system as does venous varicosis to the 
vascular. When lymphatics are unable to empty 
themselves they are easily stretched and weakened. 
The dilatation is thus progressive, especially when 
complicated by incompetency of the valves. 3 

ft Capillary Stasis. According to Cohnheim a 
" most pernicious circulus vitiosus " may be present 
when local inflammation leads to capillary stasis 
and coagulation, at any rate if the injury is so 
severe that complete repair is impossible. The 
inflammatory process leads to stasis and the stasis 
aggravates the inflammation. 4 

l Deutsches Archiv /. klin. Medicin (1900), LXVII. p. 


2 Krankheiten des Herzens und der Blutgefasse, p. 496. Cf. 

also Nobl, Der Varicose Symptomencomplex, p. 54. 
3 Busey, Narrowing, Occlusion and Dilatation of Lymph 

Channels, p. 116. 
4 General Pathology, I., pp. 339, 374-5. 

CarfcioDaecular System 59 

The successive changes which take place in a 
tissue as a response to injury are (a) dilatation of 
the blood-vessels, (b) acceleration followed by 
retardation of the blood-stream, and (c) emigra- 
tion of leucocytes and erythrocytes. These and the 
associated conditions are beneficent reactions and 
suffice under ordinary circumstances to repair the 
damage. The inflammatory process undergoes reso- 
lution and is followed by a restitutio ad integrum. 

Where, however, the trauma is severe, graver 
sequelae shew themselves ; the circulation may come 
to a complete standstill, the vessel-walls cease to be 
nourished, the contained blood coagulates and the 
surrounding tissues perish. The products of tissue 
death and disintegration then become sources of 
irritation and perpetuate the inflammation. 

At the outset such a damaged tissue is invaded 
by crowds of leucocytes which multiply rapidly and 
combine with the exudation to cause swelling and 
tension. By this means the circulation is further 
checked, nutrition suffers, and the area of necrosis 
may be extended. 1 

Moreover pyogenic cocci usually make their 
appearance, introduced either through a wound or 
derived from the blood. Many are destroyed by 
phagocytosis ; but should their numbers be too 
great or should phagocytic activity be impaired, 
the invaders find in the clotted blood a favourable 
medium for growth and proliferation. The resulting 
chemical products in their turn intensify the inflam- 
matory processes. Copious exudations of serum 

*In some forms of inflammation, such as that met with in 
gas gangrene, the bacillus aerogenes or the bacillus 
perfringens causes the development of much gas 
which aggravates the stasis. These microbes may 
also produce a condition of acidsemia which in turn 
favours their growth. Lancet, 1916, II., pp. 144, 
1063; 1918, I., 208. 

60 Dicious Circles in H>iseaec 

are poured out and in such serum float both the 
dead leucocytes that have perished in the struggle 
with the invaders and the fresh leucocytes which 
are continually hastening to the field of battle. 

As a result of these changes the exudations 
gradually change into the fluid known as pus and 
tend to collect in an abscess cavity. Such pus, on 
the one hand, contains phagocytic cells and pro- 
teolytic enzymes, which assist the damaged tissue 
in its struggle for repair. On the other hand there 
are also present bacterial products which aggravate 
the inflammation. Moreover the proteolytic enzymes, 
while useful in destroying necrosed tissues, may at 
the same time be injurious to adjacent tissues of 
low vitality and actually cause their liquefaction. 
This explains how it is that pus often causes rapid 
destruction of the damaged tissues, which tissues 
in their turn supply nutriment to the micro-organisms 
and thus increase the formation of pus. Indeed the 
pus acts much as if it were a dead tissue in a state of 
decomposition and may cause as much irritation as 
would a foreign body. In other words, when once 
formed, pus feeds itself by liquefying the tissues 
round it by perpetuating the very conditions in 
which it originated. Thus is established one of the 
most important Vicious Circles in pathology, and, 
generally speaking, pus must be evacuated before 
recovery can take place. The subject is further 
discussed in Chapter XX. 

Capillary stasis is a prominent factor in frostbite, 
and results from a variety of causes such as cold, 
wet, exhaustion and prolonged standing, conditions 
which operate powerfully in trench warfare when 
soldiers have to stand in ankle- deep mud and slush. 
In the worst cases the blood-vessels may be so 
narrowed that the part affected is blanched. Such 
stasis and the associated lowered vitality allow a 
still greater fall of temperature which may end in 

CarbtcMDascular System 61 

When tight boots are worn there is further inter- 
ference with the circulation, leading to swelling 
of the feet which in its turn increases the pressure 
of the boots. 

IvOUghnane writes : 

" In regard to boots a Vicious Circle develops. The 
wet leather shrinks and presses on the feet, thereby 
setting up traumatic inflammation and swelling, which 
swelling in turn increases the pressure from the boots." 1 


Disorders of the blood are of the first importance 
from the point of view of circular reactions since 
there is the closest interdependence between it and 
every other tissue. 2 

In health the blood is subject to daily and hourly 
variation as regards volume, composition, velocity, 
specific gravity, viscosity and so forth. Never- 
theless it remains essentially the same, ever ready 
to supply nutriment, to remove waste, to protect 
against bacterial invaders and to neutralise injurious 
toxins. Its efficiency is maintained by a self- 
regulating mechanism which is in .ceaseless operation 
and by means of which variations chemical, 
physical, histological or biological are rapidly 
remedied. 3 In other words variation evokes a 
beneficent reaction of the nature and strength 
required to restore the disturbed equilibrium. In 
disease this self -regulating mechanism is upset. 
Many reactions become excessive, overshoot the 
mark, and aggravate, in lieu of remedying, the 

1 Lancet, 1915, I., p. 803. 

2 Fuller details will be found in Vicious Circles associated 

with Disorders of the Blood, by J.B.H., Practitioner, 
1916, I., p. 621. 

3 Achard, Le Mecanisme Regulateur du Sang, Presse 
Medicate, 1901, II., p. 133. 

62 IDicioug Circles in 

Anaemia. Various disorders originate in an impo- 
verished supply of blood to organs and tissues. 
For instance, when the blood supplying the stomach 
is deficient in nutritive elements, the digestive 
fluids are deficient in potency, and in their turn 
keep the blood impoverished* (JMatC HI. f). The 
sequence is much the same whether the disorder 
starts with anaemia or with the gastric disorder. 
Robson Roose writes : 

" Blood in which some of the normal constituents 
are defective will not yield proper secretions, and thus 
the food will be liable to be imperfectly acted upon. 
In this way a Vicious Circle readily becomes established, 
inasmuch as the secretions themselves are dependent 
on the pabulum which the blood receives through the 
instrumentality of the assimilating organs." 1 

Anaemia is frequently associated with fatty degen- 
eration of the endothelial cells of the blood-vessels ; 
such degeneration may give rise to haemorrhage 
which aggravates the condition. 

Cabot writes : 

" To the fatty degeneration of the endothelial cells 
of the blood-vessels may be attributed the fact 
that in many anaemic conditions a general hsemorrhagic 
diathesis develops, which not infrequently combines 
with the primary disease to form a Vicious Circle." 2 
In other cases haemogenesis is paralysed. Blood 
impoverished of haemoglobin cannot properly nourish 
bone-marrow; hence blood-formation flags. 
Buchanan writes : 

" Haemorrhage is an obvious cause of blood loss or 
drain and is rapidly recovered from when sudden and 
profuse within limits. But continued and intermittent 

1 Nerve Prostration, p. 492. Cf. also Buchanan, The 

Blood in Health and Disease, p. 164 ; Trousseau, 
Clinical Medicine, II., p. 383 ; V., p. 109. 

2 Diseases of Metabolism and of the Blood, p. 308. 

CarbfolDascular System 63 

and small haemorrhages from the mucous surfaces may 
produce an anaemic state which may, from lack of 
recuperative power of the haemogenetic tissues, become 
' progressive ' and fatal. It is quite conceivable that 
here a Vicious Circle is established, so that the impover- 
ished state of the blood itself increases the tendency to 
haemorrhage which originally produced it." 1 

Pernicious anaemia is probably due to paralysis 
of the haematopoietic organs, associated with dimin- 
ished resisting power of the newly formed blood. 
These two factors disordered blood formation and 
increased blood consumption react injuriously on 
one another and often bring about a fatal issue. 

Eichhorst writes : 

" A Vicious Circle may be formed, when once dis- 
ordered blood-formation or increased blood-destruction 
has given rise to marked anaemia of the common kind. 
For not only does the disordered blood-formation cause 
less blood to be formed, but the smaller quantity of 
newly formed blood also possesses less resistance and 
is therefore more readily used up. Thus the two 
components of disordered blood formation and increased 
blood consumption act injuriously on one another and 
combine to bring about a rapidly fatal issue." 2 

Anhydraemia. Anhydraemia such as is associated 
with cholera establishes some correlations which 
are closely connected with the fatality of the disease. 
As a result of the profuse evacuations, which may 
amount to eight or more pints within a short period, 
the blood sometimes loses more than half its fluid 
contents. Such loss is accompanied by a danger- 
ously low blood-pressure, which sometimes falls as 

1 The Blood in Health and Disease, p. 164. 

2 Turk, Klinische Hsematologie, II. (ii.), p. 379. Cf. also 

Pick and Hecht, Clinical Symptomatology, p. 494 ; 

The Mayo Clinic (1916), VIII., p. 620. 

6 4 IMcioug Circles in 2)tseage 

low as 50 mm. Hg. 1 This low pressure, combined 
with the increased viscosity and the swelling of the 
renal epithelium, leads to suppression of urine and 
to an accumulation of the toxins, which then per- 
petuate the disease. Thus the anhydrsemia and 
anuria reciprocally aid and abet one another. 

Carbonaemia. Determann has drawn attention 
to a complication of carbonaemia (i.e. an excess of 
CO2 in the blood) due to the fact that excess of 
CO2 increases the viscosity and vice versa. The 
reciprocation is thus described by Allbutt : 

" Carbon dioxide is the most important of all the 
factors of viscosity, for the changes in viscosity by 
these gases (i.e. COz and O) are less of the plasma 
than of the corpuscles. Hence in diseases of the heart 
and lungs a Vicious Circle is established of plus viscosity, 
plus resistance, plus CO2, and so round to plus viscosity 
again a gyration which the heart may be unable, by 
increasing the pressure head, to break through." 2 

This condition of carbonsemia is often the cause 
of death through a gradual interference with 
oxygenation. Ritchie thus refers to the process : 

" Usually the act of dying is prolonged over a con- 
siderable number of hours and at the commencement 
there frequently appear disorders of respiration, which 
are indications either of oxygen-hunger or of the com- 
mencing accumulation of carbonic acid. . . . The 
essential point is a progressive failure of the heart and 
respiration in which each downward step in the capacity 
of one system is reflected in a corresponding downward 

1 In severe attacks Rogers found that the loss of fluid from 

the blood amounted to 64 per cent. Cholera and its 
Treatment, p. 149. 

2 Determann, Die Viscositat des menschlichen Blutes, 

p. 80. Cf. also Allbutt, Diseases of the Arteries, 
I., pp. 129, 130, 153 ; Hirschfelder, Diseases of the 
Heart and Aorta, p. 41. 

CarfctcMDascular System 65 

step in the functions of the other. The supply of 
blood to the lungs by the heart is diminished, and 
frequently this leads to oedema of the organs. The 
coating of the alveolar epithelium with fluid interferes 
with the interchange of oxygen between the air and 
the blood ; the heart is thus supplied with a deficiently 
oxygenated blood, its inherent weakness is thus in- 
creased and at the same time the respiratory and 
cardiac centres in the medulla have their controlling 
functions perverted. The Vicious Circle established 
increases progressively in severity of effect, and finally 
the heart comes to a standstill." 1 

Other Circles associated with an accumulation of 
CO2 are referred to in the Chapter dealing with 
respiratory disorders. 

Polycythaemia. Some interesting correlations 
may be connected with polycythaemia, a condition in 
which the red blood disks may be increased to 
10,000,000 in the cmm. or even more. The increased 
viscosity tends to produce some degree of blood 
stasis, and this in its turn favours the occurrence of 
thrombosis in the various viscera, thus further 
hampering the circulation. Again, retarded circula- 
tion and congestion in the blood-vessels of the lungs 
promote the development of chronic catarrhal 
changes, which induce cyanosis and throw extra work 
on the right side of the heart. Thus complex 
reactions are established ; the polycythsemia tends 
to impede the circulation, and the resulting blood 
stasis produced gives rise to a further polycythsemia. 2 

Another complication is sometimes observed in 
polycythsemia, a disorder in which increased form- 
ation and increased destruction of red disks act 
and react on one another. 

1 Pembrey and Ritchie, General Pathology, p. 759. 
2 Parkes Weber, Quarterly J. of Medicine (1908-9), II., 
p. 112. 

66 iDicious Circles in Bisease 

Ward writes : 

" The increase of red cells is the primary feature, so 
far as we can tell. This increases the viscosity of the 
blood and there is an increase of volume in order to 
relieve the viscosity. To this most of the symptoms 
would appear to be due. A further mechanical attempt 
of Nature to deal with the difficulty that she has 
initiated is increased destruction of red cells. This is 
shewn by the dark colour of the urine and the presence 
in it of urobilin. Unfortunately the stimulus of blood 
destruction inevitably leads to fresh blood formation, 
so that we very soon have a Vicious Circle. The total 
result seems usually to be inimical to the patient and 
the polycythsemia is steadily progressive. Arterial 
degeneration follows the increased blood-pressure, 
which depends in turn on the increased heart work 
necessary to drive round the body the highly viscous 
blood. This arterial affection often leads to death 
and the termination of the pathological process." 1 

There are a number of cardiac and respiratory 
diseases in which stagnation in the pulmonary 
capillaries and the associated deficient oxygenation 
give rise to polycythsemia and increased viscosity, 
which in their turn intensify the stagnation. Similar 
conditions, by throwing an extra burden on the 
heart, are apt to impair the efficiency of the elimina- 
ting organs and thus perpetuate the condition. 2 

Thyreo-Globinaemia. Some pathologists believe 
that an injurious circular reaction may be established 
in cases of hyperthyroidism, due to the presence of 
thyreo-globulin in the blood. The increased quan- 
tity of blood passing through the thyroid causes an 
increased secretion of thyreo-globulin and this in its 
turn causes more blood to pass through the thyroid. 
Thus the thyroid epithelium is activated by its own 
product, which returns to it through the blood. 

Bedside Haematology, p. 156. 
2 Ward, I.e., p. 182. 

CarbicMPaacular System 67 

Hirschf elder thus represents the sequence : 1 

(Basedow's disease) 

Increased thyroid g Increased blood flow 

secretion through thyroid 

According to Oswald an abnormally irritable 
nervous system is the principal factor that stimulates 
the thyroid and is in its turn stimulated by the 
thyroid secretion. 2 

Thyroid insufficiency may also establish a recipro- 
cation in which subthyroidism, weakened peristalsis, 
constipation, toxaemia and progressive thyroid inade- 
quacy constitute the factors. " Once the toxaemia 
is established, a Vicious Circle is formed." 3 

Toxaemia. Many circular reactions are created 
in the course of toxaemia. For instance, coprostasis 
in many persons is followed by the absorption of 
toxins, which weaken peristalsis and maintain the 

E. von Ofenheim writes : 

" The question is what is the effect of the stasis on 
the bacteria, and vice versa of the bacterial toxins 
on the stasis ? It has repeatedly been proved that 
a Vicious Circle exists between them. Stasis causes 

1 Diseases of the Heart and Aorta, 1913, pp. 682-3, 689-91. 
2 Oswald (Zurich), Ueber den Morbus Basedow, Corres- 

pondenz-Blatt /. Schweizer Aerzte, 1912, p. ir44. Cf. 

also Wells, Chemical Pathology, p. 606. 
3 Hertoghe, Thyroid Insufficiency, Practitioner, 1915, I., 

pp. 54-5, 66. Cf. also McCarrison, The Thyroid 

Gland, pp. 138, 188. 

68 IDidous Circles in SDisease 

bacterial poisons to be formed ; these poisons, again, 
have a paralysing effect on the intestines, and in this 
way add to the stasis." 1 

Uraemia. The term uraemia includes various 
complex disorders which supervene in the course 
of renal disease, and whose pathology is still obscure. 
But at least some of these disorders are due to the 
renal interference with the elimination of toxins 
which therefore accumulate in the blood and in turn 
aggravate the renal condition. 

The exact nature of the poisons concerned is still 
unknown, but they are probably related to the 
antecedents of urea in the chain of metabolic 

Another view is that the renal cells under certain 
conditions may themselves manufacture poisonous 
substances, known as nephrolysins, which in their 
turn perpetuate the renal disorder. 

Chauffard and lysederich write : 

" There can be no doubt that certain alterations in 
the renal cells may give rise to toxic matters, which 
in their turn perpetuate these alterations and create 
a true Vicious Circle, the effect of which is a more or 
less indefinite continuance of the nephritis." 2 

Eclampsia may be similarly complicated. 

Wells writes : 

" A reasonable view of the cause of eclampsia is 
that it is initiated by the excessive products of meta- 
bolism thrown into the blood of the mother, both 
from the fetus and from her own over-active tissues. 
These cause injury to the kidneys, leading to a further 

1 Proc. Royal S. of Medicine (1913), VI. (i.), (Alimentary 

Tox&mia), p. 326. 
2 Brouardel and Gilbert, Maladies des Reins, p. 166. Cf. 

also Osier and Macrae, System of Medicine, III., 

834 ; J. A. Kolmer, Infection, Immunity and 

Specific Therapy, p. 505. 

System 69 

retention, or injure the liver so that the normal metabo- 
lic processes of that organ (particularly oxidation) 
cannot be carried on ; or perhaps more often both 
liver and kidney as well as other organs are injured. 
In this way a Vicious Circle might be established and 
rapidly lead to an overwhelming of the maternal system 
with toxic products derived from both her own and 
the fetal tissues." 1 

Uricaernia. Injurious reciprocations may some- 
times occur when excess of uric acid in the blood is 
caused by inadequacy of hepatic metabolism and 
associated with calculous nephritis. 

For example, if from some cause or other the 
liver does not produce sufficient uricolytic enzyme 
to transform all the uric acid reaching it into urea, 
an excess of that acid passes into the blood and 
reaches the kidney, where some of it is deposited 
in the renal pyramids. In this way calculous de- 
posits are liable to form and to give rise to a secondary 
chronic nephritis (nephrite lithiasique). 

As a result of this nephritis there will be a lessened 
internal secretion, and this in turn causes lessened 
uricolytic enzyme in the liver. 

Uricsemia also perpetuates itself as a result of 
increased viscosity of the blood due probably to the 
presence of an excess of urates in a colloid form. 
There results obstruction in the capillaries, leading 
to a further accumulation of the products of imper- 
fect metabolism. 

Gilbert writes : 

" Capillary obstruction may in this way eventuate 
in an ' ill-burning fire,' in which the purin ashes of 
nitrogenous combustion (xanthin and uric acid) are 

Chemical Pathology, p. 487. Cf. also Eden, Midwifery, 
pp. iT2, 120, 123 ; Musser and Kelly, Practical 
Treatment, III., p. 634. 

70 IDicioue Circles in ^Disease 

retained and accumulate to cause further obstruction, 
thus tending to form a circulus vitiosus." 1 

According to Haig whose views, however, are by 
no means generally accepted, various other compli- 
cations may be associated with an excess of uric 
acid in the blood, and these produce a condition 
known as collaemia. For example, collaemia and 
dyspepsia are reciprocally correlated. 2 

Further circular reactions such as those associated 
with cholaemia, hyperglycsemia will be described in 
other Chapters (Cf. Index). 

" Uric Acid," XIII., L, p. 22. 

2 Uric Acid as a Factor in the Causation of Disease, 
pp. 242, 405, 407. 



HE tipper portion of the respiratory tract 
including the nose and throat will be 
dealt with in subsequent Chapters. We 
shall deal here with : 

I. The Lungs 

II. The Pleura 

III. The Bronchi 


Pneumonia. An injurious circular reaction is 
frequently met with in pneumonia, owing to the 
reciprocal embarrassment of the heart arid lungs. 
The great strain imposed on the right ventricle is 
partly due to the impeded pulmonary circulation 
and deficient aeration and partly to the action of 
toxins, and frequently leads to dilatation and failure. 
When such failure supervenes, the weakened myocar- 
dium further impairs both pulmonary circulation 
and oxygenation, the primary trouble being thus 
re-enforced (JMatC IV. a). 
Frankel writes : 

" The heart thus gets into a circulus vitiosus, since 
the blood stasis causes a further diminution in the 
supply of oxygen on which the increased cardiac 
activity depends." 1 

This process of reciprocation is especially grave 
when the heart is unsound to begin with ; then 
the patient is indeed inter malleum et incudem. 

1 Lungenkrankheiten, p. 300. Cf. also Lancet, 1874, II., 
p. 682. 


72 iDicious Circles in Disease 

Pneumonia affords a good illustration of what 
may be called an " organic " Circle, i.e. one which 
arises from the interdependence of two organs. For 
a time the congested lung is vicariously aided by 
increased cardiac activity. But if too great a strain 
is imposed on the heart, this organ in its turn is 
weakened and reacts injuriously on the lungs which 
are finally undone by conditions created by them- 
selves and for their own temporary advantage. A 
similar interdependence is present in all serious 
disorders both of the heart and of^the lungs. 

Tuberculosis. Pulmonary tuberculosis is compli- 
cated by a variety of injurious reciprocations which 
play an important share in the perpetuation and 
fatality of the disease. Only a few examples can be 
given here ; for further details reference may be 
made to a special article. 1 

The lowered resistance which so frequently results 
from tubercular infection plays a great part in the 
extension of the disease. Such lowered resistance or 
hyper-susceptibility to fresh infection within certain 
limits is a protective reaction, which tends to repel 
infection and localize disease. Bxtreme hyper-sus- 
ceptibility, however, causes grave toxaemia through 
excessive auto-intoxication, followed by a subnormal 
opsonic index and aggravation of the disease. In 
other words the machinery of immunization is 
paralysed, resulting in a further accumulation of 
toxins, these. two factors abetting one another. 
Thomson describes the process : 

" In a large proportion of cases cure by spontaneous 
auto-inoculation does not take place. The reason for 
this is two-fold. The protective influence instead of 
being stimulated is paralysed, so that we have estab- 
lished a Vicious Circle which favours active progress 
of the disease. On the other hand, owing to the latent 

1 Pulmonary Tuberculosis and its Vicious Circles, by J.B.H., 
Practitioner, 1914, I., p. 274. 

IRespiratorp System 








plate IV. Circles associated with the 
IRespiratorv System. 

74 IDtcioug (Eircleg in g>teease 

condition of the disease the auto-inoculation may not 
be sufficient to elicit any lasting immunizing response, 
in consequence of which healing does not take place, 
and the lesion remains quiescent, though ever ready 
in the presence of some favourable influence to burst 
into fresh activity." 1 

In many cases loss of vitality precedes the tuber- 
culous invasion, but the further sequence of events is 
very similar. They are thus described by Muthu : 

"Bad air and insufficient food, septic mouth and 
decayed teeth, adenoid growths and naso-pharyngeal 
catarrh, tonsillar enlargements and cervical and other 
glandular swellings, scrofulous diathesis and poor 
physical development, impaired nutrition and lowered 
vitality, all form a Vicious Circle which favours the 
entrance of tubercle and other germs in early childhood, 
when, if they do not develop and commence active 
mischief, they lie latent, and in after years produce 
pulmonary tuberculosis of adults." 2 

Another reciprocally acting disorder is associated 
with haemoptysis and the increased blood-pressure 
caused by the act of coughing and by the anxiety 
accompanying the appearance of blood (JMatC IV. b). 
Psychic conditions may send up the pressure by as 
much as 40 mm. Hg and the rise may be further 
increased by paroxysms of cough ; such increase 
tends to intensify the haemorrhage. 

Hare writes : 

" In phthisical hsemoptysis there is in operation 
one of the most highly Vicious Circles in pathology 
a Circle which is largely responsible for the profuseness 
and prolongation of the haemorrhage. The intra- 
pulmonary irritation of the effused blood causes cough : 
each act of coughing, like any other sudden exertion, 
causes rise of blood-pressure ; each rise of blood- 

1 Consumption in General Practice, p. 244. Cf. also New 

York Medical /., 1918, II., p. 431. 

2 Pulmonary Tuberculosis and Sanatorium Treatment, p. 60. 

System 75 

pressure is apt to cause fresh haemorrhage and so on 
over again, the Circle continuing to revolve in many 
cases until the loss of blood has been sufficient to reduce 
the blood-pressure materially and thus terminate the 
haemorrhage. This natural cure of haemoptysis was, 
at one period in the history of Medicine, imitated by 
physicians who resorted to venesection in this emer- 
gency a somewhat expensive, but by no means 
irrational, imitation," 1 

Pulmonary tuberculosis tends to extend by a 
process of auto-infection when a tuberculous patient 
re-inoculates himself with sputa discharged from a 
primary lesion in the lung. Cough forms one of 
Nature's protective mechanisms since infected sputa 
are thus expelled. At the same time it is attended 
with much danger of diffusing infection, for 
tubercle-laden sputa, when loosened by cough, are 
frequently aspirated into healthy parts of the lungs 
and there set up fresh foci. Thus disease spreads 
from lobe to lobe, giving rise to fresh occasions for 

cough (plate iv. c). 

In some cases sputa, when loosened by cough, are 
swallowed and infect the alimentary tract. Thence 
the bacilli pass through the lymphatics and reach 
the lungs, where fresh foci are started and further 
materials for cough are produced. 2 

1 Food Factor in Disease, II., p. 97. 

2 Various mechanisms exist by which bacilli may be trans- 

ported from one part of the body to another. For 
example, leucocytes may ingest bacilli and yet be 
unable to destroy them owing to an insufficient 
supply of intra-cellular antibodies. The bacilli may 
then be transported into neighbouring lymphatic 
vessels, and on the death of a leucocyte may escape 
into the tissues, like the Greeks from the wooden horse 
at Troy. In other cases a caseous tubercle may 
ulcerate and liberate bacilli into a blood-vessel 
Fresh foci of disease may then be started in remote 
parts of the body. 

76 IDictous Circles in ^Disease 

Occasionally the incessant cough of a consumptive 
may rob him both of sleep and of morale, and this 
gives rise to great prostration. This like every- 
thing that exhausts a patient favours the progress 
of the disease. Again, severe cough not infrequently 
injures lung tissue in process of healing, thus 
increasing the irritation. Coughing then causes 

In Judson's words : 

" Coughing increases the irritation, and the irritation 
in turn increases the coughing. This is a Vicious 
Circle, and certainly suggests the intervention of reason 
and self -control." 1 
Pottenger also writes : 

" Cough, by irritation, increases the tendency to 
cough, and by increasing secretion, increases the 
necessity for cough." 2 

The astonishing rapidity with which pulmonary 
cavities sometimes form and enlarge is due to the 
operation of circular reactions. An entire lung may 
at times be so completely destroyed that the bronchi 
open into a vast cavity bounded by little more than 
the pleura. The disintegration may be due to 
various causes. For instance, a mass of caseous 
tubercles may be discharged into a bronchial tube, 
leaving a cavity whose walls are in active tuber- 
culous evolution. The larger the surface exposed to 
infection, the more rapidly does erosion proceed ; 
the cavity thus tends to grow excentrically. Again 
the accumulation of stagnant secretions greatly 
favours the multiplication both of the tubercle 
bacilli and of other pyogenic micro-organisms. 
These mixed infections accelerate the advance of 
the tuberculosis and tend to the further enlargement 
of the cavities. 

International Congress on Tuberculosis at Washington 

(1908), II., p. 679.- 4ri < 
2 Pulmonary Tuberculosis, p. 271. 

IReeptraton? System 77 

Camac Wilkinson writes : 

" The aetiological diagnosis must take into account 
other infections, especially the common infections of 
the air passages. These infections favour tuberculosis 
and tuberculosis favours these infections. This Vicious 
Circle of tuberculosis and secondary or concurrent 
infections may play an important part even in the 
early stages of pulmonary tuberculosis, though, as a 
rule, those unfortunate accidental complications belong 
to a later stage of the disease." 1 

Laryngeal complications may also have an impor- 
tant influence. For example, the forcible propulsion 
of sputa against the vocal chords may abrade the 
laryngeal epithelium and inoculate the abrasions. 
This secondary focus may then become a fresh 
source of pulmonary infection. Dysphagia and 
insomnia are often aggravating factors. 
Davis writes : 

"When the larynx is involved a Vicious Circle occurs, 
in which the dysphagia, sleeplessness and cough pro- 
duced by the painful lesion markedly increase the 
rapidity of the progression of the lung condition." 2 
In some cases of phthisis secondary dyspeptic 
disorders accelerate the progress of the disease. 
Barbier writes : 

" These visceral troubles add to the wretchedness 
of the sufferer. Not only are they caused by the 
tuberculosis, but they accelerate its progress, both by 
diminishing the power of resistance and by inducing 

other complications associated with tubercle 

Thus is established in all its mischievous correlations 
that Vicious Circle which so often complicates 
phthisis." 3 

1 Tuberculin in the Diagnosis and Treatment of Tuberculosis, 

p. 94. Cf. also Practitioner, 1913, I., p. 157. 

2 Lancet, 1913, II., p. 1112. 

3 Brouardel et Gilbert, Maladies des Bronches et des 
Poumons, p. 495. Cf. also New York Medical /., 
1918, II., p. 474. 

\Dicious Circles in Disease 

These are a few of the conditions in which pul- 
monary tuberculosis tends to self-extension. Equally 
important are the social disabilities which result 
from and in turn feed the disease. 1 

Atelectasis. In weakly infants sudden death 
sometimes occurs as a result of atelectasis or pul- 
monary collapse, the fatal process being started by 
what at first appears to be a quite trifling catarrh. 
The rapid progress of the disease is due to the fact 
that collapse, once begun, supplies the cause for its 
further increase. On the one hand the accumulation 
of mucus tends to increase in proportion to the 
diminution in the amount of air entering the lungs ; 
on the other the increasing impurity of the blood, 
from imperfect aeration, impedes the muscular and 
nervous functions which would promote the expul- 
sion of the mucus. 

A pernicious factor is sometimes brought into 
operation in cases of dyspnoea when the lower ribs 
and even the lower end of the sternum are drawn 
inwards during the act of inspiration, instead of 
rising in the usual manner. The result may be a 
local pulmonary collapse, which by producing fur- 
ther dyspnoea may stimulate the respiratory activity, 
lead to greater drawing in of the ribs, and thus 
aggravate the collapse. 2 

(Edema. Important correlations are often pre- 
sent in soldiers who have been "gassed" by chlorine 
or other fumes during the war. According to 
Schafer, who has carefully studied the condition, the 
irritant gas gives rise to acute congestion and obstruc- 

1 Cf. Poverty and its Vicious Circles, by J.B.H., p. 40. 
2 Fagge and Pye-Smith, Text-Book of Medicine, I., p. 1057. 

Cf. also Allbutt and Rolleston, System of Medicine, 

III., pp. 89, 0,6. 

System 79 

tion of the pulmonary vessels associated with 
extensive oedema of the interstitial tissues of the 
lung. The exuded lymph may also escape into the 
alveoli, where it clots and thus intensifies the obstruc- 
tion. . 
Schafer writes : 

" Presumably the oedema is secondary to the vas- 
cular obstruction, but even if this is so, it must set 
up a Vicious Circle by increasing the obstruction, and 
this again will increase the oedema, so that in cases 
of survival the oedematous condition must tend to 
increase, at any rate for some time." 1 

Respiratory Inactivity. A variety of conditions 
are met with in which oxygenation is impaired 
owing to defective respiratory activity, and such 
deficiency tends to be self -perpetuating. For ex- 
ample, in obesity the respiratory muscles and ribs 
are over-weighted with fat and unable to expand the 
chest efficiently ; moreover the thoracic cavity may 
be encroached upon by fatty cushions in the medi- 
astina and by the fatty enlarged heart. The 
diaphragmatic pump may be unequal to forcing 
down the fatty viscera into the abdomen which is 
itself encroached upon by extensive and unyielding 
accumulations of fat. In brief, both the respiratory 
capacity of the chest and the respiratory move- 
ments of the lungs are diminished. All these con- 
ditions tend to shallow breathing movements and 
the shallower the respiration the less the assistance 
given to the return of venous blood to the heart and 
lungs. Further, the shallower the respiratory move- 
ments, the slower is the rate of oxidation ; the 
fat-forming substances are less perfectly burned up 
and are more largely deposited as fat, and thus the 
injurious sequence is renewed. 2 

1 British Me.d. /., 1915, II., pp. 246, 801. 
2 Cf. Obesity and its Vicious Circles, by J.B.H., Practitioner, 
1917, II., p. 164. 

8o \Dictou0 Circle0 in 

Feeble respiratory movements from any cause 
whatever tend to defective nutrition of the lungs, 
since such nutrition depends largely on adequate 
movements ; hence defective expansion and im- 
paired nutrition act and react on each other. In 
fact feeble movements of the chest walls are in- 
jurious in many directions. Even ansemia may be 
due to this cause. 

" The patient lies in the Vicious Circle of a reduced 

activity of the respiratory centre, due to the anaemia 

it should help to dispel." 1 

This conclusion, however, seems questionable ; 
frequently ansemia has the opposite effect. 

Asphyxia. Defective oxygenation as met with 
in asphyxia is often associated with self -aggravating 
conditions. The primary effect is increased respi- 
ratory activity which tends to compensate for the 
defect. If, however, such increased activity brings 
no relief the venosity of the blood increases, blood- 
pressure rises and the heart is slowed by the cardio- 
inhibitory centres in the medulla. Owing to the 
increased pulmonary obstruction a fronte and the in- 
creased supply of blood a tergo (due to inspiratory 
suction movements), the right heart becomes gorged 
with blood and eventually dilated and paralysed. 
This in turn leads to further venosity, which poisons 
the myocardium and tends to further dilatation, un- 
til at length the right auricle and ventricle lose all 
power of contracting. A similar process also involves 
the left side ; but the progressive and dangerous 
dilatation of the right side plays the chief role, and 
contributes mainly to the fatal exitus. 2 

A slowly progressive form of asphyxia often marks 
the close of life, due to a gradual impairment of 

1 Allbutt and Rolleston, vSystem of Medicine, V., p. 723. 
2 Norris, Blood-Pressure, p. 26. 

Itfespiraton? System 81 

the respiratory function. The oxygen-content of 
the blood may fall to a mere trace, and induce a 
general narcosis resulting in frequent and shallow 
respirations which do but little to aerate the blood 
and gradually weaken until life ebbs away. 
In the vast majority of cases the dying 

" craving nought nor fearing; 
Drift on through slumber to a dream, 
And through a dream to death." 


Pleurisy. A pleuritic effusion must, broadly speak- 
ing, be regarded as one of the natural defences of 
the organism in that it lessens the risk of adhesions 
and keeps the collapsed lung quiet. If tubercle 
bacilli happen to be present their dissemination is 
checked. On the other hand an effusion may do 
harm through interference with the lymphatic 
pump by which a constant circulation of fluid into, 
and out of, the pleuritic cavity is maintained. 
Deposits of fibrin may block the stomata and thus 
lead to an accumulation of the effusion. The 
condition then resembles that of a leaking ship 
whose pumps are plugged by sea-weeds pouring 
in with the water. 

Further, the effusion may exert such pressure on 
the stomata and superficial lymphatics as to block 
the channels by which it should be absorbed ; it 
may also make difficulties for itself by reducing or 
abolishing the respiratory movements on which the 
efficiency of the pump depends. 1 The improvement 
that so often follows paracentesis, even when only 
a small quantity of fluid is removed, is probably due 
to an arrest of this morbid process. The lymphatic 
pump has again begun to work (JMatC IV. d). 

1 West, Lancet, 1905, 1., p. 787. Cf. also New York Medical 
/., 1918, II., p. 519. 

82 iDicious Circles in Bieease 

Another circular reaction is sometimes associated 
with an empyema when pus escapes into the respir- 
atory tract and excites violent coughing. Such 
coughing, on the one hand, is an act of self-defence. 
At the same time the cough may cause such a pro- 
fuse escape of pus as to flood the respiratory passages 
and actually cause death. 

After an attack of pleurisy the pleural membrane 
often forms a locus minoris resistentice. In spite of 
recovery frcm the acute illness some residual lesion 
persists ; on trivial exposure the damaged pleura is 
attacked afresh, and each time the mischief increases, 
until the cumulative effect is considerable. The 
primary lesion by lowering resistance has led to 
recurrence ; recurrence has aggravated the primary 

Hydro-Thorax. Many forms of respiratory and 
cardiac disease, especially in their later stages, are 
complicated by a general venous stasis, of which 
dropsy of the pleura forms one condition. The 
dropsy in its turn leads to further respiratory and 
cardiac embarrassment and thus establishes a self- 
perpetuating condition which frequently gives the 
coup de grace. 


Bronchitis. Circular reactions are frequently 
established in acute bronchitis, when the bronchial 
congestion obstructs the entrance of air, hinders the 
circulation through the lungs and consequently leads 
to defective aeration of the blood. In order to 
overcome this obstruction the right ventricle at 
first beats more vigorously and under favourable 
circumstances the circulation is satisfactorily main- 
tained. But in severe attacks the heart frequently 
proves unequal to the extra burden imposed upon 
it. The right ventricle and auricle undergo dila- 
tation, and this is followed by venous congestion 

IRespiraton? System 83 

which spreads to the venae azygos, the left superior 
intercostal and to the bronchial veins, thus further 
aggravating the bronchitis. 

Other injurious correlations result from congestion 
of the coronary veins, since the nutrition of the 
whole of the myocardium is thus involved and the 
functional activity of both ventricles is impaired. 
Whether the weakness is felt a tergo or a fronte the 
bronchial congestion is increased and the bronchitis 

West thus describes the process as associated with 
the left ventricle : 

" As soon as the left ventricle fails, a fresh cause 
of pulmonary congestion is added, for there can be no 
greater obstruction to the circulation than a left ven- 
tricle which cannot drive the blood onwards. The 
pulmonary veins become congested, and the aeration 
of the blood is still further interfered with. This adds 
to the congestion of the right side, embarrasses still 
more the coronary circulation, and by further impairing 
the nutrition of the heart makes the left ventricle weaker 
still. The Vicious Circle thus established explains the 
rapid failure of the heart, which is so striking a feature 
in the later stage of many cases of bronchitis." 1 

Similar complications arise in chronic bronchitis, 
when the compensatory hypertrophy of the right 
ventricle fails and is replaced by dilatation. The 
conditions then closely resemble those already 
described, the bronchial and cardiac disorders acting 
and reacting on each other. 2 

Chronic bronchitis and emphysema are frequently 
reciprocally related to each other. Not only does 
emphysema result from bronchitis, but it in turn 
also leads to bronchitis, for the wasting of the 

1 Diseases of the Organs of Respiration, I., p. 129. 
2 Romberg, Krankheiten des Herzens und der Blutgefasse, 
pp. 156-7. 

84 IDicious Circles in 2>i0eaec 

alveoli and consequent destruction of vessels causes 
obstruction to the circulation through the lungs. 
This is liable to be followed by dilatation of the 
right heart and systemic veins, and thus lead to 
further congestion of the bronchi. l 

Bronchial congestion may sometimes be self- 
perpetuating owing to the associated paroxysms 
of coughing which increase the congestion. Pro- 
bably also the act of coughing increases the 
bronchial secretions which in their turn must be 
removed by further coughing. 

Lastly, bronchitis often supplies an example of a 
self-perpetuating disorder through the bronchial 
mucosa forming a locus minoris resistentice. In 
some persons each attack seems to lower resist- 
ance and thus predisposes to recurrence. 

Bronchiectasis. Dilatation of the bronchial tubes 
occurs in a number of disorders, and when once 
it has been started tends to increase : dilatation 
breeds dilatation. One reason for this is that the 
greater the distention the less the force required for 
further distention, a paradoxical condition observed 
in a variety of conditions. 2 

Again in bronchiectasis there is a great tendency 
to the accumulation and retention of secretions. 
This is partly due to the destruction of the ciliated 

1 West, Diseases of the Organs of Respiration, I., p. 112. 

2 Such progressive dilatation is well illustrated by the 
following experiment. Suppose A and 
B to be two similar air sacs or lungs 
attached to a Y-tube C., A being 
blown up to a certain size and then 
clamped at , while B is blown up to a 
larger size and similarly clamped at b. 
If the two clamps a and b are removed, 
B does not empty itself partially into A, but A 
partially empties itself into B and grows smaller. 

Reepiratorp S^etem 85 

epithelium, partly to the increased calibre and less- 
ened elasticity of the tubes. The secretions then 
serve as a nidus for bacterial decomposition, which 
keeps up irritation, inflammation and secretion 
(JMatC IV. e). Gases too are generated which exert 
a dilating pressure on the enfeebled walls. 1 

Scott describes the process as regards bronchial 
secretions and bacterial growth : 

" The bacteria present in chronic bronchitis are 
probably leading a saprophytic as well as a parasitic 
existence. The organisms present are living not only 
on the bronchial epithelium, but also on the bronchial 
secretions. These secretions are, in the first place, 
set up by repeated bacterial attacks on the epithelial 
cells, which are then kept actively secreting by the 
irritation of the toxins, a Vicious Circle being thus 
formed." 2 

The weakening of the bronchial walls is aggra- 
vated b}^ the frequent paroxysms of cough which 
result from the accumulated secretions ; these in 
their turn promote irritation and further secretion. 

Asthma. Various hypotheses have been sug- 
gested to account for the phenomena associated 
with paroxysms of asthma, details of which will 
be found in every System of Medicine. One re- 
markable feature of the disorder is the defective 
character of expiration which is probably due to 
the fact that the expanded state of the chest 
gives the maximum patency to the bronchial tree. 
In other words the patient dare not expire fully. 

Dixon and other writers, however, believe that 
the defective expiration is associated with a circulus 
vitiosus which operates through the following 
mechanism. A much greater force is exerted during 
inspiration than during expiration, which is mainly 

1 M. Bruce, Principles of Treatment, p. 101. 

2 The Road to a Healthy Old Age, p. 179. 

86 iptctoug Circles in Btgeaee 

due to elastic recoil of the lungs. Consequently 
where there is an asthmatic broncho-constriction, air 
may be sucked through the constriction by the 
inspiratory force brought into play, while the elastic 
recoil is unable to expel the air sufficiently rapidly. 
Another inspiration therefore takes place before 
complete expiration, resulting in over-distention of 
the lung. This over-distention in its turn diminishes 
the force of expiration, i.e. the more the lungs are 
distended the feebler becomes the power of expelling 

Dixon writes : 

a In an attack of asthma due to broncho- 
constriction a Vicious Circle is established. The more 
the chest expands and the lungs are over-distended 
the weaker its powers of expiration become." 1 

Emphysema and bronchitis are frequent com- 
plications, being both cause and effect of asthma. 

I y atham writes : 

" The amount of emphysema, the degree of bron- 
chial catarrh, and the condition of the right heart 
are the most important factors in asthma. These 
complications all increase the severity of the asth- 
matic attacks, which in turn increase the severity 
of the complications, and so the patient lives in a 
Vicious Circle." 2 

Another injurious sequence may result from the 
gradual diminution of nerve control, so that a fresh 
attack supervenes on less and less provocation ; 
recurrence indeed is largely the result of previous 
attacks ( jplatC IV. f ). The labile condition resembles 
that met with in epilepsy and in various habit 

l Proc. Royal S. of Med. (1909), II. (iii.), (Therapeutics] , 
p. r20. Cf. also Kwart, British Med. J . (igri), II., 
p. 1627. 

2 Short, Index of Prognosis, p. 182. 

Chapter Siy 


ISORDERS of digestion are usually com- 
plicated by the operation of Vicious 
Circles. This liability arises in part from 
the interdependence of the chemical, 
physical and vital processes involved, in 
part also from the close sympathy between the gastro- 
intestinal and other organs, even the most remote. 
Disease here breeds disease there, action and reaction 
being in continuous operation. This complication 
is largely accountable for the chronicity of dyspeptic 
disorders, some of which are most difficult to cure. 
The following regional classification will be con- 
venient : 

I. The Mouth 
II. The (Esophagus 

III. The Stomach 

IV. The Liver and Pancreas 
V. The Intestines 

VI. The Rectum and Anus 


Although every mouth is in some degree septic, 
it is not always that injurious reactions are provoked. 
The establishment of Vicious Circles depends on 
the number and pathogenicity of the invaders, 
as well as on the resistance offered by the host. 

Dental Sepsis. If the teeth are not properly 
cleansed, particles of food, especially carbo-hydrates, 
undergo fermentative changes, with a production of 
dextrin and of lactic and other acids as end products. 

88 IDicious Circles in 2>ieea0e 

These acids attack the lime salts of the enamel 
and dissolve the interprismatic cement, as a result 
of which the enamel breaks up and is removed 
mechanically. The solution of the lime salts of 
the dentine then follows, while the collagen of the 
dentine matrix is dissolved by proteolytic enzymes. 
By these processes cavities or pockets are formed 
in which lodge food and bacteria, leading to further 
fermentation and the- production of more acid 

(IPIate v. a). 

The deposition of lime salts from the saliva in the 
form of tartar may also establish morbid correlations 
by setting up gingivitis and causing recession of the 
gums from the tooth, leaving the neck and fang 
exposed. The exposed fang in its turn receives a 
coating of tartar, which excites further irritation 
and recession. 1 Thus the presence of dental cal- 
culus is self -perpetuating. In course of time the tooth 
loosens and drops out. 

An artefact sepsis is sometimes dependent on 
careless fillings, ill-fitting crowns, gold caps and 
tooth-plates. These frequently lead to caries by 
friction against the teeth, and thus promote an 
increase of the sepsis which rendered them necessary. 2 

The teeth, however, are not merely isolated 
structures with functions independent of those of 
other organs ; on the contrary, they have anatomi- 
cal, physiological and pathological affinities with 
the rest of the body. Hence it is that dental sepsis 
may provoke such various troubles as gastro- 
intestinal catarrh, pneumonia, infectious endocardi- 
tis, iritis or osteo-myelitis, and such secondary 
disorders react on the teeth, cause and effect aiding 
and abetting each other. 

1 Lancet, 1894,1.^.467. 

-British Med. /., 1914, I., pp. 1244, 1301. 

IDujestive System 

8 9 

a I 









plate v.- Circles associatcb with the 
Bigeettve System. 

90 iDtdoug Circles in 2Hgease 

Coleman writes : 

" Diseased teeth or their sequelae such as the con- 
stant swallowing of bacteria and their toxins .... 
may involve the entire gastro-intestinal tract and its 
annexes, so that Vicious Circles become established 
and conditions produced which at first sight ma}' appear 
to bear but little connection with the teeth. 1 

According to some writers caries may hinder the 
development of the maxillae. Such imperfect de- 
velopment in its turn promotes caries and malnu- 
trition, notably in early life. 

Goadby writes : 

" Among children we find impaired nutrition and 
with it impaired growth ; with this, again, badly 
developed maxillae and thus the Vicious Circle is 
complete." 2 

Even so common a trouble as persistent tooth- 
ache may provoke reciprocal reactions, when it 
produces insomnia, lowers the neuron threshold and 
increases sensitiveness to pain. Here is an illus- 
tration of the law that attention and hypersesthesia 
intensify each other. 

Oral Sepsis. Dental sepsis necessarily implies 
oral sepsis. But the converse does not always hold 
good, since the mouth may be septic even when the 
teeth are sound. The commonest oral disorder is 
doubtless pyorrhoea alveolaris which perpetuates 
itself locally by the formation of pockets, and also 
produces similar constitutional effects as does dental 
sepsis, lowers the resisting power of the tissues and 
thus facilitates further infection of the gums. 3 

1 St. Bartholomew's Hospital /., 1909, II., p. 37. 

2 British Med. /., 1904, II., p. 440. 

3 vSimilar injurious reactions occur amongst the lower ani- 
mals with occasionally fatal effects. British Med. 
/., 1914, L, p. 1246. Cf. also Colyer, Chronic 
Periodontitis, p. 46. 

Digestive System 91 

Great attention has been paid to these correlations 
of recent years, and a variety of disorders have 
been attributed to them. 1 
Payne writes : 

"The chronic nature of the complaints associated 
with the alimentary toxaemia is largely due to the 
fact that a Vicious Circle is established. When once 
oral sepsis has led to gastro-intestinal trouble the 
oral sepsis itself may be kept alive by the secondary 
complaint." 2 

According to Pickerill oral sepsis has much to do 
with weakening of the glosso-pharyngeal-chorda 
tympani-vagus reflexes which govern salivary and 
other secretions, and thus favours the proliferation 
of organisms and the production of toxins. 

Pickerill writes : 

" There is set up an extremely strong Vicious 
Circle. Diminished oral stimulation produces oral 
stasis and sepsis initially. These in turn produce 
gastric and intestinal sepsis, thus giving rise to toxins, 
which being absorbed still further increase oral sepsis 
and diminish taste-perception by causing intestinal 
dilatation, which increases toxic absorption. And so 
the cycle goes on getting stronger and stronger until 
the patient's alimentary system can no longer resist 
the strain or perform its function. 3 

The conditions here described are often met with 
in exhausting illness when sordes accumulate and 
interfere with mastication and digestion. The same 
is true of aphthous stomatitis where the taking of 

x Burchard and Inglis, Dental Pathology and Therapeutics, 
pp. 38, 62. 

2 Lancet, 1913, II., p. 1236 ; 1906, I., p. 509. Cf. also Proc. 

Royal S. of Med. (1913), VI. (i.), (Alimentary 
Toxcemia), p. 275. 

3 Dental Caries and Oral vSepsis, p. 304. This Circle is 

illustrated on p. 299. Cf. also Lancet, 1909, I., p. 

92 Melons Circles in Disease 

food causes difficulty and pain, and thus leads to 
increased debility. 


CEsophageal Pouch. The so-called oesophageal 
pouch is a diverticulum or hernia of the posterior 
or postero-lateral wall of the pharynx into the 
adjacent loose areolar tissues. As food enters and 
distends the sac, the oesophagus below is apt to be 
compressed, causing more food to enter the sac 
and increasing its size. Moreover the pouch, as it 
grows, may come to form the direct continuation 
of the pharynx, and this again causes more food 
to enter. As a result of this retention of food, 
decomposition is liable to occur, and this leads 
to inflammation, spasm and increased retention. 

Starck writes : 

" In the treatment of dilatation of the oesophagus the 
most important thing to bear in mind is the prevention 
of inflammation, as when this occurs a Vicious Circle 
is established. Inflammation is followed by spasm, 
spasm by obstruction, and obstruction by further 
inflammation." 1 

Unless the diverticulum can be cured, death may 
result from slow starvation. 

(Esophagismus. Spasmodic stricture or oesopha- 
gismus is not uncommon in neurasthenic individuals 
and may be of purely psychical origin. The more 
the victim fears the advent of the spasm the more 
likely is its advent, and vice versa. The condition 
illustrates the spasmophilia which characterises 
the emotional temperament. 

1 Die Divertikel und Dilatationen der Speiserohre, abstracted 
in British Med. /., 1911, II., p. 1599. An excellent 
diagram of an oesophageal pouch is given by Schmidt, 
Krankheiten der oberen I^uftwegen, p. 726. 

Digestive S^atem 93 


Reciprocity of disorder in connection with the 
stomach is of frequent occurrence. A few striking 
examples may be referred to. 1 

Chronic Gastritis. The various gastric functions 
involved in digestion are so intimately associated 
that impairment of the one involves the others. 
Deficiency of secretion spells deficiency of absorp- 
tion and of peristalsis, and vice versa. It matters 
little which function suffers first ; when the chain 
is dragged the links must follow. In Allbutt's 
words : " the stomach falls into the Vicious Circle 
of doing as ill for itself as for other parts of the 
body." 2 

Ewald describes the sequence : 

" Defective muscular movement reacts by diminish- 
ing the activity of absorption, defective absorption 
leads to stasis in the venous area, and this again to 

J The term Vicious Circle has sometimes been applied 
to disorders in which there are no reciprocal 
processes in operation, and which, therefore, do not 
fall under the definition given in the Introduction. 
Such a disorder is occasionally established after 
a gastro-enterostomy, when the gastric contents pass 
through the anastomosis and return to the stomach 
through the duodenum, or else pass first into the 
duodenum and return to the stomach through the 

Trendelenburg also describes a " Vicious venous 
Circle," which may complicate varicose veins of the 
leg where the valves are incompetent. After passing 
through the saphena vein into the veins which connect 
the superficial with the deep veins, the blood flows into 
the popliteal and femoral veins back into the saphena 
vein, thus flowing'from, instead of towards, the heart 
and completing the circuit. Da Costa, Modern 
Surgery, p. 409. 

2 Allbutt and Rolleston, System of Medicine, III., p. 388. 

94 IDicious Circles in Disease 

injury to secretion, so that a Vicious Circle is created. 
You can easily perceive that it is quite the same at 
whichever end you begin this chain ; whether the 
first trouble is secretory or motor, or absorption is 
affected, the same results must always follow, unless 
the failure of the one function can be compensated for 
by the stronger action of another, by which the dis- 
turbance might be rectified." 1 

Chronic gastritis is usually associated with some 
degree of gastrectasis, especially when there has 
been prolonged retention of food. Such retention 
leads to decomposition and fermentation, as a result 
of which enormous quantities of gas may be gen- 
erated, with the result that the stomach yields more 
and more to the pressure. The retention and 
dilatation thus aid and abet each other. 2 Such 
gastrectasis is frequently associated with stenosis 
of the pylorus due to cancer. 3 

In many cases the gastrectasis seems to excite 
boulimia which then further increases the gastric 

M. Bruce writes : 

" The subjects of chronic gastric catarrh, associated 
with a degree of dilatation of the stomach from atony 
of the wall develop an excessive appetite and eat 
largely. A Vicious Circle is established, and the morbid 
condition aggravates itself automatically." 4 

Acute gastrectasis associated with paralysis of 
the walls and retention of gases and secretions is 

Diseases of the Digestive Organs, II., p. 484. Cf. also 
Cohnheim, General Pathology, III., p. 857 ; Rosen- 
heim, Krankheiten der Speiserohre und des Magens, 
p. 96. 

2 Cohnheim, General Pathology, III., pp. 859, 862. Cf. 
also British Med. /., 1902, II., pp. 1390, 1393. 

3 Vierordt, Medical Diagnosis, p. 345. 

4 Principles of Treatment, pp. 471, 458-9. 

Digestive System 95 

sometimes seen in severe illness and is an indication 
of great danger. Here also the several factors 
intensify each other. 1 

Gastroptosis. Some degree of gastroptosis is 
invariably associated with gastrectasis, owing to the 
prolonged retention and increased weight of the 
ingest a. But the displacement becomes aggravated 
when the loaded stomach sinks so low as to produce 
a duodenal kink, since such kink further hinders 
the escape of the gastric contents. 2 The gastroptosis 
and gastrectasis then intensify each other, and 
the stomach may assume enormous dimensions. 3 
The mechanical displacement aggravates the dis- 
order to which it was due ({plate V. b). 

In some cases the distended stomach forces down 
the intestines in such a way that the mesenteric 
blood-vessels and nerves form a tight band across 
the duodenum and prevent any gas from passing. 
The tighter the band the greater the accumulation 
of gas and vice versa. 

Barnard describes the process : 

" In some cases of acute paralytic dilatation of the 
stomach it would appear that the small intestines have 
been driven downwards and backwards into the pelvis 
by the enlarging organ, and that the mesentery has been 
drawn tightly across the duodenum. In such cases, in 
addition to the stomach, the duodenum is distended to 
the point at which it is crossed by the mesentery, and a 
Vicious Circle is thus established." 4 

1 Krehl, Basis of Symptoms, p. 253. Cf. also Keen, Surgery, 

III., p. 949. 

2 Billings, Diseases of the Digestive System, p. 271. Cf. 

also British Med. /., 1902, II., p. 1397 ; Lancet, 
rgir, II., p. 215. 

3 Such a stomach may contain as much as seventy pints. 

4 Allbutt and Rolleston, System of Medicine, III., p. 769. 

96 iDicious Circles in Disease 

A curious complication may occur owing to the 
fact that any imbibed liquid does not reach the 
intestines, and consequently can neither be absorbed 
nor quench thirst. Hence the unallayed thirst 
causes more drinking, producing increased distention 
of the stomach, increased obstruction, and increased 
difficulty in satisfying thirst. Thus a paradoxical 
condition may arise in which a person is tormented 
with thirst, although his stomach contains several 
pints of fluid. 1 

Hyperchlorhydria. A circular reaction is some- 
times present in hyperchlorhydria, a condition 
which is present in various forms of dyspepsia. 
Thus Sippy writes : 

" In true hyperchlorhydria a Vicious Circle is 
established. Excessive gastric secretion is excited by 
the presence of food. The excessive acidity irritates 
the nerves of the gastric niucosa and the glands respond 
to the normal stimulus, food, by pouring out excessive 
secretion, which renders the gastric mucosa irritable." 2 

This disorder, however, is much more serious 
when it is complicated and aggravated by the 
presence of pyloric spasm. 

During normal digestion the pyloric sphincter 
remains for the most part closed, relaxing at intervals 
to allow the passage of acid chyme, and then closing 
again under the influence of the duodenal reflex. 
In cases of hyperchlorhydria, however, this mechan- 
ism is liable to be disturbed. The usual alternation 
between opening and contraction of the sphincter is 
then replaced by persistent spasm, followed by 
retention of the gastric contents. Such retention 
then provokes further hyperchlorhydria and com- 

^irchow, Archiv, CLVI. (1899), p. 306. 

2 Musser and Kelly, Practical Treatment, III., p. 367. Cf. 

also von Noorden, Zeitschrift /. klin, Medizin (1904) 

UIL, p. 7. 

Digestive System 97 

pletes the round. In fact hyperchlorhydria, pyloric 
spasm and gastric stasis may form an obstinate 
concatenation of disorders. 1 

Mathieu and Roux write : 

"Reichmann's syndrome presents a remarkable 
example of a pathogenic Vicious Circle. The following 
are the component factors : persistent pain, hyper- 
secretion of gastric juice, hyperchlorhydria and stasis. 
The spasm of the pylorus has been proved to be the 
principle cause of the pain and gastric stasis. The 
stasis in its turn perpetuates the hyper-secretion, and 
this again perpetuates the spasm. In a considerable 
number of cases there is an ulcer at, or near, the pylorus 
which causes the pain, spasm and hyper-secretion. 
In fact the hyper-secretion and stasis prevent the 
healing of the ulcer." 2 

Gastric Ulcer. The sequence of hyperchlorhy- 
dria, spasm and stasis referred to above is met 
with in many cases of gastric ulcer. Ulcers may 
also occur apart from any such spasm, in which 
case the hyperchlorhydria and ulceration perpetuate 
each other. Doubtless the presence or absence of 
spasm depends on the degree of acidity, on the 
situation of the ulcer and on the state of the nervous 

Roux describes the morbid sequence : 

" The hyperchlorhydria which is so constantly pres- 
ent in cases of gastric ulcer, may be due to reflex 
irritation. On the other hand clinical observations 
seem to indicate .... that in many cases the hyper- 
chlorhydria precedes the ulcer. We may therefore 
conclude] that the hyperchlorhydria promotes the 
formation of the ulcer, while, on the other hand, by 

1 Pyloric spasm may also perpetuate a state of hyper- 

chlorhydria by preventing any reflux of alkaline 
pancreatic juice. Lancet, 1915, I., p. 290. 

2 Pathologic Gastro-Intestinale, Series I. (1909), p. 149. Cf. 

also Practitioner, 1915, I., p. 240. 

98 IDtdcws Clrclee in SMseasc 

means of a Vicious Circle, the ulcer once formed 
increases the hyper-secretion and the hyperchlorhydria. 
This concatenation of phenomena may well explain 
the tendency of the ulcer to become chronic." 1 

The adhesions which so frequently form round 
the base of the ulcer are doubtless a provision of 
Nature to prevent perforation, or to localise the 
subsequent peritonitis, should the ulcer give way. 
Such adhesions, however, are by no means an un- 
mixed blessing, since they cause fixation of the 
ulcer, prevent its undergoing the contraction which 
is so necessary for repair, and thus delay recovery. 

Acute Gastritis. Acute gastritis is sometimes 
brought on through dietetic indiscretion, as for 
instance when unwholesome or excessive food has 
been taken. The result may be acute inflammation 
which checks digestion, and is followed by severe 
flatulence and fermentation which perpetuate the 

Ewald describes the sequence : 

" The impaired secretion and peristalsis give rise to 
inflammation of the mucosa, which in its turn further 
checks the gastric secretion and thus establishes a 
Vicious Circle in optima forma. Putrefactive and 
fermentative decomposition supervenes as an aggra- 
vating factor." 2 

Aerophagy. The habit of aerophagy or wind- 
swallowing as met with in neuropaths may be a 
self -perpetuating disorder. In some cases the eruct- 
ations consist of gas which has never passed beyond 
the oesophagus ; usually they are brought up from 
the stomach. The habit probably begins with an 

1 Debove, Achard and Castaigne, Maladies du Tube Digestif, 

I., p. 205. 
2 Eulenburg, Real-Encyclopadie der gesammten Heilkunde 

XIV., p. 258. 

Digestive System 99 

attack of flatulence which the sufferer discovers he 
can relieve by voluntary belching. The forced 
belching, however, while of some benefit, really 
aggravates the discomfort, and produces the sensa- 
tion of an object lying just behind the larynx. 
He therefore belches again and the habit may 
thus be indefinitely repeated. Indeed some persons 
are occupied all day long in rhythmic air gulping 
and eructation so as to be scarcely fit for decent 
society. More air may be swallowed than is expelled 
by eructation so that the stomach grows more and 
more distended. 1 

Mathieu and Roux describe the process : 

" Severe aerophagy generally shews itself in neuro- 
paths, and results from their predisposition and nervous 
temperament. Moreover in its turn it aggravates the 
neurasthenia or one or other symptoms of that disorder 
by means of one of those Vicious Circles that are so 
common in neuropathology. Many of the sufferers 
are inclined to worry about trifles or are subject to 
definite phobias. They dread the approach of an 
attack of aerophagy, and that is precisely what is 
likely to provoke a recurrence. Thus they tend to 
grow more and more neurasthenic." 2 

Other gastric disorders associated with neuroses 
are dealt with in chapter three. 

Parasitic Infection. Perversion of the appetite 
is sometimes produced, particularly in children, by 
the presence of the ascaris lumbricoides or one of 
the species of ankylostoma duodenale, the perverted 
appetite taking the form of pica or geophagy. 
Earth or even faeces may be eaten, and as the ova 

1 Air gulping occurs frequently in horses and cattle and may 
result in fatal wind-colic. The stomach may be so 
distended as to produce total obstruction. Wyllie, 
Edinburgh Hospital Reports (1895), III., p. 21. 

2 Pathologic Gastro-Intestinale, Series I. (1909), p. r85. 

ioo Oicious Circles in S)i0ea0e 

are excessively common in the soil this indulgence 
often increases the infection. In other words the 
infection excites the earth hunger and this perpetu- 
ates the infection. 

Geophagy is very common in Egypt and other 
countries where embryos and ova swarm in the 
soil. A single female ascaris is said to discharge 
60,000,000 ova. 

Another self-perpetuating process may be con- 
nected with the presence of the tsenia solium in the 
small intestines when the parasite sets up anti- 
peristalsis. Through this mechanism larvae may be 
returned to the stomach where the acid juice dis- 
solves the larval case and allows the parasite to 
regain the intestines. Thus a form of auto-infection 
may take place. 

The same sequence may occur in the life-history 
of the hymenolepsis nana, another tape-worm that 
is prevalent in Italy. 

The liver is closely associated with the other 
digestive organs both in health and disease. In its 
various disorders there is frequently a mutuality of 
cause and effect whose influence we have now to 

Congestion. There is some degree of hepatic 
derangement in almost all forms of dyspepsia. In 
slight attacks such as those included under the 
term biliousness the disorder is functional and 
rapidly subsides. 

In severe attacks there may be actual congestion 
resulting from, as well as aggravating, the disordered 
gastric and intestinal condition. 

Lauder Brunton thus describes the sequence of 
events : 

" Indiscretion in eating or drinking disturbs the 
digestive processes in the stomach and intestines ; 

Digestive System 101 

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 from the 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 engorge- 
ment 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." 1 

Congestion of the liver may also be associated 
with heart disease and in turn aggravate such 
disease. In the early stages of heart failure the 
liver may, owing to the interdependence of the two 
organs, give some relief to the heart by allowing 
some of the blood that would have overtaxed the 
cardiac chambers to accumulate in the capacious 
hepatic blood-vessels. But the hepatic functions 
and those of the portal viscera generally are apt, 
in their turn, to become deranged, and as a 
further consequence the cardiac failure is increased. 
Indeed death may occur as a result of a process 
which originally benefited the heart. Here is a 
good example of an organic Circle in which two 
interdependent organs injuriously affect each other. 

M. Bruce thus describes the later stages of such 
failure : 

" The da} 7 of reckoning has come. Bad has led to 
worse. A Vicious Circle is established : the penalty 
attending the accommodating process and the vicarious 
action by which one organ relieves another organ in 
distress. This result appears at first sight to be at 
variance with the self-adjusting, self-righting properties 
of the body. Instead of spontaneously recovering, one 
diseased organ is found upsetting other organs to its 

1 Disorders of Digestion, p. 25. 

102 IDtdoug (Ttrclee in SHseaee 

own further detriment, if for its own temporary relief. 
This must apparently be accepted as a primary or 
essential physiological necessity in connection with all 
complex organisations and structures. In physiology, 
just as in finance, mutual accommodation is invaluable 
and indeed indispensable, and it is often permanently 
as well as temporarily successful inasmuch as it affords 
time and opportunity for recovery of position. But 
the relation on which the employment of it depends, 
namely, the mutual dependence of associated interests, 
is liable to land us in widespread and hopeless ruin. 
In a word, Vicious Circles are one of the penalties that 
have to be paid for the many advantages of organisa- 
tion. The number and area of the Vicious Circles set 
up by disease are practically unlimited. The instances 
just given are striking examples, but a similar order 
of widening and deepening disturbances may be traced 
into all the great systems in disease of any moment : 
arrest of digestion, alimentation and elimination ; 
disorder of sleep ; interference with exercise and its 
attendant benefits, and so on." 1 

Biliary Calculus. The processes concerned in 
lithiasis are well illustrated by the formation of a 
biliary calculus, where the setiological factors include 
the stagnation of bile, bacterial infection and catarrh 
of the biliary passages. A nucleus of cholesterol is 
deposited, round which collect epithelial cells and 
bilirubin calcium. Such a nucleus, even though 
small, acts somewhat like a foreign body, causing 
irritation and desquamation of the mucosa, the 
products of which adhere to, and increase the size 
of, the nucleus. From increasing size result in- 
gravescent irritation and catarrh, and so the 
process is accelerated (jplatC V. c). 

MacCallum describes the sequence : 

" All gall-stones contain a great deal of organic 
material derived from desquamated epithelial cells and 

1 Principles of Treatment, p. 189. 

Digestive System 103 

coagulated albuminous matter as well as pigment. 
Many of them contain bacteria, and are formed in 
infected bile and within a gall-bladder which is in- 
flamed, because in this Vicious Circle the presence of 
the stone aids in giving a foot-hold to bacteria, while 
they in turn, through the inflammation they set up, 
aid in the growth of the stone." 1 

In some cases of cholelithiasis the calculus blocks 
the outlet of the gall-bladder like a ball- valve. 
Hence results an accumulation of bile, and the 
greater the accumulation the more tightly is the 
outlet plugged. 

Cholecystitis may also be self-perpetuating when 
the inflammation of the mucosa extends to the 
cystic duct and narrows its lumen. Such narrowing 
is then apt to lead to retention and putrefaction of 
bile, followed by increased narrowing, and so the 
process continues until obstruction is complete. 

Infective catarrh of the bile-ducts appears at 
times to excite a similar condition of the pancreatic 
ducts which then in turn reacts on the bile-ducts. 

Musser and Kelly write : 

" Infective cholangitis constitutes a Vicious Circle 
with chronic pancreatitis. The infection from the 
biliary tract involves the pancreas which in turn 
becomes swollen and indurated and creates more or 
less obstruction to the passage of bile down the common 
bile duct, which in two-thirds of all cases runs for a 
short distance through the head of the pancreas before 
piercing the posterior wall of the duodenum. As a 
result of this obstruction the infective phenomena in 
the biliary duct are furthered and each condition 
become mutually disadvantageous to the other." 2 

Pancreatic calculi and retention cysts develop in 

1 Text-Book of Pathology, p. 392. Cf. also Rolleston, 

Diseases of the Liver, p. 606. 
-Practical Treatment, IV., p. 697. 

104 \Dictou0 Circles In S>l0ea0e 

much the same way as do similar conditions in the 

Hepatic Insufficiency. In certain diseases such 
as acute yellow atrophy the hepatic functions may be 
gravely upset by toxic agents which endanger the 
structure of the hepatic cells. These cells may even 
undergo a process of self-digestion or autolysis 
resulting in the suppression of all the hepatic, especi- 
ally of the antitoxic, functions. The result is a 
cumulative increase of the toxic or cholsemic con- 
dition. The toxaemia and arrested antitoxic activi- 
ties aggravate each other and a fatal issue is not 

Monod writes : 

" By hepatism we mean a diathesis, hereditary or 
acquired, characterised by inadequacy of the liver cells. 
A Vicious Circle is thus created, the toxins set free 
reacting in turn on the cells of the liver. Disturbance 
of the intra-hepatic circulation follows, and, in sequence 
to this, there arises a like disturbance of circulation in 
the bowel." 1 

Wells has drawn attention to the reciprocal effect 

on each other of cholsemia and biliary obstruction- 

" Since bile salts cause haemolysis, and since in even 

haematogenous jaundice they enter the blood, it can 

readily be seen that in this way an increased formation 

of bile-pigment may be incited which leads to further 

obstruction to the outflow of bile from the liver, and 

a Vicious Circle may thus be established." 2 

This sequence of events, however, by no means 
always occurs. 3 

One form of cholaemia (acholuric jaundice) is 
caused by rapid blood destruction. This is fol- 

l Proc. Royal 5. of Med. (1913), VI. (i.), (Alimentary Tox- 

<zmia), pp. 180, 267. 
2 Chemical Pathology, p. 445. 
3 Parkes Weber, Practitioner, 1916, II., p. 145. 

H>tge0ti\>e System 105 

lowed by polycythsemia and this in its turn by 
further blood destruction. 1 The condition resem- 
bles that described under polycythaemia (p. 65). 

According to various writers eclampsia may at 
any rate be partly dependent on hepatic insufficiency. 
Probably there is reciprocation of cause and effect 
between hepatic and renal insufficiency, not only 
in eclampsia but in various toxic conditions. The 
condition has already been referred to on p. 68 2 

Other hepatic and renal correlations may be 
established when excess of uric acid in the blood 
has been caused by inadequacy of hepatic metabolism 
and is associated with calculous nephritis. For 
example, the liver under certain conditions fails to 
produce sufficient uricolytic enzyme to transform all 
the uric acid reaching it into urea. Consequently 
the excess of uric acid passes on to the kidney, 
where some of the acid may form calculous deposits 
in the renal pyramids, and give rise to a secondary 
chronic nephritis. The result will be a lessened 
internal renal secretion, and this in turn causes 
lessened uricolytic enzyme in the liver. 

Hepatoptosis. Ptosis of the liver is closely 
associated with general visceroptosis, the symptoms 
of the latter largely obscuring those of the minor 
displacement. Under normal conditions the visceral 
surface of the liver rests on a shelf formed mainly 
of the right kidney, colon, stomach and the first 
section of the duodenum and pancreas, this shelf 
being held in place by the abdominal muscles. The 
posterior portion of the liver is attached to the 
diaphragm by the meso-hepar, consisting of blood- 
vessels, connective tissue and peritoneum. 

1 Ward, Bedside Haeraatology, pp. 157, 220. 
? Wells, Chemical Pathology, p. 487. Cf. also Osier and 
Macrae, System of Medicine, III., 899. 

io6 iDtcioug Circles in ^Disease 

Under various circumstances, however, the abdo- 
minal walls become greatly stretched and weakened, 
with the effect that the support usually given to the 
shelf is lost. The liver consequently tends to rotate 
on the meso-hepar and to fall downwards and back- 
wards. The greater the relaxation of the abdominal 
walls the greater the tendency to hepatoptosis and 
vice versa. The sequence may also originate in 
excessive constriction of the thorax by the corset 
which dislocates the liver. Displacement of the 
liver in its turn involves some degree of interference 
both with the circulation of blood and of bile, and 
such interference must tend to increase the weight 
of the organ. 1 All the factors are aggravated by 
the almost invariably associated general viscero- 

The increased weight, stretched ligaments and 
disordered functions of a displaced liver are apt, 
as in the case of other displaced organs, to give rise 
to vague aches and pains, which, especially in 
neurotic persons, keep the attention constantly 
fixed on the displacement. Thus there is a con- 
stant repercussion between exaggerated sensitiveness, 
emotivity and consciousness which frequently ends 
in chronic invalidism. " A Vicious Circle is apt to 
be established owing to the inherent state of 
emotivity of the neurasthenic." 2 


Some of the circular reactions alluded to in con- 
nection with the stomach reappear mutatis mutandis 
in connection with the intestines. But a number of 

1 Experimental evidence of Biliary Obstruction in Floating 
I/iver is given by Steele, University of Pennsylvania 
Med. Bulletin (1902), XV., p. 424 

2 Mott, Lancet, 1918, L, p. 128. Cf. also Norris, Blood- 
Pressure, p. 180. 

Digestive System 107 

fresh examples result from the peculiar anatomical 
relations of the latter. 

One of the chief requirements for the health of an 
organism is that its conduits be free from obstruction. 
Everywhere does obstruction cause disorder, which 
varies from temporary discomfort to grave disease 
or even death. 1 The healthy organism possesses 
numerous mechanisms for the removal of such 
obstruction, such as vomiting, increased peristalsis 
and abdominal straining, and in minor degrees of 
disorder these mechanisms prove highly efficient. 
They are, however, of limited potency ; they 
often fail of their purpose, and it is a remark- 
able fact that such failure usually aggravates the 
primary disorder. Obstruction may be due to 
defective propulsive power, to narrowed conduits or 
to inspissation of solid or liquid matters in transit ; 
numerous examples of these conditions occur in con- 
nection with the digestive tract. 

Spasm. Excess of peristalsis sometimes takes 
the form of spasm due to irritation of the intestinal 
walls. The irritation produces spasm and the spasm 
in turn keeps up the irritation. Mansell Moullin 
thus describes the process as met with in cases of 
duodenal ulcer : 

"All that the pain really indicates is that there is an 
irritable hyper-responsive condition of the mucous 
membrane so that a stimulus which in ordinary cir- 
cumstances would produce only a normal result, calls 
into play a reaction which is not only excessive in 
amount, but which persists and continues so long as 
the condition is present. If this goes on, if the spasm 
and contraction are kept up, it ends in the establish- 
ment of a typical Vicious Circle, the increased respons- 

further details cf. Obstruction and its Vicious Circles, 
by J.B.H., Clinical /., 1915, I., p. 145. 

io8 iDictoue Circles tn Bieeaee 

iveness of the mucous membrane intensifying the 
muscular spasm, and the increased muscular spasm 
irritating the mucous membrane still more by crushing 
the tender surfaces together. It is the formation of 
this Vicious Circle that holds the secret not only of the 
symptoms that are present in what is commonly known 
as duodenal ulcer, but of the reason why they are 
relieved with such certainty and success by the oper- 
ation of gastro-enterostomy when all else has failed." 1 

The colon is another frequent seat of spasm, 
especially when coprostasis has caused irritation of 
the mucous membrane. Coprostasis may be both 
cause and effect of spasm : 

Mathieu and Roux write : 

" Not only does the spasm cause and keep up the 
constipation, but the constipation in its turn keeps up 
the spasm and the colitis." 

And again : 

" Under the influence of spasm faecal matters are 
retained in the intestine, which is thus kept in a state 
of constant irritation. This irritation then provokes 
painful manifestations and various reflexes, some of 
short, some of long circuit. Those of short circuit are 
confined to the intestinal walls, while the longer ones 
take a further route and involve the abdominal plexuses. 
These spasmogenic reflexes in their turn perpetuate the 
constipation and the intestinal irritation. Thus is 
formed a Vicious Circle, which, when once established, 
shows no tendency to disappear spontaneously." 2 

Displacement. The intestines are liable to vari- 
ous forms of displacement which may be a self- 

1 Lancet, 1912, I., pp. 564, 566. Cf. also Schryver and 

Singer, Quarterly J. of Med., VI., pp. 331, 337. 

2 Pathologic Gastro-Intestinale, Series I. (1909), pp. 149, 

442, 448 ; Series III. (1911), pp. 93, 303. Cf. also 
Schmidt, Klinik der Darmkrankheiten, p. 328. 

Digestive $6tem 109 

aggravating condition. A striking example occurs 
when the transverse colon descends into the pelvis 
forming an M-shaped loop. The longer the loop 
the greater the tendency to the accumulation of 
faeces, while the accumulated faeces favour further 
elongation and descent. In connection with such 
visceroptosis adhesions are apt to form at the various 
intestinal flexures, causing permanent kinking of the 
gut and aggravation of the stasis, as Arbuthnot 
I/ane has so frequently pointed out. 

Hernia presents another common example of 
displacement. Every time the gut descends the 
ring tends to enlarge, which enlargement facilitates 
a redescent of the gut. Further, a strangulated 
hernia frequently provokes vomiting and vomiting 
increases the strangulation (JMate V. d). 

Inflammation. Enteritis may also be self-per- 
petuating. The inflammatory condition leads to 
impaired peristalsis and this is followed by stasis, 
increased bacterial growth and further inflammation . 

E. von Ofenheim writes : 

" The question as to the effect of stasis on bacteria 
and of bacteria on stasis is interesting, for a Vicious 
Circle has repeatedly been proved to exist between 
them. Stasis causes bacterial poisons to be formed; 
these poisons again have a paralysing effect on the 
intestines, and in this way add to the stasis." 1 

The appendix is probably the commonest seat of 
enteritis. Here the inflammatory process is apt to 
cause some obstruction of the duct with a second- 
ary retention of secretions. Such retention in its 
turn aggravates congestion and obstruction of 
the duct. Progressive accumulation and congestion 
then result, until a completely closed cystic cavity 

l Proc. Royal S.of Med. (1913), VI. (i.), (Alimentary Toxa- 
mia), p. 326. 

no iDicious Circles in Disease 

is formed. 1 The retained matters also excite in- 
flammation of the muscular walls and diminish 
peristalsis, thus promoting further retention (flMftte 
V. e). 

Similar correlations may be associated with chronic 
appendicitis leading to fibrosis. 

Battle and Corner write : 

" Fibrosis of the appendix interferes with the com- 
pleteness of its peristaltic action, and as a result the 
tube will become incapable of emptying itself. By 
these means a Vicious Circle is established in that more 
pabulum remains within for the bacteria to flourish 
upon, and the more bacteria flourish, the more likely 
it is that chronic inflammation will progress, and the 
organ become still more incapable of performing its 
own evacuation. Such a condition may be called 
appendicular constipation. The inspissation of the 
contents will lead to the formation of an appendicular 
calculus or fsecal concretion, which may be likened to 
scybala elsewhere in the large intestine." 2 

The caecum is another region of the intestine 
which is very liable to inflammation, giving rise to 
typhlitis. At times the mischief may be due to the 
escape into the caecum of toxic matters from the 
appendix : 

Battle and Corner write : 

" The Vicious Circle results from the fact that the 
inflammatory condition will impair the contractile 
power of the caecum, and so lead to further bacterial 
growth and further chronic inflammation. In this 
way a colitis may be established throughout the whole 
length of the large bowel." 

a The process here described applies to many of the ducts 
of the body, e.g. the pancreatic duct, the bile duct, 
the salivary duct and intestinal diverticula. 

2 Surgery of the Diseases of the Vermiform Appendix, 
pp. 30, 38. Cf. also Stewart, Practitioner, 1910, I., 
p. 790. 


And again : 

" Owing to the pause of the products of digestion in 
the caecum, .... the fermentative processes initiated 
in the appendix will proceed to further stages in the 
caecum. As a result a secondary subacute or chronic 
typhlitis is started which leads to interference with the 
muscular action of the caecum and further retention of 
the contained fermenting faecal mass. In this way a 
Vicious Circle has been started, and the processes and 
their results may extend along the colon from segment 
to segment." 1 

Residents in the tropics are liable to a special 
form of chronic inflammation of the alimentary 
tract known as sprue or psilosis which is compli- 
cated by what Manson calls a " Vicious pathological 
Circle." The dominant factors are dyspepsia leading 
to malassimilation, with tissue starvation and de- 
struction. As a result of this lesion of the mucosa 
digestion and absorption are interfered with and 
result in further malnutrition which frequently 
terminates fatally. 2 

Obstruction. Mechanical obstruction has already 
been alluded to in connection with several disorders. 
But the same complication occurs in a variety of 
circumstances, as for example through simple inspis- 
sation of the faeces caused by unusual absorption 
of the liquid constituent. Moreover hardened faeces 
may give rise to faecal concretions which enlarge 
by further deposits, much as do biliary or vesical 

Mummery writes : 

" The longer faecal material is delayed in its passage 
along the colon, the harder will it become, owing to the 
absorption of water by the bowel walls : and the 

^xirgery of the Diseases of the Vermiform Appendix, 

pp. 30, 70. 
2 Allbutt and Rolleston, System of Medicine, II. (ii.), pp. 

550, 557- 

iDicious Circles tn Disease 

harder it becomes the less easily will it be driven on by 
peristalsis, so that a Vicious Circle is soon established." 1 

In many conditions of stasis some degree of hypo- 
thyroidism may be brought about through the 
absorption of bacterial toxins . Such hypothyroidism 
in its turn weakens nervous and muscular activity 
which is followed by further stasis. 
McCarrison writes : 

" The stasis once established may lead to subthy- 
roidism by the action on the gland of the toxic products 
of bacterial growth in the static bowel, or the abnormal 
processes of digestion may interfere with the efficient 
elaboration of the thyroid's secretion, thus reducing 
its physiological activity. A Vicious Circle is thereby 
established which in either event augments the thyroid 
defect as well as the stasis." 2 

Again faecal stasis is often associated with a great 
accumulation of gas which impairs the contractile 
powers of the muscular walls, and this impairment 
leads to further accumulation. The distention also 
perpetuates itself by diminishing the absorption of 
gases by the blood-vessels. 
Nothnagel writes : 

" As soon as the amount of gas present exceeds a 
certain limit, the intestine becomes distended, and this 
inhibits the absorption of gas by the blood-vessels of 
the intestinal wall. In addition the excessive distention 
impairs the contractile powers of the intestinal mus- 
culature. All three factors in their turn lead to the 
further accumulation of gas in the intestine. In this 
way a Vicious Circle which cannot be interrupted 
results, and causes the colossal meteorism occasionally 
seen in stenosis of the intestine." 3 

1 Diseases of the Colon, p. 219. 

2 The Thyroid Gland, pp. 138, 187. Cf. also Practitioner, 

1915, I., p. 66. 

3 Diseases of the Intestines and Peritoneum, pp. 140, 638. 

Cf, also Mummery, Diseases of the Colon, p. 35. 

Digestive System 113 

Another form of obstruction is due to intussuscep- 
tion, when the intestine is telescoped on itself and 
the intussusceptum excites active peristalsis in the 
intussuscipiens. The peristalsis in turn increases 
the length of the invaginated intussusceptum, cause 
and effect acting and reacting reciprocally on each 

Ascites. Attention has already been directed to 
the self-perpetuating character of effusion into the 
pericardial and pleural sacs. Peritoneal effusions 
may be similarily complicated. When they are 
caused by heart failure they may in their turn 
aggravate such failure and thus cause grave peril 
to life. Again ascitic effusion, by pressure on the 
renal veins, may impede the excretion of urine ; 
the impeded excretion further increases the ascites. 


Constipation. The most important process of 
reciprocation falling under this heading is that 
associated with habitual constipation, which is one 
of the commonest ills of civilized life. The dis- 
order may be congenital or acquired, local or consti- 
tutional, physical or psychical, trivial or fatal. No 
age, no sex, no occupation, no race, no country is 
immune. In brief, the disorder is of well-nigh uni- 
versal interest, particularly to the physician, the 
sociologist, the psychologist, the teacher. 1 

Some forms of constipation have already been 
alluded to in the previous section ; others are as- 
sociated with the rectum and the anus. In the 
first place must be mentioned the habitual disregard 
of the natural call, such disregard being followed by 
a progressive blunting of the associated reflex and 
by increased constipation. 

1 For further details cf . Vicious Circles of Habitual Constipa- 
tion, by J.B.H., Practitioner, 1915, II., p. 560. 

H4 Melons Circles in 

Again faeces, when unduly retained in the rectum, 
lose much of their contained liquid by absorption, 
and form dry and hard scybala. Their expulsion is 
difficult and the difficulty favours retention. 

Faecal stasis in the rectum, when persistently 
neglected, is apt to produce atony and dilatation of 
the rectum, conditions which aggravate the primary 
stasis. The dilatation thus induced may affect the 
whole circumference of the bowel ; in other cases 
the rectum becomes the seat of local pouching, 
more especially in old age. The pouching both 
results from and causes constipation. 

Nascher describes the process : 

" The weakening and waste of muscle fibres, whereby 
peristaltic activity is diminished, is frequently accom- 
panied by neglect of the aged to attend the call of 
evacuation of the bowel, and this last is the main 
cause of the dilatation of the colon and rectum, whereby 
pouches are formed. Here we see one of the many 
Vicious Circles which are found in old age. The dimin- 
ished elasticity of muscle permits dilatation of the gut, 
which consequently becomes rilled with fecal matter 
distending the bowel, this distension further stretching 
the fibres and impairing their elasticity." 1 

A similar condition may lead to the formation of a 
rectocele, such as is common in women. As the 
faeces collect in the sac caused by the bulging rectal 
wall, great straining at stool is required to expel 
the faeces. This straining increases the size of the 
pouch, leading to further lodgment and increased 

Dyschezia is another cause of habitual constipa- 
tion since it inhibits peristalsis and postpones expul- 
sive efforts. Such constipation may again increase 
the lesion which caused the pain. 

1 Geriatrics, p. 34. 

2>f<je0tiv>e System 115 

Robin and Dalche refer to some forms of dyschezia, 
which are met with in women : 

" A uterine displacement, a peri-uterine phlegmasia, 
a hsematocele, a salpingitis, a fibroid, etc., may act 
mechanically and give rise to constipation, which is 
followed by quite a number of dyspeptic symptoms. 
... On the other hand, constipation may itself do 
harm to a healthy uterus, and by means of a Vicious 
Circle may aggravate the uterine disorders to which it 
was primarily due." 1 

Iii neurasthenic persons the ovary, even when 
healthy, may become tender and cause pain when 
scybala pass over it. Such pain may then tempt a 
woman to postpone defalcation, with the result 
that her scybala get harder and cause more pain 

(BMate v. f). 

Spasm of the sphincter due to haemorrhoids or 
fissure is another cause of constipation which in 
its turn perpetuates those disorders. 
Ball writes : 

" As a result of the constant motion and distention 
and by the lodgment of particles of fseces in the rent, 
continued irritation is set up, which in turn occasions 
spasm of the sphincter. The spasm once started, the 
irritation is increased, and so a Vicious Circle is estab- 
lished, and the result is that the ulcer is never allowed 
to heal." 2 

Prolapsus Ani. There is frequently a mutuality 
of cause and effect in the case of prolapsus recti. 
Prolapse causes tenesmus and tenesmus increases 
prolapse. Prolapse also causes relaxation of the 
sphincter ; such relaxation favours prolapse. 

^raitement Medical des Maladies des Femmes, p. 18. 
Cf. also Schmidt, Klinik der Darmkrankheiten, p. 


-The Rectum and Anus, p. 131. Cf. also Treves, System 
of Surgery, II., p. 754. 

n6 tPickms Circles in S)tgea0e 

Edwards writes : 

" The more the bowel comes down, the more is the 
sphincter stretched and relaxed, and the increasing 
atony favours the repetition of the prolapse." 1 

Strangulation of Piles. Prolapsed piles some- 
times become strangulated and cause such irritation 
as to provoke spasm of the sphincter. The spasm 
increases the strangulation. 
Spriggs writes : 

" It is important to remember that whilst chronic 
constipation may cause piles, tender piles will, by 
making constipation painful, cause constipation." 2 

Oxyurides. A circular reaction may occur in 
persons whose rectum is infested with oxyurides. 
The itching and scratching at the anus lead to the 
helminths or their ova being caught under the 
nails, conveyed to the mouth or food, and swallowed 
by the host. From the stomach the ova reach the 
intestines and rapidly attain maturity. Thus the 
irritation ensures by auto-infection successive gener- 
ations of the parasite. Fertile ova are frequently 
discoverable under the finger-nails of the oxyuris 
host, and Cabot believes that fresh infection is an 
almost daily or nightly occurrence. 3 Possibly there 
may also be infection by an ascending current 
during the act of vomiting. 4 

Pruritus Ani. This forms a very troublesome 
neurosis especially in predisposed persons. The 
pruritus leads to scratching and the scratching 
intensifies the itching. 

As Treves says : 

" The itching is so intense that it is impossible to 

1 Diseases of the Rectum, Anus and Sigmoid Colon, p. 367. 

2 Practitioner, 1910, I., p. 628. 

3 Modern Clinical Medicine, p. 551. 

4 Debove, Achard and Castaigne, Maladies du Tube Digestif, 
II., pp. 306, 327. 

S>tge0ti\>e System 117 

avoid scratching, which, instead of giving relief, only 
adds to the trouble." 1 

This process of self-aggravation, however, is only 
temporary. A sense of satisfaction is also yielded by 
scratching and may culminate in a form of orgasm 
which ends in a state of depression and relief. 

The above regional description of injurious circular 
reactions may be concluded by a brief survey of the 
nervous, muscular or chemical mechanisms connect- 
ing the various portions of the digestive tract with 
one another and with other great systems of the 

The functional activities of the mouth, stomach, 
intestines, liver and pancreas are all linked together 
by reciprocally acting correlations, so that if one 
organ suffers all the others are more or less sympa- 
thetically affected. If unsuitable or badly-cooked 
food enters the stomach it may set up fermentation 
with the production of lactic and butyric acids, 
which irritate the gastric mucosa, provoke catarrh 
and cause an unhealthy secretion of mucus, which 
further hinders digestion. Moreover the excessive 
evolution of gases weakens peristalsis and this in 
turn induces stasis and more fermentation. Doubt- 
less the formation of the gastric hormone is also 

As a result of these disorders the intestines, liver 
and pancreas are subjected to abnormal reflex stimuli 
which disturb their physiological activities. The 
ingesta, as they reach the duodenum, are unprepared 
for intestinal digestion and absorption, and irritate 
the mucosa. The alkaline juices are unable to 
neutralise the normal acid secretions of the stomach 
when these are combined with lactic and butyric 
acid, so that the reaction of the food in the intestines 

1 System of Surgery, II., p. 793. Cf. also Hirschman, 
Diseases of the Rectum, p. 105. 

n8 IDictoug Circles in Disease _ 

continues acid instead of alkaline, and this results 
in irritation and disturbance of the processes of 
secretion. Bile is retained in the liver, instead of 
being poured into the intestine, and suffers in 
composition owing to the reflex irritation of the 
liver caused by the disorders in the stomach and 
intestines. The liver loses the power of arresting and 
destroying many of the toxins that reach it during 
the processes of digestion. These toxins therefore 
continue in the circulation and disturb the normal 
control of the nervous system over digestion. 

Further, owing to the loss of the antiseptic powers 
of bile, the pancreatic juice mixed with food rapidly 
undergoes decomposition, with the production of 
poisons such as skatol, indol and a variety of poison- 
ous alkaloids. These in their turn are absorbed and 
react injuriously on the processes of digestion. 
Doubtless also the production of secretin is dimin- 
ished with injurious reverberation. Thus cause 
and effect react ceaselessly on each other and 
explain the chronicity of many digestive troubles. 

But not only are there reciprocal correlations 
between the various digestive organs. There is 
also the closest synergy and sympathy between 
the digestive and all other systems, percussion and 
repercussion extending to the most intimate pro- 
cesses. Thus it is a matter of every day experience 
that the psychical state and digestive functions are 
inter-dependent. Disturbance of either may grie- 
vously upset the other. As Hippocrates long ago 
laid down in his famous aphorism : 

<ocrirep Totcrt SeVSpetriz/ rj yfj, ovrat rouri 
woiru> 17 yacrT^/o, " What the soil is to the tree 
that the stomach is to the animal." 1 

// Cf. also The Story of the Belly and 
the Members, as told by Shakespeare, Coriolanus, I. 

2>i$e0tive system 119 

It is on this relation of the digestion to the 
animal that many disorders depend. If digestion is 
out of order, the animal suffers. If the animal is 
out of health its digestion suffers ; here is involved 
the problem of nutrition in all its ramifications. 

The sensitive tissues of the nervous system might 
on a priori grounds be expected to suffer early 
where the sources of nutrition are curtailed through 
defective digestion, and such is found to be the fact. 
Impaired digestion quickly disturbs the nerve centres, 
and ill nourished nerve centres soon react on the 
digestive processes, these organs reciprocally embar- 
rassing each other. Worse still, if, in consequence 
of retention and decomposition of food, poisons 
are brewed and the blood which should nourish 
the nerve tissues is itself tainted. No wonder that 
under such conditions morbid interactions are set 
up which reverberate in many directions. Such 
interactions may be caused by disorder in any part 
of the digestive tract from the mouth to the anus. 
Everywhere may toxic conditions arise which injure 
the nervous tissues. Pyorrhoea, gastrectasis, copro- 
stasis are but a few illustrations of daily occurrence. 

Other reciprocal correlations exist between the 
digestive organs and the heart. For example, low- 
ered vitality resulting from chronic gastritis may 
lead to an irregular and weak cardiac action, which 
further interferes with digestion. Even an accumu- 
lation of flatulence may be a source of cardiac distress 
which reacts on equanimity and consequently on 
digestion. This is especially common where the 
heart is already unsound. 

Robin writes : 

" Gastric disorders are very apt to disturb the action 
of a healthy heart. All the more readily will they affect 
a diseased organ, even though the latter originally 
caused the dyspepsia. 

This Vicious Circle, as a result of which the diseased 

120 IPtctoug Circles in Disease 

heart gives rise to gastric disorders which in turn 
react on the heart, is exceedingly common, and many 
errors of diagnosis will be avoided if this fact is borne 
in mind." 1 

The respiratory functions may also be depreciated 
by disorders of digestion, the effect being especially 
injurious in children. 

Arbuthnot Lane writes : 

" The diminution in respiratory capacity which is 
brought about by indigestion in young people, is a 
matter of vital importance, and is a very material 
factor in lowering the activity of all the vital pro- 
cesses in the body. In the first instance deficient 
aeration and oxygenation result from serious alter- 
ations in the abdominal mechanics. Later a Vicious 
Circle is formed, the deficient aeration impairing 
digestion processes." 2 

These few illustrations must suffice to indicate 
some of the inter-dependences existing between the 
digestive and other systems of the body. The list, 
however, is far from exhausted ; for disorders of 
digestion are so closely associated with other dis- 
orders of the body that disturbance of the equili- 
brium existing between them radiates far and wide, 
cause and effect reacting continuously on each other. 

The study of these correlations throws fresh light 
on another aphorism of Hippocrates : 

'ZvfJiTTa.ffea TTOLVTO.' KOTO, [j.i> ovXo/xeAup TrdvTa, 
Kara /A epos Se ra eV e/caorw /ae/>et pepta TTOO? 
TO epyov. " The whole body sympathises with 
every member, and every member with the 
whole body throughout its structure." 3 

J I,es Maladies de 1'Estomac, p. 966. 

2 Operative Treatment of Chronic Constipation, p. 16. 

llepl Tpo<f>rj<s, 23. Cf. also I. Corinthians, XII., 26. 

Chapter Seven 


ISORDERS of the urinary apparatus pre- 
sent illustrations of organic, mechanical, 
neurotic and chemical forms of Vicious 
Circles, some of which possess consider- 
able clinical importance. 

We shall deal in order with : 
I. The Kidneys 
II. The Ureters 

III. The Bladder and Prostate 

IV. The Urethra 


The kidneys are the chief emunctories of the 
body and excrete large quantities of toxic and effete 
substances that result from physiological processes. 
The healthier the kidneys the greater their excretory- 
efficiency ; the greater that efficiency the healthier 
the kidneys will remain. In disease an excess of 
toxic materials of abnormal virulence is formed 
and thrown on to the kidneys for excretion, and 
such an increase of waste products within limits 
tends to increase the eliminating activity of the 
kidneys ; by means of this mechanism many dis- 
eases are self -limiting. 1 

1 A large number of diseases are self -limiting until a Vicious 
Circle supervenes and interferes with natura medi- 
catrix. Striking illustrations of such interference 
occur in nephritis, bronchitis, pleurisy, apoplexy, 
cardiac failure, tuberculosis etc. 

iDictous Circles in ^Disease 

It frequently happens, however, that such toxic 
and waste products tax the kidneys beyond their 
capacity, as a result of which they are retained 
in the blood where they further depreciate renal 
efficiency, and so the process is perpetuated. 

Nephritis. Such a mutuality of cause and 
effect is met with in various forms of nephritis. 
Toxins in the blood may produce nephritis and 
such nephritis keeps the blood toxic (JMatC VI. a). 
Retention toxaemia is added to the primary toxaemia. 
There may be slight renal impairment or total 
anuria according to the virulence of the poison. 
Cf. also p. 68. 

Adami writes : 

" Functional inadequacy of the kidneys is not with- 
out its effect upon the composition of the blood. The 
quantity of water eliminated may deviate considerably 
from the normal, and waste products may be retained 
instead of excreted. The quality of the blood is thus 
depreciated, and, being laden with toxic substances, 
it in turn exerts an irritating and deteriorating effect 
upon the kidneys. In this way a Vicious Circle is set up, 
as a result of which the condition of the patient goes 
rapidly from bad to worse." 1 

Destructive changes in the renal epithelium appear 
in some cases to cause a product of the internal 
secretion from the kidneys (renin) to be cast into 
the circulation and in its turn to further damage the 
renal tissues. 

ChaufTard and Ivaederich write : 

" There can be no doubt that certain alterations in 
the renal cells may give rise to toxic matters, which in 
their turn perpetuate these alterations and create a 

1 Principles of Pathology, II., p. 735. 

TBrinan> System 





- t 

\\ /' 










plate VI. Circles a00ociatet> witb the 
Iflrinari? Spetem, 

124 IDicious Circles in Disease 

true Vicious Circle, the effect of which is a more or less 
indefinite continuance of the nephritis. 1 

The swelling of the kidneys associated with many 
forms of nephritis is apt to interfere mechanically 
with the circulation and thus becomes a self-aggrava- 
ting condition. Total anuria may result and call 
for incision of the cortex. 
Fischer writes : 

" Vicious Circles are established in many organs 
when once the) 7 begin to swell. The swelling com- 
presses their blood supply and thus aggravates their 
already precarious state. Dehydration of the kidney 
by the salt restriction scheme of therapy may suffice 
to save it." 2 

After an attack of inflammation the kidneys are 
frequently prone to recurrence of the disease on 
slight provocation. Each fresh attack seems to 
injure fresh areas so that the disease, on each occasion, 
advances a step further. Increased susceptibility 
and recurrence act and react on each other, the 
kidneys becoming a locus minoris resistentice. 

According to Hare a circular reaction is often 
present in renal cirrhosis as a result of the associated 
vaso-constriction. This vaso-constriction leads to 
increased diuresis, thirst, increased ingestion of 
water and further diuresis. The increased amount 
of urine is the result of the circulatory changes 
instituted by the organism to maintain the ordinary 
rate of excretion. 

Hare writes : 

" There is on this view a distinctly appreciable and 
highly Vicious Circle in operation. The Circle comprises 

^rouardel et Gilbert, Maladies des Reins, p. 166. Cf. 

also Kolmer, Infection, Immunity and Specific 

Therapy, p. 505. 
2 (Edema and Nephritis, pp. 30, 613. 

1&rinan> System 125 

continuous vaso-constriction : deficiency of water in 
the tissues : thirst : increased ingestion of water ; and 
increased diuresis. The water drunk does not ade- 
quately relieve the thirst, since it fails, on account of 
the peripheral vaso-constriction, to flush adequately 
the tissues and thus to remove the essential cause of 
the thirst : in other words, the water drunk is largely 
short-circuited through the kidneys." 1 

Nephritis may also perpetuate itself when com- 
plicated by ascites, since the ascites interferes with 
the secretion of urine by pressure on the renal 
veins or on the ureters. Such interference in turn 
increases the ascites. 

Romberg writes : 

" Ascites may obstruct the escape of blood through 
the renal veins, and by thus retarding the circulation 
through the kidneys may diminish diuresis. An im- 
portant circulus vitiosus may be established in this 
way, unless the oedema and transudations can be got 
rid of." 2 

Again some forms of ascites excite thirst, the 
gratification of which may increase the dropsy. In 
the words of Horace : " Crescit indulgens sibi dirus 
hy drops." 3 

Movable Kidney. In neurasthenic persons, 
especially women, chronic ill-health may be associ- 
ated with a movable kidney. The over-sensitive 
nervous system renders the sufferer unduly conscious 
of the abnormal mobility, while tbe persistent ache 
renders the nervous system more and more sensitive. 

'Food Factor in Disease, II., p. 332. 
- Krankheiten des Herzens und der Blutgefasse, p. 282. 
3 Odes, II., 2. On the form of ascites alluded to by Horace 
cf. Parkes Weber, British Med. /., 1916, II., p. 200. 

126 IDicious Circles in Disease 

Indeed with a sensitive introspective individual the 
mere idea of possessing a floating kidney may become 
an obsession stirring up a host of subjective sym- 

Such undue mobility of the kidney is frequently 
associated with visceroptosis, the symptoms of the 
two disorders merging into one another. 

Hydronephrosis. Hydronephrosis is a serious 
lesion which may result from undue mobility of the 
kidneys, when nephroptosis leads to kinking of the 
ureter and renal vessels, followed by congestion and 
retention of urine and consequently by increased 

The origin of the ureter is normally at the most 
favourable part of the pelvis for the escape of urine. 
As the kidney descends, however, it revolves on a 
sort of pivot, leaving the uretero-pelvic junction at a 
higher level, so that the escape of urine is more and 
more impeded. 1 The condition indeed once started 
grows automatically worse ; the kinked ureter causes 
more and more obstruction to the escape of urine, 
while the increased weight of the kidney due to 
the venous congestion and retained urine aggravates 
the kink. The resulting hydronephrosis leads to a 
gradual disorganisation of the renal functions and 
to a destruction of the renal tissues (jplate VI. b). 
In course of time the whole gland may be destroyed, 
nothing but a thin-walled sac being left to mark 
the site of the original kidney. 2 

1 Kelly and Burnam give some illustrations showing the 

gradual change in the level 'of the uretero-pelvic 
junction. Diseases of the Kidneys, Ureters and 
Bladder, I., pp. 526, 531. 

2 In renal tuberculosis the gland may also be totally de-> 

stroyed by the operation of a Vicious Circle, 

1Hrinan> System 127 

In some cases the insertion of the ureter into 
the hilum may be abnormally high as to leave a 
pouch lying below the point of insertion and always 
full of urine. The pouch so formed may compress 
the ureter, causing further distension and further 
compression. Valvular folds and other abnormal- 
ities may lead to similar complications. 

According to Shattock hydronephrosis and poly- 
uria are sometimes associated with idiopathic dilata- 
tion of the bladder, the obstruction which has 
led to the hydronephrosis arising not from organic 
changes but from disordered innervation. After 
discussing alternative theories Shattock writes : 

" The pol3mria probably results from the hydro- 
nephrosis, and there being a persistent obstruction a 
Vicious Circle arises, in which the hydronephrosis brings 
about polyuria and the resulting polyuria brings about 
a further increase in the hydronephrosis." 1 

Similar idiopathic dilatation is met with in the 
case of the oesophagus, the stomach and the colon, 
the probable cause being in each case some neuro- 
pathic influence. 

Nephrolithiasis. Reciprocal conditions are 
established in connection with renal calculi, which 
originate with the deposition in the urinary passages 
of colloid or albuminous matters such as mucus, 
blood or pus. Within the meshes of this organic 
framework uric acid or other deposits are entangled 
and agglutinated into a nucleus, with consequent 
irritation of the lining membranes. This irritation 
then leads to further exudation of colloid matters, 
which in turn collect fresh deposits and provoke 
fresh irritation. In this way the process continues, 
while the stone gradually increases in size. On the 

l Proc. Roy. S. of Med. (1909), II, (iii.), (Pathology], p. 97. 

128 iptdous Circles in Disease 

other hand secondary calculi result from infective 
processes, generally associated with stagnation of 
the urine and precipitation of phosphates, the 
resulting concretion forming the nucleus of a calculus. 
From this point the process perpetuates itself 
automatically as described above. 

Much the same sequence occurs in cases of 
pyo-nephrosis complicated by a calculus. 

Morris writes : 

"The relation between renal calculi and pyo-nephrosis 
is a double one. On the one hand the calculus may be, 
and frequently is, the cause of the pyo-nephrosis, but, 
on the other hand, it may be secondary and arise from 
the phosphatic deposits of the alkaline urine in the 
renal cavity." 1 


Simple tubes such as the ureters are not so often 
associated with circular reactions as are complex 
organs. Moreover several of the ureteric disorders, 
e.g. those met with in nephroptosis and hydrone- 
phrosis, have been referred to in connection with 
disorders of the kidneys. 

There are however one or two additional ones 
which must be mentioned. 

Calculus. A renal calculus in its progress to- 
wards the bladder may be impacted in, and block, 
the ureter, setting up inflammation of the mucous 
lining. This inflammation may aggravate the ob- 
struction, and by causing stagnation of urine lead 
to an increase in the size of the stone through 
phosphatic accretion. 

If retained for a length of time the calculus may 
give rise to a diverticulum in which urine accumu- 

1 Surgical Diseases of the Kidney and Ureter, I., p. 446. 

System 129 

lates. This also leads to growth of the calculus and 
to progressive enlargement of the diverticulum. 

Dilatation. Matthews Duncan draws attention 
to a curious condition in which frequent micturition 
leads to narrowing of the vesical orifices of the 
ureters, followed by dilatation of the higher portions 
of the ureter. The narrowing in its turn perpetuates 
excessive secretion and frequent micturition, and so 
the process continues. 

Duncan writes : 

" In cases of diabetes insipidus the ureters are often 
found dilated, as also the kidneys. This curious cir- 
cumstance seems to be explained by some recent obser- 
vations which almost prove that the disease known as 
wetting of the bed in children is the cause in some cases 
of dilatation of the ureter and of the kidney, and of 
danger and even death. This wetting of the bed or 
frequent urination in children is far from being a com- 
plaint to be considered as altogether of trifling import- 
ance. In these cases retention in the ureter may occur, 
and it is explained by supposing that contraction of the 
bladder leads to the frequent urination, and also to 
closure of the vesical orifices of the ureters, produces 
dilatation of them, dilatation of the kidneys and danger 
of death. This theory will also apply to diabetes 
insipidus ; and if it is so, you have another example 
of the Vicious Circle. There is a large quantity of urine, 
which leads to frequent urination : frequent urination 
leads to obstruction of the ureters at their vesical 
orifices, and partial obstruction of the ureters leads to 
excessive secretion ; the excessive secretion requires 
frequent emptying ; the frequent emptying produces 
obstruction of the ureters ; and the obstruction of the 
ureters leads to excessive secretion, and so on." 1 

In other cases the opening of the ureter into the 
bladder may be abnormally small, impeding the 

Clinical lectures on Diseases of Woman, p. 82. 

IDicione Circles in Disease 

flow of urine, and giving rise to a sacciform dilatation. 
This dilatation may in turn further diminish the 
opening and thus complete the round. 


Cystitis. Cystitis may be complicated by various 
self -perpetuating conditions. One of these is the 
congestion and irritability of the neck of the bladder 
associated with increased frequency of micturition. 

Mansell Moullin writes : 

" The tissues become more and more swollen. The 
epithelium becomes abraded, or perhaps a small fissure 
is formed ; the neck of the bladder becomes the seat 
of an intense burning pain, which is made infinitely 
worse by the spasmodic contraction of the muscles 
around it, and a Vicious Circle is established. The 
irritation at the neck of the bladder causes increased 
frequency ; and the increased frequency makes the 
irritability worse, until at last the patient is reduced to 
a condition of the utmost misery." 1 

Decomposition of the urine is another self- 
aggravating factor, owing to the carbonate of 
ammonia which is formed and which increases the 

Leroy d'Etiolles writes : 

" In cases of phosphatic gravel, the urine is ammon- 
iacal, irritating and caustic to the mucous membrane 
of the bladder, the inflammation of which, by generating 
muco-pus, becomes in its turn a cause of alkalinity and 
of catarrh, forming thus a truly Vicious Circle in patho- 
logy, from which there is no exit without first altogether 
changing the composition of the urine." 2 

1 Enlargement of the Prostate, p. 125. 

2 Traite de la Gravelle, p. 510. Cf. also Pick and Hecht, 
Clinical Symptomatology, p. 599. 

1ftrinan> System 131 

Calculus. Some interesting reciprocal relations 
are established during the growth of a vesical 
calculus, whether such calculus has descended from 
the kidney or has been primarily formed in the 
bladder. If a small nucleus slips into a healthy 
bladder, the irritation usually causes the calculus 
to be surrounded with an envelope of mucus in 
which successive layers of crystals are deposited. 
The growth of the stone then proceeds in an acid 
medium, the film of colloid being ever ready to 
attract fresh crystals of uric acid (or other substance) 
from the urine by molecular coalescence, while 
the enlarging stone keeps up the irritation and 
causes more and more mucus to be secreted. 

Sooner or later, however, bacterial infection 
generally ensues, leading to cystitis. The film 
of mucus then becomes a nidus for the deposit of 
phosphatic accretions, and the growth of the calculus 
proceeds in an alkaline medium. The growing 
calculus increases the irritation, while the irritation 
leads to further deposits of phosphates, thus adding 
to the size of the concretion (plate VI. c). 

Retention of Urine. A striking example of a 
circular reaction is presented by retention of urine 
caused by prostatic hypertrophy. The venous plex- 
uses surrounding the prostate are always of ample 
size and undergo further dilatation in elderly men. 
This explains how it is that when an enlarged 
prostate is congested, a considerable increase in the 
size of the gland results, sufficient in many cases to 
cause complete retention. The pressure of the 
accumulated urine in turn aggravates the venous 
engorgement, these two factors acting reciprocally 
on each other. J. L,. Joyce has observed a marked 
diminution in the size of the prostate as soon as 
the bladder had been evacuated by catheterisation 

(plate vi. d). 

132 IDicious Circles in Disease 

Desnos and Minet thus describe the sequence of 
events : 

" The mechanism of the retention is clear. The 
rapid increase in size of the lateral lobes brings them 
into contact, the whole gland being compressed by 
the periprostatic plexuses. Further the congested 
and oedematous mucosa forms a plug which obstructs 

the neck of the bladder Meanwhile urine is 

accumulating behind the plug and distending the 
bladder. The pressure of the liquid in this reservoir 
aggravates the venous congestion, until the obstruction 
at the neck of the bladder becomes insuperable." 1 

In some cases of prostatic hypertrophy the 
enlarged middle lobe projects into the bladder like 
a cone in such a way that the contained urethra 
may be closed by pressure of the urine on the outside 
of the cone. The enlarged lobe may also fall over 
and close the urethral orifice like a ball-valve, as 
soon as the bladder contracts. The greater the 
straining to evacuate the bladder, the more tightly 
is the orifice closed ; the tighter the closure the 
greater the straining. 2 

Chronic retention frequently causes the trigone 
to yield under the continual pressure, giving rise 
to a thin-walled post-prostatic pouch. When once 
formed, this pouch leads to further retention of 
urine, to increased straining and eventually to further 
bulging. Occasionally the pouch has assumed di- 
mensions equal to those of the bladder itself. 

Maladies des Voies Urinaires, p. 411. Cf. also Guyon, 
Lecons Cliniques sur les Maladies des Voies Urinaires, 
II. p. 397 f. ; Fiirbringer, Die Krankheiten der 
Harn- und Geschlechtsorgane, p. 313. 

2 An illustration of such hypertrophy is given by Wallace 
in Practitioner', 1905, II., p. 305. Other self-per- 
petuating conditions are described by Frisch, Die 
Krankheiten der Prostata, pp. in, 140. 

Iflrinan? System 133 

Atony of the bladder is another occasional compli- 
cation, being due to over-stretching and consequent 
weakness of the vesical walls (jplatC VI. e). 

Lewis writes : 

" Prolonged or repeated retention, with overstretch- 
ing of the organ, from any cause whatever, results in 
weakening of the detrusor muscles, reducing their 
contractibility and producing the condition called 
atony ; while, on the other hand, atony itself contri- 
butes to further retention by reason of the inability of 
the weakened muscles to expel the urine. Thus is 
established a Vicious Circle that forms the intimate 
relation between the two conditions." 1 

Several artefacts may be created by the surgical 
interference that may be required in diseases of 
the bladder. 

For example, catheterisation is often an indispen- 
sable operation, although there is a risk of its 
increasing the existing inflammation. 

Thompson writes : 

" The cystitis, on the one hand, and the catheterism, 
on the other, exercise mutually inimical influences, and 
the patient becomes the victim of a Vicious Circle of 
actions, in which an absolutely indispensable remedy, 
the catheter, aggravates the inflammation of the bladder 
which therefore, in its turn,^demands the instrument 
with increasing frequency." 2 

Another complication frequently occurred in for- 
mer days when lithotrity was prolonged over several 
sittings. Cystitis necessitated lithotrity, while the 
resulting fragments of crushed stone increased the 

Surgery, IV., p. 299. 
Clinical Lectures on Diseases of the Urinary Organs, p. 147. 

134 IDtctoug Circles in Disease 

Guyon writes : 

" In former days when lithotrity was performed at 
short and numerous seances without chloroform, the 
fragments of crushed stone were left in the bladder. 
These more or less jagged fragments were often of 
considerable size and increased the irritation caused by 
the manipulations, which were done without any 
attempt at anaesthesia. Indeed the fragments caused 
far more irritation than did the original calculus. 
Attacks of cystitis followed, which were difficult 
either to avoid or to deal with, since they were directly 
due to curative treatment, and since their treatment 
always required a more or less considerable number of 
seances. There was no possible escape from this 
Vicious Circle." 1 

Neuroses. Irritability of the bladder is not 
an uncommon complication of neurasthenia and in 
turn perpetuates that condition. Thus there are 
persons who, in view of an imaginary inconvenience 
they may be temporarily exposed to during a long 
railway journey, go on for days previously mictura- 
ting every few minutes. They thus acquire a habit 
which may be permanent. 

Moreover the greater the frequency of micturition 
the more abundant the secretion of urine. Here 
also there is a reciprocity of cause and effect. Other 
neuropaths suffer from retention ; the harder they 
strain in order to pass their water the less they are 
able to do so. 

Such neurotic retention is doubtless due to an 
involuntary contraction of the compressor urethrae 
which totally prevents the flow of urine, and such 
retention in its turn increases the nervousness and 
incapacity. The condition is closely allied to stam- 
mering of the urinary organs which Sir James 

^a Vessie et la Prostate, p. 699. 

KHrinan> System 135 

Paget has described : 

" Stammering urinary organs are not rare ; and 
they may be known by observing, sometimes in the 
same person, the exact parallelism between the diffi- 
culty of expelling urine and that of expelling the air in 
the ordinary speech-stammering. The patient can 
often pass his urine without any trouble, especially at 
customary times and places ; and, when he does so, 
the stream is full and strong, and he has ' nothing the 
matter with him.' But, at other times, he suffers all 
the distress that he might have with a very bad urethral 
stricture. He cannot pass a drop of urine ; or, after a 
few drops, there comes a painful check ; and the more 
he strains, the less he passes ; and then complete 
retention may ensue, and over-filling of the bladder." 1 

Another neurosis due to exaggerated reflex irrita- 
bility is nocturnal enuresis. Some temporary de- 
rangement may start the habit, and this, if fre- 
quently repeated, may so act on the impressionable 
nervous system of a child as to persist after the 
removal of the exciting cause. 


Congestion. In acute gonorrhoea the mucous 
membrane may be so congested as to lead to retention 
of urine. Such retention in turn aggravates the 
congestion and so increases the obstruction. The 
more prolonged the retention the greater the swell- 
ing, and vice versa. The severe straining associated 
with tight strictures sets up a similar hyperaemic 
condition of the urethra which increases the stricture 

(plate vi. f). 

Urethral retention associated with uterine dis- 
placements is described in the next Chapter. 

Urethrocele. Strictures of the urethra are not 
uncommonly complicated by retro-strictural dilata- 

1 Clinical Lectures and Essays, p. 78. 

136 IDicious Circles in ^Disease 

tions. These dilatations contain decomposing urine 
and sometimes a calculus, and may be so situated as 
to press further on the strictured urethra and to 
provoke dysuria. Thus the dysuria is both cause 
and result of the dilatation. 

Urethroceles may also arise from catarrh of the 
urethra through relaxation of the walls and the 
gradual separation of muscular fibres. I/ittle by 
little the urine pushes aside the weakened tissues and 
forms a sac in which urine accumulates. Decom- 
position soon follows and tends to increase the 
urethritis. 1 

Thomas, Diseases of Women, p. 238. 

Chapter Eight 


HE intimate relations that exist between 
different portions of the sexual system 
as well as between the sexual and the 
other systems of the body would on a 
priori grounds lead us to expect the 
presence of morbid circular reactions in cases of 
sexual disease. Such in fact is the case. 

The two sexes will be dealt with separately. 


Masturbation. A common example is presented 
by neurasthenia associated with sexual malpractices. 
An exaggerated tendency to self-abuse is usually 
the result of a neurotic predisposition and in turn 
increases any existing nervous weakness. 

Oppenheim writes : 

" In many cases we have a Vicious Circle ; the 
tendency to masturbation is in itself a symptom of a 
neuropathic diathesis, and the masturbation again 
gives rise to a crowd of nervous disorders." 1 

Miiller also describes the process : 

" In neurasthenic persons of both sexes, especially 
if unmarried, there is a tendency to satisfy the sexual 
instinct by means of masturbation. Indeed it is 
often difficult to decide whether the masturbation 
should be regarded as a result or as a cause of the 
sexual neurasthenia, since a circulus vitiosus has 
generally been established." 2 

a Lehrbuch der Nervenkrankheiten (1913), II., p. 1486. (Eng. 

Ed., 1911, II., pp. 1125-6). 
2 Neurasthenic, p. i8r. 

138 IDtcioug Circles In 

The serious results of sexual malpractices are 
frequently seen in our lunatic asylums. Mental 
deficiency is unquestionably both cause and effect 
of such malpractices. 

Self-abuse may also result in physical disorders 
such as a chronic prostatitis and spermocystitis 
which maintain a state of erethism which favours 
an injurious degree of self-indulgence. In other 
cases there is a posterior urethritis and frequent 
spermatorrhoea, the two aggravating each other. 

The latter disorders are said to be especially due 
to congressus interruptus. 

Fiirbringer writes : 

" A condition of spermatorrhoea or of too facile 
pollution is almost invariably provoked ; moreover 
in addition to the sexual neurasthenia a chronic state 
of irritability of the posterior urethra is brought on, 
which gives rise to a circulus vitiosus." 1 

Sturgis lays emphasis on the same disorder : 

" There is a constant hankering for more inter- 
course. This inordinate desire gives rise to more 
frequent copulation, until hyperresthesia is set up in 
the prostatic urethra, which is sought to be relieved 
by more coitus, and thus a Vicious Circle is established. 
The more the patient copulates the more the irritation, 
and the greater the irritation the more the desire for 
coition." 2 

Spermatorrhoea. Injurious circular reactions 
also occur apart from self -abuse. Thus there may 
be an irritable condition of the nervous system 
which relieves itself too frequently by seminal 
discharges. Such excessive discharges frequently 
perpetuate the irritability. 

'Storungen der Geschlechtsfunctionen des Mamies, p. 41. 
2 Prostatorrhea Simplex and Urethrorrhea ex Libidine. 

/. of Cut. and Genito-U rinary Diseases, New York 

(1898), XVI., p. 270. 

Seyual System 








plate vii. circles associated with tbe 

140 lDtciou0 Circles in Disease 

Beard writes : 

" Occasional seminal discharges in the healthy and 
unmarried are physiological that is, they are not 
symptoms of disease. Such involuntary discharges, 
when excessively frequent, may be both results and 
causes of disease, indicating an abnormal, usually 
an exhausted, state of the nervous system, and in turn 
reacting on the nervous system, increasing the very 
exhaustion that caused it." 1 

There is also an element of hypochondriasis 
which complicates these disorders, and makes them 
difficult to cure. 

Paget thus describes them : 

" The patients are full of apprehension, unable to 
divert their minds from their sexual functions, con- 
stantly watchful of their sensations and making them 
constantly more intense. And further mischief follows 
from all this : for the direction of the mind to the sexual 
organs makes both them and the parts of the sexual 
system associated with them more and more irritable ; 
it increases the secretion of the seminal fluid and 
hurries its discharge. The mind thus multiplies the 
source of its own misery." 2 

Spermatorrhoea is often associated with insomnia, 
the two disorders reacting on each other. 

Holmes writes : 

" The emissions are most usually associated with, 
and probably result from, erotic dreams and images, 
which often disturb sleep ; and as the patient's mind 
may be at the same time worried by the emissions 
which he fears and of which he is ashamed, a definite 
insomnia may result. And as insomnia naturally 

1 Nervous Exhaustion, p. 70. Cf. also E. Jendrassik, 

Volkmann's Sammlung Klin. Vortrage (Innere Med- 
izin, 1906, No. 128-9. 

2 Clinical Lectures and Essays, p. 279. 

Seyual Spetem 141 

depresses his energies and lowers his resistance, a 
Vicious Circle is established, which can easily produce 
the intensest form of neurasthenia." 1 

Excessive irritability of the erection and ejacula- 
tion centres may be brought about by any local 
irritation along the genital tract, reciprocal relations 
being usually present. A common illustration of 
this is seen in gonorrhoea which renders the sexual 
centres unduly sensitive, while these latter in turn 
increase the hyperaesthesia of the urethra, especially 
of its prostatic and bulbous sections. 

Krafft-Ebing writes : 

" It must always be borne in mind that any peri- 
pheral irritation in the sexual tract of the male, what- 
ever the cause, . . . reacts on the ejaculation centre 
and induces a chronic state of increased irritability. This 
condition of irritability also spreads to the erection 
centre which is, both anatomically and functional^, 
so closely connected with the ejaculation centre. A 
circulus vitiosns is thus established, since the abnormal 
stimulation of the. erection centre gives rise in its 
turn to a peripheral hyperaemia and irritation, some- 
times even to ejaculation, which again reacts injuri- 
ously on the centres." 2 

Impotence. In the healthy individual there is a 
reflex physiological Circle formed by the reciprocal 
influence on each other of the central nervous system 
and the peripheral sexual organs, and on the har- 
monious operation of these correlations depends the 
potentia coeundi. Any psychical or physical disturb- 
ance of such correlations, on the other hand, may 
result in impotence ; for example, the fear of 
impotence may suffice to cause such disability. 

1 Practitioner, 1911, I., pp. 51, 53- 

2 Nothnagel, Sp'ecielle Pathologic und Therapie. Nervositat 

und Neurasthenische Zustande, by Krafft-Ebing, 
p. 191. 

142 IDtcioug Circles in 

Such fear is sometimes purely psychical and has 
no solid foundation ; in other cases a trivial disorder 
may arouse such a powerful obsession that the 
potentia coenndi vanishes. Over-anxiety defeats its 
end own, while on the other hand success breeds 

Morris writes : 

" vSome slight physical imperfection or want of 
general tone may give rise to a feeling of fear of impo- 
tence or of mistrust of self, or an exaggerated idea of 
the effects of past masturbation, or the memory of an 
unsatisfactory coitus may take possession of the 
mind, and an imaginary or false impotence will be the 
result. The mere thought that a sexual intercourse 
will be impossible or unsatisfactory is quite sufficient 
cause to make it so." 1 

Paraphimosis. Paraphimosis may be a self- 
aggravating disorder when the constricting ring of 
preputial skin and mucous membrane leads to venous 
engorgement of the glans, and this engorgement 
causes the ring to grow tighter and tighter. The 
strangulation leads to congestion and this in turn 
aggravates the strangulation (JMatC VII. a). 

Balano-Posthitis. Another circular reaction may 
be observed when the smegma under the prepuce 
is allowed to collect and decompose. Especially is 
this likely to happen where the orifice is narrow so 
that the prepuce cannot be readily withdrawn. 
An inflamed hypersemic condition of the mucous 
surface of the prepuce is then kept up which narrows 
the orifice more and more. The phimosis causes 
retention of the smegma ; the retention sets up 
balano-posthitis and increases the phimosis (JMatC 
VII. b). Preputial calculi occasionally form and 
add to the irritation. 

1 Injuries and Diseases of the Genital and Urinary Organs, 
p. 43. Cf. also Ziemssen, Cyclopaedia of the Practice 
of Medicine, VIII., p. 891. 

Sejrual System 143 

Corner writes : 

" The secretion decomposes and irritates both the 
glans penis and the prepuce, producing a chronic 
superficial balano-posthitis and a deeper chronic 
inflammation in the prepuce, causing its fibrosis and 
subsequent contraction on the glans penis. The 
meatus in it also becomes contracted so that it can 
no longer be withdrawn over the glans, and the secre- 
tions under it collect and ferment, producing further 
irritation. The greater the irritation of the glands by 
decomposing secretion, the greater the amount of 
secretion they produce. In this way a Vicious Circle 
is established." 1 

Varicocele. In varicocele the tortuous and depen- 
dent veins of the pampiniform plexus are enlarged, 
while the valves become incompetent and the walls 
of the veins thinned. The larger the veins the 
greater the tension on their walls ; the greater 
the tension the more do the walls yield. When 
the valves become incompetent a further aggravating 
factor is added (plate VII. c). 

Hydrocele. Hydrocele is usually attributed to 
a disturbance of the mechanism governing the 
secretion of fluid into, and the absorption of fluid 
out of, the tunica vaginalis. When the quantity of 
fluid secreted is increased, such increase may com- 
press the effluent lymphatics and so lead to a 
further accumulation. 

In other cases the blood-pressure in the spermatic 
artery may, owing to arterio-sclerosis, be unequal to 
the task of driving the blood through the veins. 
Hence may result a venous congestion of the testicle 
and from time to time a hydrocele, leading in turn 
to further congestion. 

Diseases in General Practice, p. 398. 

144 IDictoue Circles in Disease 


The sexual system plays an even greater role in 
the life of a woman than it does in that of a man. 
Indeed in the former the functional correlations 
between the genital organs and the central nervous 
system often colour her entire outlook on life. We 
should expect , therefore, that disease would awaken 
many reverberations echoing and re-echoing between 
such sensitive organs, and the facts correspond 
with the anticipation. 

Neurasthenia. Neurasthenia and local disease 
of the sexual organs very frequently perpetuate one 

Amand Routh writes : 

"We have frequently to deal with a Vicious Circle, 
with local and constitutional states so interacting, that 
no real improvement is possible until both the general 
and local states receive their due share of attention." 1 

Such a reciprocation may occur even in healthy 
females, leading a natural out- door existence with 
well-filled leisure and no undue tendency to intro- 
spection. But the disorder is far more prevalent in 
neuropaths with little to do and little else to think 
about than their own whims. General and sexual 
ill-health then form the commonest combinations, 
each disorder feeding the other. 

Faure and Siredey write : 

" Women suffering from disease of the sexual organs 
frequently shew signs of physical and moral depression 
which is closely allied to neurasthenia. Worn out by 
their sufferings, often anaemic through loss of blood or 
through prolonged confinement to the house, either in 
bed or on the sofa, these unfortunate women grow 
thin and feeble, and give way more and more to dis- 

1 Allbutt, Playfair and Eden, Gynaecology, p. 737. Cf, 
also Thomas, Diseases of Women, p. 56, 

Seyual System 145 

couragement. They are now entrapped in a Vicious 
Circle, from which escape is difficult. Their neura- 
sthenia induces dyspeptic disorders, and their mal- 
nutrition tends to aggravate their neurasthenia." 1 

This form of illness is especially apt to occur 
where there has been some physical or mental 
drain on the nervous system. For example, the 
excitement associated with parturition or such a 
local disorder as metritis, leucorrhrea, dysmenorrhcea 
or dyspareunia may start the morbid chain of events 
in which both the central and peripheral factors 
play a part. 

MacNaughton Jones writes : 

" All recent authorities agree that the nervous 
system can, through vasomotor effects and central ner- 
vous influences, induce ill-health and perversion of 
functions in the genitalia, causing, for example, amen- 
orrhcea, dysmenorrhoea and menorrhagia. The con- 
verse is equally true, that morbid states of the genitalia 
which lead to excess, diminution or absence of func- 
tional activity, will affect the ganglionic and central 
nervous system. This ' action and reaction' it is 
that, once the Vicious Circle is formed, maintains the 
ill-health of both." 2 

One of the commonest local disorders is hyperses- 
thesia of the ovaries. Owing to the lowering of the 
neuron threshold the woman is worried and kept 
awake at night by an ache which would not affect 
consciousness, were she less sensitive. Her worry 
and insomnia then perpetuate her hyperaesthesia 
and often render life a burden both to herself and 
others. The menstrual period usually aggravates 
the disturbance. 

x Traite de Gynecologic Medico-Chirurgicale, p. 396. 

2 Practitioner , 1911,!., p. 68. Cf. also Herman and Maxwell, 
Diseases of Women, p. 73 ; Rohin and Dalche, 
Traitement Medical des Maladies des Femmes, p. 27. 

146 IDicious Circles in Disease 

Herman and Maxwell write : 

" In chronic pelvic pain with neurasthenia effects 
follow one another in a Vicious Circle. The patient 
feels more severely the pelvic pain because her nervous 
system is too sensitive. The persistent pelvic pain 
keeps her nervous system weak and sensitive and further 
weakens it." 1 

Chlorosis. Chlorosis, although usually a cause of 
scanty menstruation, at times leads to menorrhagia 
and metrorrhagia, which in turn aggravate the 

Matthews Duncan writes : 

" When a woman is chlorotic she fortunately has 
generally amenorrhcea, but if not, she will be very 
likely to have menorrhagia. And you have here an 
illustration of a Vicious pathological Circle. The 
menorrhagia increases the chlorosis, and, vice versa,, the 
chlorosis aggravates the menorrhagia." 2 

Croom writes in the same strain : 

"These cases are amongst the most difficult to treat, 
because they interact in such a way as to produce a 
Vicious pathological Circle the drain on the system by 
the haemorrhage tending to aggravate the very systemic 
condition which, in its turn, leads to the menorrhagia." 8 

It is difficult to account for the menorrhagia when 
the body can so ill spare the loss of blood. Possibly 
the explanation lies in the increased volume or 
low specific gravity or coagulability of the blood, or 
in a faulty nerve control. 

Pruritus Vulvse. Pruritus vulvse is at times 
complicated by a circular reaction. The irritation 
may be purely nervous, but it is more often due to 

Diseases of Women, p. 79. Cf. also British Med. /., 

1910, I., p. 183. 

2 Lectures on the Diseases of Women, p. 124. 
3 Allbutt, Pla} r fair and Eden, Gynaecology, p. 85. 

Seyual System 147 

some local disease. In either case the severe itching 
leads to scratching, and the scratching abrades the 
skin and accentuates the itching. 

Gibbons writes : 

" Scratching produces temporary relief, and with it 
those changes in the tissues which themselves lead to 
scratching, so that a Vicious Circle is established. The 
scratching eases the itching for a time, but the very 
relief which is brought about is at the cost of minute 
changes in the which cause further scratching." 1 

Vulvitis associated with vaginal discharges may be 
complicated in much the same way ; the irritation 
and rubbing reciprocally provoke each other ; the 
disorder is specially common in young girls. 

Brocq writes : 

" The child experiences a more or less acute sense of 
burning and itching which compels it to scratch itself. 
The scratching merely serves to augment the inflam- 
mation." 2 

Allied to vulvitis is a condition resembling balano- 
posthitis in the male. If the smegma secreted by 
the vulvar or clitoridean glands is allowed to accum- 
ulate, decomposition, inflammation and excoriation 
of the mucous surfaces may result, leading to 
increased secretion and accumulation. 

Vaginismus. Vaginismus is another disorder due 
largely to an abnormal nervous excitability of the 
woman, combined with irritability of the external 
sexual organs. The general and local conditions aid 
and abet each other (JMatC VII. d). 

Robin and Dalche write : 

" It matters little whether the general state of health 
is the cause or the effect of the local condition, for the 
two react on, and aggravate, each other in a Vicious 

1 British Med. /., 1912, I., p. 471. 

2 Dermatologie Pratique, I., p. 348. 

148 Oicious Circles in Disease 

Circle. Treatment must be directed to the nervous 
system, to the dyspepsia, to any visceral ptosis,to the 
anaemia, in fact to the entire organism which is out of 
order. Only when this is done will the local treatment 
of the vulvar irritation prove efficacious and per- 
manent." 1 

Vaginismus is closely associated with dyspareunia 

which is often due to a slight laceration of the hymen. 

The difficulty of coitus causes more force to be used 

and as a result the hymen suffers further injury. 

Berkeley and Bonney write : 

" In patients such as these a dual condition exists, 
one physical and the other psychical. The orifice is 
undoubtedly tender the pain that results in attempts 
at intercourse abolishes the sex-sense and inhibits the 
flow of mucus which normally under the influence of 
sexual excitement should assist the act. In conse- 
quence, resistance efforts are made, both voluntarily 
and involuntarily, the chief of which consists in a 
spasmodic contraction of the levatores ani muscles 
(vaginismus) whereby the orifice is narrowed and the 
act rendered yet more difficult and painful. Thus a 
Vicious Circle is established, its inception depending 
upon the sensitive condition of the hymen." 2 

Displacement of the Uterus. A variety of 
self -perpetuating conditions occur in connection with 
displacement and congestion of the uterus, a disorder 
which may be caused in a variety of ways. The 
primary prolapse leads to congestion and this 
favours increased prolapse (plate VII. e). Especi- 
ally is such a sequence common if a woman returns 
to hard work soon after childbirth before the com- 
pletion of involution. Not only is the uterus bulky 
and heavy, but the ligaments are weak and relaxed. 

The further the uterus descends in the pelvis the 
greater will be the interference with the circulation 

^raitement Medical des Maladies des Femmes, p. 284. 
2 Gynaecology, p. 106. 

Seyual S0tern 149 

through its walls. Hence will result a persistent 
engorgement of its tissues ending in their hyper- 
trophy. Such hypertrophy keeps up the displace- 

Complete procidentia is especially injurious, since 
the veins of the broad ligaments are then so com- 
pressed that the return of blood is impeded, resulting 
in oedema and still greater weight. 1 

Goodell draws attention to reciprocal relations 
that may be established between the uterus, vagina 
and bladder, especially in connection with hyper- 
trophic elongation of the supra-vaginal portion of 
the cervix : 

"It is a Vicious Circle throughout ; the prolapsing 
organ say the vagina tugs at the bladder, which 
yields, and in turn lends its weight towards the further 
descent of the former by alternately coercing and being 
coerced ; their united action at last begets the circular 
hypertrophy of the cervix ; the latter returns the 
favour by edging and nudging on the vagina, which 
responds by still more increasing the prolapse of the 
bladder and the hypertrophy of the cervix, and by 
aiding them in drawing out the supra-glandular portion 
of the cervix. Thus the reciprocation is kept up until 
the constantly elongating and growing cervix has 
attained length and weight enough to act aggressively." 2 

In some cases such a hypertrophied cervix causes 
great vaginal irritation, acting much as if it were 
a foreign body and exciting expulsive efforts. Such 
efforts in their turn increase the descent and hyper- 
trophy. 3 

Again an elongated and protruding cervix may be 
so strangulated by the vulvar ring that the return of 
blood is obstructed ; the strangulation leads to 

Playfair and Eden, Gynaecology, p. 197. Cf. 
also Thomas, Diseases of Women, p. 383. 

2 Wessons in Gynaecology, p. 227. 

3 Barnes, Diseases of Women, p. 623. 

I 5Q Dtcious Circles in 2)tgease 

oedema of the cervix and this aggravates the strangu- 
lation. The resulting swelling may be so great that 
considerable force may be required for replacement. 1 
The condition somewhat resembles that of penis 
captivus described by Huhner. 2 

Salpingitis. When mucus or pus collect in the 
Fallopian tube, congestion and obstruction of the 
ostium uterinum are liable to follow, giving rise to 
hydrosalpinx or pyosalpinx. As the retained secre- 
tions undergo decomposition, further irritation is set 
up which aggravates the obstruction. In other 
cases a kink of the Fallopian tube is the primary 
cause of retention, followed by a greater weight. 
The greater weight increases the kink, and so the 
process continues, while the lumen grows steadily 
smaller, and the accumulation of secretion more 

Disorders of Pregnancy and Parturition. A 

mechanical disorder in which there is mutuality of 
cause and effect may be brought about when a 
retroverted gravid uterus is so impacted in the 
pelvis as to press on the urethra and cause retention 
of urine. The distended bladder increases the 
retro version ; the retro version increases the retention 

(Iplate vii. f). 

Matthews Duncan writes : 

" In cases of retro version of the gravid uterus the 
retention of urine is both cause and effect. In other 
words there is in this disease what is sometimes called 

a Vicious Circle The replete bladder increases 

the retroversion and makes it, for the time at least, 
incurable, and it was the retroversion that made the 
retention of urine by pressure on the urethra. So the 

x An illustration of this state of strangulation is given by 
Herman and Maxwell. Diseases of Women, p. 112. 
2 Disorders of the Sexual Function, p. 183. 

Seyual System 151 

first is the cause of the second, and the second is, 
inversely, the cause of the first, both combining to form 
a Vicious Circle. In this kind of retention there is 
frequently, and probably always, a kind of insipid 
diabetes present." 1 

Congestion of, and haemorrhage into, the decidua 
may also establish a pernicious circular reaction. 
Such haemorrhage is very apt to cause detachment 
of the decidua and this in turn promotes further 
haemorrhage. Abortion frequently results from the 
process, which is frequently associated with impac- 
tion of the gravid uterus. 

Kiistner writes : 

" The broad ligaments are twisted, . . . the thin- 
walled veins are compressed and their lumen diminished, 
resulting in congestion of the uterus. This congestion 
is probably the usual cause of the interruption of the 
pregnancy that so often takes place and of the abortion 
that so often follows spontaneously. The congestion 
leads to haemorrhages in the decidua. These, although 
slight at the outset, lead to further damage to tissues, 
and this in turn to further haemorrhage, until the Vicious 
Circle of a commencing abortion is established." 2 

Where there is a threatened abortion the portion 
of ovum that is first detached may act somewhat 
like a foreign body and provoke uterine contractions 
which cause further detachment and so on until 
abortion is complete. 

According to Fuchs a process of reciprocation may 
be observed in cases where an unusually large foetus 
is associated with partus serotinus or deferred 
delivery. The dimensions of the giant foetus compel 
almost complete physical repose of the mother 

1 Clinical Lectures on the Diseases of Women, p. 78. Cf. 

also Pouliot, Annales des Maladies Genito-Urinaires, 

1909, p. 5. 
2 Veit, Handbuch der Gynakologie, I., p. 248. 

IDicious Circles in Disease 

during the last weeks of her pregnancy, which 
repose further contributes to the foetal growth. 

Fuchs writes : 

" The primary dimensions of the foetus compel the 
pregnant woman to a life of complete repose while 
such repose promotes the further enlargement of the 
child, thus completing the circulus vitiosus." 1 

Asphyxia neonatorum is frequently complicated 
by what Lenzmann terms " a very grave Vicious 
Circle." This will be described in Chapter XVII. 

Uterine inertia after delivery sometimes per- 
petuates itself as a result of the secondary dis- 
tention of the uterus with blood. The condition 
is especially liable to occur if there is any neglect 
in the supervision of the uterus after delivery. The 
uterus may then fill with blood without there 
being any external appearance of haemorrhage and 
the inertia is thus maintained. 2 

Another post-partum complication may be associ- 
ated with uterine inversion, when the fundus is 
indented so as to project into the uterine cavity 
like a polypus. For the inverted portion may then 
provoke contractions which increase the inversion, 
the remainder of the process being completed by the 
uterus itself, which, so to speak, swallows the in- 
dented portion. 3 

Eclampsia is discussed on p. 68. 

1 Mtinchener med. Wochcnschrift, 1903, p. 1462. 

* Eden, Midwifery, p. 518. 

3 A similar process is sometimes observed when a submucous 
fibroid projects into the cavity of the uterus. Her- 
man and Maxwell, Diseases of Women, p. 313. 

Chapter IFUne 


NDER this heading will be described some 
pernicious circular reactions associated 
with constitutional diseases, including : 

I. Obesity 
II. Diabetes 
III. Rickets 


Obesity may be defined as the condition which 
results from long continued excess in the amount of 
food consumed over that katabolised ; it becomes 
pathological when it interferes with functional 
activity. In its severe form obesity tends to affect 
almost every function of the body, and, owing to 
what Dyce Duckworth calls the " Vicious Circle of 
malign events," spells disaster to its victim. For 
convenience sake disorders of the cardio-vascular, 
the respiratory, the digestive, the nervous, the 
muscular and other systems will be dealt with 
separately. 1 

(a) Cardio-Vascular Disorders 

Cardio-vascular disorders result from the extra 
strain thrown on the heart and the blood-vessels, 
and do much to aggravate the primary evil. In 

^or further details cf. Obesity and its Vicious Circles, by 

J.B.H., Practitioner, 1917, II., p. 164. 

154 IDidous Cirde0 in IDisease 

health the weight of the cardiac muscle is roughly 
in proportion to the weight of the body. In cor- 
pulence, however, this proportion is disturbed owing 
to the excess of adipose tissue, and an increased 
burden is imposed on the myocardium. In order 
to cope with this extra work the heart undergoes 
a beneficent hypertrophy, and under favourable 
circumstances can for many a long year meet the 
unusual demands made upon it. Sooner or later, 
however, the hypertrophied heart tends to insuffi- 
ciency, the time when such insufficiency manifests 
itself depending much on the mode of life. As the 
cardiac decompensation progresses, the left ventricle 
can no longer drive the whole of its contents into 
the aorta, and the familiar conditions of venous 
stasis gradually supervene. These unfortunately 
react on the heart, and the circular reaction of heart 
failure and venous stasis is established. 

The result is a serious interference with the activ- 
ities of life. Consciously or unconsciously such 
tasks as cause discomfort are avoided, and the 
muscular work accomplished is greatly diminished. 
This aggravates the primary evil. 

Von Noorden writes : 

" Obesity makes great demands on the functional 
activities of the heart and blood-vessels, leading to 
excessive strain and weakness. Conversely every 
primary cardio-vascular disorder cceteris paribus is more 
dangerous in a corpulent than in a thin patient. As 
a result of this injurious Vicious Circle a large pro- 
portion of corpulent persons sooner or later, slowly 
or rapidly, present signs of cardiac failure and chronic 
blood-stasis ; in the long run most stout persons die 
of cardiac failure." 1 

Not only does obesity affect the heart through the 
increased burden imposed ; there are other directly 

^ie Fettsucht, p. 30. 

Constitutional Diseases 


C,ard/a c 


\Auscu/ d/1 









plate viii. Circles assodatefc with 
Constitutional Diseases. 

156 IDicious Circles in Disease 

injurious effects. Fat may accumulate in the heart 
in two ways. In the first place there may be exten- 
sive deposits beneath the pericardium, along the 
auriculo- ventricular and inter- ventricular sulci, be- 
tween the strands of muscle and even beneath the 
endocardium; sometimes the weight of such deposits 
exceeds that of the muscular tissue itself. Fat may 
also be deposited in the mediastina and these deposits 
combine with those in the heart itself to interfere 
with the cardiac movements and aggravate the 
myocardial incompetence of the obese. In the 
second place in fatty degeneration fat is deposited 
as fine droplets within the cardiac muscle-cells. 
Hence results a weakened systole and a lessened 
power of resistance. These injurious effects of 
obesity are of course intensified when fatty infiltra- 
tion and degeneration co-exist. The associated 
symptoms appear earlier as well as in greater urgency 
and tend to aggravate the obesity. The corpus 
adiposum leads to the cor adiposum and vice versa 

(plate VHI. a). 

Much the same sequence is observed when some 
cardiac disorder supervenes in a healthy person. 
Such disorder obliges the cardiopath to renounce all 
laborious work, thus favouring the accumulation of 
fat, imposing a further burden on the heart and 
increasing the risk of failure. 

Von Noorden writes : 

" Cardiovascular disorders lead to corpulence, and 
the corpulence accelerates the cardiac failure, thus 
giving rise to a most pernicious Circle (verderbliche 
Wechselwirkung) ." l 

Arterio-sclerosis and chronic interstitial nephritis 
are frequent complications of obesity, and in time 
recoil on the heart and eventually on the obesity. 
The sclerotic changes are especially prone to invade 

1 Die Fettsucht, p. 98. 

Constitutional S>i0ea$e0 157 

and narrow the coronary arteries, leading to ischsemia, 
degenerative myocarditis and further weakening 
of the coronary circulation. 1 

Warfield writes : 

" The primary change is an increased tension in the 
arterioles which later leads to thickening of the coats 
of the vessels and to the other consequences of arterial 
disease. A Vicious Circle is thus established which 
has a tendency to become progressively worse." 2 

Such cardiac insufficiency greatly curtails all 
forms of physical exercise with the result of increased 
corpulence. The interference with the coronary cir- 
culation due to corpulence may in fact create two 
concurrent Circles, one of short (A), the other of 
longer circuit (B) : 


Impaired coronary Malnutrition of 

circulation * myocardium 

Feeble systole 


Impaired coronary Cardiac insufficiency 
circulation , 

i ' 

Increased corpulence ** Lessened physical 


Obese persons frequently suffer from anaemia, 
due to the lessened amount of haemoglobin associ- 
ated with decreased absorption of oxygen and a 

1 Kisch, Die Fettleibigkeit, pp. 116, 145. 
2 Arterio-sclerosis, pp. 87, 113, 163. 

158 IDtctoug Circles in Bisease 

slowing of the oxidation processes. The resulting 
symptoms are shortness of breath, giddiness, tinnitus, 
palpitations and a tendency to temporary anasarca. 
All these troubles tend to indolence and so favour 

(b) Respiratory Disorders 

Various respiratory disorders result from, and in 
turn promote, obesity. For example, the thoracic 
cavity may be encroached upon by fatty cushions 
in the mediastina and by the fatty enlarged heart ; 
the respiratory muscles and ribs may be overweighted 
with fat and unable to expand the thoracic walls 
efficiently; the diaphragmatic pump may be unequal 
to the task of forcing down the fatty viscera in 
the abdomen, which is itself encroached upon by 
extensive and unyielding accumulations of fat. 
Thus both the respiratory capacity of the chest 
and the respiratory movements of the lungs are 
restricted; the patient quickly becomes dyspnoeic 
on slight provocation. These conditions tend to 
shallow breathing movements, and the more super- 
ficial the respiration, the less the negative pressure 
in the chest, and the less the assistance given to the 
return of venous blood to the heart and to the 
pulmonary circulation. 

The shallower the respiratory movements the 
slower the rate of oxidation ; the fat-forming sub- 
stances are less perfectly burned up and are more 
largely deposited as fat, all these conditions being 
closely linked in reciprocal correlations. 

Increase of obesity is also favoured by the im- 
paired respiration leading to hypertrophy and dila- 
tation of the right heart with their influence on 
venous stasis and impeded oxygenation. 

Campbell writes : 

" Since obesity restricts both costal and diaphrag- 
matic movement, and at the same time curtails the 

Constitutional Diseases 159 

respiratory area, it necessarily impedes the circulation, 
causing the blood to flow with increased difficulty 
through the lungs. Hence the tendency to hypertrophy 
and dilatation of the right heart in the obese, and for 
the blood to be dammed back upon the great veins. 
The circulation being sluggish and the respiratory 
action curtailed, the further formation of fat is favoured. 
Thus fat begets fat." 1 

Feeble respiratory movements from these or 
other causes lead to defective nutrition of the lungs, 
since such nutrition largely depends on adequate 
movements ; impaired pulmonary nutrition in its 
turn tends to feeble movements. 

Another consequence of impaired movement and 
imperfect aeration is increased liability to bronchial 
catarrh, which tends to become chronic and further 
to impede oxygenation. The associated cough is 
less effective in expelling pulmonary and bronchial 
secretions. Chronic bronchitis and emphysema are 
frequent and self -aggravating sequelae. Corpulent 
persons are bad breathers. 

These pulmonary disorders curtail physical activ- 
ity. Every exertion that embarrasses breathing is 
gradually abandoned and such diminished exercise 
in its turn favours corpulence. 

(c) Digestive Disorders 

We may deal in order with the stomach, the liver 
and the bowels. 

In health an automatic self-regulating mechanism 
of great accuracy governs the daily imports and 
exports of the body. This mechanism leads the 
individual unconsciously to adopt a maintenance 
diet, i.e. the quantity and kind of food on which 
imports and exports are in equilibrium, and on 
which an average weight is maintained. 

1 Respiratory Exercises in the Treatment of Disease, p. 137. 

i6o \Diciou0 Circles in Disease 

Under various conditions, however, this mechan- 
ism is thrown out of gear ; appetite ceases to be a 
trustworthy guide, and more food is consumed than 
is required for the nutrition of the body. 1 

In obesity such a perverted appetite often leads 
to an excessive consumption of food. In fact bou- 
limia may accompany a strong conviction that 
the appetite is in no way abnormal. 

Again corpulence often creates a sense of exhaus- 
tion and the sufferer stuffs himself with food in the 
hope of obtaining relief. The result is in many 
cases gastrectasis with hunger-pain, followed by a 
ravenous appetite and further dilatation and obesity. 
This sense of exhaustion frequently leads obese 
persons to resort to alcoholic drinks, a remedy which 
is particularly insidious in such persons since the 
drinks are generally added to an already ample 
diet. Moreover alcohol promotes obesity through 
its ready oxidation ; it is a source of energy and 
a sparer of fat. According to von Noorden one 
grm. of alcohol, with a physiological value of 7 
calories, saves the body -75 grm. of fat or 1-7 grm. of 
carbohydrate. When it is remembered how many 
people take 50 grm. of alcohol a day and even much 
more, the important role played by alcohol in pro- 
moting obesity is evident. 2 Corpulence and alcohol- 
ism reciprocally favour each other. 

Craving for food is also largely dependent on 
habit. If the stomach is accustomed to a high 
degree of repletion a meal does not yield full satis- 

1 Obese persons need relatively less food than others. About 

26-36 calories per kilo, of body-weight suffice, in- 
stead of the normal 34-45 calories. This is due to 
the relatively small surface of their body, to the 
smaller loss of heat, to the fact that fat does not 
consume energy, and to the less amount of exercise 
usually taken. 

2 Von Noorden, Die Fettsucht, p. 28, 

Constitutional dieeaeea 161 

faction until the customary distention has been 
reached. Heavy meals tend to become habitual. 
As a result of boulimia some obese persons become 
plethoric, and not anaemic as occurs under other 
circumstances. Their blood is rich both in red 
cells and in haemoglobin; their circulatory and di- 
gestive systems are usually active. These con- 
ditions aid and abet each other. For some years 
such persons may enjoy robust health and unusual 
powers of work. There is, however, always a ten- 
dency to sclerotic changes and eventually to cardiac 

Martinet describes the correlations : 

" The over-nutrition leads to a state of plethora with 

its concomitants, and is associated with an abnormal 

activity of the vascular aud renal systems. The active 
. circulation excites more copious digestive secretions 

and these again maintain the over-nutrition. A Vicious 

Circle is thus established." 1 

The viscera are apt to become the seat of fatty 
deposits in obese persons ; such a condition tends 
to indolence and favours the increase of obesity. 
An excellent illustration of this is presented by the 
liver which may become greatly enlarged and weigh 
many pounds more than the healthy organ. The 
proportion of the fat may rise from the normal of 
1-4 p.c. of the hepatic tissue to 30 or even 80 p.c. 2 
Moreover as soon as the obesity has led to venous 
stasis, a fresh factor is introduced which affects the 
whole portal area, leading to increased weight of the 
body, impaired activity and further corpulence. 

Constipation is another complication resulting 
from, and in turn favouring, obesity. Peristaltic 
movements are impeded, the abdominal muscles 
are weakened and physical activity is lessened. 

^ressions Arterielles et Viscosite Sanguine, p. 226. 

2 Bouchard and Brissaud, Traite de Medecine, I., p. 424. 

162 iDictoiis Circles in Disease 

The progress of the intestinal contents is slowed, 

and a larger proportion of the ingesta is absorbed. 

All these factors aggravate obesity. 1 

Krehl thus sums up the cumulative effect of the 

various conditions : 

" These causes, singly or together, are responsible 
for most cases of obesity. It is merely a problem in 
arithmetic. A certain amount of energy is taken in 
the form of food, a certain amount is lost as heat and 
work, and the remainder is stored up in the body mainly 
as fat. As soon as the accumulation of fat begins to 
deter the patient from taking exercise, a Vicious Circle 
is established and he tends to increase in weight more 
and more." 2 

(d) Nervous Disorders 

Corpulence is frequently associated with a slug- 
gish nervous system, although this relation is by no 
means constant ; many obese persons are mentally 
and physically active and get through a large 
amount of work. 

Von Noorden writes : 

" Nervous and physical indolence often long precede 
corpulence, but they favour its onset and accelerate 
its progress. On the other hand the corpulence in its 
turn acts as an additional cause for indolence and 
inactivity." 3 

In other cases corpulence is independent both of 
excess of diet and of deficiency of exercise, and 

1 H. Lohrisch found that in a diet with an energy value of 
7,000 calories about 270 calories are lost in the 
faeces of a person with regular action of the bowels, 
while only 170 calories are lost in a constipated 
person. Deutsch. Archiv f. klin. Medizin, LXXIX. 
(1904), p. 383. Cf. also Medizinische Klinik, V. 
(1909), p. 439- 

2 Basis of Symptoms, p. 315. 

3 Die Fettsucht, p. 79. 

(tonstitutional Diseaaee 163 

results from retarded katabolism due to such con- 
ditions as hypothyroidism and hypopituitarism (en- 
dogenous obesity). The correlations are obscure, 
but it seems probable that hypothyroidism and 
hypopituitarism, possibly associated with some form 
of toxaemia, may in turn react on nervous functions, 
thus perpetuating the disorder. 

Many obese persons sleep abnormally long, even 
as much as ten or twelve hours a day. This excess- 
ive somnolence may be due to a chronic carbonaemia 
dependent on cardiac insufficiency, diminished respir- 
atory capacity or defective diaphragmatic activity. 
Whatever the cause, such somnolence favours cor- 
pulence since only about half as many calories are 
expended during sleep as during work. L,6bisch 
estimates that an obese person who, without other- 
wise changing his diet or mode of life, increases his 
hours of sleep from seven to eight adds 1043*9 grm. 
of fat during the year. From 8 '2-8 -5 grm. less 
CO2 per hour is excreted by a sleeping than by a 
waking person. 1 

Other complications are superadded when cor- 
pulence is complicated by cardiac insufficiency, 
since the voluntary effort required to keep up 
active habits involves heavy drafts on the reserve 
energy. The necessary strength of will is usually 
either lacking, or is exerted at such cost that exhaus- 
tion supervenes before enough muscular work has 
been performed to influence metabolism. The greater 
the sense of weakness the greater the effort required 
and the less can be accomplished. 

Various other nervous symptoms may be present, 
such as giddiness, tinnitus and muscse volitantes, 
all of which tend to lower self-confidence and impair 
physical activity. They are probably dependent 
on deficient blood-supply to the nerve centres. 

, Die Fettleibigkeit, p. 17. 

164 Dicious Circles in 2>teea$e 

(e) Cutaneous and Sexual Disorders 
Both the cutaneous and sexual systems are affect- 
ed by corpulence and the resulting disorders may 
aggravate the primary trouble. For instance, de- 
posits of subcutaneous fat diminish the amount of 
heat given off by radiation and conduction, and 
conserve the body heat. The result is a lowered 
metabolism of heat-producing materials and a 
tendency to increased corpulence. A further effect 
is sluggishness of the heat-regulating mechanism. 
The superficial area of the body is smaller in a 
corpulent than in a spare person in proportion to the 
weight ; this tends to check the loss of heat, while 
pyrexia is more obstinate and involves greater peril. 
On the other hand under the influence of muscular 
exercise or of emotion, perspiration and evaporation 
are more active in obesity. Many corpulent persons 
are like Falstaff " subject to heat as butter .... in 
continual dissolution and thaw." 1 Unfortunately, 
however, such profuse perspiration leads to much 
discomfort and diminishes inclination for exercise, 
thus tending to increased corpulence and hyper- 
hidrosis. 2 

Hewlett writes : 

" The outlook for a spontaneous cure of obesity is 
not good. As obesity increases the avoidance of exer- 
cise becomes more and more necessary, on account of 
the increasing tendency to sweating and the shortness 
of breath on exertion. A Vicious Circle is thus estab- 
lished, for the increasing weight limits the exercise, and 
the limited exercise tends to increase the weight." 3 

This liability to profuse perspiration is specially 
marked in moist warm climates such as are often 

1 Merry Wives of Windsor, III., v. 

2 Von Noorden gives a table shewing the great difference 

in the amount of perspiration in thin and stout 
persons. Die Fettsucht, p. 114. 
3 Musser and Kelly, Practical Treatment, III., p. 52. 

Constitutional Diseases 165 

found in the tropics, and accounts for the inability 
of stout persons to undertake physical exercise. 
At times the excessive moisture causes maceration 
of the skin of the soles and tenderness of the feet. 
Walking becomes painful and this favours progressive 

Fat women sometimes suffer from vulvitis and 
excoriations of the nymphse which may be associated 
with difficulty in the removal of smegma. Such 
vulvitis may cause exercise to be restricted within 
the narrowest limits. 

The excretion of fat via the sebaceous glands is less 
active in corpulent than in normal persons, if some 
observations by L,eubuscher are to be relied upon. 
This factor must tend to perpetuate obesity. 1 

The sexual appetite is distinctly lowered in obese 
persons according to Dyce Duckworth. 2 On the 
other hand inertness of the sexual organs may in its 
turn favour the deposition of fat ; this correlation, 
however, is by no means a constant one. 

(f) Muscular Disorders 

Important correlations connect corpulence with 
the muscular system. 
Adami writes : 

" The accumulation of fat in the tissues, when ex- 
treme, hinders activity, and, doing this, brings about 
diminished oxidation, thus setting up a Vicious Circle." 3 

During the earlier half of life increase of fat appears 
usually to lead to an associated growth of muscle 
fibre. But this beneficent relation ceases as the 
years roll by, and muscular development no longer 
keeps pace with advancing adiposity. On the 
contrary the obese person needs to expend greater 

'XVII. Kongress f. innere Medizin (1899), p. 457. 
2 Allbutt and Rolleston, System of Medicine, IV., p. 493. 
8 Principles of Pathology, I., p. 379. 

166 iDicious Circles in Disease 

effort in the performance of physical work, conse- 
quently he tires more easily and seeks to avoid 
exertion. The more he weighs the less he exercises ; 
the less he exercises the more he weighs (JMatC VIII. a). 
Gilford describes the correlation : 

" Muscular correlation is sometimes very defective, 
especially when fatness sets in after middle age, when 
the muscular system is no longer able to rise to the 
occasion. A Vicious Circle is often established. The 
tired muscles insist upon rest, but more rest means 
more fat, and so the inadequacy of the muscles is still 
further increased." 1 

As a rule the muscular system, both voluntary and 
involuntary, is under-developed and weak in stout 
persons, who too often neglect to take the exercise 
which is so necessary if the tendency to corpulence 
is to be checked. 

Von Noorden writes : 

" As a rule stout persons do not exercise their muscles 
sufficiently to bring those muscles and the myocardium 
into relation with the demands made on them by the 
increased weight of their body. Even if they try to 
do so, their weight frequently increases so rapidly that 
the adaptation of the voluntary muscles and still less 
of the cardiac muscle cannot keep pace with it. More- 
over in the case of those numerous persons whose cardio- 
vascular system is'naturally somewhat under-developed, 
the progressive adaptation of the heart ceases at an 
early age. Here then is a form of circulus vitiosus. 
Persons with a feeble circulatory system give up active 
habits at an early age (i.e. soon after the close of adoles- 
cence) and pave the way for obesity (exogenous obesity 
from inactivity). The further this advances (many 
conditions may contribute), the greater becomes the 
maladjustment between the vigour of the heart and 
the weight of their body." 2 

Disorders of Post-Natal Growth and Development, p. 515. 
This Circle is illustrated by J . S. Kellett Smith. The 
Cure of Obesity and Obese Heart, p. 64. 

2 Die Fettsucht, p. 85. 

Constitutional SHaeaaee 167 

Even more serious is this condition in elderly 
persons whose recuperative powers are greatly re- 

Von Koranyi writes : 

" When in elderly persons changes and disorders 
of the organs of locomotion, of circulation, of respira- 
tion and of the nervous system lead to diminished 
exercise and consequent obesity, a Vicious Circle is 
established. For such increase in weight leads in 
turn to further restriction, loss of power of locomotion, 
and to progressive disorder of the circulation and re- 
spiration." 1 

In advanced cases of obesity the unusual efforts 
required by the lumbar and sacral muscles in order 
to maintain the erect posture induce persistent 
back-ache which interferes much with locomotion 
and leads to an indolent life on the sofa. Some- 
what allied to these incapacitating conditions are 
sprains, muscular stiffness and flat foot. Flat foot 
frequently results from, and aggravates, obesity. 
There is also " the obese patient with enlarged, 
grating and painful knee joints, which limit activity 
and so help to complete a Vicious Circle." 2 


Diabetes may be complicated by several self- 
aggravating conditions. 

In some forms of the disease the ingestion of 
sugar diminishes the power of the diabetic to split 
up the molecule of glucose. Thus the consumption 
of a definite quantity of sugar may lead to the 
elimination in the urine of a larger quantity than has 
been consumed. In other words the increased 
glycsemia reduces the power of burning up sugar. 

Allen has proposed to use this observation as a 
means of distinguishing diabetes from glycosuria, 
and has formulated the following law : "In normal 

1 Schwalbe, Lehrbuch der Greisenkrankheiten, p. 719. 
2 Kellett Smith, The Cure of Obesity and Obese Heart, p. 62. 

168 IDicious Circles in Disease 

individuals the more sugar is given the more is 
utilised, while the reverse is true in diabetes." 

Another circular reaction may be established as a 
result of inadequate nutrition in cases of severe 
glycaemia. Metabolism may indeed be so greatly 
disturbed that the administration of carbo-hydrates 
is required in order to prevent rapid inanition. 
The carbo-hydrates in their turn intensify the glycse- 
mia and increase the inanition which requires further 
administration of carbo-hydrates (JMatC VIII. b). 
In these cases the amount of carbo-hydrate that can 
be utilised must be carefully ascertained so that 
the patient receives this amount and no more, other- 
wise the glycosuria may actually be aggravated. 
Pick and Hecht thus allude to this process : 

" Strict individualisation and constant regulation of 
the diet, with control of the general symptoms, and 
exact quantitative determination of the urinary con- 
stituents, often permit us to avoid the dangers of this 
Vicious Circle." 1 

Many physiologists hold that there is a constant 
tendency of the liver to convert glycogen into sugar 
through the action of a diastatic or glycogenolytic 
ferment, which tendency is held in check by an 
inhibitory mechanism controlled from a centre in 
the floor of the fourth ventricle. If this is so, it 
seems not unlikely the nutritive disorders resulting 
from chronic diabetes may weaken this inhibitory 
mechanism and perpetuate the glycosuria. On this 
theory the gradual increase of diabetes would also 
be explained. 

Again in cases of chronic hyperglycsemia the 
kidneys lose somewhat of their fine sensitiveness to 
increase in the blood sugar, and the degree of 
hyperglycsemia tends to rise progressively. 

Rickets is believed to be due to defective and 

1 Clinical Symptomatology, p. 592. 

Constitutional SDtgeaseg 169 

perverted nutrition, mainly caused by an insufficient 
supply of animal fat and of earthy salts in the form 
of phosphates, combined in many cases with a 
shortage of animal protein. The result is a general 
disorder of a large number of the tissues and struc- 
tures of the body, including the nervous, respiratory, 
digestive, haemopoietic and muscular systems. These 
disorders acting cumulatively aggravate and perpet- 
uate the processes of malnutrition. The sequence of 
events doubtless varies under different circumstances. 
At times the digestive system is chiefly disturbed, 
leading to fermentation, flatulence and catarrh of the 
digestive tract, which seriously affect assimilation 
and intensify the primary disorder (JMatC VIII. c). 

In other cases the liver and nervous system bear 
the brunt of the disorder. 
Pritchard writes : 

" The pathogenesis of the disease thus defined must 
be regarded as a Vicious Cycle of events in which each 
individual link in the chain acts and reacts on the 
others. In describing this Vicious Cycle it is difficult 
to know at what point to begin ; indeed, in the pro- 
duction of rickets there is no starting-point ; the 
disease may start in a variety of ways. 

The Vicious Cycle may be briefly described as consist- 
ing of an inefficient liver associated with a disturbed cen- 
tral nervous system acting and reacting on one another. 
These are the two pathological pivots on which, 
according to my view, the symptoms mainly hinge. 
The liver may be primarily damaged by faulty 
methods of feeding, from abuse of its functions, or from 
overwork, or it may be inherently or congenitally weak. 
As a rule there is first indigestion, with the formation of 
toxic products of indigestion, then efforts on the part 
of the liver to oxidize or destroy these products, then 
collapse or failure of liver function with the escape of 
these unoxidized products into the general circulation, 
and finally poisoning of the nervous system itself. 

Poisoning of the nervous system, from whatever cause 
induced, not only intensifies the liver inefficiency by 
interfering with its nervous mechanism, but it also 

170 Dicious Circles in disease 

leads to incapacity of other furnaces in the body, and 
herein lies the essence of the Vicious Cycle of events." 1 
The respiratory mechanism is especially involved 
in some forms of rickets. This mechanism is always 
functionally weak, and where the ribs are much 
deformed a line of depression may be seen running 
transversely across the chest from the lower end of 
the sternum, and corresponding roughly to the line 
of attachment of the diaphragm. Even in ordinary 
inspiration and still more when there is any obstruc- 
tion to breathing the chest may be drawn in during 
inspiration along this line, thus interfering with 

Beneath this line patches of collapsed lung are 
often found, and such collapse by producing dys- 
pnoea may lead to further drawing in of the ribs 
and thus aggravate the collapse. This sequence is 
frequently observed in the bronchitis which is so 
frequent a complication of rickets (plate VIII. c). 
Still writes : 

" Bronchitis is very frequent in rachitic children 

and this tendency is favoured, in severe cases, by the 

softness of the ribs and the weakness of the respiratory 

muscles. There is, in fact, a Vicious Circle. For 

mechanical reasons the lung is very imperfectly filled 

with air and the collapse thus induced favours the 

occurrence of bronchitis and hence further collapse." 2 

The thoracic deformity of rickets appears at times 

to be not merely a result of softening, but also a cause 

of further softening owing to the continued irritation. 

McKenzie writes : 

" It is a well-recognised fact that the rickety deform- 
ity manifests itself most in those parts exposed to 
mechanical strain. The mechanical strain produces 
a deformity in the first place and in the second excites 
further rachitic softening by its irritation, thus pro- 
ducing for a time a Vicious Cycle of events." 3 

x The Infant, p. 234. 

2 Osier and Macrae, System of Medicine, I., p. 884. 

3 British Med. /., 1911, I., p. 930. 



ISORDERS associated with the eyes may 
conveniently be discussed under the 
following headings, although the classi- 
fication cannot always be strictly adhered 

to : 

I. The Eyes 

II. The Eye-lids 

III. Errors of Refraction 

IV. Neuroses 


Conjunctivitis. Conjunctivitis gives rise to 
various secondary conditions which perpetuate the 
conjunctivitis. One of the commonest of these 
is blepharospasm which may accompany any form 
of conjunctival inflammation. By its means irri- 
tant secretions are pent up and their retention 
perpetuates the irritation. 

Perhaps the severest form of blepharospasm is 
met with in the phlyctenular conjunctivitis of 
children. The lids are kept tightly closed for hours 
together, thus retaining the discharges in prolonged 
contact with the inflamed surfaces. Moreover the 
exclusion of light renders the retina more and more 
sensitive, and this factor also tends to intensify 
the blepharospasm. 

In some forms of conjunctivitis the discharges are 
highly virulent, as for example in ophthalmia 
neonatorum and gonorrhceal ophthalmia. The irri- 
tating secretions may also be confined under consider- 


172 IDicious Circles in IDisease 

able pressure and such pressure increases their 
deleterious action. 

Blepharospasm may also be associated with 
entropion which causes the inturned eye-lashes to 
irritate the inflamed conjunctiva and thus to per- 
petuate the ophthalmia. Such a condition is not 
uncommonly seen in children when a foreign body 
has lodged in the eye. 

Other reciprocally acting conditions may com- 
plicate granular conjunctivitis or trachoma. The 
granulations are stated to be both cause and effect of 
the inflammation, each disorder contributing to the 

Burnett writes : 

" There has always been a question as to whether 
the granulations are the cause or the result of the 
inflammation. From the fact, however, that they 
have been found in eyes which have not been inflamed, 
it would appear more likely that the inflammation is 
not the first step in the process, though undoubtedly 
the inflammation, when it is once set up, facilitates its 
progress and encourages new deposits, and thus a 
Vicious Circle is completed." l 

Conjunctivitis frequently depreciates the general 
health and thus delays recovery . For example, phlye- 
tenular conjunctivitis is prevalent in ill-nourished 
strumous children who in order to escape all light 
remain indoors in darkened rooms, and bury their 
faces in cushions or under shawls. The seclusion 
from light, air and exercise lowers the already 
depressed nutrition and aggravates the disease. 
Again gonorrhoeal conjunctivitis is often associated 
with extreme physical and mental depression caused 
by remorse and the anticipation of blindness. Such 
fears naturally lower vitality and retard processes of 

Morris and Oliver, System of Diseases of the Eye, III., 
p. 209. 








plate ix. Circles aesociateb wttb 

174 tDicioue Ctrclee in Disease 

Keratitis. Some of the circular reactions de- 
scribed in connection with conjunctivitis apply to 
keratitis. In fact conjunctivitis and keratitis are 
intimately associated, and the influence of blepharo- 
spasm in causing retention of secretions is equally 
injurious in both disorders. 

Trichiasis due to entropion is especially dangerous 
when there is ulceration of the corneal surface, since 
the usual epithelial protection is lost. 

Lawson writes : 

" The corneal inflammation causes great pain with 
photophobia and lachrymation, owing to which the 
patient keeps his eyes convulsively closed (blepharo- 
spasm), and by so doing causes a still greater approxi- 
mation of the incurved lashes to the cornea, and 
establishes a Vicious Circle. If the condition is not 
relieved by artificial means matters will go from bad 
to worse, and in time the sight will be completely 
destroyed." 1 

Another troublesome complication of corneal ulcer 
is incessant blinking, which causes the upper lid to 
rub against and irritate the inflamed surface and thus 
hinders repair (plate IX. a). 
L,awson writes : 

" The movement of the upper lid, by rubbing against 
and irritating the ulcerated surface, increases the pain 
and photophobia, and in this way keeps up a Vicious 
Circle, which is arrested by a light bandage." 2 

In some cases of chronic keratitis the corneal 
tissues may be so softened and thinned as to be 
unable to resist the intra-ocular pressure. A staphy- 
loma corneae then results, with progressive bulging 
which causes further attenuation and further bulg- 
ing. 3 A similar sequence is sometimes associated 

Injuries and Diseases of the Eye, p. 459. 

*L.c., p. 145. 

3 Roemer, Text-Book of Ophthalmology, p. 532, 

anfr ^e^Itbg 175 

with keratoconus and scleral ectasise. These con- 
ditions will be further alluded to in connection with 
secondary glaucoma. 

Corneal ulcer is another example of a chronic 
disease whose duration is prolonged by a depreci- 
ation of vitality. Such depreciation may keep up 
the local disorder and vice versa. 

Iritis. A striking feature of iritis is its liability 
to establish a locus minoris resistentice with a strong 
tendency to relapse. This proclivity was formerly 
attributed to irritation caused by synechiae. But 
the modern view is that recurrence results from the 
persistence of some such constitutional dyscrasia as 
may be caused by syphilis or rheumatism, and that 
the damaged iris constitutes a susceptible focus. 
With each attack a slighter provocation suffices for 

Glaucoma. Glaucoma is frequently complicated 
by injurious circular reactions (JMatC IX. b). In 
the words of Priestley Smith, " cause and effect 
react upon each other in a Vicious Circle and the 
glaucoma intensifies itself." 1 

In the healthy eye the intra-ocular fluid, after 
being secreted by the capillaries of the ciliary pro- 
cesses, passes into the posterior and then through the 
pupil into the anterior aqueous chamber, filters 
through the meshes of the ligamentum pectinatum 
and spaces of Fontana, and escapes into the canal 
of Schlemm and thence into the anterior ciliary 
veins, a state of equilibrium being maintained by a 
self-regulating mechanism. 

1 Internation. Ophthalmologen Congress, Heidelberg, 1888, 
p. 243. Cf. also Norris and Oliver, System of 
Diseases of the Eye, III., p. 648. Pinto describes 
no less than five processes by which glaucoma may 
perpetuate itself. Encyclopedic Fran9aise d' Ophtal- 
mologie, V., pp. 109, 113, 121, 124, 128, 

176 IDlctcmg Circles in Disease 

In glaucoma this equilibrium is disturbed, with 
the result that the intra-ocular pressure rises. The 
exact mechanism, however, is not fully understood, 
and a variety of theories have been suggested. 

According to the popular retention theory, the 
root of the iris, is under certain predisposing con- 
ditions, approximated to the root of the cornea, 
diminishing the nitration angle, hindering the escape 
of the intra-ocular fluid and raising the pressure in 
the whole eye-ball. 1 This impedes the flow of blood 
through the choroidal veins and adds to the con- 
gestion of the ciliary processes. As a result of these 
factors the increased quantity of intra-ocular fluid 
pushes forward the lens and iris, further blocking 
the filtration angle and checking excretion. 2 

Lawson writes : 

" The sudden raising of the intra-ocular pressure 
increases the congestion, to be followed in its turn by 
a serous exudation from the venous channels, with 
a consequent further increase of pressure ; and thus a 
Vicious Circle is quickly established, with symptoms 
of ever-increasing violence." 3 

Kuschel believes that other factors contribute 

to the progressive increase of intra-ocular pressure : 

" The increased pressure in the vitreous humour 

forces the coronary division of the hyaloid membrane 

J The normal intra-ocular pressure of about 25 mm. Hg 
may in glaucoma rise to 60 mm. 

2 It is well to remember that correlations that appear to us 

injurious may with the progress of knowledge come 
to bear another explanation. Thus in 1867 Wecker 
suggested a different cause of glaucoma : " The 
diminished elasticity of the sclerotic plays a highly 
important role. It establishes a Vicious Circle in 
respect of the ciliary nerves, which are more and 
more compressed." Maladies des Yeux, I., p. 502. 

3 Diseases and Injuries of the Eye, p. 236. Cf- also Hender- 

son, Glaucoma, p, I3r, 

anb iB^lifcs 177 

(vorderer Grenzschicht) into the intervals between 
the ciliary folds (Ciliartaler) and thus blocks them. As 
a result fluid can no longer escape from the vitreous 
in consequence of which a further rise in pressure takes 
place, followed by a further blocking of the inter-ciliary 
spaces. The Vicious Circle thus established leads to 
an enormous increase of intra-vitreous pressure and 
to a complete arrest of the circulation of intra-ocular 

And again : 

" The increased tension in the vitreous exerts severe 
pressure on the choroid especially on its anterior 
section . . . Hence results partial or complete obstruc- 
tion to the venous flow through the ciliary processes, 
whose veins open into the anterior venae vorticosse. 
The ciliary processes consequently become disturbed 
and encroach upon or even entirely obliterate the 
inter-ciliary spaces. In this way another Vicious 
Circle is established which must further raise the 
pressure in the vitreous." 1 

According to Fischer glaucoma is due to an abnor- 
mal absorption of water by the colloids contained in 
the eye. The resulting swelling of the colloids then 
compresses the blood-vessels passing into or out of 
the eye. Hence the glaucoma has a tendency to 
self- aggravation. 2 

Even so simple a disorder as eye-strain may at 
times suffice to start the morbid sequence of events, 
at any rate in a small eye that is so to speak pre- 
disposed by a hypertrophied ciliary muscle. 

Clarke thus alludes to the setiological factors : 

" The congestion caused by the eye-strain leads to 
hyper-secretion, perhaps to a mild form of cyclitis : 

1 Der Intra-Okulare Fliissigkeitsstrom in seinen Beziehungen 

zum biomechanischen Aufbau des Auges unter 
gesunden Verhaltnissen, beim Glaukom und bei 
der Kurzsichtigkeit, pp. 120, 129. 

2 (Edema and Nephritis, pp. 7, 61, 653-4. 

178 IDtcloug Circles in Bisease 

obstruction at the filtration angle takes place, tension 
goes up and a Vicious Circle is established. If the 
eye-strain is removed by correcting the error the attack 
may be indefinitely postponed." 1 

In the later stages of glaucoma the walls of the 
eye-ball are gradually stretched and thinned, some- 
times in the region of the equator, sometimes in the 
ciliary zone. These processes of stretching and 
thinning aid and abet each other, and occasionally 
end in rupture of the globe. 

Reciprocal relations also complicate secondary 
glaucoma, as for example where staphyloma results 
from perforation of the cornea associated with 
cicatrisation of the prolapsed iris. There is then 
more or less complete obliteration of the filtration 
angle, followed by increased tension and increased 

The sequence is described by Kick : 

" Staphyloma corneae is a corneal scar which, with 
the adherent iris, bulges outward. . . . The adhesion 
of the iris to the cicatrizing cornea produces traction 
on the ciliary body, that vascular and nervous part of 
the inner tunic of the eye by which the aqueous humour 
is secreted. Irritation of the ciliary body so it is 
assumed increases secretion ; the internal pressure 
of the eye is thereby raised. This heightened tension 
pushes the scar forward with greater force ; the 
ciliary body is thereby still more dragged upon, with 
the consequence of shutting up the circulus vitiosus"' 2 - 

Retinitis. Various affections of the retina are 
liable to be complicated by harmful circular reactions. 
An example is met with in myopic persons with 
retinal hyperaesthesia and muscae volitantes. 

1 Clinical /., XXXVI., p. 322. 

2 Diseases of the Eye and Ophthalmoscopy, p. 257. 

anb i\>e<*lib0 179 

L,andolt writes : 

" The myope sees these phenomena with greater ease, 
because he is seldom adapted to the source of light. 
Moreover, when the myopia is pernicious, the sensitive- 
ness of the retina undergoes, from the beginning, a 
pathological exaggeration. Later on, to these almost 
physiological corpuscles are added others which are due 
to the retinal and choroidal exudation. The latter 
are now more numerous, larger and more troublesome 
and disquieting to the patient. He ascribes to them 
all kinds of shapes, and never wearies of their descrip- 
tion, which he willingly accompanies with a faithful 
sketch. This is a proof of the torments to which they 
subject him and of the anxiety with which he observes 
them. This observation itself places him in a Vicious 
Circle of action and reaction, for the more he pursues 
these phantoms, the more he is harassed by them, 
nothing being more fatiguing than the observation of 
such entoptic phenomena. Thus it is that they 
become a cause, both direct and indirect, of the weaken- 
ing of the eyesight." 1 

Various other local conditions arouse injurious 
auto-suggestions in neuropathic individuals and 
feed the neurosis. Thus a trifling hypersesthesia 
may lead to the adoption of injudicious procedures, 
as for instance when recourse is had to tinted lenses 
and darkened rooms, which only serve to increase 
the trouble. Even apart from hyperaesthesia some 
persons wear tinted glasses, what Bonders terms 
" conservative spectacles," on account of their 
agreeable and soothing effect. Such glasses with- 
draw the healthy stimulus of white light, intensify 
the retinal sensitiveness, and thus create a perman- 
ent necessity for their employment. 

A more serious disorder may be associated with 
papilloedema. The primary cause is usually found 
in an increase of intra-cranial pressure due to hydro- 

1 Refraction and Accommodation of the Eye, p. 457. 

I&Q IDtctoug Circles in Disease 

cephalus or a new growth, which forces the subar- 
achnoid fluid into the sheaths of the optic nerve. 
Hence result engorgement of the central vein of the 
retina, oedema of the optic nerve, and swelling of 
the papilla. The nerve becomes incarcerated at 
the point where it fits tightly in the foramen sclerse, 
and causes strangulation of the papilla and further 
engorgement in the vein. The oedema provokes 
strangulation and the strangulation oedema. 

Dacryo- Cystitis. An injurious reciprocation may 
occur in cases of dacryo-cystitis owing to stricture 
of the lachrymal duct. The trouble begins with 
congestion of the lachrymal sac, causing some 
obstruction of the duct, which in turn is followed by 
excessive flow, stagnation and decomposition of the 
secretions. The consequent irritation produces fur- 
ther narrowing, often ending in complete obstruction. 

Evans writes : 

" The irritation of the sac and conjunctiva sets up 
an excessive reflex secretion of tears, and thus is 
established a Vicious Circle which perpetuates the 
inflammation and distension of the sac." 1 

As a further result of the constant distention 
of the lachrymal sac by the fluid, the walls gradually 
lose their elasticity so that the tears no longer pass 
into the nose, even when the duct again becomes 
patent. The sac tends to grow steadily larger until 
a conspicuous fluctuating mucocele is produced. 


The eye-lids have already been alluded to more 
than once as associated with diseases of the eyes. 
Some additional illustrations of circular reactions 
may be given under a special heading. 

1 British Med. J., 1907, I., p. 420. 

anb E^libs 181 

Ectropion. Kctropion is a common self-per- 
petuating disorder which both results from, and 
provokes, epiphora ; any attack of persistent epi- 
phora that produces a macerated and contracted 
state of the skin of the lower lid may start the process 
(platC IX. c). The contraction of the skin draws 
down the margin of the lid and leads to eversion of 
the punctum, this being followed by increased 

Panas writes : 

" The skin, incessantly irritated by the tears flowing 

over it, contracts more and more, thus establishing a 

Vicious Circle which ends in ectropion." l 

An example of these correlations is met with in 

elderly persons in whom, owing to diminished elasticity 

of the skin, the lower lid is apt to drop away from the 

eye-ball, leaving the conjunctiva exposed. In course 

of time the conjunctiva undergoes hypertrophy and 

the increased weight leads to further displacement. 

The resulting epiphora is apt to provoke an ecze- 

matous condition of the lower lid (tinea or ophthal- 

mia tarsi), and thus further aggravates the displace- 


Fuchs writes : 

" As a consequence of the wetting with the tears, 
the skin of the lower lid is attacked with eczema or 
becomes rigid and contracted, so that the free edge of 
the lid is no longer in perfect apposition with the 
eye-ball. As a result of this the punctum lacrimale 
no longer dips into the lacus lacrimalis, so that the 
transportation of the tears into the lachrymal , sac is 
impeded, the epiphora increased, and thus again a 
still further injurious reaction upon the character of 
the skin is produced. In this way there is formed a 
Vicious Circle which leads to a constantly increasing 
depression of the lower lid (ectropion)." 2 

Maladies des Yeux, II., p. 333. 

2 Text-Book of Ophthalmology, p. 148. Cf. also Berry, 
Diseases of the Eye, p. 58. 

182 IDtctoug Circles in 

In order to mop up his tears the sufferer usually 

wipes from above downwards and so increases the 

malposition ; a better plan is to wipe the face from 

below upwards so as to press the lid back into place. 

Clarke writes : 

" The causes of this eversion, which displaces the 
punctum, are many. Among the most common are 
chronic inflammation of the lid and conjunctiva, 
granular lids and blepharitis. The lid becomes thick- 
ened, the punctum is drawn away from the eye, epiphora 
results ; this causes irritation of the skin, which leads 
to contraction, causing more eversion, and in a very 
short time, through the Vicious Circle of events, a well- 
marked ectropion exists." 1 

Bishop Harman also writes : 

" There is set up a Vicious Circle. The blepharitis 
predisposes on even slight provocation to conjunc- 
tivitis and eczema of the skin, and these in turn exagger- 
ate the blepharitis ; ultimately both cilia and Meibonian 
glands may be destroyed." 2 

Prolonged epiphora may in itself lead to blephar- 
itis since cicatricial tissue resulting from the blephar- 
itis causes the conjunctiva to be drawn forwards over 
the lid, thus thickening its edge and preventing its 
close application to the eye-bail. As a result tears 
now run down over the lid and intensify the blephar- 
itis. Tears in fact do no little damage to the eye. 

Another form of ectropion sometimes occurs in 
connection with chemosis of the eye-lids, when the 
bulging conjunctiva stretches the ciliary portion of 
the orbicularis, the contraction of which causes 
eversion of the lid. The everted lid and contracting 
orbicularis then act like a ligature and aggravate the 
chemosis by strangulating the conjunctival veins. 

1 Clinical /., XVI., p. 67. Cf. also Roemer, Text-Book of 

Ophthalmology, p. 298. 
2 L.c., XXVIII., p. 361. 

anfc ^e^Ub9 183 

A similar form of spastic ectropion not infrequently 
follows an attempt to open the palpebral fissure in a 
child with swollen lids and blepharospasm. 
Weeks writes : 

" Examples of this form of ectropion are observed in 
infants with ophthalmia neonatorum. In attempts to 
treat the conjunctiva slight traction is made on the 
skin of the lids. The infant cries, blepharospasm 
is induced, and the lids, both upper and lower, become 
everted. With increase of spasm, venous congestion 
becomes marked, and the ectropion may be perpetuated. 
Ectropion formed in this way is complete." l 

Entropion. Hntropion is frequently caused by 
incurvation of the lid margins through spasmodic 
contraction of the ciliary fibres of the orbicularis, 
and then perpetuates itself through the associated 
trichiasis (JMatC IX. d). The condition is often 
seen under circumstances of relaxation and oedema 
of the skin and loss of subcutaneous fat ; thus it 
occurs after cataract extraction in old people. 

Terson writes : 

" When once the displacement of the lid has occurred 
a Vicious Circle is established, for the subcutaneous 
oedema is increased by the irritation of the trichiasis 
and can only be arrested when the eye-lid has been 
replaced by traction." 2 

Cicatricial entropion may be associated with con- 
traction of the conjunctiva and cartilage ; the 
commissure is frequently narrowed, producing what 
is known as blepharophimosis and further increasing 
the tendency to inversion. Muscular spasm and 
trichiasis frequently act as aggravating factors. 

In other cases of entropion with blepharospasm 
a superficial ulceration is caused by the folding 
of the skin at the outer canthus and by the 

1 Treatise on Diseases of the Eye, p. 189. 

2 Encyclopedic Francaise d' Ophtalmologie, V., p. 505. 

184 IDidous Circles in Disease 

conjunctival discharges. This ulceration by reflex 
irritation increases the spasm and acts as an impor- 
tant factor in maintaining the irritation of the eye. 


Every error of refraction may at times be com- 
plicated by self -perpetuating factors. Many of these 
are associated with asthenopia. 

Myopia. There has been much discussion as to 
the aetiology of myopia. There is general agree- 
ment that the disorder is acquired through elongation 
of the eye-ball, but doubt exists as to the cause of 
this elongation ((Mate IX. e). 

The older view attributed the elongation to pres- 
sure on the eye associated with convergence, the 
injury being most easily produced in children whose 
ocular tissues had not reached their full power of 
resistance. The greater the pressure the more the eye- 
ball tended to yield ; the more the eye-ball yielded 
the greater the convergence required for clear vision. 

This view was held by L,andort who writes : 

" The influence of near work may manifest itself in 
different ways. It will be noticed even that the three 
principal modes of production of myopia that we have 
mentioned are so intimately related to each other 
that one of them necessarily suggests the others. 
Exaggeration of convergence leads to that of accommo- 
dation. The latter of itself alone, and also by the 
excessive nearness of the object which it necessitates, 
and the position which gives rise to cephalic hvperrcmia, 
favours the production of choroiditis. The affection 
of the membranes of the fundus oculi entails a diminu- 
tion of the acuteness of vision, which, in its turn, makes 
the gradual approach of the object and exaggeration of 
convergence obligatory. 

.Sometimes this Vicious Circle will be opened, on 
the contrary, by diminution of the acuteness of vision, 
and, at other times, by a spasm of accommodation. 
But at whatever point this wheel of misfortune 

anb iB^c^libe 185 

takes up the victim, he must go round with it, and 
will have to inexorably pass through the series of 
injurious influences, which reinforce each other to 
aggravate the evil. When we take into consideration 
this linking together of harmful causes, we are no 
longer surprised at the rapid and constant progress 
made by myopia in an eye which it has once attacked, 
especially when the latter has been, from birth, disposed 
to it, or is deprived of the ability to resist it." l 

There are, however, various objections to this 
explanation which has been to a large extent 

According to Eldridge Green myopia is probably 
due to some obstruction to the outflow of lymph 
into the lymph spaces of the optic nerve. 2 Such 
obstruction increases the intra-ocular tension, dis- 
tends the sclerotic posteriorly where it is weakest 
and causes myopia by elongation of the eye-ball. 
Any great physical exertion or even violent coughing 
may cause such obstruction, and when once the 
sclerotic has given way, its resulting weakness will 
predispose to further yielding. The progressive 
nature of the disease is thus readily explained. 

Myopia, when once established, often produces 
much local discomfort which affects the general 
health and lowers vitality, especially in the case of 
children and neuropathic individuals. 
Lawson writes : 

" The general health in young children often suffers 
greatly from the aching and general discomfort they 
experience, and in this way a Vicious Circle may be 
established which favours the rapid advance of the 
disease." 8 

1 Refraction and Accommodation of the Eye, p. 454. Cf. 
also Noyes, Diseases of the Eye, p. 64 ; Trans, of 
the Ophthalmological Society of the U.K. (1907), 
XXVII., p. 12. 

"-Lancet, 1918, 1., p. 137. 

3 Diseases and Injuries of the Eye, p. 67. 

186 IDicioue Circles in 

Myopia and spinal curvature also stand in re- 
ciprocal relation, if Liebreich's views may be 
accepted : 

" Spinal curvature and short-sightedness seem to 
form a circulus vitiosus, in so far as short-sightedness 
produces curvature, and curvature favours short-sight- 
edness ; while evidently the same bad arrangements 
are at the foundation of both these anomalies." 1 

Hypermetropia. Hypermetropic asthenopia is 
frequently a self- aggravating disorder. The over- 
strained accommodation causes the removal of any 
small object looked at to a greater distance and thus 
leads to diminished acuity of vision. This latter 
compels the sufferer to attempt closer work, involving 
increased effort of accommodation. Thus the two 
factors of over-strained accommodation and indis- 
tinct vision react on each other. 

Presbyopia. A similar complication comes into 
operation with the advent of presbyopia as a result 
of the effort to obtain distinct vision by accommoda- 
tion. Owing to the great distance at which the 
presbyope reads, the retinal image is small and indis- 
tinct, and this tempts him to bring his work closer 
to his eyes. At the nearer distance, however, he 
overtaxes his accommodation, and this in return 
renders his work indistinct and again compels its 

Anisometropia. Another self-intensifying dis- 
order is anisometropia caused by exhaustion of the 
fusion centre and of the muscles of accommodation. 
Bach of these factors reacts injuriously on the other. 

Doyne writes : 

" The trouble arises from a Vicious Circle. The 
fusion centre demands clear images and makes demands 
on the lower centres which control the muscles of the 

1 School Life in its Influence on Sight and Figure, p. 16. 

anb iS^e^Itbg 187 

eyes ; the muscles become exhausted, the images 
become indistinct and the fusion centre becomes more 
imperious, as its task becomes more difficult. Moreover, 
all these details are mainly subconscious and inde- 
pendent of the will." 1 

Much the same correlations may complicate 
astigmatism. The associated eye-strain involves a 
serious drain on the vital forces and their diminution 
involves further eye-strain. 


Various ocular neuroses have been already referred 
to in connection with special disorders. Such for 
example are the auto-suggestions connected with 
muscse volitantes in the myope and the asthenopia 
which complicates so may errors of refraction. The 
latter neurosis is so important as to demand a 
further reference. 

Asthenopia. Asthenopia is a wide-spread dis- 
order, especially in young persons whose ocular 
tissues possess little power of resistance, or in neuro- 
paths whose nervous capital is limited and readily 
used up. The weakened tissues of children are mainly 
concerned in progressive myopia, while neuropaths 
suffer most from astigmatism or anisometropia. 

Asthenopia may show itself in various ways. At 
times there is a continual sense of fatigue, headache 
or photophobia, caused by the abnormal and some- 
times unsymmetrical effort of the ciliary and other 
ocular muscles to secure accommodation and bino- 
cular vision. The necessary effort consumes much 
energy and soon brings on exhaustion (JMfltC IX, f). 
There is what Goodhart calls a want of " watts, 
amperes and volts of nervous energy." 2 

In such a state of exhaustion increased effort is 
required both in order to correct refraction and to 
secure clear images, and still greater and wasteful 

1 British Med. /., 1910, II., p. 363. 
z Lancet, 1916, I. 1122. 

i88 IDidous Circles in Disease 

expenditure results ; nervous bankruptcy may super- 
vene. Insomnia occasionally constitutes an aggrava- 
ting factor ; the restorative influence of sleep is 
then lost and the pernicious process is accelerated. 
Clarke writes : 

" Insomnia is a very prominent symptom of eye- 
strain and so a Vicious Circle is started. Eye-strain 
produces among other troubles insomnia, and insomnia 
in its turn aggravates the patient's condition, because 
the all-important restorative is wanting." 1 
In yet another group of cases asthenopia impairs 
the processes of digestion and assimilation. Vitality 
is depressed and this renders the nervous and 
muscular tissues still more vulnerable to the abnor- 
mal strain thrown upon them. 

" There is a Vicious Circle of cause and effect. 
Eye-strain with its pain and nervous disturbances, 
produces interference with assimilation and nutrition, 
which in its turn so reduces the general physical con- 
dition as to induce an increase in the asthenopia." 2 

Shell Shock. The wide-spread use of high explo- 
sives in the recent war has supplied numerous 
examples of neuroses in soldiers suffering from shell 
shock. Such soldiers may complain of blindness 
although no injury can be discovered which would 
account for the loss of sight. By a process of sugges- 
tion the visual perception structures in the brain may 
have been dissociated from the nervous tracts con- 
veying the light stimuli from the eyes. The man 
is blind because he believes he is blind and makes no 
attempt to use his eyes. Such auto-suggestions are 
of course commonest in individuals with neuropathic 
introspective proclivities. Similar dissociation pro- 
cesses may cause sufferers from severe shock to 
become deaf or mute. 

1 Practitioner, 1911, I., p. 26. 

2 Norris and Oliver, System of Diseases of the Eye, IV., 

p. 405. Cf. also Gould, British Med. /., 1903, 

II., p. 663. 

Chapter Eleven 


HE rebellious character of many diseases of 
the nose is due to the presence of self- 
perpetuating conditions. Amongst them 
are variations in the calibre of the 
nasal passages, both in the direction of 
excess and deficiency. These will be dealt with first. 

Stenosis. The nasal cavities form a rigid box 
with highly vascular walls through which flows a 
tidal current of air. If as a result of obstruction to 
this current the air tension is diminished the vas- 
cular walls become distended with blood and lymph, 
and so to speak a dry cupping process is initiated. 
If this process is long continued a chronic condition 
of congestion and catarrh will result, ending in a 
permanent vaso-motor paresis and hyperplasia. 

Such primary obstruction may be due to a variety 
of causes including injury, neglected or recurrent 
colds and so forth. The mucosa is maintained in a 
state of congestion, loses its contractility and gradu- 
ally undergoes hypertrophy. These conditions then 
aggravate the obstruction to which they were due. 

Scanes Spicer writes : 

" Causative stenosis is followed by hypertrophic 
catarrh. Hypertrophic catarrh causes increased obstruc- 
tion, and so a Vicious Circle is created, the circumfer- 
ence of which is far-reaching and ever-widening." 1 

1 British Med. /., 1900, II., p. 346. Cf. also Gradle, Diseases 

of the Nose, Pharynx and Ear, p. 46. 

Dicious Cirdes in ^Disease 

Stenosis may also call forth other conditions 
which maintain the stenosis. Thus behind the 
point of obstruction the inspiratory pressure will be 
less than in a patent nostril and this diminished 
pressure perpetuates the turgescence and promotes 
further hypertrophy. Again when once establish- 
ed the stenosis interferes with the expulsion of 
secretions and favours an accumulation which 
increases the obstruction. L,ike all cavities lined 
with mucous membrane the nostrils tend to become 
narrowed when their drainage and ventilation are 
interfered with. 

Yearsley writes : 

" Defective drainage of the nasal cavities predisposes 
to microbic infections and their resulting inflammations. 
Bacteria find a suitable nidus behind a septal deflection, 
and the result is that recurrent attacks of rhinitis occur, 
each attack leaving the patient with increased obstruc- 
tion and greater tendency to fresh infection ; conse- 
quently a Vicious Circle is established of obstruction, 
defective drainage, rhinitis, increased obstruction. 
This is the mechanism by which patients with nasal 
obstruction are so frequently the victims of the common 
cold. But the results of the Vicious Circle are more 
far-reaching than may appear on the surface." 1 

Deflection of the septum is another cause of 
stenosis on the convex side, since such deflection 
leads to diminished tension behind the obstruction 
and such diminution tends to increase the deflection. 

Watson- Williams writes : 

" As a consequence of the partial nasal obstruction 
from deflected septum, inspiration causes a rarefaction 
of the air behind the obstruction ; as a consequence 
over-filling of the vessels and constant hypersemia 
with chronic rhinitis and further increase of the nasal 
stenosis may result." 2 

1 Practitioner , 1914, II., p. 503. 

2 Diseases of the Upper Respiratory Tract, p. 337. 

tlbc IRose 









IPlatc X. Circles aseociateb witb 
the lRo0e. 

192 Dicioue Circles in Disease 

Riseley draws attention to the " Vicious Circle 
of events " which occurs when, owing to deformities 
of the scroll bones of the nostrils and to deviations 
of the septum or vomer, the nasal chamber is so 
narrowed that the opposing sides come into contact, 
or approach so nearly that any congestion of the lining 
mucosa brings them together. Here, too, a self -ag- 
gravating factor comes into play, since the oppos- 
ing pressures perpetuate the congestion. Congestion 
breeds congestion. The nose is choked by the 
turgid soft tissues and drainage is checked. 1 

Obstruction is frequently caused by adenoids, 
which tend to enlarge as the result of the asso- 
ciated catarrh and infection. 

Fraser writes : 

" In case of adenoids a Vicious Circle is set up. The 
child suffers from attacks of coryza which cause 
enlargement of the naso-pharyngeal tonsil. This again 
gives rise to nasal obstruction and tends to keep up 
the catarrhal condition of the nose and naso-pharynx, 
and predisposes the child to fresh attacks of cold in 
the head." 2 

Adenoid growth is also favoured by the factor 
already alluded to, viz. the diminished barometric 
pressure accompanying the act of inspiration in 
cases of nasal obstruction. Every such act di- 
minishes the pressure behind the obstruction, leads 
to hypersemia and hyperplasia and so tends to further 
adenoid growth. Many children rind it difficult to 
clear their naso-pharynx from the secretions produced 
by adenoids. These secretions then increase the 
irritation and further obstruct the naso-pharynx. 
Eventually the child is forced to breathe through 

1 British Med. J., 1906, II., p. 1869. Cf. also Ballenger, 

Diseases of the Nose, Throat and Ear, p. 142. 

2 Encyclopaedia Medica, L, p. 169. Cf. also Crowley, The 

Hygiene of School Ivife, p. 38, 

She Itiose 193 

the mouth and this introduces a fresh factor which 
further intensifies the stenosis. In the absence of 
the normal currents of air through the nose secretions 
tend to accumulate and undergo decomposition, 
with the result that the mucous imembrane is 
maintained in a state of chronic hypersemia (JMatC 
X. a). 

As Mayo Collier says : 

" Mouth-breathing introduces a further aggravating 
factor. A Vicious Circle is set up ; mouth-breathing 
tends to obstruct the nose, and this very obstruction 
maintains and continues the mouth-breathing." 1 

Another sequence of reciprocal events may be 
observed in cases of enlarged tonsils, when these 
interfere with nasal, and thus conduce to oral, 
respiration. In mouth-breathers the hypertrophied 
tonsils are readily inoculated by any air-borne 
contagion, and then undergo further enlargement. 
Doubtless the enlargement is primarily a response 
to a demand for a greater leucocytic activity in 
order to get rid of microbial irritation and to that 
extent is a beneficent reaction. If, however, the 
enlargement is followed by mouth-breathing more 
harm is done than good, and the evil is aggravated. 

Bloch writes : 

" Enlarged tonsils frequently interfere with nasal 
respiration, and thus cause mouth-breathing, which 
in its turn acts injuriously on the tonsils that lie directly 
in the air-current. In fact these organs form the first 
important obstruction to the otherwise almost unim- 
peded current of air. They thus serve as the most 
convenient site for the deposition of the grosser impur- 
ities in the inspired air, and give rise to a true circulus 

1 Mouth-breathing, p. 12. Cf. also Hogarth, Medical In- 

spection of Schools, p. 285. 

2 Die Pathologic und Therapie der Mundatmung, p. 73. 

i94 IDicious Circles in Disease 

According to some writers adenoid vegetations 
through increased activity of the pharyngeal, mylo- 
hyoid and other muscles lead to contraction of the 
mandible and maxilla, and vice versa. 

Pickerill writes : 

" A Vicious Circle originates in the following way : 

1. A common cold causes blocking of the nasal 
cavities, swallowing efforts and contraction of the 

2. The contracted mandible causes contraction of 
the maxilla. 

3. The contracted maxilla causes contraction of the 
nasal cavities, and their further blocking by vegetation, 
and this leads to further strained deglutition." 1 

Stenosis is liable to cause collapse of the alse nasi. 
The sides of the nostrils then fall inwards on inspira- 
tion instead of expanding, and may convert the 
anterior nares into mere slits. In severe cases the 
alse may actually fall against the septum. 
Gradle writes : 

" Although itself the consequence of some intranasal 
anomaly causing stenosis, it (i.e. the collapse of the 
sides of the nose) intensifies the latter. With every 
inspiration the sides of the external nose sink in, thereby 
slightly narrowing the vestibule." 2 

Dilatation. It is interesting to observe that 
abnormal nasal patency may also be a self-perpetu- 
ating condition (JMatC X. b). This may be illustrated 
by the course of events in a case of atrophic rhinitis, 
a disorder which at any rate in its later stages is 
closely associated with undue patency of the nasal 
fossae both as cause and effect. So wide is the 
nasal cavity as frequently to allow a clear view of 
the posterior wall of the pharynx. 

1 Dental Caries and Oral Sepsis, pp. 60, 64. Cf . also Stoma- 

tology, p. 28 ; British Med. /., 1914, II., p. 1026. 

2 Diseases of the Nose, Pharynx and Ear, p. 196. 

Iftose 195 

There is considerable difference of opinion as to 
the setiological factors. In some cases atrophic 
rhinitis results from a diseased state of the nasal 
mucosa associated with deficient secretion and 
the formation of crusts. In other cases there has 
been deep ulceration or necrosis of bone or cartilage. 
But whatever may have been the primary cause 
atrophic rhinitis is characterised by wasting of the 
soft tissues lining the nasal fossae as well as of the 
turbinated bones, combined with shrinking of the 
glands, fatty degeneration of their epithelium and 
diminution of the secretion. These conditions result 
in an abnormal width of the nasal passages from 
which in chronic cases the turbinates have almost 
vanished, leaving a dry, pale surface with adherent 

As the velocity and force of a stream grow less 
with a wider channel so does the air passing through 
such dilated nasal passages lose the velocity and 
force required for the expulsion of tenacious nasal 
secretions. Hence the nasal fossae are no longer 
swept clean by the usual tidal air currents and 
the secretions become inspissated and dry. The 
adhesiveness of the secretions is partly due to the 
ciliated epithelium having been replaced by squam- 
ous cells owing to the earlier rhinitis, partly also to 
the secretions contracting like a film of collodium, 
causing still further atrophy of the soft and bony 
tissues and still greater nasal patency. Thus the 
morbid process is perpetuated, and we have the 
paradoxical condition of dilatation preventing the 
removal of obstruction. 

In many cases atrophic rhinitis is complicated by 
sinusitis, the two disorders favouring each other. 
Adam writes : 

" In most cases atrophic rhinitis is the end stage 
of a chronic hyperplastic purulent rhinitis, involving 
first the membrane, then in more than half the cases 
the sinuses. This sinusitis, by a Vicious Circle, reacts 

196 IDidous <tirde0 in 2)isea0e 

on the membrane and perpetuates the inflammatory 
process there." 1 

In other cases the removal of a polypus seems 
to supply the primary stimulus to the degenerative 

MacDonald writes : 

" After the removal of nasal polypi in cases where 
the inferior turbinals had previously presented a normal 
appearance, there is sometimes induced a muco- 
pumlent discharge, which, partly from its tenacity, and 
partly on account of the unnaturally widened fossae, the 
patient is unable to extrude. It putrefies and produces 
an ozaenic smell ; it dries and contracts the venous 
sinuses of the erectile tissue. A Vicious Circle is 
instituted, which, if neglected, might presumably 
result in true atrophy." 2 

Rhinitis sicca is almost invariably complicated 
by the presence of crusts, associated with infective 
processes which lead to the destruction of the mucous 
membrane and cause much itching. This gives rise 
to nose-picking with further injury to the mucosa 
and the development of fresh crusts (platC X. c). 
Ribary writes : 

" The erosions which are associated with anterior 
rhinitis sicca and which frequently provoke epistaxis, 
may either heal or give rise to polypoid excrescences 
(bleeding polypus of the septum), or they may extend 
to the. deeper parts and lead to ulceration by means 
of infective processes. Where healing has taken place, 
white, tendon-like, glistening, tongue-shaped processes 
of epidermis may be observed to extend from the edge 
of the skin on the septum into the normal mucosa. 
In fact as a result of the morbid process the mucous 
epithelium has perished, and been replaced by epider- 
mis. The new epidermis however appears to have less 
resisting power than has normal cutis, since a sense of 

1 British Med. /., 1908, II., p. 1271. 

2 Allbutt and Rolleston, System of Medicine, IV. (ii.), 
p. 21 ; Diseases of the Nose, p. 152. 

Cbe Iftose 197 

tension persists and results in renewed nose-picking 
and in further injury to the mucosa with its sequelae. 
In this way a circulus vitiosus forms which perpetuates 
the disorder and generally lasts for the remainder of 
life." 1 

The same process often leads to a perforating 
ulcer, as Griinwald points out : 

" I have observed several cases of this kind of per- 
foration, and the Vicious Circle was always the same : 
crust formation on the septum ; picking off the crust 
and so causing bleeding, which led to the formation of 
a larger and more firmly adherent crust ; and so on, 
the whole process being started by some inflammatory 
condition, such as suppuration in the vestibule or in 
the interior of the nose." 2 

Sinusitis. Sinusitis has already been referred to 
in connection with rhinitis sicca. But there are 
some further circular reactions met with in this 
disease. Owing to the narrowness of the ducts 
draining the sinuses, any catarrhal congestion readily 
leads to obstruction, followed by retention and 
putrefaction of the secretions, paralysis of the cilia 
and further retention. 3 Moreover the growing irri- 
tation may steadily increase the obstruction until this 
becomes complete (flMatC X. d). 

l Archiv f. Laryngologie und Rhinologie, 1896, IV., p. 314. 
Cf. also Cartaz, Castez and Barbier, Maladies du 
Nez et du Larynx, p. 34. 

2 Nasal Suppuration, tr. by Lamb. p. 180. 

3 Under the name "Vicious Circle" of the nose Ballenger 
describes and illustrates an area in which the ostei 
of the posterior ethmoidal and sphenoidal sinuses 
drain into the superior meatus above the middle 
turbinate, while the frontal, anterior ethmoidal 
and auxiliary sinuses drain into the middle meatus 
beneath the turbinates. This use of the term 
" Vicious Circle " is, of course, entirely distinct 
from that employed in this volume. Diseases of the 
Nose, Throat and Ear, pp. 118, 199, 202 f. 

Dicious Circles in Disease 

Kuhnt thus describes the condition as met with in 
the frontal sinus ; it may serve as a type of other 
forms of sinusitis : 

" In cases of rhinitis it is quite possible for an inde- 
pendent disorder to be set up in the frontal sinus, which 
may last long after the rhinitis has subsided. The 
mucous, muco-purulent or purulent secretions are 
either unable to escape or only do imperfectly. They 
are then apt to decompose, and in their turn accentuate 
the irritation of the mucosa. Bven anatomical changes 
frequently result, especially in the naso-frontal duct, 
close the Vicious Circle, and thus prevent any prob- 
ability, or even possibility, of a natural recovery." 1 

Another aggravating factor may be present in 
purulent sinusitis, being due to the destruction of the 
ciliated epithelium. The aggregate effect of millions 
of cilia in removing the secretions, especially when 
working in opposition to gravity, must be of great 
importance. Acute inflammation, however, and 
especially the retention of pus rapidly destroy 
ciliated epithelium, and thus neutralise Nature's 
scavenging provisions. Retention leads to retention. 

Polypus. The growth of a polypus seems fre- 
quently to be due to persistent irritation caused by 
suppuration, which is then kept up by the presence 
of the polypus (JMate X. e). The same reciprocity 
has been observed in other parts of the body such as 
the ear and the larynx. 

Heymann writes : 

" The polypus irritates the adjacent structures, and 
thus excites, as well as maintains, a condition of 
inflammation. In saying this we adopt the view that 
a polypus may owe its origin to a condition of inflam- 
mation, so that a form of circulus vitiosus is established. 
.... In many, probably most, cases suppuration 

1 Heymann, Handbuch der I/aryngologie und Rhinologie, 
HI., P- 361. 

IRose 199 

has started and led to the formation of the polypus ; 
at the same time the irritation of the polypus may 
cause or at least keep up the suppuration. It is 
scarcely necessary to add that the continual bathing 
of the mucosa in pus may in turn give rise to fresh 
polypi." 1 

The increase in size of a polypus when once formed 
has been attributed to gravitation, to the kinking of 
the blood-vessels, to the traction caused by blowing 
the nose, and to a to-and-fro movement of the 
polypus due to respiration. It seems at any rate 
possible that these factors may accelerate growth, 
and the larger the growth, the more effectual will 
these factors be. 

McKenzie thus refers to the action of gravity on 
the growth of a polypus : 

" It is partly to the influence of gravity that we may 
attribute the liability of the lower border of the middle 
turbinal to polypi, for this area, hanging as it does free 
and unsupported over the middle meatus, will, when it 
becomes oedematous, sag and bag so that a bulging of 
certain limited portions will occur. And so polypoid 
excrescences will form. Further, the return circulation 
from these excrescences naturally becomes more and 
more difficult as their bulk increases. In this way a 
Vicious Circle is formed, and the size of a polypus is 
limited by the capacity of the space around it, and not 
by any natural tendency to stop growing." 2 

Rhinolith. The formation of concretions and 
calculi in the body is dependent on reciprocal 
reactions between the primary nucleus and the 
subjacent mucosa, and the same principle applies to 

1 Handbuch der Laryngologie und Rhinologie, III., p. 824. 

Cf . also Stoerk, Erkrankungen der Nase, des Rachens 
und des Kehlkopfes (Nothnagel's Pathologic und 

Therapie), p. 188. 
'"Practitioiwr, 1910, II., p. 186. 

200 IDidoue Circles in Disease 

the rhinoliths occasionally met with (plate X. f). 
The nucleus, whether consisting of a foreign body, of 
blood or of mucus, becomes encrusted with salts 
derived from the nasal secretions, and in turn 
acts as a source of irritation to the mucosa. The 
greater the irritation the more abundant the secre- 
tions and the more rapidly does the concretion grow. 
In some cases the nares may be completely blocked. 

Rhinitis. Some attacks of nasal catarrh, even 
after recovery, greatly diminish the resistance of 
the nasal mucosa, a condition which shows itself 
by increased liability to catarrh, and each attack 
leaves the nose more predisposed, in fact a locus 
minor is resistentice. A similar condition is associated 
with the various nasal neuroses, and depends on the 
principle that a reflex disturbance once produced is 
so much the more easily renewed. Every attack 
appears to diminish the control of the nerve 
centres and to induce an attack on less and 
less provocation. 

A good illustration is met with in hay fever, a 
paroxysmal neurosis which is especially liable to 
attack susceptible persons when exposed to certain 
kinds of pollen or effluvia. Each attack makes the 
individual more susceptible to the subtle influence 
of pollen grains, and increases the probability of 
fresh seizures. 1 In other sufferers from hay fever 
the idiosyncratic hyperaesthesia of the nasal mucosa 
seems to provoke an inflammatory hyperplasia of 
the affected membrane, which hyperplasia then 
renders the mucosa even more sensitive to the 
noxious agent than before. Thus cause and effect 
abet each other. This injurious sequence, however, 
is by no means constant. 

1 Quain, Dictionary of Medicine, I., p. 786. 

Chapter twelve 


ISEASES of the throat may be compli- 
cated by some circular reactions of great 
clinical importance. 

Diphtheria. The throat is the favour- 
ite seat of diphtheria, a virulent disease 
whose tendency to extension depends on the patho- 
logical changes which take place in mucous mem- 
branes when invaded by the Klebs-Ix>ffler bacillus 
(JMatC XI. a). These changes vary in different 
cases. Sometimes a definite membrane is formed ; 
in other cases there is merely a delicate network of 
fibrin enclosing leucocytes, red corpuscles and bac- 
teria. To these conditions are superadded stasis 
and exudation in the mucous membrane, portions of 
which may even be necrosed. These local effects of 
the bacilli and their toxins injure the neighbouring 
tissues in such a way that a favourable culture- 
medium is prepared for the proliferation of the 
bacilli and the increase of their toxins which then 
enter the blood. Hence it is that the morbid process 
tends to extend so rapidly, both superficially and in 
depth. Lowered resistance favours extension of the 
evil and vice versa. 

(Edema of Aryteno-Epiglottidean Folds. In 

cases of congestion of the aryteno-epiglottidean folds 
the two cedematous swellings may be seen lying like 


202 IPictoug Circles in Disease 

valves above the glottis. There is then a risk that 
they may be sucked together during inspiration and 
provoke acute dyspnoea. The greater the dyspnoea 
the greater the inspiratory efforts and the more 
closely do the cedematous folds approximate, death 
sometimes resulting from suffocation. 

Tongue-Swallowing. Death may also result from 
tongue-swallowing, a rare accident in children whose 
fraenum is too long or has been divided. The danger 
arises from the tongue being so retracted into the 
pharynx at the time of deglutition as to hinder 
the entrance of air during inspiration. The conse- 
quent dyspnoea is apt to lead to further retraction ; 
the tongue may even come to be fixed in the gullet 
like a wedge, obstructing the larynx so completely 
that no air can reach the lungs. Several cases of 
asphyxia due to this condition are on record. 1 

Laryngitis. laryngitis is frequently a self-per- 
petuating condition through its effects reacting on 
their cause. For example, congestion and erosion 
of the cords provoke severe paroxysms of coughing. 
The inflamed surfaces are brought into violent 
contact, and this in turn aggravates the mischief. 

The accumulation of adhesive secretions is another 
source of irritation, which is accentuated by the 
constant efforts that are made to clear the throat. 
The secretions also interfere with the repair of an 
inflamed mucosa or of an ulcer, an injurious reci- 
procation being maintained in all these ways. Even 
hoarseness does harm by the increased effort involved 
in the act of speaking or singing. The greater the 
effort the more does the laryngeal congestion increase. 

1 An illustration shewing how readily such asphyxia may 
be brought about is given by Hare, Practical Thera- 
peutics, p. 670. 









/> S ^\* 


1 to 

^ J 

^^^^ 5u\^ o^ 




plate xi. Circles aseociatefc with the 

204 IDtdoug Circles in %)t0ease 

Injurious correlations also occur in tubercular 
laryngitis owing to the associated cough, vomiting 
and dysphagia. In consequence of the irritability of 
the larynx the cough may be incessant, and rob the 
sufferer of the sleep and laryngeal rest which are so 
essential if the progress of the disease is to be checked. 
The cough may also be accompanied by frequent 
vomiting so that an insufficient amount of food is 
retained. The resulting malnutrition diminishes the 
power of resistance and accelerates the disease. 
Again when the epiglottis is invaded by tubercular 
deposits there is often acute pain on deglutition, and 
the suffering and dysphagia may cause the refusal of 
all food, however appetising. The victim is in as 
grievous a predicament as Tantalus of old ; emaci- 
ation and aggravation inevitably result. 

In patients in whom there is an exaggerated reflex 
susceptibility of the nervous system, excessive cough 
may so irritate and exhaust the medullary centre as 
to pervert the reflex mechanism. The cough be- 
comes uncontrollable and persists even though all 
local irritation has subsided. 

Chronic laryngitis is frequently associated with the 
formation of neoplasms, each disorder favouring the 
other. The sequence of events is much the same 
as those occurring in the nose and the ear (platC 
XI. b). Sometimes a pedunculated growth may be 
sucked into the glottis so as to provoke urgent 
dyspnoea, followed by increased impaction and 

Schrotter writes : 

" Chronic catarrh is very frequently associated with 
new growths in the larynx, a Vicious Circle being 
clearly present. The catarrh leads to the formation 
of the neoplasm and this, especially if pedunculated, 
keeps up the catarrh." 1 

^orlesungen iiber die Krankheiten des Kehlkopfes, p. 66. 

ftbroat 205 

Chronic laryngitis presents an illustration of that 
condition in which primary disease leaves behind 
it a diminished resistance to fresh attack, a liability 
to recrudescence on the slighest exposure. There 
is no permanent restitutio ad integrum, and each 
attack may end in an increase of mischief. 

Laryngismus Stridulus. According to various 
writers the respiratory glottic spasm of laryngismus 
stridulus may be a self-perpetuating condition owing 
to the increasing venosity of the blood due to the 

The spasms are supposed to cause venosity, which 
venosity induces fresh spasms which occasionally 
prove fatal. 

This view was held by Charles West : 

" When once convulsions have occurred, a new 
element soon comes into play, which aggravates the 
danger and increases the frequency of an attack. The 
blood, imperfectly depurated, if the disturbance of 
respiration has been considerable, seems in itself to 
exercise an injurious influence, by increasing the 
irritability of the nervous system and thus promoting 
the return of the attack. If once convulsions have 
occurred, the probability of their recurrence is much 
increased ; and the oftener they have happened, the 
more often are they likely to return, and the graver is 
the prognosis which you are compelled to form. This 
rule holds good, too, not only with reference merely 
to spasmodic croup, but with reference to all spasmodic 
affections of the respiratory organs, and whooping 
cough affords one of its best exemplifications. In 
some fit of coughing more violent than any of the others, 
the spasm of the larynx is of longer continuance, the 
face grows livid, a fruitless expiratory effort is made, 
and before the spasm relaxes a convulsion takes place. 
This convulsion is but very seldom a solitary one. 
You notice that for hours it is succeeded by very 
accelerated breathing ; by which, however, the blood 
is very imperfectly depurated, as you see by the lips 
which never resume their natural colour. At length 

206 IDidous Circles in disease 

the disturbance once more reaches its climax, and 

another, and then another convulsion occurs, with 

a gradually-diminishing interval, until death takes 
place." 1 

Hughlings Jackson held similar views : 

" Great venosity of the blood will much over- 
stimulate the naturally very excitable respiratory 
centres in infants,' and thus produce respiratory con- 
vulsions. When there has been first set up any degree 
of spasm of any part of the respiratory apparatus, the 
venosity will become greater still, and thus there will 
be a rapid multiplication of effects. In other words 
a Vicious Circle is established. Super- venosity initiates 
the paroxysm, which increases the super-venosity." 2 

This theory is, however, by no means generally 
accepted. In many cases the increased venosity 
seems to arrest rather than prolong the convul- 

Another form of spasmodic closure of the larynx 
is sometimes observed in cases of reflex rigidity 
caused by a surgical operation. This may also 
be a self-perpetuating condition, as Mortimer points 
out : 

" Reflex rigidity from surgical proceedings is accom- 
panied by more or less spasmodic closure of the larynx 
and retraction of the tongue, and efforts must be made 
to maintain a free air-way by such means as pushing 
forward the tongue, and introducing a tube between 
the tongue and palate. Non- aeration increases rigidity, 
the extraordinary respiratory muscles being called 
into action, so that a Vicious Circle is formed." 3 

Paralysis of the Abductors. A deadly vortex 
may be set up in connection with paralysis of the 
abductors, i.e. the posterior crico-arytenoid muscles 
(JMatC XI. c). In normal respiration the glottis 

1 Medical Times, XIX., p. 522. 

2 Brain, IX., pp. 14, 15 ; XII., p. 4gi. 

3 St. Bartholomew's Hospital /., 1917, I., p. 89. 

Gbe Gbroat 207 

dilates with every inspiration, and the deeper the 
inspiration the wider the glottis. When, however, 
the abductors are paralysed, inspiration is no longer 
assisted by dilatation of the glottis, but, on the 
contrary, is impeded by increased approximation 
of the cords, which are separated by a mere chink. 
The narrowing of the glottis provokes dyspnoea and 
the dyspnoea leads to further narrowing. A sufferer 
from bilateral posticus paralysis has a sword of 
Damocles hanging over him. 

Stammering. Exaggerated self -consciousness 
and stammering are frequently correlated (JMatC 
XI. d). Many persons stammer but slightly when 
perfectly at ease. But any mental perturbation at 
once aggravates their disability, and this aggrava- 
tion in turn intensifies their perturbation. The 
stutterer stutters most when he is trying hardest 
to avoid stuttering. 

Another neurosis is associated with the globus 
hystericus, the sensation of a lump that rises in the 
throat and is probably due to pharyngeal spasm. 
The disorder is one that occurs in sensitive intro- 
spective persons and in its turn excites auto- 

Tracheal Stenosis. Dangerous correlations may 
occur in cases of enlarged thyroid, where this gland 
compresses the trachea and reduces the lumen to a 
slit ; acute and sometimes fatal attacks of dyspnoea 
are liable to come on quite unexpectedly (platC XI.e). 
Started, perhaps, by some casual effort, the dyspnoea 
calls the supplementary respiratory muscles (especi- 
ally the sterno-hyoids and -thyroids) into action. 
These in contracting press the hypertrophied thyroid 
against the trachea, further diminish the lumen and 
so increase the dyspnoea. Thus the victim is caught 
in a dangerous sequence, and unless skilled help is 
promptly given, dies miserably self-garotted. The 

208 iDidous Circles in Disease 

very mechanism devised for increasing the supply 
of air through the narrowed trachea aggravates the 

Frankel writes : 

" The sufferer gets into the clutches of a Vicious 
Circle. The greater the want of oxygen, the more 
vigorous and prolonged the muscular contractions ; 
the more vigorous the latter, the greater the compression 
of the trachea and the less room for the admission of 
air." 1 

A goitre is also liable to press on or stretch nerves 
which reflexly produce respiratory spasm.; this 
then leads to further pressure. 

Again the heightened blood-pressure produced 
during expiration raises the pressure in the extensive 
plexus of veins that encircle the thyroid gland. In 
this way increased swelling of the goitre is brought 
about, and the stenosis is aggravated. Venous 
haemorrhage into adenomatous cysts may also set 
up morbid correlations. The increased pressure on 
the trachea leads to dyspnoea, to over-filling of the 
right heart, and to congestion of the veins of the 
neck. This congestion in turn aggravates the 

Similar complications follow, when, instead of the 
trachea being compressed from without, there is endo- 
tracheal stenosis, due to syphilis or a new growth. 
The stenosis brings on dyspnoea and increased 
activity of the respiratory muscles. This causes an 
overfilling of the right side of the heart during 
inspiration owing to the increased suction action. 
During expiration, on the other hand, the high 
intra-thoracic pressure exerted on the lungs hinders 
the entry of the blood into the lungs, and the effect 
of this is further to increase dyspnoea. 

1 lyungenkrankheiten, p. 8. Cf. also Jacobson and Row- 
lands, Operations of Surgery, I., p. 6ro. 


Frankel writes : 

" Any condition which accelerates the venous flow 
on the right side of the heart must under such circum- 
stances aggravate the state of the patient. This 
applies especially to increased muscular activity, and 
to the increased dyspnoea necessarily associated with it. 
A circulus vitiosus is thus established as a result of the 
increased respiratory activity." 1 

Enlarged Thymus. A fatal process of recipro- 
cation is occasionally associated with thymic enlarge- 
ment, owing to the readiness with which any hyper- 
plasia of the gland causes pressure on the trachea 
and dyspnoea (gMatC XI. f). 

The normal thymus weighs about 6 grms., but 
in cases of lymphatism the weight may rise to 50 
grms. or even more. In early Hfe the interval be- 
tween the manubrium and the spinal column only 
measures 2.5-3 cm., so that even a moderate hyper- 
plasia may produce tracheal stenosis and conse- 
quent dyspnoea. Such dyspnoea in turn leads to 
venous engorgement and further enlargement of the 
thymus, thus setting up a " Vicious Circle that may 
quickly lead to suffocation." 2 

Mutism. In cases of shock, such as that due to 
the high explosives used in modern warfare, various 
nervous disorders have been met with due to a 
suspension of the connection between the peripheral 
impulses and the higher cortical centres of the 
nervous system. The victim may be so convinced 
that he is mute that he actually becomes so 
through auto-suggestion, and makes no attempt 
to speak. Suggestion sometimes succeeds in switch- 
ing on the interrupted synapses between the vocal 
organs and the cerebral cortex and thereby restores 
the power of speech. Parallel conditions have been 
described in connection with vision and hearing. 

1 Lungenkrankheiten, p. 29. 

- Osier and Macrae, System of Medicine, IV., p. 926. 

Chapter thirteen 


OR the purpose of description the ear 
is divided into three parts : external, 
middle and internal. Injurious circular 
reactions associated with the ear may 
be arranged in the same divisions. 


The external ear is liable to various inflammatory 
conditions which may be self -perpetuating. 

Otitis Externa. Simple otitis externa gives rise 
to unhealthy secretions which if allowed to stagnate 
in the meatus set up irritation and congestion, which 
excite further secretion and accumulation. This 
complication is especially common if the canal is 
narrowed, since the tendency to retention is thus 

In some inflammatory conditions mycotic infection 
may be present, due to the spores and mycelium of 
the aspergillus niger or other fungus. The parasite 
nourished by the secretions penetrates beneath the 
epidermis and excites further inflammation. Indeed 
the disease largely depends on the fact that the 
fungus increases the discharge and thus promotes its 
own growth. 

The skin of the meatus may also be the seat of 
an infective disorder, when one or more hair-follicles 


Gbe Ear 211 

are invaded by staphylococci. The invasion is 
generally accompanied by itching, which leads to 
scratching, abrasion and fresh inoculation. The 
succession of boils so often observed is usually due 
to auto-inoculation caused by scratching. 

Another common inflammatory disorder is eczema 
which is frequently complicated by pruritus. This 
pruritus leads to scratching which perpetuates 
the trouble. 
Guisez writes : 

" Eczema of the meatus is always associated with 
very severe itching, which obliges the sufferer to 
scratch. The resulting abrasions perpetuate the inflam- 
mation of the epidermis and thus prevent recovery." 1 

The formation of crusts also tends to prolong 
the disease by retaining secretions which are liable 
to become infected. Such infection aggravates the 
irritation and inflammation of the subjacent tissues. 

Accumulation of Cerumen. Occasionally per- 
sons are met with who suffer from an excessive 
secretion of cerumen due to hyperaemia of the lining 
membrane (]MatC XII. a). A laminated epithelial 
plug may thus be formed composed of the horny 
layer of the cutis of the auditory canal. Such a 
plug if allowed to remain in situ excites further 
irritation and hypersemia, and stimulates the glands 
to abnormal activity. 


Otitis Media. A serious self-perpetuating con- 
dition arises when, as a result of Eustachian obstruc- 
tion, inflammatory discharges are pent up in the 
tympanum and undergo putrefaction, forming indeed 
a septic tank. Such discharges irritate the mucous 
lining of the cavity and excite further discharge 
which aggravates the disease (jplatC XII. b). 

1 La Pratique Oto-Rhino-Laryngologique, III., p. 83. 

212 tDicious Circles in 2>i0eaee 

Again the accumulation of inflammatory products 
in the tympanum exerts pressure on the superficial 
veins and lymphatics and blocks the natural channels 
of absorption. Such closure leads to increased 
accumulation and increased pressure. 

The destruction of ciliated epithelium by pus is 
another source of injurious correlations. During 
health the movements of the cilia are directed to- 
wards the pharynx and assist in clearing the 
tympanum of epithelial or other detritus. Retained 
pus, however, destroys this epithelium and abolishes 
the scavenging mechanism. Retention leads to 

A similar sequence may involve the accessory 
cavities of the tympanum, viz. the antrum and 
mastoid cells. Indeed the conformation of the 
temporal bone, with its warm and moist cavities 
and the awkwardly situated efferent ducts, greatly 
favours the imprisonment and putrefaction of inflam- 
matory and other debris, the narrow communicating 
channels being readily obstructed and blocked. 

Chronic catarrhal otitis associated with Eustachian 
obstruction is often complicated by rarefaction of 
the air in the tympanic cavity due to a process 
of absorption. The result is that the drum mem- 
brane is gradually stretched and eventually conies 
to lie against the internal wall of the tympanum, 
thus maintaining the otitis. 

Bench writes : 

" A gradual stretching of the drum membrane 
takes place from the continued pressure from with- 
out, until finally further displacement is prevented 
by contact with the internal tympanic wall. The 
pressure against this resisting barrier increases the 
local inflammatory process. The movement of the 
drum membrane inward and its persistence in this 
position is favoured by the action of the tensor 
tympani muscle, which by contraction draws the 

She ar 





plate XII. Circles aesoctateb with 
tbe Ear, 

214 IDtctoug Circles in ^Disease 

membrane inward against the wall of the middle 
ear. From disuse the tendon becomes shortened, 
this change being aided by the inflammatory process." 1 

An occasional consequence of purulent otitis 
media is the formation of a cholesteatoma, consisting 
of inspissated pus mixed with exfoliated epithelial 
cells ((Mate XII. c). The constant friction of this 
mass irritates the enclosing walls and provokes a 
continual proliferation and desquamation of cells, 
which in turn become adherent to the mass and so 
add layer to layer. The cholesteatoma thus increases 
much as does a vesical or a biliary calculus, irritation 
leading to growth and growth to increased irritation. 
The mass may in time reach the size of a walnut, 
and produce grave or even fatal results by invading 
the labyrinth or cranial cavity. 2 

Polypus. Aural polypus may be associated with 
similar morbid correlations to those observed in 
connection with the nose. In some cases at any 
rate an aural polypus appears to result from, as 
well as to perpetuate, suppuration. 

Cradle writes : 

" Well- ascertained histories often teach that polypi 
are started by prior suppurative disease, which their 
presence then serves to perpetuate." 3 

Deafness. Deafness may itself tend to further 
deafness by preventing the accurate adjustment of 
the tensor tympani to the vibrations of sound that 
reach the drum, and thus making it difficult to give 
the attention necessary for good hearing. 

Diseases of the Ear, pp. 310, 360. 

- Denker and Briinings, Krankheiten des Ohres und der 

Luftwege, p. 125. 
3 Diseases of the Nose, Pharynx and Ear, p. 1910. This 

quotation applies to the ear as much as to the nose. 


Urbantschitsch writes : 

" Impaired hearing is aggravated by inadequate 
auditory stimulation, by inattention as well as by 
inability to participate in social life. Hence a para- 
lysing isolation envelops the hard-hearing person 
more and more closely. Systematic auditory exercises 
are obviously of great importance." 1 

Deafness may also be aggravated when persons 
suffering from relaxation of the drum and associated 
disorders of the ossicles and labyrinthine window 
endeavour to improve their hearing by continually 
inflating the tympanum. Some sufferers use the 
Valsalvan method of inflation, others blow their 
nose in order to force air into the Eustachian tube. 
Although there may be a temporary improvement 
as a result of this nanoeuvre, its constant repetition 
leads to further stretching of the membrane, the 
loose folds of which come to rest on the inner 
tympanic wall and incudo-stapedial articulation. 
The deafness is thus permanently increased through 
the operation of an artificial Circle. 

Heath writes : 

" The constant distension of the tympanum with 
air must increase the relaxation of the weakened 
tympanic structures, and this allows of a further 
unopposed muscular stretching of the labyrinthine 
window, thus aggravating the condition which is the 
essential cause of the deafness." 2 

After an attack of otitis media the middle ear 
often remains a locus minoris resistentiw. The 
incompleteness of recovery is shown by a 
disposition to relapse, by a diminished resistance to 
fresh disease, and with every attack the permanent 

1 Deutsche Klinik, VIII., p. 274. 

2 The Treatment of Deafness (Paracusis Willissii), p. 64. Cf. 

also Politzer, Diseases of the Ear, pp. 142, 198, 342. 

216 IDicious Circles in Biseaee 

lesion increases until the cumulative mischief may be 
very extensive. 

An allied condition may be met with when 
serious and debilitating illness has greatly lowered 
the resistance of the organism to pathogenic influ- 
ences. During health a great variety of micro- 
organisms are present in the normal mucosa of 
the tympanum without causing any symptoms. 
If, however, prolonged pyrexia or other drain on the 
system lowers resistance and renders the tissues 
more vulnerable, the pathogenic microbes may 
become active and virulent. For example, a suppur- 
ating ear may produce a lowered state of health ; 
such ill health will keep up the suppuration which 
would cease under more favourable bodily conditions. 
The local and general disorders perpetuate each 


Neuroses. In neuropaths severe tinnitus may be 
both cause and effect of neurasthenia. Acute 
torment may be caused, and the more the mind 
is concentrated on the disorder the more is the 
sufferer harassed. Even men of strong nervous 
temperament have been so grievously obsessed by 
noises in the head as occasionally to commit suicide. 
A somewhat similar condition arises, when the 
persistent otalgia that complicates some forms of 
aural disease induces hyperaesthesia and neurasthenia, 
especially if insomnia is superadded (JMatC XII. 
d, e). 

Even apart from tinnitus and otalgia, any impair- 
ment of hearing power is likely to react unfavour- 
ably on neurasthenia, owing to the continued aural 
strain involved in the effort to hear. Such strain is 
a constant tax on the reserves of nervous energy. 
In the morning, when refreshed by a night's rest, the 
patient hears fairly well. But as the day passes the 

Ear 217 

nervous system becomes over-taxed and he loses the 
power of concentrating attention. This involves 
increased deafness and increased auditory strain. 

Dench writes : 

" After being subjected to the fatigue consequent 
on the day's activity, the hearing power becomes much 
diminished, and any effort on the part of the patient 
to disguise the symptom simply magnifies it. The 
local impairment, in turn, reacts upon the general 
condition of the patient to a considerable degree, 
frequently causing him to become hypochondriac, and 
in some cases leading to acute melancholia." 1 

Many forms of deafness seem to impair vitality, 
doubtless owing to the fewer stimuli that reach 
the sensorium. This is frequently observed in early 
life. Deaf children lack vitality and such lessened 
vitality increases their deafness. 

Auto-Suggestion. Another form of deafness is 
due to auto-suggestion. For example, after the 
explosion of a shell a soldier may be convinced that 
he is deaf and make no attempt to listen (platC XII. f). 
The aural perceptive structures in the brain may be 
dissociated from the nervous tracts which convey 
the peripheral stimuli from the ears, so that sound 
vibrations fail to produce the slightest auditory 
sensations. Suggestion frequently succeeds in restor- 
ing the hearing by re-association, by switching on 
the interrupted synapses. 

Hurst writes : 

" The momentary deafness, which is the natural 
result of the terrific noise caused by the explosion of a 
big shell in the immediate neighbourhood, may make 
such an impression on the mind of a soldier that, on 
coming to himself, whether he has actually lost con- 
sciousness or not, his first thought is for his hearing, 
especially if it was already impaired by preceding 

Diseases of the Ear, p. 663. 

218 IDfcious Circles in IDiseaee 

disease, and he may be so convinced that he is per- 
manently deafened that he becomes actually deaf as a 
result of auto-suggestion. Hearing necessitates listening. 
Inattention during a dull sermon results in total 
deafness to the sermon, and in hysterical deafness the 
patient is so convinced that he cannot hear that he 
does not listen ; although the sound vibrations reach 
the ear in the normal way, they do not give rise to the 
slightest' auditory sensation because of this inattention. 
The synapses at one or more of the cell-stations in the 
auditory path to the cerebral cortex must therefore be 
unswitched, probably as a result of retraction of the 
dendrons." 1 

Vertigo. Vertigo is another aural neurosis which 
reacts on the primary disorder and so perpetuates 
its own cause. The victim may lose confidence in 
himself and becomes the prey of phobias which feed 
the neurosis. 

Bing writes : 

" If a neurasthenic has once experienced a subjective 
difficulty of this sort the fear of vertigo makes itself 
felt in a very marked form and the recurrence of such 
symptoms naturally increases this fear a painful 
Vicious Circle. Fortunately in very few cases does an 
actual permanent vertigo appear." 2 

l Proc. Royal S. of Med. (1917), X. (iii.), (Otology), p. 115. 
2 Nervous Diseases, p. 412. 

Chapter fourteen 


HE following classification of disorders 
of the skin will be found convenient : 

I. Inflammatory Disorders 
II. Parasitic Disorders 
III. Disorders associated with Append- 
ages of the Skin Hair, Nails, 
Sweat and Sebaceous Glands 
IV. Neuroses 


Eczema. Eczema will serve as a type of various 
disorders which are self-perpetuating through the 
pruritus which they excite ((Mate XIII. a). The 
itching and associated scratching aggravate, and 
may indefinitely prolong, the lesion that produced 

McCall Anderson, speaking of acute eczema, 
says : 

" Scratching always aggravates the disease and 
tends to bring out fresh crops of eruption. . . . Often 
in mild cases, where there is not much infiltration, the 
disease is kept up by the scratching alone." l 

Similar correlations occur in chronic eczema, 
as Kaposi points out : 

" The attendant itching is generally very severe and 
induces violent scratching. This acts as a cutaneous 
irritant and may excite a fresh eczema." 2 

Diseases of the Skin, p. 103. 
2 Diseases of the Skin, p. 345. 


220 iDtctoug Circles in gHecage 

When scratching has been indulged in over a 
long period, the skin may undergo a process known 
as lichenification, characterised by the presence of 
pseudo-papules and accompanied by furious itching 
due to irritation of the nerve endings by the 

Malcolm Morris writes : 

" The itching provokes scratching, the scratching 
sets up lichenification which irritates the nerve endings 
and provokes further itching. The main object of 
treatment is to break this Vicious Circle by reducing 
the lichenification and restoring the damaged tissues 
to the normal state." 1 

Chronic eczema is often associated with varicose 
veins and ulcers of the leg. The varices give rise 
to itching and scratching, as a result of which papules, 
excoriations, haemorrhages and crusts are produced. 
The consequent inflammation and itching lead to 
deeper excoriations and increased inflammation. 
Eventually the skin breaks down, giving rise to the 
well-known varicose ulcer. 
Kaposi writes : 

" These secondary inflammatory processes aggravate, 
for the time, the local exudation and congestion and are 
themselves, again, causes, leading to the destruction of 
the scarcely reproduced young tissue, that is, of 
the granulations and cicatrices. They are, therefore, a 
source of ulceration, at the same time that originally 

they resulted from it Such a condition of the 

skin predisposes in a high degree, per se, to renewed 
attacks of inflammation on the slightest provocation ; 
and, since the inflammation again tends to maintain 
and increase the ulceration, we have here an endless 
circulus vitiosus."* 

Varicose ulcers may also be complicated by what 
Unna terms an " incurable circulus vitiosus " due to 

1 British Med. /., 1912, I., p. 1472. Cf. also Mraeek, 

Handbuch der Hautkrankheiten, II., p. 300, 
2 Hebra, Diseases of the Skin, V., p. 25. 

Che Sfcin 



/^ Pus/ % 



(c) ACNE 




UMate Xili. Circles associated with 
the Shin. 

222 tnctous Circles in Disease 

a disappearance of elastin caused by a chronic 

Unna writes : 

" Owing to the loss of elastin, the oedematous skin 
gradually loses more and more elasticity ; that is, the 
spontaneous elastic recoil of the collagenous tissue, 
displaced by pressure or by movements of the body, 
takes place more and more slowly and incompletely ; 
the muscles of the skin lose a great part of their action 
on the skin texture. Thus we have an additional 
factor, favouring the oedematous swelling of the cutis. 
By the oedema directly attacking the elastin it interferes 
with the most important factor in the healing of 
oedema and induces an incurable circulus vitiosus, which 
terminates in complete loss of resistance of the skin, 
rupture of the epidermis, and lymphorrhcea externa." 1 

Eczema may also provoke reverberations in 
distant regions of the body which react on the 
primary disorder. Such reverberations are not 
uncommonly observed in elderly persons \vhose 
depressed vitality may have favoured the dermatitis, 
while this is in turn aggravated by its effects. 

Insomnia due to persistent irritation is not an 
uncommon intermediary. In other cases the diges- 
tive system appears to be affected by the cutaneous 
eruption and vice versa. 

Malcolm Morris writes : 

" The irritation of the skin may . . . set up reflex 
irritation in the intestine, preventing the proper 
digestion of food. The irregularity of the bowels 
-reacts in turn on the skin, and thus a Vicious Circle is 
established." 2 

1 Histopathology of Diseases of the Skin, p. 40. Cf. also 

Koch, Archiv /. Dcrmatologic und Syphilis, XXXIV., 
p. 228. 

2 Diseases of the Skin, p. 276. Cf. also Kaposi, I.e., pp. 

918-922 (quoted in British J. of Dermatology, 1901, 
XIII, p. 37-) 

Sfcin 223 

Intertrigo. Morbid correlations may also com- 
plicate intertrigo, a dermatitis which is liable to 
occur when opposing surfaces of the skin remain 
long in contact and exposed to the natural heat 
and moisture of the body. The superficial epithelium 
is then apt to desquamate, leaving the deeper layers 
of the skin exposed to the air. From these denuded 
surfaces free exudations take place which tend 
to undergo decomposition and to set up further 
irritation and further exudation. Cause and effect 
react on each other. 

Examples of such intertrigo are often seen in 
young children whose ears are covered and pressed 
to the sides of the head by a tight fitting cap or 
bonnet, this head-dress amongst the poor being 
often worn for days together. The posterior aspect 
of the auricle and the adjacent integument of the 
head are then often attacked by intertrigo. 

Hyde writes : 

" In such localities the disorder, beginning as an 
erythema traumaticum, proceeds by its irritative 
effects to stimulate the secretion of sweat, which is 
freely poured out between the adjacent folds of skin, 
and may there temporarily be imprisoned. The 
surface, heated and reddened, is also somewhat macer- 
ated by the effused perspiration, and the latter, when 
chemically altered, as it is frequently under these 
circumstances, adds still further to the original dis- 
order." l 

Urticaria. Urticaria is another form of der- 
matitis which is accompanied by severe itching and 
burning, which compel the patient to scratch 
furiously in order to obtain relief. The scratching, 
whilst affording a sense of satisfaction, only too 
often provokes a fresh crop of wheals. 

Diseases of the Skin, p. 143. 

224 IDicioug Circles in Disease 

Gaucher writes : 

" The wheals are accompanied by intense itching, 
which causes the sufferer to scratch himself. This 
scratching gives rise to a further crop of wheals." 1 

A very similar process occurs in lichen ruber. z 

Clavus. A corn is primarily a protective hyper- 
keratosis caused by intermittent pressure, and occurs 
in situations where the skin is most liable to pressure, 
such as the plantar region. In the centre of the 
thickened horny layer a conical plug or core usually 
forms and this by pressing on the underlying sensitive 
corium sets up irritation and stimulates the papillae 
to rapid proliferation. The more the papillae are 
irritated the more rapidly they grow, and the more 
they grow the more is the corn raised above the 
surface and therefore exposed to pressure. 

Ellis writes : 

" The relation between corns and too tight or badly 
fitting boots is too obvious for dispute. Corns are 
illustrations of the law that intermittent pressure and 
friction cause over-growth. The cuticle becomes thick- 
ened at the pressure point until, in turn, it becomes 
itself a cause of pressure from its own hardness and 
large size. Here removal of the cause is speedily 
followed by disappearance of the effect." 3 

Callosities are also due to hypertrophy of the 
horny layer and are often complicated by inflam- 
mation of the underlying corium, cause and effect 
reacting on each other. A similar reciprocation 
is present in the case of bunions. 4 

1 Maladies de la Peau, p. 60. 
2 Gaucher, I.e., p. 133. 

3 The Human Foot, p. 89. 

4 Ellis, l.c., p. 86. 

Sfun 225 

(a) Animal Parasites 

Oxyurides. A familiar illustration of reciprocal 
correlations due to an animal parasite is met with in 
the case of oxyurides. The irritation at the anus 
and the consequent scratching lead to portions of 
the helminths or to their eggs being caught under 
the finger-nails, conveyed to the mouth and swal- 
lowed. From the stomach the ova pass into the 
intestines and rapidly attain sexual maturity. In 
this way the irritation ensures, by auto-infection, 
successive generations of the parasite. 

Scabies. Scabies may also be perpetuated through 
the itching and scratching excited by the acari. 
The parasite may lodge under the finger-nails, and 
thus be transferred from one part of the body to 

Pediculosis. Similar correlations may be associ- 
ated with pediculi capitis. The crawling and suck- 
ing of the lice cause itching, the itching provokes 
scratching of the infected area, the scratching 
transfers the lazy louse to fresh pastures. Moreover 
the finger-nails often produce excoriations and 
exudations, and thus supply further food material 
for the lice and accelerate their propagation. The 
louse itself secures its own nutriment, for when it 
has satisfied its appetite and withdrawn its haustel- 
lum, a drop of blood wells up to the surface, thus 
supplying further food. 

Again the inflammation and tenderness of the 
skin associated with pediculosis prevent the proper 
use of the brush and comb. The diseased spot and 
its infesting colony are left undisturbed so that 
the lice can multiply at their leisure. Moreover the 
cutaneous exudations readily form crusts and glue 

226 IDicious Circles in S>ieea0e 

the hairs together, thus affording a hiding-place 
for the increase of the parasites. Especially is this 
the case in those countries where the plica polonica 
is still in fashion ; no wonder that, in Hebra's 
words, " the lice swarm as if one had disturbed a 
nest of ants." 

Some writers believe that severe deprivation and 
exhaustion such as occur during war greatly favour 
the extension of lousiness, while this condition 
tends to further debility. This sequence of events 
was often observed during the Crimean war, and 
was doubtless dependent on the severe hardships 
endured by the troops. 

Longmore writes : 

" The lice multiplied with marvellous rapidity in the 
clothes and persons of men who became ansemiated and 
much debilitated, and the increase of vermin, and 
increase of debility, by mutual co-action, went on at 
least at geometrical ratio, until death carried off the 
man." l 

(b) Vegetable Parasites 
These may be subdivided into : 
(i.) Fungi 
(ii.) Bacteria 

(i.) Fungi 

Ringworm. Some important reciprocations are 
established when ringworm invades the hairy or the 
glabrous regions of the skin. For example, if an 
endothrix member of the trichophytons insinuates 
itself between the cuticle cells of the hair, it rapidly 
proliferates, so that the shaft becomes stuffed with 
spores, grows brittle and readily splits or breaks 
off. The detached portion laden with spores is then 
free to spread infection far and wide ; in fact the 

1 British Med. /., 1914, IT., p. 679. 

Gbe Sfctn 227 

continual breaking off of the hair is the chief means 
by which the spores of the parasite are dispersed. 
The fragment of hair remaining in the follicle may 
also perpetuate the infection. 

Another complication occurs when ringworm pro- 
vokes itching and scratching, and so leads to the 
auto-inoculation of fresh foci. The parasite is apt 
to lodge under the nails and to be transferred to 
another portion of the scalp ; or the nail itself 
may be invaded by onychomycosis, which facilitates 
the inoculation of fresh areas. The ordinary comb- 
ing and cleansing of the hair also assists in diffusing 
infection, and this leads to further cleansing. Es- 
pecially injurious is the washing of the hair, since 
water nourishes the fungus. 

Sabouraud writes : 

" Any attempt to cleanse the diseased scalp dis- 
perses the infective agent and creates fresh points of 
inoculation. In girls, for instance, the linear tracts 
left by the use of the comb are indicated by rows of 
diseased hairs." 1 

When the fungus infects the non-hairy skin, it 
causes dissociation of the epidermic cells, and the 
debris supplies the parasite with the sustenance 
necessary for its further growth. The irritation 
also provokes inflammation and exudation, both of 
which are favourable to rapid multiplication. 

Similar correlations are established in the case of 
favus and tinea versicolor. The fungus may provoke 
inflammatory reactions, as shown by discomfort, 
burning or itching. The consequent rubbing or 
scratching may then transfer the fungus to fresh 
areas, where the infection is reproduced. 

In some regions of the body fungus infection is 
especially prone to provoke hypersecretion which 
supplies further nutriment and thus favours parasitic 

Pratique Dermatologique, IV., p. 480. 

228 IDictoug Circles in Bieeaee 

growth and extension. A good example of this is 
presented by otomycosis due to some form of 
aspergillus or other fungus. Both the ceruminous 
and sebaceous glands of the external auditory 
meatus may be stimulated by activity of the 
parasite which penetrates into the lining membrane. 
Even obstruction of the meatus with retention of 
secretions is occasionally brought about. 

(ii.) Bacteria 

Impetigo. Impetigo contagiosa may be taken 
as an example of a dermatitis due to bacterial 
infection. The eruption gives rise to discomfort 
and itching ; the itching leads to scratching. 
The finger-nails become infected by the sero-pus 
containing the streptococci, which then are readily 
inoculated into any excoriations produced by the 
scratching (platC XIII. b). Indeed repeated auto- 
inoculations may cause an indefinite persistence of 
the disease. 

Sequeira writes : 

" The eruption itches, and auto-inoculation is 
exceedingly common. By scratching and simple con- 
tact fresh spots form with great rapidity, and large 
areas may be involved." * 

Ecthyma, furunculosis and sycosis may be per- 
petuated by a similar mechanism. 




(a) The Hair 

Several circular reactions associated with the 
hair (e.g. pediculosis, ringworm etc.) have been 
already alluded to. There remain others which 
must now be dealt with. 

1 Diseases of the Skin, p. 149. 

SFun 229 

Baldness. According to some writers baldness 
may be dependent on reciprocally acting factors. 
Owing to the fashion of keeping the head covered 
and of thus depriving the hair of sun, air and 
nourishment (especially if a hard-rimmed, tight hat is 
worn) the hair in the regions most frequently covered 
tends to atrophy and fall out. The result is more 
or less extensive baldness, which in its turn necess- 
itates increased use of the head gear. 
Brocq writes : 

" Persons who keep their heads constantly covered 
with a heavy and tightly fitting hat lose their hair 
much more rapidly than those who keep their head 
uncovered." 1 

Hirsuties. The opposite condition, viz. hirsuties, 
is often associated with an artefact owing to the 
practice of epilation or to the application of depila- 
tories. Neither of these methods of getting rid of 
hair possesses any permanent value ; they merely 
make new hair grow more luxuriantly than before by 
increasing the local circulation and provoking hyper- 
trophy of the papillse. The hypertrichosis leads 
to epilation and this to further hypertrichosis. 
It must, however, be added that the causation 
both of baldness and hirsuties is still sub judice. 
The sequence of events suggested above is by no 
means universally accepted ; doubtless the aetio- 
logical factors vary in different cases. 

(b) The Nails 

The nails have more than once been mentioned 
as agents in the perpetuation of disease. At times 
they aggravate the pruriginous disorders they are 
intended to relieve, as in the case of eczema and 
urticaria. At other times, when used to relieve 
pruritus, they become the carriers of infection, as 
in the case of oxyurides or impetigo. 

1 Pratique Dermatologique, I., pp. 318, 375. 

230 IDicious Circles in Disease 

Onychogryphosis. The nails themselves are 
sometimes diseased. Thus Heller has drawn atten- 
tion to a process of reciprocation that is established 
in onychogryphosis, owing to a keratoma in the 
nail bed : 

" This cushion-like growth, caused by the inflam- 
matory irritation in the matrix, raises up the nail- 
plate and disturbs its natural growth. This raising 
of the nail also increases the angle between the matrix 
and the nail-plate, as this latter emerges from the 
posterior fold. A circulus vitiosus is now established, 
since the space between the plate and the matrix 
(owing to the plate being obliquely raised) again 
becomes filled by the horny growth." 1 

Ingrowing Toe-Nail. A somewhat similar pro- 
cess may complicate onychia, where inflammation 
leads to accelerated growth, and this in turn intensi- 
fies the inflammation. This condition occurs with 
ingrowing toe-nail, as Sir Jonathan Hutchinson 
points out : 

" As soon as any degree of inflammation has been 
set up, the conditions aggravate each other ; the 
inflamed nail expands and grows laterally against the 
raw surface, now unable to tolerate any pressure. 
No doubt, also, as in onychia maligna, the secretion 
produced is in itself a source of irritation." - 

(c) The Sebaceous Glands 

Sebaceous Cysts. Various skin disorders are 
due to obstruction of efferent ducts and the con- 
sequent accumulation of retained secretions. For 
example, hyperkeratosis of the outer third or funnel 
of a pilo-sebaceous follicle may give rise to a comedo 
plug, whose presence acts as an irritant and pro- 
motes further hyperkeratosis. Sebaceous cysts often 

a Mracek, Handbuch der Hautkrankheiten, IV. (ii.), p. 569. 
-Lectures on Clinical Surgery, I. (i.), p. 144. 

Sfcin 231 

arise by a similar process, the accumulation of 
sebaceous matter causing hyperactivity of the 
follicular walls and increased accumulation. The 
same may be said of acne vulgaris, where in- 
flammation of the walls of the follicles is probably 
associated with microbic infection. The increased 
secretion leads to increased irritation and vice 

lyarge accumulations of fat and epidermis, due to 
seborrhcea, are sometimes observed in the umbilical 
fossa. In course of time this mass may become 
rancid and irritating, thus provoking increased 
secretion and accumulation. Seborrhcea genitalium 
is another example, which arises when, through 
want of cleanliness, smegma is allowed to collect 
and decompose. 

Acne Rosacea. Some reciprocal correlations may 
be displayed in acne rosacea and account for its 
chronicity. The disease often begins with tem- 
porary but recurrent angio-neurotic flushing of 
the skin over the central portion of the face. In 
course of time these flushes give rise to a network 
of vascular dilatations associated with telangiectases 
and acne-like papules, resulting eventually in inflam- 
mation of the sebaceous glands. The telangiectases 
and the pustules appear to favour one another. 
Brocq writes : 

" A form of Vicious Circle is established. The 
inflamed acne favours the afflux of blood to the face, 
and aggravates the dilatation of the blood-vessels ; 
while, on the other hand, the chronic congestion of 
the skin favours the production of acne and the indura- 
ation round the base of the pustules." 1 

The latter stage of the disease is characterized by 
an enormous development of sebaceous glands and 

1 Dermatologie Pratique, I., p. 831. Cf. also Pratique 
Dermatologique, I., p. 227. 

232 IDicious Circles in H)i0ea0e 

fibrous tissue changes which reciprocally aggravate 
one another (]MatC XIII. c). The process is similar 
to that met with in rhinophyma and acne cheloid. 
Wilfred Fox writes : 

" The fibrous tissue obstructs further the sebaceous 
ducts, renders the outflow more difficult, and by 
stagnation favours additional pustulation, which in 
its turn produces fresh fibrous tissue, and so a Vicious 
Circle is set up." l 

(d) The Sweat Glands 

Hyperhidrosis. General hyperhidrosis is met 
with in both acute and chronic diseases ; in both 
cases it may perpetuate its own cause. Almost 
every severe disease that is accompanied by great 
prostration may be complicated by excessive sweats, 
which, on the one hand, result from the state of 
exhaustion, and, on the other, aggravate such ex- 

Bouveret writes : 

" The colliquative sweats of convalescence are no- 
thing more than the expression of a state of profound 

weakness The convalescent perspires because 

he is weak, and this perspiration aggravates his weak- 
ness. This is a Vicious Circle from which he must 
escape without delay." 2 

Perhaps the most violent attacks of hyperhidrosis 
are seen in tuberculosis, where they may cause 
complete soaking of the linen. The excessive sweats 
weaken the patient to an extraordinary degree and 
are said often to hasten the end. 3 

The same process in a less severe form is seen in 
neurasthenia, rheumatism and obesity. Neuro- 
pathic individuals not uncommonly are troubled 

J Allbutt and Rolleston, System of Medicine, IX., p. 697. 

2 I,es Sueurs Morbides, p. 121. 

3 New York Medical /., 1918, II., p. 475. 

Skin 233 

by night sweats which perpetuate the nervous 
debility. 1 

In rheumatic persons, on the other hand, it is 
especially the skin over the affected muscles that 
sweats, but this is very apt to lead to chill and 
increased rheumatism. 

Llewellyn and Jones write : 

" A local hyperidrosis of the loins, by leading to 
soaking of the adjacent underclothing and conse- 
quently to local cooling, almost infallibly induces an 
exacerbation and thus a Vicious Circle ensues." 2 . 

Some stout persons whose adipose tissues dimin- 
ish the amount of heat given off by radiation and 
conduction, are much troubled by abundant perspir- 
ations. These make the sufferer lazy, and thus 
tend to increased obesity and perspiration (JMatC 
XIII. d). 

Hyperhidrosis of the axillary regions frequently 
causes women to wear impervious shields in order 
to protect their dress from unsightly stains. These 
shields, however, encourage retention and decom- 
position of the secretions, and thus favour irritation 
of the skin and further hyperhidrosis. 

Anhidrosis. In persons who take too little 
exercise an inadequate amount of perspiration may 
also establish morbid correlations. The want of 
exercise causes anhidrosis, insufficient consumption 
of liquid, constipation, lassitude and a further 
disinclination for exercise. 

Dyshidrosis. Some dermatologists have attri- 
buted pompholyx or dyshidrosis to disorder of the 
sudoriparous apparatus, although the matter is still 
under discussion. There can, however, be no doubt 
that the associated itching and scratching are both 
cause and effect of the disorder. 

1 Miiller, Handbuch der Neurasthenic, p. 166. 
2 Fibrositis, p. 174. 

234 Dicious Circles in disease 

Brocq writes : 

" The patient complains of intense itching and 
burning. The more he scratches himself the more 
numerous and the larger do the vesicles become. 
They seem almost to develop under the fingers at the 
itching spots as these are being rubbed." 1 
Retention cysts of the sweat glands may be due 
to the same mechanism as produces retention cysts 
elsewhere. Owing to the narrow lumen the sweat 
duct is readily obstructed or kinked, leading to 
accumulation of sweat and cystic dilatation. This 
may in turn cause further obstruction and accumu- 
lation, until the cyst reaches a considerable size. 


All dermatoses are liable to be complicated by a 
neurotic element. But it will be convenient to 
group under a separate heading some conditions 
where the neuroses are predominant. 

Pruritus. A familiar example is presented by 
pruritus, a disorder which may be independent of 
local irritation or of pathological changes in the skin. 
In some neuropaths who have suffered from pruritus 
the mere fear of an attack may suffice to bring it on. 
The liability is greatest in such a place as a church 
or a theatre, where there is no opportunity of grati- 
fying the desire to scratch. The itching gradually 
increases in intensity, and when scratching can be 
indulged in the pruritus is further aggravated owing 
to increased reflex irritation. The phobia thus 
nourishes itself (plate XIII. e). 

After a period of pleasurable excitement a form 
of orgasm takes place accompanied by a discharge 
of nervous energy and a relief of the pruritus. 

In cases of persistent pruritus there may be estab- 
lished what Unna calls the " circulus vitiosus of 

1 Dermatologie Pratique, II., p. 133. 

Gbe Sfcin 235 

scratching and hyperkeratosis," 1 a correlation which 
has been strongly upheld by Brocq and Jacquet, 
although other dermatologists believe that a slight 
eczema or other lesion may start the process. If 
the scratching has been indulged in for long, a 
permanent change known as lichenification is apt 
to follow. This again perpetuates the pruritus, as 
Macleod has described : 

" When lichenification is established, a Vicious Circle 
is set up, for the thickening of the skin irritates the 
nerve-endings and so keeps up the pruritus, whilst 
the rubbing which is indulged in to relieve the pruritus 
increases the lichenification." 2 

In other cases of long-continued pruritus inner- 
vation may be so disturbed as to produce an exagger- 
ated activity of the reflex mechanism of scratching. 
The habit may persist after all peripheral lesion has 
disappeared . The condition resembles that occasion- 
ally met with in other muscular mechanisms such as 
blepharospasm, cough or vomiting. 

Pruritus ani and pruritus vulvae have been dealt 
with in Chapters VI. and VIII. 

Prurigo. In prurigo also the neurotic element 
plays an important part. There has been much 
dispute as to whether the scratching gives rise to 
the papules or the papules to the scratching ; but 
whatever the primary cause the two conditions act 
and react on each other. Thus Sir Jonathan 
Hutchinson writes : 

" Prurigo, from whatever cause it may have begun, 
tends to perpetuate or even to aggravate itself. It 
causes itching, and the itching causes scratching, and 
the scratching extends the prurigo, and thus the 
patient goes on from bad to worse." 3 

Blushing. Another nervous disorder is associ- 
ated with blushing a vaso-motor condition pro- 

^Iracek, Handbuch der Hautkrankheiten, II., p. 306. 
~ Allbutt and Rolleston, System of Medicine, IX., p. 298. 
3 Lectures on Clinical Surgery, I. (i.), p. 30. 

236 IDtcious Circles in Disease 

voked by emotional disturbance and showing itself 
by dilatation of the blood-vessels of the skin. It is 
especially common in nervous, self-conscious women. 
The more self-conscious, the more they blush. The 
harder they try to avoid blushing the worse they 
suffer (plate XIII. f). 

Roussy and lyhermitte write : 

" Blushing and trembling are as a matter of fact 
simply reflex manifestations of an emotional temper- 
ament. Just as the blushing of an ereutophobe in- 
creases with the progress of his phobia, so the trembling 
of the tremophobe increases with his dread of tremb- 
ling. The physical phenomenon creates the obsession 
which in its turn aggravates the physical reaction ; 
the aggravation of this latter similarly reacts on the 
mental trouble. Thus is established a Vicious Circle 
of reciprocal psychophysical reactions, of which the 
result is a real state of obsession." 1 
In some sensitive females ereutophobia has been 
a real martyrdom and destroyed all the happiness 
of life. Girls have had to abandon school life ; 
women have even contemplated suicide to escape 
their obsession. Facial seborrhcea in neurotic women 
may also be a self-perpetuating condition through 
a similar mechanism. 2 

In certain predisposed persons great mental 
anxiety or depression may provoke cutaneous 
eruptions, thus shewing how intimately the skin 
and nervous system are connected. The eruption 
naturally aggravates the neurosis. 
Fernet writes : 

" Continual mental stress and want of sleep may lead 
to a form of eruption on the skin which when wide- 
spread is in itself so irritating as to lead to further 
depression of the sufferer, in a word to what is called 
a Vicious Circle." 3 

^es Psychonevroses de Guerre, p. 65. 
2 Kaposi, Diseases of the Skin, p. 123. 
3 The Health of the Skin, p. 19. 

Chapter jfifteen 


ANY of the Vicious Circles occurring in 
the domestic animals are similar to those 
occurring in man, as indeed might 
be expected from their morphological 
and physiological affinities. 
On the other hand domestic animals afford 
examples that are little known in human pathology, 
owing to peculiarities in structure and function. 
Amongst them are various forms of impaction of 
food in such regions of the alimentary tract as the 
peculiarly shaped stomach of the horse, the rumen 
of cattle or the crop of the bird. Again hairy, 
woolly or feathery coats favour parasitic disease 
to an extent that man happily escapes. 

Attention may be drawn to a few examples which 
occur in the more important domestic animals, and 
which may serve to illustrate the morbid process. 
We may deal in order with the nervous, the cardio- 
vascular, the respiratory, the digestive and other 
systems. 1 

Apoplexy. Cerebral haemorrhage is less common 
in the domestic animals than in man since they 
are less subject to degenerative changes in the 
arteries. Nevertheless horses, cattle, dogs, birds 
and other animals suffer occasionally, and the 
haemorrhage may perpetuate itself by the following 
mechanism : 

l Cf. also Veterinary Diseases and the Vicious Circle, by 
J.B.H., The Veterinary News, 1918, I., pp. 218, 226. 


238 IDicious Circles in SHeeaee 

Under normal conditions the blood-pressure in. 
the cerebral arteries is considerably higher than the 
intra-cranial pressure, being in horses equal to ca. 
200-300 mm. Hg and in dogs to ca. 100-150 mm. 
Hg, while the intra-cranial pressure is practically 
nil. Cerebral haemorrhage, however, raises the intra- 
cranial pressure nearly up to arterial pressure, and 
in so doing renders the vaso-motor centres anaemic. 
In their urgent need for blood these centres respond 
by a great splanchnic vaso-motor constriction, 
which may raise the pressure far above the normal 
level. Unhappily the rise is apt to prove disastrous 
by starting the haemorrhage afresh. A further 
increase of intra-cranial pressure then results, and 
the whole sequence is repeated. 

The increased blood-pressure frequently causes 
death by paralysis of the respiratory centre in the 

Hydrocephalus. Chronic hydrocephalus is often 
complicated by the presence of a Vicious Circle 
which may lead to the destruction of the brain. 

In health the cerebro-spinal fluid is continually 
being secreted by the choroid plexus into the 
ventricles, whence it escapes into the subarachnoid 
space, secretion and absorption being adjusted by a 
self -regulating mechanism. Various morbid pro- 
cesses, however, may narrow the communicating 
passages, causing an accumulation of fluid in the 
ventricles, which may so displace the adjacent 
parts as to increase the stenosis to which the dilat- 
ation was primarily due. For example, the tentorium 
cerebelli may be pushed down on the corpora 
quadrigemina and these in turn may press on the 
Sylvian duct, thus tending to diminish its lumen ; 
the obstruction in turn increases the ventricular 
accumulation and so on. Such accumulation may 
lead to disastrous consequences. The pressure of 

IDeterinan? Diseases 










Gr*. ^ /" ^s%^ 

^ ^f/ \ \ 

J i( )! 




Scf /& 





xiv. Circles associated with 
IDeterinarg Diseases, 

240 Dlcious Circles in Disease 

fluid in the ventricles stretches their walls which 
grow thin and weak. The more they stretch the 
thinner they grow and vice versa. The associated 
changes in the brain may be very striking. In the 
worst cases the cerebral tissues may be so com- 
pressed and stretched as to be reduced to a thin 
membrane, all trace of convolutions being lost, and 
the basal ganglia scarcely recognisable. 

The changes caused by hydrocephalus are most 
readily effected in newly born animals, whose skull 
and membranes are yielding and the sutures un- 


Cardiac Disease. Domestic animals frequently 
suffer from heart disease and such disease is com- 
plicated by a variety t>f circular reactions (||MHte 
XIV. a). Striking examples are met with in horses 
which, whether used for draught or for racing 
purposes, are liable to excessive demands on the 
heart, which not uncommonly breaks down under 
the strain. The resulting disease, whether myocar- 
diac or valvular, calls forth compensatory changes 
which tend to make good the insufficiency and may 
continue operative for a number of years. 

Sooner or later, however, such compensation 
usually fails, and the heart becomes unequal to its 
work. The other organs that depend on the heart 
for their activity, such as the lungs, intestines, liver, 
kidneys etc. are then thrown into disorder. The 
processes of oxygenation, nutrition and elimination 
are impaired, while this impairment of vital func- 
tions reacts injuriously on the damaged heart, 
increasing its disability and aggravating its weak- 

Such a Vicious Circle may end in chronic invali- 
dism or in death. 

IDeterinan? Dieeaeee 241 

Worm Aneurysm. Another common disorder 
in horses is the so-called worm aneurysm due to 
the presence in the anterior mesenteric or other 
arteries of the larvae of the haematozoon strongylus 
vulgaris (sclerostomum vulgare). These larvae set 
up endo-arteritis, as a result of which the arterial 
walls grow weak, yield to the blood-pressure and 
form an aneurysm. 1 The more they yield the 
larger the aneurysm ; the larger the aneurysm the 
greater the tension on the walls, since vascular tension 
increases with calibre. Thus the dilatation is pro- 
gressive and the aneurysm may eventually rupture 
with fatal results. 

The aneurysm and associated thrombosis may 
also cause serious circulatory failure in the intestines, 
followed by loss of peristalsis, stasis, fermentation 
and dilatation. These conditions aid and abet one 
another, so that further reciprocations are initiated. 


Chronic Catarrh of the Guttural Pouches. An 

interesting Vicious Circle may be associated with 
chronic catarrh of, and retention of secretions in, the 
guttural pouches of the horse. The mucous mem- 
brane lining the pouches may from various causes 
become congested or inflamed, resulting in retention 
and decomposition of the secretions. Such decom- 
position leads to narrowing of the openings into the 
pouches and further obstruction to drainage. Thus 
the greater the obstruction the greater the irritation 
and vice versa. In course of time the retained 
secretions may form cartilaginous concretions or 
chondroids which set up further irritation. Con- 
cretions weighing as much as 2 Ibs. have been 
recorded. 2 

1 Neumann, Parasites and Parasitic Diseases of Domesticated 

Animals, p. 622. 
2 M611er, Operative Veterinary Surgery, p. 92. 

242 Dicioue Circles In Disease 

Tuberculosis. Tuberculosis is a wide-spread 
disease affecting many of the domestic animals and 
involving various organs in the animals attacked. 
The difficulty of eradication is largely due to the 
various Vicious Circles that are formed. Space 
will only permit of a few references to the disease 
as met with in cattle. 

Bovine tuberculosis propagates itself in a variety 
of ways. For example, tubercle-laden sputa, when 
loosened by cough, may be aspirated into healthy 
parts of the lung, and thus start fresh foci. Or the 
sputa may be swallowed and infect the alimentary 
tract, whence the bacilli pass through the lymphatics 
and return to the lungs where the disease starts 
again, and where fresh materials are generated for 

The astonishing rapidity with which pulmonary 
cavities sometimes form and enlarge is also due to 
the operation of Circles. In some cases an entire 
lung may be destroyed, so that the bronchi open 
into a vast cavity bounded by little more than the 
pleura. The process may be the result of various 
causes. Thus a mass of caseous tubercles may be 
discharged into a bronchial tube, leaving a cavity 
of which the walls are in active tuberculous evolu- 
tion. The larger the surface exposed to infection, the 
more rapidly does disintegration take place. Thus the 
cavity tends to grow eccentrically. Again the 
accumulation of the stagnant secretions greatly 
favours the multiplication both of the tubercle 
bacilli and of other pyogenic micro-organisms. 
These mixed infections accelerate the advance of 
the tuberculosis and tend to the further enlargement 
of the cavities. 

With these and other Vicious Circles at work it 
is no wonder that tuberculosis is so destructive 
a disease. Moreover the tuberculous animal may 
disseminate infective sputa far and wide. All the 

lDetertnan> H)i9ea0c0 243 

residents in a cow-shed may be infected by the 
introduction of one diseased animal. 

Emphysema. The expression " broken wind " 
is loosely applied to several disorders, but is best 
restricted to a chronic emphysema of the pulmonary 
alveoli which is a steadily progressive condition due 
to the operation of Vicious Circles. The disease, 
frequently met with in the horse, may result from 
various causes, chronic bronchitis being perhaps 
the commonest. The bronchitis is often accom- 
panied by severe coughing and by very tenacious 
expectoration which is expelled with difficulty. 
The cough leads to increased intra-pulmonary 
pressure as a result of which the alveoli yield and 
dilate. Their walls lose their natural elasticity and 
frequently a number of alveoli become confluent. 
The secretions tend to stagnate in the dilated 
alveoli and thus perpetuate the cough which in its 
turn promotes further alveolar dilatation. Thus 
the process is self-aggravating and as a rule is 

In order to overcome the loss of elasticity in the 
alveoli a greater expiratory effort is required ; 
indeed a double .expiratory movement frequently 
takes place while inspiration is shorter than usual. 
A chronic dyspnoea is also often present, dependent 
on the pulmonary changes. 

In course of time the circulation through the 
emphysematous lungs is impeded, as a result of 
which the right side of the heart undergoes hyper- 
trophy, followed by a subsequent dilatation which 
increases both the bronchial congestion and irritation. 

While the horse is at rest or doing light work 
respiration may be comparatively easy. But labori- 
ous work requiring a more abundant supply of 
oxygen severely taxes the emphysematous lungs. 
All the signs of respiratory distress show themselves. 

244 IDieious Circles in Disease 

In order to assist respiration the diaphragm acts 
more vigorously than usual, and as a result the 
abdomen frequently assumes a pot-bellied appear- 

Lung- Worm Disease. This disease, sometimes 
called verminous bronchitis, and caused by several 
species of strongylus, attacks domestic animals 
such as pigs, cattle, sheep and goats (JMatC 
XIV. b). In pigs the . strongylus paradoxus is the 
special parasite which inhabits the bronchial tubes 
and lungs, where it provokes congestion and the 
formation of large cavities known as worm-nodules. 1 

Both the trachea and bronchi may be dilated 
into sacciform pouches in which the worms lie 
coiled, surrounded by mucus, pus and other secretions 
from which they derive nourishment. The more 
numerous the parasites the greater the injury caused 
and vice versa. The affected animal may perish 
from asphyxia due to an accumulation of the worms. 

Syngamosis. A common parasitic respiratory 
disease, popularly known as " gapes," is due to a 
nematode called the syngamus trachealis or wind- 
pipe worm which inhabits the upper part of the 
trachea and gives rise to tracheo-bronchitis in 
fowls and other birds. 2 The worms attach them- 
selves by suction discs to the mucous membrane 
from which they suck blood. The larger the worms 
the more blood do they inbibe and vice versa. 
Adult fowls with a full-sized trachea are not much 
troubled ; but in younger birds the entire trachea 
may be blocked, death taking place from asphyxia. 

1 Friedberger and Frohner, Veterinary Pathology, II., 

p. 700. 

2 Neumann, Parasites and Parasitic Diseases of Domesticated 

Animals, p. 606. 

IPeterinarg Diseases 245 

Half a million pullets are said to perish every year 
from the disease. 1 


Impaction of Food. Domestic animals are pecu- 
liarly liable to impaction of food in various portions 
of the digestive tract. The oesophagus, the stomach, 
the intestines, the rectum may all be affected by 
this dangerous complication, which depends partly 
on anatomical peculiarities and partly on the 
nature of food. 

In cattle the region most often attacked is the 
rumen or paunch, a capacious sac capable of 
holding 50 gallons or more. This rumen is physio- 
logically the first of three cesophageal dilatations 
(rumen, reticulum and omasum), the fourth com- 
partment or abomasum being the true digestive 

Most cows fill their rumen with enormous quanti- 
ties of grass, especially when feeding on luxuriant 
turf, and no harm results. By means of rumination 
and peristalsis the ingesta are soon distributed to 
other portions of the alimentary tract where digestion 

In the case of a greedy feeder, however, the 
rumen is liable to be distended to such an extent 
that the muscular walls are overstretched and 
weakened, while peristalsis is diminished or even 
arrested. The ingesta are then retained, instead of 
being passed on, and undergo fermentation with the 
production of gas which causes further dilatation 
and weakness and adds to the trouble. Indeed 
such impaction, unless relieved, may end in rupture 

Friedberger and Frontier, Veterinary Pathology, II., 

P- 753- 

246 IDictous Circles in Bieease 

of the rumen and speedy death (JMatC XIV. c). 
Impaction of food in the oesophagus is also 
frequently met with in poultry and other birds, 
and goes by the name of ingluvial stagnation. 
After an unusually heavy meal the food may stretch 
the crop to such an extent that its muscular walls 
lose their power of contracting and of propelling 
the ingesta. The degree of distension may be 
quite extraordinary. Zurn met with a hen's crop 
which with its contents weighed 2 Ibs. 14 oz. Another 
hen's crop had a circumference of 16 inches and 
a diameter of 6 inches. 1 The greater the dilatation 
the weaker muscular walls and vice versa. Occasion- 
ally the crop actually ruptures. 2 

1 Friedberger and Frohner, Veterinary Pathology, II., p. 39. 

2 A fatal pathological Circle may be established in fleas 

which have been infected with bacillus pestis through 
sucking the blood of infected rats. When such 
fleas have swallowed plague bacilli these bacilli 
produce solid jelly-like colonies which multiply 
in the stomach and are prevented from returning 
to the proventriculus by an efficient valve which 
remains closed during digestion. Under certain 
circumstances, however, colonies grow in the pro- 
ventriculus as well as in the stomach, when the}* not 
infrequently lead to complete blocking of the pro- 
ventricular valve by a coherent mass of germs. 
As the wretched flea grows thirsty it sucks more 
blood which, however, cannot reach the stomach 
and so does nothing to quench thirst, while the 
gullet is more and more blocked. In other words 
the more the flea sucks the greater the obstruction 
and the less can it relieve its thirst. Occasionally 
the obstruction in the proventriculus undergoes 
autolysis so that the passage again becomes clear ; 
otherwise the flea perishes from starvation or desic- 
cation. Cf. Bacot and Martin, Journal of Hygiene, 
1914 (Plague Supplement III.), p. 423. 

IDeteriuaiy Bieeaseg 247 

Another form of impaction is frequently met with 
in the horse, whose stomach, owing to its small size 
and conformation, is peculiarly liable to suffer. In 
the first place the cardiac opening of the oesophagus 
is small and obstructed by thick folds of mucous 
membrane. 1 Moreover the oesophagus enters the 
stomach in an oblique direction, the opening being 
guarded by a powerful sphincter which acts vigor- 
ously when the stomach contracts and tightly 
occludes the lower end of the oesophagus. It is 
for this reason that the horse rarely vomits. 

On the other hand the duodenum just beyond the 
pylorus forms a U-shaped bend, the limbs of which 
are readily compressed, when the stomach is over- 
distended. Thus both gastric orifices are easily 

If a horse happens to indulge in an unusually 
large meal, or if fermentation processes increase the 
contents of the stomach beyond a certain limit, 
there is always a danger that the ingesta may 
become so tightly impacted in the stomach that 
even vigorous peristalsis fails to dislodge the 
mass. Indeed the peristalsis may, owing to the 
'anatomical conformation, actually prevent all escape. 
The more vigorous the peristalsis the less the chance 
of relief and vice versa, so that a dangerous impasse 
is brought about, and the ingesta come to resemble 
" a pudding boiled in a cloth." In course of time 
the muscular walls grow exhausted and the animal, 
unless relieved, passes into a state of fatal collapse ; 
rupture of the stomach may be the immediate 
cause of death. 

Almost every part of the intestines may be 
occluded as a result of the impaction of food, the 

1 An illustration of the stomach is given by Chauveau, 
Comparative Anatomy of Domesticated Animals, 
P- 457- 

248 \Diciou0 Circles in Bieease 

details being similar in principle to those already 
described. A few words, however, may be added 
in reference to faecal impaction of the rectum. 
This disorder is common in dogs, and may be due 
to dry and concentrated food associated with 
insufficient exercise. If these or other causes have 
led to prolonged coprostasis, secondary reactions are 
frequently provoked which intensify the first. 

Another common cause is the inability to obey 
the natural call at the natural hour, especially in 
the case of house-dogs trained to habits of cleanliness. 
The resulting accumulation of faeces distends and 
weakens the rectum, enabling it to hold more 
without discomfort and diminishing the power of 
defaecation. These conditions aid and abet each 
other and may result in obstinate coprostasis. 

Aerophagy. Aerophagy or windsucking is fre- 
quently a self-perpetuating condition in horses, and 
probably originates in a gastric catarrh attended by 
flatulence, which the animals seek to relieve by the 
swallowing and eructation of air. 

Owing to the powerful sphincter at the cardiac 
orifice and the oblique opening of the oesophagus* 
into the stomach eructations are difficult to effect, 
unless something is swallowed at the same time so 
as to relax the sphincter. Consequently the horse 
gets into the habit of swallowing air so as to be 
able to belch up flatus. Unhappily, however, less 
air as a rule is belched up than is swallowed and so 
the stomach grows steadily larger. The greater 
the distension the more the horse resorts to air- 
swallowing, and so the process gradually becomes 
habitual. Flatulence and aerophagy aid and abet 
each other. 

If the habit is practised with great frequency, the 
resulting gastritis reacts on the general nutrition. 
In severe cases the stomach mav become excess- 

IDeterinan? SHseaeee 249 

ively distended, and this results in a com- 
plication known as gastric tympany. The intra- 
gastric pressure may then occlude both the oesopha- 
geal and pyloric openings. So completely indeed 
may both exits be blocked that if, after death, the 
gullet and the duodenum are divided the whole 
inflated stomach may be removed without any 
gas escaping. 

Intestinal Tympany. Allied to the impaction of 
food is another dangerous condition, known as 
flatulent colic or intestinal tympany, which is 
frequently due to an animal having partaken of 
some food that readily ferments and evolves large 
quantities of gas, causing acute distension of the 
intestinal walls and arrest of peristalsis. The 
more the walls are stretched the weaker they grow, 
while the weaker they grow the more do they yield 
to pressure. According to some writers fermentative 
changes in the ingesta may also be caused by 
suppression of the secretions owing to ansemia, 
debility, febrile diseases or intestinal catarrh. 
Hoare writes : 

" Diminution or arrest of intestinal movements 
may depend on suppression of the secretions quite 
independently of actual obstruction of the bowel, 
and gives rise to excessive fermentation of the ingesta. 
Anaemia, debility, febrile diseases, chronic intestinal 
catarrh, etc., interfere with the normal secretions of the 
intestines. Severe work immediately after a period 
of repose, also over-exertion, interfere with the normal 
circulation of the intestine, and thus bring about 
indigestion and the formation of gases. The latter 
in their turn distend the intestinal walls, and diminish 
the blood-supply thereto, and also the secretions, so 
that a Vicious Circle is thus established." 1 

System of Veterinary Medicine, II., pp. 181, 531. 

25Q \Dtctou8 Circles in SHseaee 

Such attacks of wind colic or tympany aggravate 
themselves, and appear incurable. But happily 
nature often wakes up to the danger before it is 
too late, and by a sudden violent increase of peristal- 
sis expels the accumulated gases and breaks the 

Wool-Eating. Wool-eating or mallophagia be- 
longs to a group of habit Circles of which a variety 
of examples are met with. In the sheep the first 
impulse to wool-eating arises in some slight dyspepsia 
or want of food which creates the desire to nibble at 
something, since such nibbling gives satisfaction. 
Hence the trick is repeated and in course of time 
becomes habitual. The grooves of habit in the 
nervous system wear more and more deeply ; the 
nerve centres grow more and more labile, so that 
repetition occurs on less and less provocation. 

Another Vicious Circle is associated with pica or 
perversion of the appetite, which probably results 
from some dyspeptic condition which creates an 
abnormal and perverted sense of hunger. The 
affected animal will eat almost anything that offers, 
e.g. clay or even its own faeces. Such a diet natur- 
ally increases the primary dyspepsia. In course of 
time a chronic flatulence results and gives rise to 
a pot-bellied condition. 


Hydronephrosis. Hydronephrosis is a serious 
and not uncommon disease in cattle and other 
domestic animals. The disorder may be primarily 
due to unusual mobility of the kidney as a result 
of which the ureter is kinked, followed by an 
accumulation of urine in the renal calyces. Such 
accumulation causes an increased weight of the 
organ, a further descent in the abdomen and further 
obstruction to the escape of urine. Thus retention 

lDeterinan> Diseases 251 

begets retention. In course of time the pressure of 
retained urine may lead to hydronephrosis followed 
by gradual destruction of renal tissue. Indeed 
the kidney may be converted into an enormous 
cyst whose urinary functions have been lost. 

Urinary Calculi. Urinary calculi may be associ- 
ated with similar Vicious Circles as in man, and 
the details given above will apply. 

In the domestic animals, however, some peculiar 
anatomical configuration may establish dangerous 
correlations of special interest. An example is 
met with in the bull which of all animals suffers 
most from urethral calculi (JMate XIV. d). The rea- 
son is to be found in the small lumen and extra- 
ordinary twist of the urethra which readily arrest 
the progress of any calculi that descend from the 
bladder. Not only is the urethral orifice narrowed 
to |- inch, but the duct takes an S-shaped bend 
which cannot be traversed by the catheter, and at 
which even small calculi may be retained and cause 
obstruction of urine. 1 Such obstruction, if complete, 
may cause rupture of the bladder and speedy death. 
But if the obstruction is not complete the calculus 
forms a nucleus round which accretions accumulate. 
The larger the nucleus the more rapidly it grows 
and vice versa. Thus an obstruction that at first 
was only partial may become complete and prove 

A very similar S-shaped curve is present in the 
urethra of the ram, another animal that suffers 
much from calculi. 

Milk Fever. Milk fever is not uncommon in 
milch cows and is often complicated by dangerous 
circular reactions. The milk, after being formed 

! The S-shaped twist is well illustrated by M oiler. Opera- 
tive Veterinary Surgery, p. 321. 

252 IDicfous Circles in Disease 

in the glandular tissues, flows into the milk ducts 
which convey it to a large cavity at the base of the 
teat termed the galactophorous sinus, there being 
one galactophorous sinus and teat for each division 
of the udder. From the galactophorous sinus 
a narrow duct lined with mucous membrane leads 
to the open air. 

The causes of milk-fever are still obscure, but there 
is probably in many attacks some infection by 
micro-organisms, followed by inflammation of the 
parenchyma of the udder as well as of the galacto- 
phorous sinus, with narrowing of the effluent duct 
and stagnation of milk. Owing to this stagnation 
the milk tends to undergo decomposition, and this 
further aggravates the primary inflammation and 

In some cases the inflammation leads to gradual 
narrowing of the duct followed by stagnation, 
putrefaction and further obstruction, eventually 
resulting in a completely closed abscess cavity. 
The severity of the disease varies with the virulence 
of the infective organisms and with other conditions, 
but a lethal result is not uncommon. 

Egg-Binding. Another circular process is associ- 
ated with egg-binding, and is due to an egg distend- 
ing the oviduct to such a degree that the muscular 
walls are thinned and lose their power of con- 
traction. Such paralysis arrests all progress, and 
this in turn perpetuates the distension and weak- 
ness (JplatC XIV. e). Moreover the arrested pro- 
gress of the egg causes the bird to strain violently 
and this causes swelling and inflammation, tending 
to increased obstruction. 1 In some cases the oviduct 
ruptures and allows the egg to pass into the peritoneal 
cavity, where dangerous peritonitis is set up. 

1 L/aw, Veterinary Medicine, III., p. 295. 

lt)eterinan> Bieeaeee 253 


Parasitic skin affections, such as scabies and 
ringworm, are frequently complicated by self -per- 
petuating conditions. The variety of such disorders 
is so great that only one or two examples can be 
given, but they suffice to illustrate the principle 
that the parasite is able to secure its own diffusion 
by means of the irritation excited by its presence 

(BMate xiv. f). 

A common example is presented by the sarcoptes 
scabiei which infests the dog. This acarus sets up 
severe pruritus which the dog seeks to relieve by 
scratching and rubbing. As a result the paws 
become infected with the acari or their ova, and 
transfer them to other parts of the body where 
fresh outbreaks of the -scabies are started. 

Three forms of acarus are found in the sheep, 
but the most important variety is the dermodectes 
communis which gives rise to the dermodectic mange. 
In some countries a majority of the sheep are 

The parasites chiefly attack parts of the body 
that are covered with wool, since this affords them 
protection. Abundant vesicles and pustules are 
formed, giving rise to secretions which glue the 
wool together and create large scabs. The eruption 
is often accompanied by violent itching which 
compels the animal to rub and scratch itself. By 
this means the acari are readily transferred to 
fresh areas where they spread the disease. The 
scabs also favour the multiplication of the acari, 
since such shelter supplies food, warmth and pro- 

Another cutaneous disorder in sheep is due to the 
tinea tonsurans which leads to felting of the wool 
beneath which scabs form. Here also considerable 
itching may be caused by the infecting fungus, and 
such itching leads to the transference of spores to 

254 Didous Circles in Biscase 

healthy areas by means of the feet or lips. 

Birds often suffer from the form of ringworm 
known as the achorion schonleinii, which gives 
rise to favus or fowl mange. The eruption frequently 
starts on the comb or ears, whence it gradually 
spreads until the entire comb and even the whole 
body is covered with a mouldy deposit. The 
secondary itching provokes scratching and is largely 
responsible for the rapid diffusion of the spores. 

This brief account of some Vicious Circles in 
Veterinary diseases will, it is hoped, suffice to 
illustrate their importance. There is ample scope 
for a volume dealing with this morbid process in 
zoo-pathology, and especially with the best methods 
of arresting it. 

Chapter Siyteen 


|N the Chapter devoted to Aetiology the 
Vicious Circle in animal and plant diseases 
was attributed to a disturbance of the 
physiological correlations present in all 
organised living things. There is, how- 
ever a striking difference in the morbid process as met 
with in animals and in plants. In the former owing 
to the higher differentiation of organs numerous 
specific circuli vitiosi are met with. A specific 
lesion giyes rise to a secondary specific lesion which 
in turn aggravates the primary one, and this endless 
chain can be studied link by link. * 

Future research may reveal similar conditions in 
plant pathology. But at present specific reactions of 
morbid processes have been but little studied in 
plants. On the other hand the general principle of the 
Vicious Circle is in universal operation. lowered 
resistance due to one or more adverse circumstances 
renders the plant susceptible to some injurious 
factor, such as parasitic infection, which in its turn 
further lowers resistance. The death of plants 
frequently results from this morbid process. 

Lowered resistance may be due to a great variety 
of causes. Amongst them are unsuitability of soil, 
temperature or climate, and excess or deficiency 
of water. According to recent researches by Appel 2 

1 Cf. also Plant Disease and the Vicious Circle, by J.B.H., 

/. Royal Hort. S. (1919), XLHL, p. 309. 

2 Gardener's Chronicle, 1915, II., p. 322, 


256 IDlcioue Circles in Disease 

excess of air in the tissues associated with insuffi- 
ciency of water acts in the same direction. 

Another cause is immaturity of tissue. The epider- 
mis in early life is both tender and thin, and may be 
penetrated by bacteria or fungi that are power- 
less to injure plants whose epidermis has become 
cuticularised or replaced by cork. On the other 
hand advanced age also predisposes to infection. 
In young coniferous trees well provided with resin 
canals injuries of the cortex are at once sealed by an 
exudation of turpentine and thus protected from 
wound fungi, while in older trees turpentine and 
resin are less freely exuded as styptics. Again 
wounds are more slowly occluded by callus in old 
age than in youth. Such predisposing factors 
enable organisms successfully to effect an entrance, 
and further to weaken the host. 

Parasitic invaders may abstract their food from 
the host-plant by various methods. Some ramify 
in the inter-cellular spaces and middle lamellae ; 
others send haustoria into the actual cells. Many 
secrete enzymes or toxins which destroy cells or 
cell-walls, the materials of which then promote 
further growth and proliferation of the parasites. 
Hence fresh enzymes or toxins are secreted for the 
destruction of remoter cells, which in their turn 
fall a prey to the ever-spreading invader. The 
morbid process vires acquirit eundo. 

The effects of injurious circular reactions may be 
briefly discussed under three headings : 

I. The Perpetuation of Disease 
II. The Destruction of Organs 
III. The Termination of Life 

These groups, however, are by no means sharply 
defined ; diseases placed in I. and II. may under 
exceptional conditions prove fatal, while diseases 

plant IDiscascs 


& x~ ~^\^ 

*/ V, Jfc 





U 0\V 


plate XV. Circles aseociateb with 
plant 2)ieea0e0. 

25$ HMcious Circles in 2Hgease 

placed in III. may be so chronic as scarcely to shorten 
the duration of life. 1 

The perpetuation of a disease through insufficient 
chlorophyll assimilation has already been referred 
to (p. 3). In other cases the morbid condition may be 
initiated by living organisms (JMatC XV. a). Both 
the true fungi as well as Schizomycetes (Bacteria) 
and Myxomycetes (Slime Fungi) may be concerned. 

Peridermium Pini. A striking example may be 
found in the case of pine-blister caused by the 
Coleosporium Senecionis (Peridermium Pini, var. 
corticola), a fungus which attacks the cortex of the 
Scotch and Wey mouth pines amongst others. The 
hyphse grow in between the green cells of the cortex 
as well as in the bast-tissues, and may even penetrate 
the medullary rays and resin-canals. Other hyphse 
pierce the cells, consume the starch and other food- 
stuffs, and cause a serious loss of resin which both 
soaks into the wood and exudes from the bark. 
This loss of resin involves a serious impairment of 
vitality. Moreover the effusion of turpentine into 
the wood interferes with conduction of sap in these 
tissues and lowers the nutrition of the tree, especially 
above the point of attack, since the flow of sap is 

Meanwhile the parasite nourishes itself on the 
juices which it has liberated and on the contents 

1 Many beneficent circular reactions occur both in plants 
and in animals. Thus in the healthy plant the 
leaves, the roots and other organs are reciprocally 
dependent on each other and " enable the ideally 
correlated system to go on working at maximum 
energy " (Ward, Disease in Plants, p. 94). A more 
specific process of reciprocation is associated with 
leguminous plants and the presence of nitrifying 
bacilli. More vigour : more galls : more nitrogen : 
more vigour constitute the sequence. 

[plant 3Di0eases 259 

of the cells it has invaded. Thus a struggle takes 
place which may last for many years. If the tree 
is vigorous it may, by the diversion of metabolic 
material, form sufficient cork to shut in and suffocate 
its enemy. But as a rule the invader extends his 
ravages and converts a robust thriving tree into 
a dwarfed sickly one. The more the parasite can 
arrest the flow of sap and the greater the loss of 
resin the more is vitality impaired, and the less 
the vitality the more rapid the progress of the 
invader. Cause and effect aid and abet each other, 
and the result is a chronic invalidism of an enormous 
number of trees that are attacked by this disastrous 

A similar process is frequently observed as a result 
of bacterial invasion. Hrwin F. Smith has described 
a number of leaf-spot diseases in which the parasite 
penetrates through stomata in the unbroken leaf 
and stem surface, and multiplies in the substomatic 
chamber, causing a local destruction of tissue. 
Thus Bacterium phaseoli is responsible for the spot 
disease of beans, Bacterium maculicolum for the spot 
disease of cauliflowers, and other examples have 
been observed. Leaf spots are often slow in their 
progress and confined to small areas, the reason 
probably being that the vascular system is not 
invaded. Nevertheless the bacteria weaken or de- 
stroy the cells of their host. With increasing supplies 
of food and a nidus rendered alkaline by their own 
excretions the bacteria multiply more and more, 
unless indeed, as sometimes happens, the host can 
arrest the process by separating the diseased from the 
healthy tissues by the formation of a corky layer. 

Another result of an injurious circular reaction is 

the destruction of an organ either by a non-living 

or a living agency. 
The effect of a non-living agency is illustrated 

260 iDicious diccles in Disease 

by the premature shedding of leaves or of twigs 
which may be thrown off in great numbers as a 
result of organic tissue changes (plate XV. b). 

The disorder is most often observed in the case 
of leaves, and is initiated by an impairment of 
assimilation and transpiration processes, as a result 
of which the suction force by which under healthy 
conditions the sap is drawn up is lost. Conse- 
quently the sap accumulates in the basal leaf zone 
through which the line of cleavage ultimately passes, 
and which becomes excessively turgid with osmotic 
materials. This turgor stimulates to premature 
activity the dormant cells of the abscission layer ; 
the partition wall between adjacent cells swells and 
a process of dissociation is inaugurated. The effect 
is a further impairment of vitality of the leaves, 
culminating in complete detachment. To quote 
Sorauer : " Every premature shedding of leaves 
is due to a disturbed equilibrium in the distribution 
of turgor." 1 In other words the process of premature 
cleavage is due to an arrest of metabolic activity 
causing pathological turgor at the basal zone, 
followed by a progressive loss of activity. 

A similar process accounts for the premature 
shedding of twigs or shoots, which may occur as 
early as July. The oak and the poplar are frequently 
affected, the ground being in some cases thickly 
strewn by the detached twigs. 

The destruction of organs may also be due to 
the attacks of parasites, some of which display a 
preference for certain organs, such as leaves, twigs, 
tubers or buds. A lowered state of vitality pre- 
disposes to such parasitic invasion which then 
further lowers nutrition, culminating in the total 
destruction of the organs. 

Lophodermium Pinastri. As an example of a 
parasitic leaf-shedding disease may be mentioned 

1 Pflanzenkrankheiten, I., p. 357. 

plant Diseases 261 

the Pine Needle-cast caused by the fungus Lophoder- 
mium Pinastri, also called the Pine Leaf -scurf or 
leaf -shedding fungus. 

The disease chiefly attacks the young and tender 
leaves of the Scots and Austrian Pines and other 
Conifers, and may cause many of their leaves 
suddenly to wilt and drop. The needles when first 
attacked are merely speckled with brown spots 
containing the mycelium of the fungus ; but in the 
following year they wither, turn red or brown and 
die off in hundreds. This loss of leaves seriously 
weakens the plants and thus hastens the progress 
of the disease. The greater the loss of foliage the 
less the power of resisting infection. It is for this 
reason that the parasite is most destructive in shut-in 
valleys or low-lying situations where the trees 
possess least vitality and consequently succumb 
most readily. 

The destruction of twigs is often brought about 
by infection with the Botrytis Douglasii. 

Ustilago. Another illustration of a similar pro- 
cess may be found in the operations of the cereal 
smuts (Ustilago), which attack such grains as are 
rendered liable to infection by lowered vitality. The 
smuts reduce the ovules to a black powdery mass of 
spores which are carried away on the wind or other- 
wise dispersed, leaving nothing but the bare axis 
on which the flowers were originally situated. 


Many examples might be given of the destruction 
of plants as a result of a Vicious Circle. It was 
formerly supposed that disease in animals was 
usually caused by bacteria, while diseases in plants 
was almost invariably due to fungi. But recent 
research has shewn that even in plants many 
bacterial diseases occur. Both Schizomycetes and 
Myxomycetes may be concerned ((Mate XV. c). 

262 iDtctous Circles in Disease 

E. F. Smith thus describes the process by which 
bacteria can provide for their own indefinite multi- 
plication, when once a foot-hold has been secured : 
" Enzyms, toxines, acids and various by-products 
of the bacterial growth also undoubtedly play their 
part, weakening the cells of the host or destroying them 
outright. With increasing supplies of food, and a 
nidus rendered suitably alkaline by their own excre- 
tions, the bacteria multiply more and more, obstructing 
some tissues and dissolving, displacing and crushing 
others. The tissues are poisoned more and more by 
absorption of the continually increasing quantity of 
bacterial by-products, cells are separated, cell-walls 
are softened or dissolved, protoplasm, amids, acids, 
starch, and sugars are consumed. Beginning, therefore, 
with a tiny superficial nidus in an open wound, a 
facultative parasite gradually burrows its way into 
the deeper tissues, forming closed cavities or open 
wounds, and finally destroying the entire plant or 
limiting its operations to special organs, as the case 
may be. Such is the impression one gets from a study 
of wound-infections." 1 

Two fatal diseases may now be described, one due 
to a fungus and one to a bacillus. 

Dasyscypha Willkommii. The well-known larch 
canker, associated with the invasion of the Dasy- 
scypha Willkommii, is an example of a fungoid 
disease which is responsible for the loss of an enorm- 
ous number of trees in our woodlands. The larch 
is indigenous in the Alps where there is a long 
winter season, followed by a short or no spring, 
and by a short hot summer. Owing to the rapid 
transition from winter to summer the larch buds 
open very rapidly when once they start. Hence 
the period during which the foliage is young and 
tender, and susceptible to attack is very short, since 
the tree passes rapidly into its summer state with 
its increased power of resistance. When, however, 
the larch is planted in such a country as England, 

1 Bacteria in Relation to Plant Diseases, II., p. 51. 

plant 2>tsea0e0 263 

with a mild winter and a long and damp spring, 
the period of foliation extends over six or eight weeks, 
instead of two as in the Alps, so that insects and 
fungoid enemies have a much longer period during 
which to do damage. 

The great enemy of the larch is the Dasyscypha 
Willkommii, which effects a lodgment in wounds 
in the young leaves and shoots made by plant lice 
(Chermes laricis) or the mining-moth (Coleophora 
laricella), or by some other agency which breaks the 
surface continuity. In such a wound the spores 
find a favourable nidus, whence the mycelium 
penetrates into the cortex during the quiescent 
period of winter. 

If the tree has sufficient vitality, it may succeed 
during the period of active growth in cicatrising 
the canker-spot, by surrounding the blister by a 
tough corky layer and thus arresting its progress. 

But, under less fortunate conditions, when autumn 
returns the mycelium penetrates further into the 
cambium and enlarges the canker-spot. Event- 
ually it reaches the wood and interferes with the 
flow of sap. The further the invader advances, the 
more is the resisting power of the host-plant weakened, 
while such loss of resistance quickens the progress 
of the fungus. In course of time the tree sickens 
and dies. 

Bacterium Hyacinthi. The yellow bacteriosis 
of hyacinth bulbs may serve as an example of 
a specific and fatal bacterial disease, due to 
the Bacterium Hyacinthi. Healthy bulbs are rarely 
attacked ; but if a wound or other injury has 
impaired vitality infection readily follows. The 
sequence may thus be represented : 

Growth of Bacteria * > Breaking up of living Cells 
Supply of Nutriment to Bacteria 

264 IDicious Circles in Disease 

In the early stage of bulb infection the disease is 
confined to the vascular bundles, from one to fifty 
of these being yellow and full of bacterial slime ; 
but at a later stage the disease spreads to the 
intervening parenchyma, and finally the whole 
bulb is destroyed. 

These examples of injurious circular reactions in 
phyto-pathology might be indefinitely multiplied ; 
but they suffice to indicate the operation of a 
wide-spread principle. The process belongs to those 
fundamental biological phenomena which are com- 
mon to both the higher animals and plants. Within 
the limits of health organisation is of unquestioned 
advantage. On the other hand the liability to 
pernicious and reciprocal correlations is a serious 
penalty paid for such organisation, when physiological 
processes are disturbed by disease. 

The simpler organisation of plants probably 
explains why this complication of disease is so much 
less specific than it is in zoo-pathology. Another 
reason is that in the animal every organ is fully 
developed and performs its functions to the utmost, 
while in the plant there are always present the 
rudiments of new organs as well as accumula- 
tions of reserve materials, and each of these 
provisions can assist in making good any failure 
of functional activity. A further explanation may 
be found in the more intimate union of cells in the 
animal as compared with the plant, allowing, as it 
does, of closer inter-dependences. 

Apart from these reasons, however, there can be 
little doubt that with the growth of our knowledge of 
correlations in plants many examples of specific 
circuit vitiosi will be revealed. A further proof 
will thus be supplied of the essential unity in the 
laws governing animal and vegetable pathology. 

Chapter Seventeen 


ICIOUS Circles may exert an injurious 
influence in three directions : the per- 
petuation of disease ; the destruction of 
organs j 1 the ending of life. Numerous 
examples of each of these effects have 
been given in the preceding pages. But it may be 
useful to emphasise the fatal influence of this 
morbid process -and to shew how common is mors 
ex circulo vitioso. The expectation of life is materially 
affected by this complication of disease. 

It has been pointed out above that the Vicious 
Circle usually arises through disorder in an organ 
or part of an organ creating disorder in other organs 
or parts of organs, the reaction of which aggravates 
the primary disorder. The evil is therefore one of 
the penalties paid for specialisation of structure and 
function, and is only encountered in the higher mem- 
bers of the animal and vegetable kingdoms which have 
reached a certain stage in organic evolution. The 
gravity of the complication naturally depends on the 
importance of the organs affected and on the nature 
of the morbid process at work. 

1 As illustrations of the destruction of organs may be men- 
tioned the brain in hydrocephalus, the eye in 
glaucoma, the kidney in hydronephrosis and the 
lung in tuberculosis. 


266 iDictoue Circles in Di0ea0e 

Many years ago Bichat sought to distinguish 
between death by the heart, death by the lungs and 
death by the brain. 1 Such a classification cannot 
be accepted' in the light of modern pathology, 
since we know that, by whichever gate-way danger 
first approaches, actual death results from the 
arrest of all the vital functions. Nevertheless, as a 
matter of convenience, we may associate deaths with 
the same triumvirate of vital organs and describe : 
I. Deaths associated with the Vascular 

II. Deaths associated with the Respiratory 

III. Deaths associated with the Nervous 


Wynn Westcott found that the chief factor in 
sudden death was cardiac in 60 per cent., cerebral 
in 30 per cent, and pulmonary in 10 per cent. 2 


Heart Failure. Heart failure ranks as one of 
the commonest modes of death, and occurs under 
a great variety of circumstances (JMatC XVI. a). For 
example, acute cardiac dilatation may weaken 
the coronary circulation to such a degree that 
insufficient blood reaches the myocardium to allow 
of its continued activity. The less the blood 
supplied to the myocardium the feebler the systole 
and vice versa. This sequence probably caused the 
death of the famous soldier Eucles who raced to 
Athens with the news of Marathon, shouting 
Xcupcre, x a ' L Pl J ' (LV > an d dropped dead on arrival. The 
prolonged strain led to high blood-pressure, to 
cardiac dilatation, to inadequate coronary circula- 

^echerches sur la Vie et la Mort. 
2 British Med. /., 1908, I., p. 491. 

She Circle as a Cause of Death 267 







plate xvi. be Circle as a Cause 
of Death. 

268 Dicious Circles in Disease 

tion, to inadequate nutrition of the myocardium, 
to further dilatation and finally to syncope. 

Death frequently results from coronary obstruction 
due to sclerosis, a condition which accounts for the 
death of many elderly persons, to whom the end 
comes like a " bolt from the blue." The morbid 
process has probably been in progress for years, 
until a stage is reached when the lumen of one or 
both coronary arteries is seriously narrowed by 
degenerative processes. The exaggerated vis a 
fwnte requires an increased vis a tergo, if life is to 
continue, whereas the diminished coronary blood- 
supply actually weakens the force of the systole. 
In other words the defective coronary circulation 
and the myocardiac weakness progressively aggra- 
vate each other, until death closes the scene. Fatal 
angina pectoris may be due to this sequence of events, 
some unusual effort, with its extra requirement of 
blood, proving the proverbial last straw. Syncope 
may be instantaneous, coeval with a single pang, 
attitude and expression remaining perfectly placid. 
No blood, no systole here represents the mechanism 
of death. 

In other cases the fatal issue may be due to the 
reciprocal action of cardiac venous engorgement 
and cardiac malnutrition. As the heart grows 
incompetent, the coronary veins are the first to 
feel the back pressure and their congestion inter- 
feres with the circulation through, and therefore 
with the nutrition of, the heart. 

S. West thus describes the pathological sequence : 
" If the nutrition is thus affected, the muscle will be 
weak, and the heart will dilate. This weakness still 
further increases the venous congestion, which in turn 
increases the weakness again. So a Vicious Circle 
is established, and an explanation given to the extra- 
ordinary rapidity with which the heart failure often 
develops when once it has set in." 1 

1 British Med. /., 1905, II., p., 1032. 

Circle as a Cause of Death 269 

Another dangerous condition is the paradoxical 
association of an over-strained and weakened heart 
with an abnormally high blood-pressure. The slow- 
ing of the circulation tends to produce anaemia of the 
medullary centres, which respond by inducing vaso- 
constriction in order to bring about increased 
pressure and so to secure a larger quantity of 
blood. The already weakened heart is thus called 
upon for a supreme effort, and the weaker it is the 
more do the imperious medullary centres insist on 
more blood. At length comes a moment when the 
pressure within the weakened ventricle is raised 
beyond endurance. Suddenly, in accordance with the 
" all or nothing " law, the heart stops in diastole. 
The process is thus graphically represented by 
Hirschfelder : 1 

Cardiac weakening 

Increased cardiac effort Slowed circulation 
High blood-pressure through medulla 


Some fatal correlations also occur in connection 
with valvular disease. For example, an aortic 
valve may rupture during violent exertion, the 
regurgitating blood throwing a sudden and severe 
strain on the heart, which has no time to accommo- 
date itself to altered conditions. Dilatation of the 
ventricle follows, with a feebler systole, increased 
regurgitation and in severe cases immediate death. 

Amongst the various forms of chronic valvular 
disease, stenosis and incompetence of the aortic 
orifice, associated with dilatation of the ventricle, 

Diseases of the Heart and Aorta, p. 315, 

270 IDtcioug Circles in Disease 

most frequently lead to death. After perhaps 
many years of fairly comfortable life, the com- 
pensatory hypertrophy wears out and is replaced 
by further dilatation. The fatal sequence may be 
summarised thus : regurgitation, dilatation, weakened 
systole, impaired coronary circulation, further dilata- 
tion and increased regurgitation. 1 

Another fatal sequence is common in patients 
suffering from mitral stenosis. 
Coombs writes : 

" In a large majority of all cases of mitral stenosis 
death is due to gradual cardiac failure. The forces 
responsible for this are two. The heart, and especially 
the left auricle, is asked to do more work by reason of 
the valvular obstruction ; and generally increasing 
venous stasis undermines the nutrition of the cardiac, 
and particularly the auricular, musculature. An un- 
conquerable Vicious Circle is thus established. The 
results are pulmonary engorgement, auricular break- 
down, and ultimate ventricular failure." 2 

Sudden death is sometimes due to thrombosis or 
embolism of the heart or large vessels. If not 
immediately fatal, the embolus or thrombus may 
cause eddies and obstruction which in their turn 
lead to rapid and extensive clotting. This steadily 
adds to the size of the embolus or thrombus, thereby 
increasing the obstruction. The greater the obstruc- 
tion the larger the surface on which the blood can 
coagulate, and the more rapidly does the obstruction 

1 According to Manson the reciprocal influence of cardiac 

dilatation and weakness accounts for death in many 
cases of beriberi. " Gradually the right side of the 
heart becomes more dilated, and in proportion to the 
dilatation more weakened, passing into one of those 
hopeless Vicious Circles so common in pathology." 
Davidson, Hygiene and Diseases of Warm Climates, 

P- 473 

2 Short, Index of Prognosis, p. 320, 

Circle ae a Cause of 2Deatb 271 

Pericardial Effusion. Interference with diastolic 
filling, owing to pericarditis or to rupture of an 
aneurysm, is frequently fatal, since such interference 
prevents the stretching of the cardiac muscle which 
is so essential to the full development of its energy. 
A case in which death occurred from this cause is 
described on p. 52. 

Congenital Heart Disease. Congenital morbus 
cordis is not an uncommon cause of death, and has 
been already alluded to in Chapter IV. Some- 
times the demise may be due to an open foramen 
ovale. This malformation is usually complicated 
with pulmonary stenosis which allows enough blood 
to reach the lungs, so long as a quiet mode of life 
is pursued, while the remainder of the blood passes 
through the foramen ovale. If, however, violent 
exercise is taken, more blood must pass through the 
foramen directly to the left side of the heart and 
thus escapes aeration. The result of the venosity 
is a rise in blood-pressure, which again causes more 
blood to be driven through the foramen, ending at 
times in speedy death. 

Rupture of Heart. Spontaneous rupture of the 
heart may be due to progressive degenerative 
changes and dilatation of the cardiac muscle (jplatC 
XVI. b). As the strain on the walls of a sphere or 
spheroid increases with its circumference, so the 
heart dilates the more the greater the strain on its 
walls, leading to further dilatation and occasionally 
to rupture. When rupture has occurred, the primary 
loss of blood stimulates the vaso-motor centre, which 
stimulus calls forth a general vaso-constriction, 
raises the blood-pressure, and thus intensifies the 
haemorrhage. A similar sequence may be associated 
with rupture of an aneurysm or a penetrating wound 
of the heart. Probably King William Rufus died 
from perforation of his heart by Walter Tyrel's 

272 IDicioue Circles in ^Disease 

arrow, which " per medium cordis regem sauciavit 
qui subito mortuus corruit." 


Asphyxia. Asphyxia, due to the interruption 
of respiration, is a frequent cause of death, and 
may occur under a variety of conditions. 1 

In consequence of the obstructed respiratory 
exchange the venosity of the blood increases, 
respiratory movements grow more vigorous, blood- 
pressure rises, and the heart is slowed by the cardio- 
inhibitory centres in the medulla. The increased 
pulmonary obstruction then causes the right heart 
to become gorged with blood, and eventually dilated 
and weakened. This in turn leads to further venosity 
which poisons the myocardium and tends to further 
dilatation, until at length the right auricle and 
ventricle lose all power of contracting. A similar 
process also involves the left side ; but the pro- 
gressive dilatation of the right side plays the chief 
role, and contributes mainly to the fatal exitus 

BMate xvi. c). 

Pulmonary atelectasis is frequently fatal in weakly 
or rickety infants, whose death gives rise to great 
consternation, since what appeared at first to be 
a trifling catarrh may suffice to start the fatal 
sequence. Any accumulation of secretion is liable 
in such weaklings to diminish the quantity of air 
entering the air cells, and such diminution favours 
a further accumulation. The associated venosity 
of the blood may, through interference with the 
normal reflexes, constitute an aggravating factor. 

The gradual asphyxia which so often supervenes 
during the terminal stage of illness is also com- 

1 A case of death due to the Vicious Circle associated with 
goitre and tracheal stenosis was published by the 
author in 1887. Lancet, 1887, I., p. 570. 

ftbe Circle as a Cause of 2)eatb 273 

plicated by a circular reaction. The shallow respira- 
tions do little to aerate the blood, and thus induce 
narcosis of the respiratory centre, still shallower 
respirations and death. This is indeed a merciful 
process which leads to a peaceful painless end. 
Nature often provides her own anaesthetic for us 
at the last. 

Asphyxia neonatorum is often complicated by a 
Vicious Circle and may result from any condition 
which leads to an accumulation of CO2 in the blood 
of the foetus. The danger arises from the fact that 
such accumulation may prematurely interrupt the 
state of apnoea which should persist during intra- 
uterine life. 

If CO2 accumulates beyond a certain point, it 
stimulates the respiratory centre so that the foetus 
makes its first respiratory effort and inspires amniotic 
fluid if the amniotic sac is intact, or that fluid mixed 
with blood and mucus if the sac has burst. Thus 
as in the case of a drowning person inspiration does 
little toward oxygenation, but tends rather to further 
accumulation of CO2. Moreover during the state 
of apnoea the lungs receive but little blood, since 
the powerful right auricle propels the greater portion 
of its blood through the ductus Botalli into the 
aorta. With the first inspiratory effort, however, 
the blood in the right auricle is aspirated into the 
pulmonary artery instead of passing directly into 
aorta. The result is that the blood-pressure in the 
aorta falls considerably, leading to further venosity. 
Unless speedy relief is forthcoming, the respiratory 
centre is paralysed by the excess of CO2 and death 
supervenes from what Lenzmann calls " a very 
grave Vicious Circle . " l 

Asphyxia may also prove fatal before a single 
respiration has taken place when the accumulation 

1 Emergencies in Medical Practice, p. 17. 

274 IDicious Circles in 

of CO2 is so gradual as never to reach the limit of 
stimulation. In such cases the acid increasingly 
narcotises the respiratory centre and renders it 
less and less susceptible to stimulation until death 
takes place. 1 

Haemoptysis. Haemoptysis may be complicated 
by dangerous correlations which are largely respon- 
sible for the profusion and prolongation of the 
haemorrhage (JMatC XVI. d). In the first place the 
irritation of the effused blood induces cough ; 
coughing, like any other exertion, raises blood- 
pressure ; increased blood-pressure is apt to renew 
the haemorrhage. Thus in a severe attack a person 
may be choked in his own blood. Mental excite- 
ment supplies an aggravating factor, as it also 
does in the allied condition of haematemesis. Such 
excitement may produce a rise of as much as 40 mm . 
Hg in the systolic pressure. Lastly, we may have 
the same general vaso-constriction due to anaemia 
of the vaso-motor centre that has already been 
alluded to. These factors, acting cumulatively, 
adequately explain the fatal haemoptysis that is 
sometimes met with. A man may cough himself 
into his grave. 

A similar mode of death may result from the 
perforation of an empyema into the respiratory 
passages. Every cough, although an act of self- 
defence, increases the flow of pus, which may flood 
the passages, in spite of vigorous expectoration. 

Pick and Hecht write : 

" The more the patient coughs, the more profusely 
the pus streams into the bronchi as a result of the 
expiratory rise in pressure, and such a circulus vitiosus 
can only end in death." 2 

1 Lenzmann, Emergencies in Medical Practice, p. 18. Cf . also 

Schultze, Der Scheintod Neugeborener, pp. 77-8, in. 

2 Clinical Symptomatology, p. 259. 

ftbe Circle as a Cause of Death 275 

The condition is, however, by no means so hopeless 
as Pick and Hecht suggest. 

Other fatal disorders associated with the respir- 
atory tract will be found in Chapters V. and XII. 


Apoplexy. Cerebral haemorrhage may prove 
fatal through the intermediary of a striking circular 
reaction. The causal factors have already been 
described (p. 29) and need not be repeated. Where 
death supervenes rapidly, the effused blood has 
probably compressed and paralysed the vagal and 
respiratory centres in the medulla. Such a course 
of events, however, is uncommon ; the fatal issue 
is more often due to another sequence in which 
exhaustion of the vaso-motor centre leads to 
splanchnic dilatation, cerebral and cardiac anaemia, 
further exhaustion and death (JMate XVI. e). 

Vase-motor Paralysis. Death is sometimes due 
to inhibition or paralysis of the vaso-motor centres 
as a result of terror or other strong emotion (iDlate 
XVI. f). 

During health the activity of those centres is 
increased or diminished according as arterial press- 
ure falls or rises. But strong emotion ma}' paralyse 
the vaso-motor mechanism ; the splanchnic sluice 
gates are opened, the blood-pressure falls, the 
cerebral vessels are emptied, with the result that the 
depression of the centres is accentuated, possibly 
beyond recovery. The heart too may be involved in 
the injurious process, since, owing to the progressive 
accumulation of blood in the splanchnic area, an 
insufficient quantity may return to the heart to 
enable the circulation to be carried on . The defective 
coronary circulation still further weakens the myo- 
cardium, with the effect that the heart may suddenly 
stop in diastole. This is probably the mechanism 

276 IDicious Circles in Disease 

of death in various forms of shock, in the collapse 
often met with during acute disease, 1 in severe 
diarrhoea, in perforation of abdominal viscera etc. 2 

Convulsions. Convulsions are not infrequently a 
cause of death, owing to the associated increased 
venosity of the blood which may be both the result 
of preceding, and the cause of subsequent, convulsions. 
Such a sequence is commonly observed in the status 
epilepticus, as has been already explained on p. 28. 

Hydrocephalus. Death is occasionally met with 
in cases of hydrocephalus, when the fluid has accumu- 
lated in the ventricles owing to a mutuality of cause 
and effect. The primary lesion may be some 
obstruction in the communicating channels, leading 
to dilatation of the ventricles. The dilated ventri- 
cles may then so displace the adjacent parts as to 
press on, and increase, the obstruction in the narrowed 
channel to which the accumulation of fluid was 
primarily due. For example, the cerebellum and 
medulla may be pressed down into the foramen mag- 
num so as to plug that aperture. Such plugging in 
turn increases the distension of the ventricles, raising 
the pressure to such a level that the respiratory 
centre is paralysed. 

These illustrations suffice to establish the pro- 
position that the fatal issue of disease is frequently 
due to the operation of an injurious reciprocation of 

Similar conditions are operative in many forms of 
violent death, e.g. drowning, hanging, cut-throat and 

*A 50 p.c. mortality in attacks of influenzal broncho- 
pneumonia is attributed by Symonds to the Vicious 
Circle of toxaemia and nephritis. Lancet, igi8, II., p. 665. 

2 Heineke, Die Todesursache bei Perforationsperitonitis, 
Deutsches Archiv f. klin. Medicin (1901) , LXIX., p. 429. 

Chapter Eighteen 


ANY injurious circular reactions are associ- 
ated with the natural processes of 
pathology. Others are dependent on 
injudicious therapeutics or social customs. 
These may be termed Artificial Circles 
circuli factitii, and various examples have already 
been described in the preceding pages. Their impor- 
tance, however, justifies a separate Chapter, which 
may serve to warn the profession of the evil effects 
that often result from ill-considered treatment. 

Cathartics. The excessive use of cathartics, due 
to the blatant advertisement of the quack or to the 
impatience of over-zealous disciples of ^sculapius, 
is responsible for a highly pernicious sequence of 

Like all other physiological processes, faecal evacu- 
ations vary in frequency and in quantity within the 
limits of health. Over-stimulation on one day is 
followed by a period of diminished activity the 
next day and vice versa. By this self -regulating 
process Nature ensures a sufficiency of intestinal 

Unfortunately many persons attach undue impor- 
tance to trivial deviations from normal defsecation 
and, forgetful of Nature's powers of adjustment, 
fly to cathartics whenever there has been a deficient 
relief. The result is an over-stimulation of the 


278 IDicioue Circles in Disease 

bowels followed by an aggravated constipation, 
which is then attacked by larger doses of aperient. 
So the process continues, resulting in intestinal 
catarrh and atony, and provoking more and more 
obstinate coprostasis ((Mate XV11. a). 

Sir Henry Holland many years ago called attention 
to this sequence of events : 

" The habitual irritation of the mucous membrane 
by cathartics alters and depraves its secretions through- 
out the whole course of the alimentary canal, becoming 
thereby a further source of mischief and suffering 
to the patient. These disordered secretions are too 
often urged in proof of the need of further evacuation. 
And thus the practice proceeds in a Vicious Circle of 
habit from which the patient is rarely extricated with- 
out more or less injury to his future health." 1 

Wilkinson has thus described the injurious effects 
of excessive purgation : 

" The use of drugs requires clinical acumen, common 
sense and shrewd observation, lest the drugs make 
matters worse by establishing a still greater inhibition 
of the ordinary processes, digestive, muscular and 
nervous, upon which the regular and complete evacua- 
tion of the bowel depends. Such want of skill and care 
may establish a Vicious Circle at one segment of which 
such severe and distressing conditions as membranous 
colitis, chronic catarrh and even visceral neurasthenia 
may obtrude themselves." 2 

Morphia. Another important artefact is associ- 
ated with the habitual use of morphia and other 
narcotics (jMate XVII. b) ; the habitue becomes en- 
snared within the coils of a habit from which 
escape is all but hopeless. The drug, while satiating 

1 " On the Abuse of Purgative Medicines." Medical Notes 
and Reflections, 1839, P- IO - This is the earliest 
reference to the expression " Vicious Circle " which 
I have met with in a medical work. 

2 Practitioner , 1910, II., p. 638. 

artificial Circles 







plate XVII. artificial Circles. 

280 iDlcioug Circles in IDigcase 

the immediate craving, creates an appetite for 
further indulgence, and weakens that self-control 
without which no salvation is possible. As Virgil 
says: cegrescit medendo, " the disorder increases with 
the remedy." 

Tourette writes : 

" This condition gives rise to a true Vicious Circle. 
. . . The morphinomaniac flies to his syringe before 
meals in order to awaken an appetite which is always 
indifferent. After meals the injection is repeated in 
order to assist digestion. ... As time goes on, the 
drug is used more and more often and in larger and 
larger quantities." 1 

Tanzi also describes the condition : 

" Each new injection must be larger or more quickly 
repeated than the preceding one, in order to give the 
desired effect. Thus a Vicious Circle is established, 
which gives morphinism the character of a fatally 
progressive habit." 2 

Morphia has frequently been used in attacks of 
cardiac dyspnoea, with results which in the long run 
have proved highly injurious. The drug temporarily 
relieves distress, but at the same time diminishes the 
irritability of the respiratory centre and thus allows 

1 Maladies du Systeme Nerveux, p. 244. Cf. also 

Curschmann, L,ehrbuch der Nervenkrankheiten, p. 


2 Text-Book of Mental Diseases, p. 334. Cf. also British 

Med. /., 1911, I., Epitome, p. 32 ; Haydn Brown, 
Advanced Suggestion, p. 191. Brown substitutes 
the expressions " positive or favourable " and 
" negative circlings " for " virtuous or vicious 
circles." In another Volume " The Secret of Human 
Power" the operation of Vicious Circles is discussed. 
Thus on p. 73 he writes : "In future no organic 
or functional disorder can be adequately studied 
without regard for negative and positive circling ; 
such is the importance of the subject." 

Hrtifidal Circles 281 

more CO2 to accumulate in the blood. The patient 
then requires an increasing dose of morphia in order 
to obtain relief, and a dangerous condition is created 
which Hirschf elder represents in the following way :* 

Accumulation of CO 2 Paroxysm of 

in the lungs acapnia 

Diminished irritability < * Morphine 
of respiratory centre 

In some cases the patient is so addicted to 
morphia that he brings on a paroxysm of dyspnoea 
voluntarily, and of course does himself great harm 
by so doing. 

Similar correlations may be established by cocaine 
and other drugs whose use leads to repetition, to 
habituation and finally to volitional palsy. Cocaine 
may impose an even worse slavery than does 

Alcohol. The habitual indulgence in alcohol 
frequently ends in the establishment of a Vicious 
Circle, which possesses great interest both for the 
physician and the sociologist. Indeed it is owing 
to this complication that alcoholism exacts such a 
heavy toll in disease, in poverty, in crime and in 
death. 2 

There are many reasons for the prevalent addiction 
to alcoholic indulgence. Amongst the commonest 
are its power of creating a sense of bodily and 
mental comfort, and of promoting a temporary 
oblivion of misery and poverty. As we read in 

Diseases of the Heart and Aorta, p. 205. 

2 Cf. Chronic Alcoholism and its Vicious Circles, by J.B.H., 
British ] . of Inebriety, 1915, II., p. 13. Cf. also 
Poverty and its Vicious Circles, by J.B.H., p. 56. 

282 IPidoue Circles in 2>tsea0e 

the Book of Proverbs " Give wine unto the bitter 
in soul ; let him drink and forget his poverty, and 
remember his misery no more." 

Moreover alcoholic indulgence is particularly 
seductive and dangerous, since it does not evoke 
that sense of satiety which generally attends excess. 
On the contrary, over-indulgence induces a craving 
for more ; Nature gives no signal when to stop 
Iplfltc XVII. c). Self-control is therefore required 
in order to keep consumption within judicious bounds 
and that self-control is often lacking. Any primary 
weakness of volition is further increased by its 
results, so that the evil is steadily re-inforced. 

Stocker writes : 

" Chronic alcoholism always plays a very pernicious 
role, since it leads to the establishment of a Vicious 
Circle. The injury to the brain caused by excessive 
use of alcohol provokes a further desire to drink and 
diminishes the power of resistance to the injurious 
effects of alcohol." 1 

While every person who indulges regularly in 
intoxicant liquors is liable in course of time to the 
evil effects of habituation, neuropathic individuals 
run the greatest danger, owing to their greater 
nervous instability. 

McBride writes : 

" The instability of the nerve force in neurasthenic 
individuals induces the taking of alcohol, which in turn 
increases the instability, this leading to excessive use 
of the stimulant ; and thus the Vicious Circle goes on, 
to the complete undoing of the victim." 2 

Apart from the mental effects of chronic alcohol- 
ism, there are often local disorders which also tend 
to self -perpetuation. One of them is dilatation of 

1 Beitrag zur Frage der Alcoholpsychosen, p. 296. 

2 The Modern Treatment of Alcoholism and Drug Narcotism, 

p. 78. 

artificial Circles 283 

the stomach associated with impaired peristaltic 
activity. This condition provokes a sense of ex- 
haustion and disinclination for work, which tempts 
to further indulgence. The dilatation and stasis 
also tend to flatulence, which aggravates the dilata- 

Horsley and Sturge write : 

" In this condition the stomach never contracts 
fully and effectively so as to expel its contents into the 
bowel ; hence it always contains some remnants of a 
meal, which ferment and cause ' wind.' This in its 
turn tends to inflate the stomach and itself to increase 
the dilatation, and thus the Vicious Circle goes on." 1 

If the misguided victim still flies to the bottle 
for relief, he but pursues a will-o'-the-wisp that lures 
to destruction. 

Bromides. The incautious use of bromides has 
done great harm. Few drugs have a stronger 
tendency to lower the recuperative power of a 
disordered nervous system. Yet, especially in former 
days, bromides have been extensively administered 
to benefit the very conditions in which that recuper- 
ative power was lacking. 

Traumatic neurasthenia, such as is sometimes 
caused by a railway accident, may serve as an illus- 
tration. Such accidents are frequently followed by 
spinal tenderness, stiffness and pain, associated with 
nervous prostration. These symptoms were form- 
erly attributed to irritation or inflammation of the 
spinal cord, which must be arrested by sedatives, 
and led to the administration of large doses of 
bromide of potassium for weeks together. Unfortun- 
ately bromide may produce symptoms closely akin 
to those of traumatic neurasthenia, with the result 
that unwary practitioners often confused the effects 

1 Alcohol and the Human Body, pp. 193, 205. 

284 IDicious Circles in Disease 

of the bromide with those of the injury and continued 
to increase the dose. No wonder that the symptoms 
steadily grew worse. Cause and effect were inex- 
tricably confused, further bromide of potassium 
being administered to remove the very disorder 
the drug had produced. 

A case of litigation is actually on record in which 
a claim was based on the presence of inflammation of 
the cord and its membranes as proved by a cutaneous 
eruption, which eruption was in reality an acne 
induced by bromide of potassium ! l 

Strychnine. Strychnine is another drug which 
has often been incautiously used, e.g. in cases of post- 
operative shock, associated with exhaustion of the 
vaso-motor centres and fall of blood-pressure. Recent 
research, however, proves that stimulants are useless 
for the purpose of arresting such a fall. In fact 
their administration both weakens vaso-motor action 
and lowers pressure, being tantamount to flogging 
a tired horse (plate XVII. d). In other words, 
the presence of shock led to the administration of 
strychnine, the very drug best calculated to increase 
shock. 2 

Iodides. A grievous artefact has at times been 
established when potassium iodide has been pre- 
scribed for the cure of various forms of dermatitis, 
and has then provoked an iododerma which is 
attributed to the original disorder. Increased doses 
of iodide may be then ordered in ignorance of the 
real cause of the aggravation, and in the hope of 
curing the very lesions the drug has produced ! 

1 Medical Times, 1885, I., p. 437. 

2 Cook and Briggs, John Hopkins Hospital Reports, 1903, 

p. 470. Cf. also Crile and Lower, Anoci-Association, 
p. 20. 

artificial Circles 285 

There can be no doubt that death has sometimes 
resulted from such a lamentable error. 

Thibierge writes : 

" The various lesions provoked by iodide of potassium 
are often mistaken for manifestations of syphilis. This 
error of diagnosis leads to further use of the remedy, or 
even to increased doses. Hence result a persistence 
and aggravation of the eruption." 1 

Brocq, speaking of iodide eruptions, says : 

" When the true nature of the eruption is not recog- 
nized, and the physician consequently persists in the 
administration of the iodide, the cutaneous lesions 
rapidly increase in number and severity, invade the 
mucous membranes, and become haemorrhagic. Album- 
inuria, diarrhoea and marasmus gradually supervene, 
and the patient may succumb." 2 

The danger is perhaps all the greater from the 
fact that there seems to be no such thing as accou- 
tumance to iodides. One attack of a drug eruption 
seems to intensify the susceptibility to subsequent 
attacks. 3 

Sulphur. The prolonged use of sulphur in the 
treatment of scabies occasionally excites a dermatitis 
that may be mistaken for the original disease and 
is therefore continued more vigorously than before, 
with annoying consequences. Indeed such a der- 
matitis may be kept up for many months, long 
after all the acari have been destroyed. 4 Some- 
times the error is due to ignorance. In other cases 
neurotic auto-suggestions lead to this prolonged 

1 Pratique Dermatologique, II., p. 487. 

2 Dermatologie Pratique, I., p. 412. 

3 Morrow, Monographs on Dermatology, 1893, pp. 367, 500. 
4 Hartzell, Diseases of the Skin, p. 449. 

286 iDtctoug Circles in Disease 

Dubreuilh writes : 

" There are some persons who have recovered from 
scabies, but who, in consequence of the attack and of 
the treatment adopted, are still suffering from a more or 
less extensive eczema. They will not believe them- 
selves cured, and worry their doctor to order them 
more and more active treatment. This only aggravates 
the eruption and the itching, so that the poor sufferer 
cannot escape from the Vicious Circle in which he is 
caught." 1 

Anaesthetics. Dangerous correlations may occur 
during the administration of chloroform, especially 
if the vapour is administered in too concentrated a 
form. The danger depends on the anatomical 
arrangement in virtue of which the heart receives 
the blood containing the largest quantity of the 
anaesthetic, which only reaches other portions of 
the body after passing through the heart. 

Meyer and Gottlieb write : 

" The heart can be very seriously poisoned by the 
sudden entrance into it of blood containing too much 
chloroform, even before any general narcosis has 
developed. If by such abrupt administration of 
chloroform the action of the left ventricle is markedly 
weakened for even a short time, a Vicious Circle is 
produced, which with each instant augments the damage 
suffered by the heart. For, as the heart empties 
itself but incompletely, it is directly exposed to a 
persisting poisonous action of the blood stagnating 
in it and containing poisonous amounts of chloroform, 
and consequently results in death of the heart." 2 

Another injurious sequence often complicates 
the administration of anaesthetics when there is 
persistent reflex rigidity, since such rigidity may be 
accompanied by spasmodic closure of the larynx 

1 Pratique Dermatologique, II., p. 739. 

2 Pharmacology, p. 64. 

artificial Ctrclee 287 

and retraction of the tongue. The resulting non- 
aeration of the blood may in its turn aggravate 
rigidity, and give rise to a dangerous complication 
which must be dealt with by inducing a deeper 
anaesthesia . This process of reciprocation has already 
been referred to on p. 206. 

Artefacts are by no means confined to drugs ; 
many illustrations are connected with surgery and 
surgical appliances. 

Venesection. Perhaps the most tragic example 
may be found in the use of venesection as practised 
for many centuries. Formerly, indeed, venesection 
was regarded as a panacea for almost every ailment, 
acute or chronic, and the evidence is only too clear 
that venesectio ad mortem was no uncommon occur- 
rence, death being erroneously attributed to the 
illness instead of to the loss of blood. 

The custom was to bleed until the patient became 
faint, when recovery was allowed to take place. In 
the case of some diseases, such as pneumonia, 
peritonitis and typhoid, where there is fever or pain, 
some remission of the symptoms followed recovery 
from the faintness, a remission which was hailed 
as evidence of the beneficence of the operation, 
and led to its being repeated again and again, if 
fever or pain recurred. 

When, however, blood is drawn pleno rivo, the 
symptoms produced (palpitation, vertigo, violent 
headache, jactitation, convulsions, coma) are apt to 
resemble those of inflammatory disorders, and are 
then liable to be imputed to a recrudescence of the 
original mischief, although really due to anaemia. 
Unwary practitioners confused cause and effect, 
venesection being repeated to remove the very 
symptoms it had produced (plate XVII. e). In 
fact the more marked the effects caused by the loss 
of blood, the more freely was blood drawn. Vene- 

288 iDidous Circles in Disease 

section was carried to such excess as to kill many 

patients who would have recovered perfectly if they 

had been left alone. 

The Lancet of 1827 records an illustrative case 

which may be briefly summarized : 

A man fell from a scaffold and fractured several ribs. 
On reaching St. Bartholomew's Hospital early on a 
Friday morning he was bled 18 oz., and at noon 20 oz. 
more. The next day a further 18 oz. were taken, and 
on the following day 18 oz. at noon and 18 oz. in the 
evening. On Monday the pulse was small and jerking, 
but very compressible. This condition was regarded 
as " indicative of inflammation and not resulting from 
loss of blood or hsemorrhagic irritation." Accordingly 
bleeding was again ordered to the extent of 18 oz. The 
dresser in charge of the case, however, alarmed by the 
condition following the loss of a few ounces, desisted 
from drawing any more. Nevertheless, when about 
two hours later two surgeons saw the man in consulta- 
tion, they ordered 20 oz. more to be drawn. After 
this the pulse became a mere flutter, death taking place 
a few hours later. 1 

Irrigation. Even so simple an operation as 
irrigation may be the means of perpetuating the evil 
it is intended to cure. Thus in cases of gonorrhoea 
the careless use of the syringe may carry infection 
from the anterior into the posterior urethra and even 
into the bladder. Gonococci implant themselves in 
what has hitherto been virgin soil and frequently 
excite posterior urethritis, epididymitis and cystitis. 
The syringe may prove a curse rather than a blessing. 

Even vaginal irrigations may be followed by 
injurious results. They are frequently ordered for 
a slight increase of the "whites," which are as normal 

1 Lancet, 1827, II., p. 94. Cf. also Copland, Dictionary 
of Practical Medicine, I., p. 177 ; Hale White, Text- 
Book of Pharmacology and Therapeutics, p. 915. 

artificial Circles 289 

for some women as is a slightly increased nasal 
discharge in others. Such slight leucorrhcea gener- 
ally cures itself, if left alone. 

The habit of douching, however, washes away 
the normal and sterile acid secretions, destroys the 
superficial Ia3'ers of cells and irritates the subjacent 
layers. Local hypersemia is thus stimulated, the 
quantity of secretion is increased, and even menor- 
rhagia may be provoked. When these have super- 
vened intensified douching is prescribed, cause and 
effect abetting one another. 1 

Mechanical Support. Injudicious treatment is 
sometimes associated with mechanical supports, 
whose primary effect may be beneficial, while the 
ultimate result is to increase the disability. For 
example, in many cases of spinal weakness, mechani- 
cal support by the spinal jacket is relied upon for 
the cure of the muscular weakness. The support 
increases the spinal weakness, which by degrees 
requires more and more support. Applying the 
lesson to a much commoner article of attire, we 
may say that the corset creates the demand which 
it supplies. 

The same principle applies to the use of irons 
for weak-boned children, a plan which violates 
the principles of all sound practice. Unless such 
treatment is applied with great circumspection, 
more harm than good may result. 

Restraint in Insanity. Another illustration is 
supplied by the general use in earlier days of fetters, 
hand-cuffs, strait waistcoats and other brutal appar- 
atus for the coercion of the imbecile or the insane. 
Such restraint, in lieu of promoting amelioration, 
provoked intense resentment and excitement or even 

^othergill, British Med. J., 1918, I., p. 445. 

290 IDicious Circles in 

permanent mania, the secondary irritation being 
urged as a plea for further coercion (JMatC XVII. f). 
Frequently a temporarily excited or eccentric person 
was goaded into a condition of permanent lunacy by 
the treatment that was inflicted. 1 

These atrocious methods, not so long ago univer- 
sally advocated by the profession, should keep us 
chastened in spirit, and serve as warnings lest a 
nimia diligentia lead to methods of treatment of 
which it may be said : 

plus a medico quam a morbo periculi. 

1 Gardiner Hill, Non-Restraint System of Treatment in 
Lunacy, pp. 103 f. Cf. also Griesinger, Mental Di- 
seases, pp. 491 f ; British Med. /., 1910, I., p. 519. 

Chapter Bineteen 


N first thoughts such a self-perpetuating 
process as a Vicious Circle might be sup- 
posed incurable. Indeed the supposition 
would, in many cases, be justified, as is 
shewn by the epithets " endless," " eter- 
nal," "fatal," "lifelong," "hopeless," "infernal," 
" unconquerable" which have been applied to this 

The conclusion that no Circle can be broken would, 
however, be a serious error. Nature frequently 
succeeds in interrupting in j urious reciprocations . By 
what mechanism is such a result obtained ? 

In the Chapter on .^Etiology it was pointed out that 
pernicious circular reactions are largely the result of 
the inter-dependences of organs. When the power 
of giving vicarious assistance to a diseased organ is 
unduly taxed, the second organ or series of organs 
fails to meet the extra demands made upon it and 
succumbs. Such failure then reacts injuriously on 
the first, and so the process continues. 

The ability to render vicarious assistance varies 
greatly, being dependent on age, nutrition, environ- 
ment and other factors. Hence there is an infinite 
variety in the processes of reciprocation called 
forth, when injurious reactions have been initiated. 

The problem may also be stated thus : In the 
sum-total of reactions provoked by a primary 


292 tDicious Circles in SMseaee 

disorder, some are beneficent and some are male- 
ficent. If the beneficent reactions are dominant 
the disorder takes a favourable course ; the opposite 
result ensues if the maleficent reactions prevail. 
This predominance -of certain reactions over others 
then determines the issue, whether in perpetuation, 
aggravation or recovery. 1 

Where the factors that constitute the Vicious 
Circle are isodynamic, recovery is impossible. If, 
for example, in severe pneumonia and secondary 
cardiac failure there is an equilibration of patho- 
logical factors no balance of recuperative forces is 
left. Again if in the case of pulmonary haemorrhage, 
the cough (factor A) expels an ounce of blood from 
the respiratory passages, while the concurrent in- 
crease of blood-pressure (factor B) causes another 
ounce to escape from the bleeding vessel, the morbid 
process will continue until death results from anaemia . 
Or if in pruriginous disease the secondary scratching 
causes as much fresh eruption and irritation as the 
vis medicatrix cures, we have what Kaposi calls an 
' ' endless circulus vitiosus. " Again if chlorosis causes 
as much blood to be lost by epistaxis or menorrhagia 
as can be manufactured by the haemopoietic organs, 
no progress is possible. In Trousseau's words, 
" we shall always be turning round in the same 
Vicious Circle." 2 Since, however, the beneficent 
reactions are as a rule predominant, recovery is the 
rule ; Nature triumphs. 

The methods employed by Nature vary greatly. 
Some of them aim at strengthening one organ in 
rendering vicarious assistance to another by such 
simple processes as enforced rest, hypertrophy, 
dilatation and so forth. In many other cases, 
however, an extra-ordinary mechanism is called 

1 Allbutt, Clinical /., III., p. 194. 
- Clinical Medicine, V., p. 109. 

a be Breahino of Circles b mature 293 









plate xvni ITbe rcahinfi of tbe Circle 
b\> IRature. 

294 lDiciou9 Circles (n 2)igcase 

into operation ; this is what Parkes Weber calls 
the " explosive method." 1 

Rest. The enforcement of rest is an important 
method by which injurious circular reactions are 
interrupted. Thus progressive myopia may be at- 
tended by such severe asthenopia that all work 
involving accommodation must be abandoned. The 
strain on the ocular muscles during convergence and 
accommodation is thus relieved ; the pressure 
on the eye-ball is lessened ; the progressive posterior 
staphyloma is arrested ; the incessant demands 
on the visual centres are lightened. Reserves of 
nervous energy can be accumulated, and after an 
adequate period of recuperation the self-aggravating 
factors of progressive myopia are brought to an end. 
((plate XVII 1. a). The abandonment of binocular 
vision and the establishment of an external squint 
are other means of securing rest and avoiding the 
necessity for convergence. 

The morbid correlations associated with inflamed 
varicose veins may be interrupted in a similar may. 
Enforced recumbency relieves the reciprocally acting 
tension and dilatation which rendered the disorder a 
steadily progressive one. The congestion and tension 
are relieved. In other cases spontaneous clotting 
may completely arrest the morbid process (IplatC 
XVIII. b). 

Another common sequence is associated with 
congestion and prolapse of a subinvoluted uterus, 
causing continuous back-ache, whenever the woman 
is on her feet. Prolonged rest in bed or on the sofa 
allows the displaced and engorged organ gradually 
to return to its normal situation, congestion and 
prolapse being simultaneously relieved. 

Vicious Circles in Disease and Nature's Efforts to deal 
with them. Practitioner, 1916, II., p. 145. 

Breaking of Circlee by IRature 295 

Rest is also the usual mechanism by which dyspep- 
tic disorders are cured. Here the functions of peristal- 
sis, secretion and absorption are simultaneously 
impaired, depreciating each other and constituting 
" a Vicious Circle in optima forma." Nature imposes 
physiological rest by the suppression of appetite, 
and the production of nausea or pain. Time is thus 
allowed for the complete digestion of remnants of 
food, for the removal of disordered secretions and for 
the building up of reserves of enzymes and further 
aids to digestion. In other cases increased 
peristalsis transfers the ingesta into the bowel 
before they are able to do more mischief. 1 At the 
same time Nature often awakens a desire for extra 
exercise, such as a gallop, a stiff walk or out-door 
game, thus hastening recovery both by stimulating 
the portal circulation, promoting peristalsis and 
evacuating the products of imperfect digestion. 

Sleep is another of Nature's methods of arresting 
circular reactions, especially in neurotic disorders 
which are complicated by insomnia. The obstinate 
correlations may continue in operation until the 
neuron threshold is greatly depressed and the 
victim a complete mental and physical wreck. All 
at once, as if by the wand of a magician, " tired 
Nature's sweet restorer balmy sleep " breaks the 
Circle. 2 

Hypertrophy. Hypertrophy of the heart is an 
admirable example of Nature's method of arresting 
processes of reciprocation in many cases of valvular 

! Ewald, Diseases of the Digestive Organs, II., p. 485. 

2 There are many other ways in which neurotic Circles 
may be broken. Dr. Claye Shaw tells of a lady 
who was cured of insomnia, depression and headache 
by the very natural process of having a baby. 
Lancet, 1911, I., p. 357- 

296 IDidoue Circles in HHeease 

disease. For example, in acute aortic regurgitation 
the coronary arteries are inadequately filled, the 
myocardium is enfeebled, leading to a feebler 
systole and increased regurgitation. In course of 
time compensatory hypertrophy will largely make 
up for the valvular defect, improving the coronary 
blood-supply, promoting the nutrition of the 
myocardium, and enabling the heart, even though 
unsound, to carry on the circulation with a large 
measure of success (JMatC XVII I. c). 

Another example is seen in cases of portal cirrhosis. 
In this disorder large numbers of hepatic cells are 
destroyed, their proteins being absorbed into the 
circulation, producing hepatic anti-bodies or cytoly- 
sins, which lead to further destruction of liver cells. 
This dangerous toxic process may be checked by 
hyperplasia of the hepatic parenchyma. By this 
means the evil day may be staved off, although 
there is always a danger that the progressive 
cirrhotic process may involve the hyperplastic areas 
and engulph the new cells. 1 

Cough. So physiological an act as coughing 
may be the means of breaking injurious circular 
reactions, as, for example, when tuberculous matter 
is evacuated from the lung, although, owing to many 
collateral factors, such a fortunate termination is not 
common. When a tubercular focus has formed in 
the pulmonary tissues, the bacilli give rise to 
enzymes and toxins, which weaken and destroy the 
surrounding cells and provide increasing supplies 
of food for the bacilli. Thus the latter multiply 
more and more, and give to tuberculosis its pro- 
gressive character. Where, however, the circum- 
stances are favourable and the tissues have adequate 

1 Rolleston, Diseases of the Liver, Gall-Bladder and Gall- 
Ducts, pp. 193, 292. 

Breaking of Circles b IRature 297 

powers of resistance, this process may be arrested. 
Indeed the whole tuberculous mass may be loosened 
and expectorated. The host triumphs over the 
invader and the morbid process is at an end. 


At other times some extra-ordinary mechanism is 
called into operation in order to deal with the 

Emesis. Biliousness is a symptom-complex due 
to an interwoven chain of disordered functions in 
which various organs are involved. It frequently 
originates in some error in diet which disturbs the 
gastric functions and sets up fermentation, with the 
production of lactic and butyric acids, which irritate 
the mucosa and cause it to secrete an excess of 
mucus which adds fuel to the fire. The irritated 
stomach ceases to convert its contents into peptones 
and chyme, and expels into the duodenum semi- 
digested materials entirely unfit for intestinal diges- 
tion and absorption, and which disorder the small 
intestines. The bile and pancreatic juices are unable 
to neutralise the gastric juice plus the lactic and 
butyric acids, with the result that the intestinal 
juices remain acid, instead of becoming alkaline, 
and in turn irritate the mucosa and provoke the 
secretion of unhealthy mucus. Simultaneously with 
these processes angry reflex messages are travelling 
from the stomach and intestines to the liver and 
pancreas, perverting the functions of these glands 
and interfering with the due discharge of their 
secretions. Moreover the hepatic antitoxic functions 
are largely arrested, so that the organic poisons 
which reach it from the portal system continue to 
circulate, disturbing the functions of the nervous 
system and giving rise to headache, giddiness and 
other symptoms. Thus the primary disorder spreads 

298 Dicious Circles in Disease 

far and wide, with echoing reverberations from 
one organ to another. 

Nature often breaks the sequence by active 
emesis. The fermenting ingest a together with the 
unhealthy secretions of the stomach are expelled, so 
that the mucous membrane can once again resume 
its normal activities. The liver is compressed so 
that the inspissated bile is squeezed out and can 
once again take part with the pancreatic juice in 
intestinal digestion. The reflex disorders in the 
liver, pancreas and other organs are arrested and 
the complex reciprocations of disturbed functions 
come to an end. The chain of interacting disorders 
has been broken. 

A similar mechanism may operate in cases of 
gastrectasis where dilatation and retention aggravate 
each other. For a long time the usual reflexes lie 
dormant and peristalsis is in abeyance. But sooner 
or later the burden may become insupportable. 
The machinery of vomiting is started and the 
stomach pumps up its contents, perhaps to the 
extent of a bucketful. Even a greatly dilated sto- 
mach may in this way be again braced up, the 
unburdening leading to great amelioration or even 
to recovery (flMate XVIII. d). 

Peristalsis. Attention has been drawn above 
to the sequence of events occurring during the 
growth of a biliary, renal or other calculus. For 
years the morbid correlations may persist, while 
the victim endures a weary martyrdom. But all 
at once, without apparent cause, active peristalsis 
may be called into operation and the offending 
calculus is expelled. Nature has done the trick 

(plate xvni. e). 

Again in obstinate coprostasis faecal stasis 
may lead to paralysis of the intestinal wall, and 
the paralysis to yet more obstinate stasis. Danger- 
ous correlations are in operation and the condition 

Breaking of Circles b\> IRature 299 

appears one of impasse. After a period of rest, 
however, vigorous peristalsis may return and sweep 
away even a great accumulation of faeces. Such an 
extraordinary effort, although not free from danger, 
may be completely successful. 

Decompression. Many cases of heart failure 
are aggravated by secondary visceral congestion. 
Here the vis medicatrix may take the form of a 
sharp attack of gastric or intestinal haemorrhage ; 
indeed such a loss of blood is often a blessing in 
disguise, and prove vitce artifex, mortis fugator. 
On the one hand the overburdened heart is relieved 
while, on the other hand, the viscera can resume 
work and again supply wholesome nutriment to the 
failing myocardium. The lost equilibrium of the 
vascular system is restored ((Mate XVIII. f). 

Uraemia is another disease in which haemorrhage 
is common and frequently beneficent. Epistaxis, 
haematuria, melaena, metrorrhagia may occur. Nature 
bleeds herself ; the organism is its own physician, 
as Hippocrates pointed, out many centuries ago. 

Syncope. In other cases of haemorrhage dangerous 
correlations may be interrupted by temporary 
cardiac failure. For example, in pulmonary 
haemorrhage the intra-pulmonary irritation of the 
effused blood causes a cough : each act of coughing 
sends up the blood-pressure : each rise of blood- 
pressure is apt to renew the haemorrhage. Under 
such conditions syncope, instead of destroying, 
proves the. very means of preserving, life. The 
weakening of the heart's action allows time for 
the stagnating blood to coagulate within the bleeding 
vessel and close the orifice. A natural haemostasis 
is achieved. 

Inflammation. The self-perpetuating processes 
that complicate ringworm are sometimes arrested by 
means of kerion. Trichophytes may live in the 

300 IDidous Circles in Disease 

skin for many years without provoking any obvious 
reaction. In certain cases, however, when the 
tinea tonsurans has penetrated to the bottom of the 
hair follicle, an inflammatory reaction, often associ- 
ated with pyogenic organisms, supervenes, as a 
result of which the hair is detached from its papilla 
and is thrown off carrying the parasite with it. 
In other words the reaction cures the disease by 
expelling the parasite, and as soon as this has been 
accomplished the reaction subsides. The attacks 
of ringworm which appear the most severe frequently 
have the most favourable termination. 

Sabouraud describes the process : 

" There is a whole category of tineas which tend to 
suppurative folliculitis and give rise to kerion. In 
these cases an afflux of leucocytes takes place in the 
follicle and provokes the loosening of the hair, which 
is detached from its papilla. The hair then acts like 
a foreign body and is spontaneously expelled or else 
removed by the slightest traction. In these cases 
epilation is automatic and recovery fairly rapid ; these 
are tineas which soon get well. I call them autophagous 
since the extension of the parasite provokes an organic 

defence which brings about the expulsion 

Kerions cure themselves by a spontaneous epilation." 1 

Kerion is only one example of the inflammatory 
process by which Nature is continually breaking the 
circuli vitiosi associated with injury (cf. p. 59). 

These illustrations may suffice to shew that the 
resources of Nature are frequently successful in 
arresting injurious circular reactions. Her meth- 
ods are uncertain, clumsy and painful ; never- 
theless they often accomplish the end in view. 
There are, however, many conditions which it is 
beyond her power to cure. Here Art must succour 

a Les Teignes, p. 765. 



| HE breaking of Vicious Circles by the 
ars medica is so extensive a subject as 
to require a special treatise if anything 
like justice is to be done to it ; physicians 
as well as surgeons are perpetually 
engaged in breaking Vicious Circles. 1 All that can be 
attempted here is to focus attention on therapeutics 
as viewed from a particular standpoint. 2 

The treatment of disease when complicated by 
the citculus vitiosus presents problems peculiar to 
itself. The physician is no longer confronted with 
a morbid process in which the dominant reactions 
are beneficent ; these reactions are feeding the 
disorder. The vis medicatrix has become a vis 
vastatrix, and what looms before the sufferer is at 
best a prolonged disorder, at worst a descensus 
Averno. One teacher writes: " I/et it be a cardinal 
principle of treatment to make an effort to interrupt 

1 The treatment of " Vicious Circles from which safe emer- 

gence is difficult or impossible," and the restor- 
ation of disturbed functional equilibrium is dis- 
cussed by Carter. British Med. /., 1900, II., p. 1301. 

2 Doubtless this aspect of therapeutics will receive more 

attention in the future. As a helpful contribution 
may be mentioned a series of articles by Dr. Sajous 
on " Vicious Circles in Respiratory Disorders and 
their Treatment." New York Medical /., 1918, II., 
PP- 344, 387, 43i, 475, 519, 564- 

302 IDtctoue Circles in ^Disease 

Vicious Circles." 1 Another says : " At all costs 
the Vicious Circle that has been established must 
be broken through." 2 Unfortunately, however, 
our text-books give but little assistance in the 
solution of the special problems involved. An 
attempt must therefore be made to discuss the 
subject of treatment as influenced by the presence 
of circular reactions and to illustrate the procedure 
by some examples. 

Therapeutics may roughly be divided into (i) the 
treatment of the disease, and (2) the treatment of 
symptoms. Both of these methods are concerned in 
the interruption of Vicious Circles. 

The more important task of the therapeutist is 
the cure of the actual pathological condition from 
which the patient is suffering. By this treatment, 
which Gilbert describes as " therapeutique patho- 
genique, etiologique ou specifique la therapeutique 
des causes," 3 the cause of the disease is attacked, 
and when this can be accomplished the effects, i.e. 
the symptoms, disappear. Ablata causa tollitur 
effectus. Its difficulty consists in the discovery of 
the actual morbid processes that are at work, and 
this frequently involves a long and arduous search. 
Even when discovered the morbid process cannot 
always be arrested. 

The other method, i.e. symptomatic treatment, 
appears at first sight to be the easier one. Consti- 
pation is treated by aperients, haemorrhage by 
haemostatics, pain by sedatives, fever by antipyretics 
and so forth. To such symptomatic treatment, 
however, there are serious draw-backs which may 
become dangerous if it be indiscriminately followed. 
Attention is concentrated on superficial manifest- 

1 M. Bruce, Principles of Treatment, p. 263. 
2 British Med. /., 1912, II., p. 1459. 
3 Gilbert, Clinique Medicale, pp. 34, 38 

ffbe Breaking of IPIdous Circles b art 303 

ations of disease, instead of on its fundamental 
factors. Moreover many symptoms are the outcome 
of Nature's beneficent efforts at resistance and 
reparation, and such symptoms must be carefully 
distinguished from other injurious manifestations. 
In spite of its attendant dangers, however, 
symptomatic treatment may be called for by urgent 
conditions which threaten life or provoke acute 
suffering. At times indeed the precise nature 
of the disease cannot be ascertained ; in these 
and similar conditions symptomatic treatment must 
be resorted to, while its associated perils are borne 
in mind. 1 Such symptomatic treatment, some- 
times denounced as unphilosophical, then becomes 
the height of wisdom and is fully justified by its 
results. Sajous has so well described symptomatic 
treatment in relation to Vicious Circles that his 
remarks may be quoted in full : 

" Interruption of a Vicious Circle, intentionally or 
unwittingly, appears sometimes to account for per- 
sistent benefit from purely symptomatic treatment 
which could not otherwise be readily explained. Thus 
cough, whatever be its cause, tends to produce con- 
gestion of the lower respiratory passages. This con- 
gestion, in turn, promotes local irritability and tends 
to increase the frequency of the cough paroxysms. 
These, again, augment the congestion, and a Vicious 
Circle thereby results which tends to aggravate and 
perpetuate the disturbance, even though the original 
cause usually some form of local irritation has 
spontaneously or artificially been eliminated. Admin- 
istration of a drug, such as codeine, to depress the 
cough centres in cases of this type, would at first 
sight appear to constitute merely symptomatic treat- 
ment, the beneficial effects of which will disappear 
when the drug is discontinued, the irritative cause 

admirable account of the advantages and dangers of 
symptomatic treatment is given by M. Bruce. Prin- 
ciples of Treatment, p. 135. 

304 HMcioug Circles in ^Disease 

of the cough persisting. As a matter of fact, however, 

the codeine in addition breaks into the Vicious Circle 

just referred to, preventing the increase of cough due 

to local congestion, likewise the increase of local 

irritability due to this cough, and consequently the 

aggravation and perpetuation of the latter, which 

would otherwise have occurred through the operation 

of the Vicious Circle. If at the same time one has 

succeeded in removing the irritative cause of the cough, 

complete recovery will be hastened by the artificial 

interruption of the Vicious Circle ; even if one has 

not, the benefit from the remedy will be far more 

lasting on this account than if the Vicious Circle has 

not been present and a purely symptomatic effect alone 

had been produced. By repeated administration of 

short courses of codeine treatment the evil effects 

of the Vicious Circle can be continuously obviated 

and, through the consequent removal of an important 

factor of aggravation, a great reduction of the severity 

and duration of the disturbance is secured." 1 

As soon as a Vicious Circle has been recognised, 

an effort must be made to effect a breach at the 

locus minor is resistentice, for a signal advantage 

presented by such a morbid process is that there are 

at least two points at which the evil round may be 

attacked. In the words of L,auder Brunton : 

" We must see where the Circle can best be broken, 

since if we break the Circle at one point, we allow 

recovery to commence." When the gyration has 

been stopped, the whirling currents will be restored 

to their normal direction. The hound which had 

turned to hunt its own tail will once again be put on 

the track. Each practitioner will seek to effect a 

breach at what appears to him the point of election. 

One will attack at A, another at B, a third at A 

and B. Hence results a variety of methods which 

at times puzzles the public, especially when several 

practitioners are consulted in succession. Yet each 

1 New York Medical /., 1918, II., p. 344. 

Breaking of Otctous Circlee bp Hrt 305 

may be right in his aims, and the same goal may be 
reached by different routes. Some illustrations of 
the modus operandi may be grouped under the 
following heads : 

I. Hygienic Measures 

II. Drugs 

III. Surgical Appliances 

IV. Surgical Operations 

Fuller details as to the Vicious Circles referred to 
will be found in the preceding Chapters. 


The ars medendi can do much both to prevent, and 
to arrest, injurious reciprocations, when expert know- 
ledge is permitted to regulate life in accordance with 
physiological righteousness. Only too often, how- 
ever, is wholesome advice disregarded. The dictates 
of fashion and the love of self-indulgence generally 
prevail in opposition to a rational regime. 

Rest. The prescription of rest in bed is often 
of great benefit. Thus in various forms of cardiac 
disorder a dilated and over-burdened myocardium 
is associated with pulmonary and visceral engorge- 
ment, the two conditions feeding on one another 
under the stress and fatigue of the daily activities of 
life. Recumbency relieves the heart, the warmth 
of bed stimulates the activity of the skin and assists 
the kidneys. Improved cardiac, renal and hepatic 
activity reacts favourably on the lungs ; the relief 
of pulmonary congestion further invigorates the 
heart. All these cumulative factors tend to a 
better circulation and a more aerated blood. Pure 
blood spells better nutrition of the nervous system, 
and so by degrees all the organs help one another 

3o6 IDicioug Circles in ^Disease 

in an ascending scale. Brilliant results often follow the 
prescription of rest in bed for patients threatened 
with cardiac failure ; even seemingly moribund 
persons recover and continue in fair health for 
years ((Mate XIX. a). 

I^auder Brunton emphasises the value of absolute 
rest : 

"As in many other things the conditions in cardiac 
disease form a Vicious Circle. The disordered circula- 
tion disturbs the function of other organs, and these 
in turn make the circulation worse. . . In such cases 
it is evident that the patient is bound to die, and to 
die a somewhat painful death, unless medical art can 
afford him some assistance. It is very fortunate, 
however, that in such cases medical art can do much. 
... If we can break the Vicious Circle at one point, 
we allow recovery to commence ; and one of the most 
important agents I think I ought to say the most 
important agent in the physician's power is absolute 
rest." l 

It must, however, be remembered that there should 
be moderation in all things, and that so valuable a 
therapeutic measure as rest may be abused. Exces- 
sive rest may induce corpulence and throw an extra 
burden on the heart. A careful course must be 
steered between Scylla and Charybdis. 

In other disorders mental rest is required, as 
for example in some forms of neurasthenia, where 
business worries and insomnia are interacting factors 
A holiday in Switzerland, an ocean voyage or any 
similar change of scene that gives rest to the exhaus- 
ted neurons may quickly and permanently bring 

Mental repose is of equal importance in various 
forms of insanity such as folie circulaire. 

1 Therapeutics of the Circulation, p. 232. Cf . also Faught, 
Blood-Pressure, p. 438. 

fb^ienic flfteaeuree 








plate XIX. She iJBreafetng of the Circle 

3o8 IDtdoug Circles in Disease 

Clouston writes : 

" The great point in treatment is to prevent the 
brain getting into the Vicious Circle of continuous 
alternation, by endeavouring really to complete the cure 
in all cases of mania especially in all cases of adoles- 
cent mania and to enforce prolonged quiet and brain- 
rest after attacks in persons who have shewn a tendency 
towards recurrence and relapse." l 

Exercise. The old proverb " What is one man's 
food is another man's poison " applies to exercise 
as well as to food. Increased exercise in lieu of rest 
may be required for the interruption of other 
circular reactions. A common illustration is afforded 
by dyspeptic disorders associated with anorexia 
and inertia. Such interacting processes may often 
be relieved by appropriate exercise. Tissue-hunger 
is awakened, psychical appetite returns, active 
gastric secretion and improved nutrition follow. 
The Vicious Circle is effectually interrupted. 

Obesity is another disorder often relieved by 
exercise, where the accumulated fat hinders activity 
and so perpetuates itself. The form of exercise 
to be prescribed depends on the degree of obesity 
and the individual temperament. Riding, walking, 
home gymnastics may all render service under 
suitable circumstances (JMatC XIX. b). Exercise, 
when so regulated as to promote cell nutrition, is a 
valuable means of strengthening the resistance of 
the body in tuberculosis, and thus forms a valuable 
curative measure. The severity of the exercise 
must of course depend on the stage and activity 
of the disease. But when the temperature is steady 
at a normal level and the general condition is 
satisfactory, the exercise may be gradually increased 
with advancing convalescence. Digestion and nutri- 
tion improve, sleep is more natural, physique is 
strengthened and resistance to toxins is increased. 

Cental Diseases, p. 245. 

t>\>dienic (IDeaeures 309 

Nutrition. The regulation of nutrition is another 
valuable therapeutic measure. Many persons, es- 
pecially young women, habitually eat too little. 
Either from a dread of corpulence, from want of 
energy, from dyspepsia or other cause their daily 
consumption falls below their expenditure. Emaci- 
ation results and this may lead to increased inertia 
and dyspepsia. 

Mathieu writes : 

" Many of these patients are enclosed in a veritable 
Vicious Circle. They have no appetite because they 
are insufficiently nourished, because they have grown 
weak, because their processes of metabolism are too 
greatly reduced." 1 

The prescription of a suitable diet, so that it may 
include a sufficiency of protein, fat and other 
constituents, may in itself suffice to restore both 
mental and physical vigour (flMate XIX. c). 

Under other circumstances, such as obesity, 
restriction of food must be cautiously imposed. 
The corpulent person will soon begin to feel the 
benefit of diminished avoirdupois ; the boulimia 
created by the malady will be less imperious, and 
after a few weeks the patient will be less harassed by 
his self-denial. Frequently also more varied and 
active occupations will become possible, allowing 
less leisure for self-indulgence at lengthy meals. 
Some limitation in the amount of liquid consumed 
will help in the same direction. Many fat persons 
imbibe large quantities of fluid which enable them 
to wash down their food rapidly and throw an extra 
burden on their circulation. Less fluid will often 
cause an immediate loss of several pounds owing to 
a relative drying of the body. Such diminished 
weight with the concurrent lessened perspiration 

1 Maladies de 1'Estomac et de 1'Intestin, p. 447. 

IPidous Circles in 2>isease 

results in greater comfort and allows more exercise 
to be taken. 

According to Haig a self-perpetuating condition 
may be associated with a diet which consists too 
largely of meat. The meat, in his view, by producing 
uric acid and a state of collaemia, serves as a stimu- 
lant, whose action is succeeded by depression. 
For the relief of such depression, more meat is 
consumed, and if this fails alcohol is resorted to. 
A vegetable diet produces less uric acid and less 
depression, and thus arrests the sequence. 

Haig writes : 

" Vegetarianism cuts through this Vicious Circle by 
making it impossible for there ever again to be any 
great excess of uric acid in the blood, and so removing 
a cause of the depression which leads to the craving 
for stimulants." 

And again : 

" Meat is a stimulant whose first action is to clear 
the blood of uric acid, and all substances that produce 
this effect are stimulants. 

Like all other stimulants it produces depression later 
on when the retained uric acid passes again into the 
circulation. Hence stimulant taking in one form or 
another is an inevitable result of meat eating, and 
here originates the demand for tea, coffee, alcohol, 
morphine, cocaine, to counteract the secondary depress- 
ing effects of the original stimulant. 

It follows that there is no escape from this Vicious 
Circle but the complete abandonment of meat and all 
the stimulants that have been brought into use by 
it." 1 

An interesting Circle associated with nephritis 
and ascites can often be interrupted by dietetic 
dechlorinisation. In some forms of nephritis the 

1 Uric Acid as a Factor in the Causation of Disease, pp. 242, 
303> 405, 407, 835, 846. 

1>0ienic Measures 311 

kidneys lose their power of excreting sodium 
chloride, which consequently accumulates in the 
blood, cellular tissues and serous cavities. Owing 
to the influence of osmosis a considerable quantity of 
ascitic fluid may collect in the peritoneal cavity, 
when it may further curtail renal efficiency. 

This sequence may be relieved by a diet con- 
taining a diminished proportion of salt. For ex- 
ample, a purely milk diet of 2-3 litres per diem only 
contains ca. 2j-5| grms. of salt, whereas an ordinary 
diet contains 10-12 grms. By a milk diet, therefore, 
a gradual dechlorinisation may be brought about. 
Milk also possesses a valuable diuretic action. A 
similar dechlorinisation may be effected if solid foods 
which contain but little sodium chloride are con- 
sumed, such as meat, eggs, rice and potatoes. 

Hydrotherapy. Many disorders liable to recur- 
rence are associated with a low power of resistance, 
which seems to grow lower with every attack of 
disease. For example, in patients subject to attacks 
of bronchitis the skin and bronchial tubes become 
exceedingly sensitive to changes of temperature, the 
power of reaction being greatly depressed. Lowered 
resistance, susceptibility to cold, bronchitis, lowered 
resistance form an obstinate sequence. 

Under such circumstances a careful hardening 
regime may cure the liability to catarrh, and in 
that regime cold baths and affusions, if used with 
discretion, are of great value. Indeed such cold affu- 
sions may establish a power of resistance to bronchial 
and cutaneous impressions, where debility or sensitive- 
ness previously led to ever-recurrent attacks of 

Regularity of Def aecation. Much harm is done 
by a habitual disregard of the natural call to 
stool, since such disregard leads to progressive 
blunting of the associated reflexes and to increased 

312 Dicious Circles in Disease 

constipation. Moreover faeces when retained in the 
rectum lose much of the fluid constituents by 
absorption, and produce dry and hard scybala 
which are difficult of expulsion and favour retention. 
In this way many persons contract injurious habits. 
The adoption of such a diet as stimulates the 
natural desire will in many cases suffice to regulate 
defalcation and arrest the bad habit that has been 
formed (plate XIX. d). 

Cleanliness. Numerous disorders have been men- 
tioned in which want of cleanliness has initiated 
disease, which in its turn perpetuates the want of 
cleanliness. Amongst these are pyorrhoea, accumu- 
lation of wax in the auditory meatus, seborrhoea 
genitalium and intertrigo. Appropriate methods of 
removing stagnant secretions as a rule readily 
check the morbid correlations (jplate XIX. e). 

The same principles apply to those parasitic 
disorders in which infection is transferred from one 
region to another by the fingers and thus starts 
fresh foci of disease. 

Breathing Exercises. Nasal obstruction and the 
resulting mouth-breathing are frequently associated 
as cause and effect. For example, in weakly 
children nasal secretions are allowed to accumulate 
and block the nostrils so that mouth-breathing is 
resorted to. This in its turn favours the retention of 
nasal secretions and increases the nasal obstruction. 
If attended to early, this injurious process can readily 
be arrested. By an efficient use of the pocket- 
handkerchief or by induced sneezing 1 the nasal 
passages can be kept clear, while the habit of 
nasal respiration is carefully inculcated. Adenoid 
vegetations would be less common if such nasal 
hygiene received greater attention (plate XIX. f). 

1 Lancet, 1918, II., p. 240. 



Many Vicious Circles can be broken with the 
help of drugs, provided these are wisely selected and 
adapted. The deeper the insight of the physician 
into the self-perpetuating processes that are in 
operation the more" successful will be his treatment. 
Remedies should resemble the bullet that flies from 
the rifle direct to the bull's eye rather than the 
scattering shot of the fowling-piece. 

Space will only permit of a few illustrations, but 
these will suffice to indicate the modus operandi. 
We shall deal first with some constitutional dis- 
orders associated with the nervous, vascular, diges- 
tive and other systems, and afterwards with local 


Pain and Insomnia. Pain, insomnia and a lower- 
ed neuron threshold form the links of a very common 
and grievous concatenation, which is met with in vari- 
ous disorders, each link being both cause and effect. 
An aching tooth, a tender ovary, an over-taxed 
ciliary muscle, a palpitating heart and so on may 
fix the consciousness of the sufferer on the lesion, 
arouse phobias, produce insomnia and steadily 
aggravate both suffering and misery. Under such cir- 
cumstances the administration of a narcotic which 
secures sound sleep may be followed by such rais- 
ing of the neuron threshold that pain vanishes as 
with the wave of an enchanter's wand. Evidently 
the drug acts on the paths by which a lesion affects 
consciousness ; probably it interrupts those paths 
at their synapses in the region of the great cerebral 
ganglia. When irritability has been diminished, 
the stimuli again become subliminal, and no longer 
prevent sleep. The sleep further diminishes irrit- 
ability by allowing time for a renewal of the sub- 

3*4 Dictoug Circles in ^Disease 

stances consumed by the discharge of energy, and 
thus raising the neuron threshold (JMatC XX. a). 

There are, of course, many drugs that act as nar- 
cotics, but in efficiency none can rival morphia 
TO <f>dpfjiaKoi> vr)iTv@e<: "the soothing drug." 

As Mitchell Bruce says : 

" Rest is urgently required for all cases of this kind, 
and has to be secured in many instances by means of 
morphine which breaks the Vicious Circle of unrest 
and irritability, and, a beginning once made, rest 
begets rest." 1 

Another condition in which sedatives are invalu- 
able is what has been called the " most highly Vicious 
Circle in pathology," viz. that which is associated 
with haemoptysis and haematemesis, and which 
largely accounts for the profuseness and prolongation 
of haemorrhage. Not only does the tendency to 
cough and vomit suffice to start the haemorrhage 
afresh, but the associated mental perturbation and 
physical restlessness raise the blood-pressure and 
operate in the same direction. The morphia or 
other sedative keeps the patient quiet mentally and 
bodily, thus breaking three Circles simultaneously, 
and is therefore perhaps the most valuable drug for 
controlling haemorrhage. 

Morphia is of course only a type of various 
sedatives that may be used, but it is supreme in its 
power of dulling over-excitability, and in producing 
a central hypalgesia. It has a greater power than 
any other drug " sedare dolor em divinum opus." 

Epilepsy. Certain disorders, such as epilepsy, are 
associated with a progressive proclivity to paroxysms 
which may be acquired through constant repetition, 
the attacks being probably due to explosive impulses 
arising in the cerebral cortex. Every attack in- 

1 Principles of Treatment, p. 230. 




I / V 






plate \x.Khe Breaking of tbe Circle 

316 IDidoug Circles in 

creases the labile condition of the nerve centres and 
after being effect becomes also cause. In other 
words the neuron threshold is gradually lowered 
so that a given stimulus more and more readily 
provokes a paroxysm. 

Such exaggerated irritability of the nervous 
system can be controlled by bromides ; indeed the 
prognosis in cases of epilepsy has been revolutionised 
since this treatment has been introduced. In a few 
cases there are no further attacks even when the 
drug is discontinued ; the bromide may then be 
said to have cured the disease. In the large majority 
of cases (90-95 per cent.), however, the frequency of 
paroxysms is greatly diminished, or the patient may 
be entirely free as long as the treatment is kept up, 
although the attacks return when the drug is 
discontinued (plate XX. b). 

Bromides probably exert their beneficial influence 
by retarding the passage of impulses along the 
paths which connect the various motor and sensory 
centres in the brain. The earlier the fits are arrested, 
the less fixed will be the proclivity to repetition. 
Even in the status epilepticus the drug renders 
service, although that status has other self-per- 
petuating and dangerous complications which must 
not be neglected. 

Mott thus refers to the status epilepticus : 

" To stop the fits early and prevent the establish- 
ment of the Vicious Circle by chloral or bromide ; to 
relieve venous congestion by purgation or enemata ; to 
support the heart by nutrient enemata and stimulants, 
and, if necessary, relieve the engorged distended right 
heart by venesection, appear to be the rational mode 
of treatment. When people die in the status epilep- 
ticus it is often because these measures have not been 
adopted soon enough." 1 

1 Archives of Neurology, I., p. 502. 

Drugs 317 

Paralysis. In various forms of paralysis, such 
as those due to acute anterior poliomyelitis, there 
is a progressive increase of the disorder owing to loss 
of the reciprocal relations between the tropho-motor 
neurons and their corresponding muscle cells. These 
two elements form but a single unit ; disease of 
the one involves disease of the other. Sometimes 
the damaged neurons are unable to transmit any 
impulses down to the muscles ; at other times 
these impulses are too feeble to evoke any responsive 
contraction. In either case the absence of response 
checks the nutrition, and delays the recovery, of the 

In such conditions the elective action of strychnine 
on the reflex arcs of the nervous system is most 
valuable. Even small doses may so raise the 
irritability of the neurons that they may again 
become susceptible to peripheral stimuli from the 
muscles, nutrition and repair thus being promoted. 
The activities of the receptive organs in the cord and 
brain, which have been depressed by degenerative 
processes may in some measure be restored, so that 
the reflex mechanism again responds to physiologi- 
cal stimuli. 

The action of the strychnine is probably localised 
at some point between the entrance of the affected 
fibre and the synapse of the motor cell. At that 
point the passage of impulses through some of the 
synapses of the spinal cord is facilitated. 

Shock. In surgical shock various reciprocally 
acting conditions are present, including a depleted 
arterial and an engorged venous system, combined 
with a low blood-pressure and a feeble cardiac 
activity. As a consequence the vaso-motor centres 
are inadequately nourished with blood and in 
severe cases rapidly lose their control over the 
circulation. In other words the fall of blood- 
pressure and the inactivity of the vaso-motor centres 

3*8 IDictoug Circles in 

re-inforce each other, and the reciprocally acting 
process frequently ends in death. Under such 
conditions the intr a- venous injection of adrenalin 
constricts the small blood-vessels and raises blood- 
pressure. Indeed a full dose of the drug may 
drive a large volume of blood into the arterial 
system and flood the tissues with blood, while 
at the same time it strengthens the cardiac systole 
by stimulating the myocardium. In both these 
ways the drug may break the Vicious Circle associ- 
ated with shock and prevent what appears imminent 
death. In recent years adrenalin has become one 
of our most valued remedies owing to the reliability 
of its action. 

Cardiac Failure. Circulatory insufficiency may 
result from disease of the myocardium or of the 
valves, when the resulting interference with the 
circulation is not adequately compensated. The 
principal compensatory change is brought about 
by hypertrophy of the muscles of one or more of 
the cardiac chambers, which are thus able to pump 
out the blood in sufficient quantity and with suffi- 
cient force to supplement any deficiency in the circu- 
lation. L,ater on, however, as a result of progressive 
valvular or myocardial disease or of impaired nu- 
trition, compensation usually breaks down, and stasis 
supervenes in the pulmonary or systemic circuit or 
in both, with secondary results pulmonary, systemic 
and portal congestion, ascites, oedema etc. all of 
which aggravate the cardiac failure. 

Under such conditions digitalis and other plants 
of the digitalis series yield the sovereign remedy for 
breaking the dangerous Circles that have become 
established (plate XX. c). 

A ventricle which has become insufficient can 
under the influence of digitalis regain sufficiency. 
The immediate effect of this will be an improved 
coronary circulation which in its turn will promote 


a more vigorous systole. There will also be a lower- 
ing of the excessive peripheral vaso-constriction 
which has been provoked by the medullary centres 
in order to keep themselves supplied with blood, 
but which is no longer required. This will lighten 
the burden imposed on the failing myocardium. 
Thus is brought about an improvement both in the 
vis a tergo and in the vis a f route, as a result of which 
the blood which had accumulated in the venous 
system flows more freely to the heart and arteries, 
thus further benefiting the myocardium. The con- 
dition of the blood also improves since the impaired 
processes of secretion, excretion and aeration are 
invigorated, and the purer blood tends to more active 

Another effect of digitalis is to increase the tone 
of the myocardium and thus to moderate tachy- 
cardia. An enfeebled myocardium is compelled 
to beat rapidly in order to carry on the circulation, 
even though such rapid action leads to progressive 
weakening, since the cardiac chambers can neither 
fill nor empty themselves as they should. With 
increased tonicity the systolic output is increased, 
so that fewer beats are required. 
Pavlov writes : 

" An uncompensated heart beats rapidly and thereby 
only aggravates its condition. Its time of rest, that 
is of recovery, of restitution of the organ is shortened. 
A Vicious Cycle is set up. The weak action of the 
heart lowers blood-pressure, the lowering of this leads 
(from known physiological causes) to an increase in the 
number of beats, the quickening leads to weakening of 
the organ. Without doubt the digitalis aids by break- 
ing through this Vicious Cycle in that it greatly slows 
the pulse, and thereby gives new power to the heart." 1 
This slowing action of digitalis is especially 
beneficial in auricular fibrillation, and may be due 

1 The Work of the Digestive Glands, p. 233. 

32Q IDiclous Circles in SDtseage 

to a retarding action on the conductivity of the 
bundle of His and to a diminished irritability of 
the motor ganglia in the heart. 

As a result of the improved tonicity the auricular 
and ventricular orifices contract, and this enables 
the valves, even though damaged, to close the 
orifices more effectually and thus to lessen regurgita- 
tion ; there is also less tendency to over-distention 
during diastole. The increased diuresis brought 
about by digitalis is of further benefit by relieving 
the general oedema which so often complicates 
cardiac failure, and throws so much extra work 
on the myocardium. The kidneys share in the 
general acceleration of the blood-flow and secrete 
more vigorously. The accumulated fluid in the 
tissues tends to return to the blood-vessels and 
to be excreted by the kidneys. With diminishing 
ascites the pressure on the renal veins is relieved 
and so progress is accelerated. 

Thus in various ways digitalis renders brilliant 
service in cases of cardiac failure ; no wonder 
that it is regarded as a sheet-anchor. Many other 
drugs are also of value ; digitalis has merely been 
selected as a type. 

Opotherapy has also at times been used with 
success. Some cases of cardiac failure, which 
Martinet has termed (< hyposphyxia," appear to be 
complicated by hypo-endocrinism, which may be 
advantageously treated by suitable pluriglandular 
extracts, in conjunction with physical and other 
means calculated to strengthen the circulatory 
function. Martinet believes that in these cases 
" there is a digestive disorder which reacts upon the 
circulatory disturbance and forms a Vicious Circle." 
He therefore treats it with secretin preparations, and 
and at the same time relieves the endocrinous 
dyscrasia by pituitary or adrenal extracts, combined, 
where necessary, with thyroid and ovarian extracts. 


Excellent results are said to be obtained from such 
opotherapy in cases of hyposphyxia following acute 
infectious diseases, malnutrition, neurasthenia and 
in the pretuberculous state. " The primary Vicious 
Circle is broken by this treatment." 1 

Angina Pectoris. Angina pectoris is another 
disorder which is frequently complicated by a 
Circle, and for which amyl nitrite is used. The drug 
is most successful in the form of paroxysm known as 
" angina pectoris vasomotoria," i.e. attacks of vaso- 
constriction associated with a high blood-pressure. 
In such cases the effects of amyl nitrite are unsur- 
passed in certainty. 

Allbutt describes this form of angina : 

" Vaso-constriction often becomes an active part of 
angina. A movement or an emotion raises arterial 
pressure ; by this the sore parts are annoyed and, 
the medullary centres being irritated, pressures may 
rise more and more, and a Vicious Circle be established 
until by nitrites pressures are reduced, or by morphia 
the centres blocked." 2 

When administered in the form of an inhalation, 
the drug gives speedy relief, sometimes in less than a 
minute, and, although the vaso-dilation brought 
about may only be temporary, the distressing 
symptoms may be arrested for a considerable period. 

Other nitrites, such as sodium nitrite, exert a 
similar effect to amyl nitrite,^ although their use is 
less convenient. On the otlier hand their effect 
may last longer. 

Martinet, Traitement des Hyposphyxies, Presse Medicate, 
1913, XXI., p. 635. Cf. also narrower, Practical 
Hormone Therapy, p. 421. 

2 Diseases of the Arteries, including Angina Pectoris, II., 
p. 236. 

323 Melons Circles in 

Anaemia. Anaemia is frequently a self-perpet- 
uating condition through its effects reacting upon 
and aggravating the cause. Hence the chronicity 
of the disorder. 

The administration of iron seems beneficial in all 
forms of primary anaemia, and arrests the recipro- 
cally acting correlations. It is in the chlorotic 
form, however, that the drug achieves its most 
brilliant triumphs. Few drugs can be more con- 
fidently relied upon to interrupt the reciprocations 
associated with a disease ; a large proportion of 
sufferers recover completely. " There is absolutely 
no question that administration of iron restores the 
composition of the blood to normal, usually quite 
rapidly " (plate XX. d). 

In chlorosis there is always a deficiency of 
haemoglobin and usually a deficiency of red blood cor- 
puscles, disorders which may be due to insufficient food 
or to excessive menstrual loss. In a healthy woman's 
diet, the average daily amount of iron is only 6-8 
mgrms. (jV-g gr.), and, as this only just balances 
the excretion, a very small margin is left for haemo- 
poiesis. If, therefore, the average intake is reduced 
by dyspepsia or if the output is increased by 
menorrhagia, the body gradually becomes depleted 
of iron and the haemoglobin is the constituent which 
suffers most. Hence result breathlessness, cardiac 
weakness and oedema. 

When, however, iron is taken in addition to that 
contained in the ordinary food, haemopoietic activity 
is gradually increased, and both the proportion of 
haemoglobin and the number of red corpuscles in- 

The value of iron has been established not only 
clinically but by experiments on the lower animals, 
which show that the drug may not only be utilised 
as material for the synthesis of haemoglobin but also 
exerts a specific action on the blood-marrow and 


other blood-forming organs. 1 The combinations of 
iron as met with in chalybeate waters, such as those 
of Spa or St. Moritz, are often highly efficient in 
arresting the morbid process. 1 

Bronchitis. Recovery from bronchitis largely 
depends on the success with which natura medicatrix 
can get rid of the large quantity of mucus and other 
secretions which are poured out into the bronchial 
tubes and which tend to obstruct the free passage of 
air. Such expulsion is brought about by means 
of the ciliated epithelium and of cough, which 
tend to remove impurities from the lungs. 

In severe attacks of bronchitis, however, these 
natural agencies fail to achieve their object. The 
retained secretions become infected with bacteria, 
and destroy the ciliated epithelium. Bronchiec- 
tasis and emphysema may also supervene with 
impaired power of expectoration. Often indeed 
the bronchiectasis causes stasis and vice versa. 

These various circular reactions may be more or 
less broken by expectorants. Some drugs, e.g. 
carbonate of ammonia, stimulate ciliary action and 
assist in the removal of secretion, or excite the 
unstriped bronchial muscles which expel the secre- 
tions from the alveoli into the bronchial tubes. 
Others, such as ammonium chloride, facilitate the 
removal of secretions by increasing their alkalinity. 
Yet others, such as terebene or turpentine, may 
exert some disinfectant action and check bacterial 
growth . Ipecacuanha both increases bronchial secre- 
tions and renders them more liquid, so that the 
mucus can be more easily expectorated. Moreover 

1 Chlorosis in plants is due to an insufficiency of iron in the 
green chlorophyll of plants, and can be cured by the 
administration of iron. Ward, Disease in Plants, p. 

324 IDictous Circles In 2)tsea6e 

the increased secretions sometimes do good by 
protecting the inflamed and irritable mucosa from 
cold air and renewed catarrh. Where it is desirable 
to liquefy tenacious phlegm, creosote or benzoin 
may be used in an inhaler or a nebulizer. In all 
these ways injurious circular reactions may be 

Asthma. Asthma is another respiratory disorder 
complicated by a circulus vitiosus, which can often 
be broken by drugs. " Emphysema, bronchial 
catarrh and diseases of the right heart all increase 
the tendency to asthmatic attacks, which in turn 
increase the severity of the complications, and so 
the patient lives in a Vicious Circle." 1 

No single drug succeeds in arresting the paroxysms 
in every form of asthma. But stramonium, nitrate 
of potash, chloroform, morphia may all act as 
specifics under certain circumstances. By arresting 
the paroxysms they relieve the correlated disorders 
which tend to bring on the attacks. 

The value of codeine in breaking the Vicious 
Circle of cough and congestion has already been 
alluded to (cf. p. 303). 

Anorexia. Amongst the commonest of disorders 
of daily life is anorexia or loss of appetite which may 
arise from a variety of causes. 

In a person enjoying good health the following 
sequence of events establishes a circulus virtuosus, 
or what Mathieu and Roux term a " reflex physio- 
logical Circle," in which both central and peripheral 
reactions take part. 2 

1 Short, Index of Prognosis, p. 132. 

2 Mathieu and Roux, Pathologic Gastro-Intestinale, Series 

IV. (1913), pp. 23, 35. 


The ordinary activities of life arouse what is 
known as tissue hunger due to the need for nutritive 
materials to replace those that have undergone 
combustion. This tissue hunger rapidly provokes 
a cerebral condition which makes itself felt as 
appetite, and is followed by a flow of digestive 
juices (appetite juice). The secretion of such juices 
in its turn reacts on the brain and further stimulates 
the sense of appetite. If a good meal is now enjoyed, 
rapid assimilation follows, nutrition is promoted, 
arousing a desire for exercise, which in its turn 
awakens fresh tissue hunger and so completes the 

Under various circumstances, however, this se- 
quence is disturbed and we get in its place languor, 
absence of tissue hunger, want of appetite, deficiency 
of gastric secretion, nausea at the sight of food, 
impaired nutrition, disinclination for exercise and 
languor. Obviously several arcs of the Circle can 
be attacked. Active exercise, psychical influences or 
drugs may all, under suitable circumstances, interrupt 
the evil concatenation. Here we are merely con- 
cerned with drugs. Bitter preparations introduced 
into the stomach have long been known to possess 
the power of exciting the appetite. This is followed 
by a flow of gastric juices which in their turn further 
stimulate the appetite. Consequently more food 
is taken, and this is followed by improved nutrition, 
increased vigour and a desire for exercise. From such 
exercise result increased metabolism, tissue hunger 
and further appetite, the circulus vitiosus being re- 
placed by a circulus virtuosus. 

The value of such bitters as strychnine, quinine, 
gentian and quassia is thus readily intelligible. 1 

Chronic Gastritis. Chronic gastritis is often 
complicated by impaired secretion, absorption and 

Pavlov, The Work of the Digestive Glands, pp. 94, 225. 

326 IDicious Circles in Disease 

peristalsis, these several factors aggravating each 
other. Ewald has admirably described the recipro- 
cation of events (cf. p. 93). 

Such a self-perpetuating form of gastritis is 
frequently cured by the administration after meals 
of dilute hydrochloric or other mineral acid, with 
which a suitable diet must of course be combined. 
It is not certain in what way the drugs act. Accord- 
ing to Cushny the acid both arrests the lactic 
fermentation which is so often present, and increases 
peristalsis. At any rate patients often express 
themselves as immensely benefited by the remedy, 
to which some physicians have attributed their 
great success in curing chronic dyspepsia. 

Hyperchlorhydria. A remarkable circular reac- 
tion is sometimes associated with what is known as 
Reichmann's syndrome, in which stasis, hyper- 
chlorhydria and pyloric spasm reciprocally per- 
petuate each other. The syndrome is characterised 
by paroxysms of severe pain coming on three or 
four hours after meals and probably connected with 
spasm of the pylorus. In these cases a dose of 
bicarbonate of soda frequently gives immediate 
and complete relief, by neutralising the excess of 
acid, followed by relaxation of the spasm, the 
retained food being thus enabled to pass into the 
duodenum (plate XX. e). 

Another plan recommended by Mathieu is the 
administration of the alkali in small doses as soon 
as the approach of pain is felt, the dose being re- 
peated every five minutes until the spasm ceases. 1 

The attacks of pain may often be completely 
arrested by such a treatment extending over a few 

1 Mathieu and Roux, Pathologic Gastro-Intestinale (1913), 
Series IV., pp. 90, 96, 98. 

Drugs 327 

Cast recta sis. An obstinate Vicious Circle may 
complicate the condition of chronic dilatation of 
the stomach associated with prolonged retention of 
food. The dilatation conduces to stasis and the 
stasis to dilatation. The administration of an 
emetic such as ipecacuanha or sulphate of zinc may 
at once arrest these reciprocating factors. Even a 
greatly dilated and over-loaded stomach may again 
be braced up, the unburdening being followed by 
renewed tonicity and functional activity. The 
emesis relieves the stasis, the relief of the stasis 
cures the gastrectasis. 

Habitual Constipation. Habitual constipation 
is frequently due to a neglect of the natural call, the 
resulting retention of faeces being followed by an 
undue absorption of their fluid constituents. The 
reduced mass of dry faeces is then unable to excite 
adequate peristalsis, so that there is an interplay of 
cause and effect which accounts for the obstinate 
coprostasis that is so often met with. 

This circular reaction is readily interrupted by a 
saline cathartic, such as sodium sulphate, which, 
being but slowly absorbed by the intestines, entails 
the simultaneous slow absorption of the water in 
which the drug is dissolved. If therefore a dose 
of sodium sulphate dissolved in water is administered, 
a greater quantity of water will reach the large 
intestine than when a similar quantity of pure 
water is drunk. The intestinal contents are thus 
rendered more fluid than usual, and pass more 
easily on towards the rectum. At the same time 
the bulk of fluid and the distention of the bowel 
promote a more active peristalsis and the whole 
alvine contents are easily evacuated. Many mineral 
waters such as Carlsbad and Hunyadi Janos owe 
their efficiency to the presence of sodium sulphate. 

Another invaluable drug for habitual constipation 
is cascara sagrada, since it not only empties .the 

328 IDtdoug Circles in 

bowel of faecal matter but simultaneously acts as a 
tonic to the intestinal walls, and thus prevents the 
constipation which follows the use of most aperients. 

Parasitic Infection. Parasitic infection of the 
intestines occasionally establishes circular reactions 
which may be arrested by drugs. 

A familiar illustration is presented by oxyuriasis, 
a disorder in which continual reinfection occurs as a 
result of the anal irritation. Such irritation, especially 
in children, leads to infection of the fingers with ova 
which are then liable to be transferred to the mouth, 
and eventually regain the intestines. 

This Circle may be broken by enemata of quassia. 
But since the parasites lodge mainly in the caecum 
and continue to descend into the rectum in successive 
swarms during the last four or five out of the six or 
seven weeks following a single infection, the treat- 
ment, to be permanently successful, must extend 
over this period as a minimum. A pint of quassia 
infusion for an adult or five ounces for a child will 
destroy such worms as are lodged in the rectum, 
and as soon as all the parasites have descended 
from the caecum, and have been killed by further 
injections, a radical cure ought to be effected, 
provided that no fresh auto-infection has been 

The irritation round the anus may be relieved 
by the use of a weak mercurial ointment or by 
sponging with carbolic lotion. 

Nephritis. Nephritis is frequently a self -per- 
petuating condition owing to the secondary retention 
of toxins, which in their turn further impair renal 
activity. Toxaemia may thus be both cause and 
effect of nephritis. 

The reciprocation may at times be successfully 
interrupted by a profuse diaphoresis which withdraws 
large quantities of water together with salts and 

Drugs 329 

toxins by way of the skin, and thus brings relief 
to the kidneys. 

One of the best drugs for the purpose is pilo- 
carpine, by far the most powerful sudorific in the 
pharmacopoeia, and one which, if injected hypoder- 
mically, usually produces profuse sweating in ten or 
fifteen minutes. The diaphoresis lasts about two 
hours during which as much as two kilos, of fluid 
may be excreted. The functional activity and 
nutrition of the kidneys are often greatly promoted 
and the injurious reactions arrested. The use of 
such an aperient as magnesium sulphate assists 
the sudorific by eliminating impurities by the bowel 
and thus further relieving the toxsemia. 

I^angdon Brown points out that diaphoresis may 
be helpful in breaking the Circle associated with 
chloridaemia : 

" Here we have the clue to the kind of case in which 
diaphoresis will be of service namely that in which 
there is a defect in the elimination of sodium chloride 
with consequent oedema, for the retained salt increases 
the osmotic pressure of the tissues, and this tends to 
increase oedema and to diminish excretion. The 
elimination of salt by the skin may therefore be of 
indirect service by breaking a Vicious Circle." ' 

Diphtheria. Space only permits of a brief 
reference to serum treatment. A notable illustration 
is afforded by the use of anti-diphtheritic serum, 
which neutralises the toxins in the tissues and thus 
arrests their pernicious effects. In other words the 
serum prevents the death of the cells on which the 
bacilli are growing. These protected cells therefore are 
able to resist the invaders, and as a result the local 
lesion improves rapidly. The fatal tendency to 
extension is arrested (cf. p. 201). 

'Physiological Principles in Treatment, p. 208. 

33Q IDidoug Circles in Disease 

Tuberculosis. An example of vaccine therapy 
is afforded by tuberculin which now asserts its 
claim, more modest than that originally and 
arrogantly asserted, of being able to help many 
and injure none. When judiciously administered 
in early stages of the disease, tuberculin seems to 
control the leading symptoms of tuberculosis such 
as fever, cough, loss of weight and dyspnoea. The 
sputa and expectorated bacilli gradually diminish 
and the disease loses its actively progressive 

Hypothyroidism. The value of opotherapy may 
be illustrated by .the use of thyroid extract in 
cases where hypothyroidism is a self-perpetuating 
condition as described above (cf. p. 67). 

The essential principle is thyreo-globulin, an iodine- 
containing substance which may be extracted from 
the follicles of the thyroid gland and used to supple- 
ment deficient thyroid secretion. The drug is often 
successful in arresting the reciprocally acting pro- 
cesses ; indeed the treatment forms a notable 
forward step in rational therapeutics. 


Glaucoma. Glaucoma is a remarkable self-per- 
petuating local disorder. In the words of Priestley 
Smith " cause and effect react upon each other in a 
Vicious Circle, and the glaucoma intensifies itself." 
Nevertheless the morbid process can sometimes be 
arrested by the use of such a my otic drug as eserine. 

It is especially in the premonitory stages and in 
the inflammatory forms of glaucoma that eserine 
is of incontestable efficiency. If on the first indi- 
cations of an attack eserine is instilled into the eye 
myosis shows itself in from 20-40 minutes, and all 
the symptoms may be relieved without leaving a 
trace behind them. As the pupil contracts, the 


increased intra-ocular pressure subsides, the cornea 
becomes clear, intra- and peri-ocular pains vanish, 
visual acuity returns. 1 

Such treatment may result in a complete cure 
without the necessity of surgical interference. The 
value of the drug lies in its power of dilating 
Fontana's spaces by causing the iris to be stretched 
in a radial direction and so drawn away from the wall 
of the eye-ball. Filtration processes are thus pro- 
moted Unhappily, however, symptoms of glaucoma 
usually return. 

Nasal Obstruction. The Vicious Circle associated 
with obstructive hypertrophic rhinitis can sometimes 
be broken by such a caustic as trichloracetic acid, 
which may be applied to the turbinal tissues so as to 
form linear scars. In a few days the resulting cica- 
trices contract so that the nasal passages again become 
patent. In this way the reciprocally acting pro- 
cesses are brought to an end. 

Corns. Corns owe their persistence in large 
degree to a self-perpetuating factor. As often as 
pressure is applied, the central core irritates the 
hypertrophied papillae of the corium, as a result 
of which they are stimulated to increased prolifera- 
tion. The more the papillae grow, the more the 
projecting corn is liable to pressure and vice versa. 
The Circle may be arrested by the application of 
salicylic acid which causes necrosis of the core of 
epithelial cells. The entire corn is thus got rid of, 
including the hypertrophied callosity which previ- 
ously was continually exposed to pressure and 

Scabies. The extension of scabies is largely the 
result of the itching and scratching caused by the 

1 Encyclopedic Frar^aise d'Ophtalmologie, V., p. 142. 

332 ItMcious Circles in Dtseaee 

acari, the parasite being transferred from one part 
of the skin to another by means of the finger-nails. 

This very chronic disorder may be cured by 
a variety of applications, of which the popular and 
best is sulphur ointment (|MatC XX. f). The male 
parasite remains on the surface of the skin and is 
readily destroyed by sulphur, but the female burrows 
under the epidermis so that the epidermal covering 
of the burrows must first of all be softened by 
soaking in hot water, and removed by a rough 
towel. The female parasite will then be exposed 
and is quickly killed by the ointment. 

If at the same time the clothing is disinfected, the 
circular reactions will be speedily broken and the 
disease cured. 

Similar principles apply to the treatment of 

Pruritus. Pruritus may be a self-perpetuating 
condition quite apart from the presence of parasites, 
and occurs most frequently in connection with 
certain parts of the body such as the anus or the 
vulva. So intense may the itching be that the 
sufferer cannot refrain from scratching, and this, 
while giving temporary relief, in reality accentuates 
the trouble. Frequently the scratching even pro- 
duces organic changes in the skin which lead to 
further pruritus. Various local applications such as 
carbolic acid or perchloride of mercury lotions some- 
times act like a charm in arresting this obstinate 
disorder. In other cases a neurotic element is pre- 
sent which needs constitutional treatment. 

These few examples must suffice to indicate how 
drugs may be used to interrupt morbid processes 
that are aiding and abetting each other. The 
history of medicine shows that, in the past, much 
therapeutical gold has been mixed with dross. 
Even Homer knew that ^ap/xaK-a iroXXa ptv eV0Ad 
, TroXXa Se Xvypa.. " Many remedies in the 


cup are healing, but many are also harmful." 1 If 
disease is studied from the point of the circulus 
vitiosus, i.e. both as cause and as effect, drugs will 
be prescribed with greater precision as to the end 
in view ; therapeutics will become more rational 
and more successful. 


Surgical appliances are frequently successful in 
arresting injurious circular reactions ; a few exam- 
ples will suffice to illustrate their utility. 

Mechanical Supports. Mechanical supports in 
the shape of pads or springs often relieve the self- 
intensifying conditions complicating flat-foot, a 
disorder which as a rule is primarily due to weakness 
of the calf muscles, the tibialis anticus and the per- 
oneus longus. Owing to such weakness the plantar 
arch loses support and subsides, such subsidence be- 
ing aggravated by the stretching of the supporting 
ligaments and consequent valgus ; the greater the 
stretching the more does the arch subside. The 
concurrent subluxation of the tarsus then throws 
further strain on the supporting tendons and 
ligaments, and so the process steadily advances. 
At other times flat-foot may be caused by some 
minor traumatic displacement of the tarsal or 
metatarsal bones. Such displacement causes weak- 
ening of the neighbouring muscles which is soon 
followed by their atrophy and by further flat-foot. 

Cyriax writes : 

" These displacements often escape notice because 
they are so slight in amount, or if recognised are con- 
sidered to be only a trivial secondary result of the 
flat-foot. Of course, in many cases they are actually 
secondary, but even then they are of considerable 

Odyssey, IV., 230. 

334 IDicione Circles in Bieease 

importance, because they form part of a Vicious Circle, 
and may be aggravating, or at any rate preventing 
amelioration of, this condition." 1 

Other sequelae may result from trie continual 
aching and pain associated with flat-foot, which 
may be so severe as to curtail active exercise. The 
sufferer in consequence tends to put on flesh, thus 
throwing further weight on the weakened arch and 
perpetuating the disorder. The weaker the arch 
the greater the accumulation of fat and vice versa. 
Treatment depends on the severity of the disorder. 
In the early stages systematic exercises and massage 
of the calf muscles, combined with periods of rest, 
may suffice to effect a cure. But where the mode of 
life involves prolonged standing with little relief 
by the exercise of walking, some mechanical support 
is usually desirable which will retain the arch in its 
normal position, so that the irritated joints may be 
rested and the muscles which have been over- 
stretched and over-loaded through the malposition 
be relieved from strain. Such mechanical supports, 
even if only temporary expedients, serve a good 
purpose until the primary weakness has been 
corrected by means of massage and improved 

The treatment of varicose veins by means of 
elastic bandages is another example of a process of 
injurious reciprocation being arrested by means of 
a mechanical contrivance A well-adjusted bandage 
supports the weakened vein-walls and prevents fur- 
ther dilatation as well as valvular incompetence 

(flMate XXL a). 

Other illustrations may be found in the application 
of a truss for hernia, a belt for splanchnoptosis, a 
jacket for spinal curvature or a pessary for uterine 
displacement (flMate XXI. b, c). 

1 Flat-foot in its Clinical Aspects, Clinical /., 1918, p. 140. 

Suraical appliances 


\{ \ 

It 71 

vv I /J 






plate XXI. She 36reahtnG of tbe Circle 
b Suroical appliances. 

336 Dicioue Circlce in Bteease 

Catheterisation. Some circular reactions associ- 
ated with retention of urine which have been 
described in Chapters VII. and VIII. are frequently 
arrested by catheterisation. Where congestion has 
led to retention and retention to congestion, evacu- 
ation of the bladder allows the congestion to subside 
and the sequence to be broken (fMfltC XXI. d). In 
the case of retroversion of the gravid uterus, associ- 
ated with retention, evacuation of the bladder is 
often followed by replacement of the uterus. 

Other injurious correlations are arrested by the 
use of the Eustachian catheter in aural disease. 

Obstruction may be also relieved by probes or 
bougies. Stenoses of the lacrymal duct, oesophagus 
or rectum are cases in point. 

Hypodermoclysis. Hypodermoclysis is a method 
of supplying fluid to the body, which may be of 
great service in certain self-perpetuating conditions 
associated w r ith shock or haemorrhage. Those con- 
ditions are marked by a low blood-pressure, with a 
feebly acting heart, a depleted arterial and an 
engorged venous system, the anaemic vaso-motor 
centre having lost control of the splanchnic area. 
Saline injections of fluid may be the means of restor- 
ing the blood-pressure. The heart, which had 
lost its contractility through want of blood, regains 
its systolic activity and is able to pump a supply up 
to the vaso-motor centres. Thus one improvement 
leads to another, until the morbid process is arrested ; 
indeed the treatment is often extraordinarily success- 
ful. Adrenalin is sometimes added to the solution, 
as referred to on p. 338. Abdominal or rectal 
injections may be used for a similar purpose. 

Intra- venous injections of hypertonic saline solu- 
tions are also successful in interrupting the dangerous 
correlations that complicate cholera. In favourable 
cases such injections immediately introduce the stage 
of reaction ; the circulation is invigorated, the 

Surgical appliances 337 

diarrhoea ceases, the functional activity of the 
kidneys returns ; the elimination of toxins is 
re-established. The patient who appeared little 
better than a corpse is resuscitated. 

Irrigation. Self-aggravating conditions may be 
arrested by irrigation with syringes or irrigators. 
Illustrations of such methods may be found in 
cases of accumulation of wax in the meatus (JMatC 
XXI. e), of coprostasis, of pus in the antrum or the 
bladder and so forth. 

The use of the stomach tube in cases of gastrectasis 
is another example. Patients are sometimes met 
with in whom the dilated stomach has so sunk in the 
abdomen as to form a kink with the duodenum. 
This kink retards the escape of food through the 
pylorus, thus causing retention and further gastrect- 
asis. If the retained ingest a are washed out with 
the help of a stomach tube, the ptosis is relieved ; 
the pyloric kink is abolished and the retention of 
the ingest a ceases. 

Artificial Lens. Many disorders have been refer- 
red to above in connection with errors of refrac- 
tion, and can frequently be cured by the use of 
artificial lenses. For example, in progressive myo- 
pia the short-sightedness and the elongation of the 
eye-ball react on one another. The use of concave 
lenses removes the near point, relieves the undue 
pressure on the globe, and checks the progress of 
the myopia (gMatC XXI, f). 

Again in hypermetropia the excessive strain on the 
ciliary muscle frequently produces accommodative 
asthenopia leading to neurasthenia, headache and 
insomnia, cause and effect reacting on each other. 
Here a suitable convex lens may relieve the over- 
taxed ciliary muscle and give relief. 

Rbntgen Rays. Rontgen rays are of great 
value in breaking the Circles associated with 

33$ IDicious Circles in Disease 

trichophytosis ; this treatment constitutes a notable 
advance in dermatology. 

Hitherto the fungus in its retreat at the bottom 
of the hair follicles has proved inaccessible to attack 
since no parasiticides could reach it, while every 
attempt at epilation, owing to the brittleness of the 
diseased hair, left in the follicle a fragment which 
sufficed to perpetuate the disease. Fortunately 
X-rays exert an extraordinary depilatory effect, as a 
result of which the entire hair in spite of its brittle- 
ness is thrown off. So successful and reliable is this 
method of treatment that a single application of an 
adequate dose of X-rays for about fifteen minutes 
will usually cure a patch of ringworm. A few 
days after treatment all the hair, both healthy and 
diseased, on the area exposed to the rays is shed, 
and as soon as the last diseased hair has fallen out, 
the infection is at an end. In at most twenty-five 
days after the application of the rays the disease 
ought to be cured. 

Amongst other appliances that are used for 
arresting circular reactions may be mentioned 
electrical batteries for cases of paralysis, tourniquets 
for cases of aneurysm, and cauteries for neoplasms. 


Some Circles can only be broken by the knife of 
the surgeon. At such times: ov 77/305 larpov <ro(j>ov 
Vpijvtlv cVojSas 7T/30S To/xaWi Tn^arj, " Skilful leach 
mutters no spell o'er sore that needs the knife." 1 

The following classification of operations adapted 
to this purpose will be found convenient : 
I. Organectomy 
II. Organopexy 
III. Organoplasty 

'Sophocles, Ajax 581. 

Surgical perattone 339 

IV. Lithotomy 

V. Stricturotomy 

VI. Tenotomy 

VII. Osteotomy 

VIII. Decompression 

IX. Removal of Neoplasms 

X. legation of Vessels 

XI. Drainage 


The total removal of an organ is sometimes 
required for the arrest of a pernicious circular 
reaction. Appendicectomy and hysterectomy will 
serve as examples. 

Appendicectomy. Appendicitis usually arises 
from some inflammatory condition which narrows 
the appendicular duct and causes a retention of 
secretions. Such retention in its turn aggravates 
both inflammation and obstruction, and eventually 
a closed septic cavity results, involving serious 
illness and even danger to life. Such an injurious 
sequence may be arrested by appendicectomy ((Mate 
XXII. a). 

Hysterectomy. Another operation with a similar 
result is the removal of a bulky, inflamed and 
procident uterus which is mechanically interfering 
with the uterine circulation and so contributing to 
its own enlargement. The procidence is then both 
cause and effect of congestion, and often can only 
be effectively remedied by hysterectomy. 

Amongst other examples of organectomy that 
break the Circle are splenectomy for haemolytic 
jaundice, 1 cholecystectomy for cholelithiasis, excision 

1 Lancet, 1916, II., p. 889. 

34Q iDidous Circles in 

of the lachrymal sac for dacryocystitis, 1 prostatect- 
tomy for prostatic retention and colectomy for 
intestinal stasis. 


Various organs are liable to undergo displace- 
ment, and such displacement aggravates the primary 

Gastropexy. An enlarged and loaded stomach 
sometimes sinks in the abdomen and pulls down 
the first section of the duodenum. Hence results 
a kink which hinders the escape of the gastric 
contents and provokes further gastroptosis. The 
more extensive the ptosis the greater the kink and 
the more obstinate the stasis. Such a displacement 
may be cured by means of gastropexy which restores 
the stomach to its natural position and retains it 
there, either by suturing the organ to the abdominal 
parietes or by shortening and strengthening the 
natural supporting ligaments. In successful cases 
the self-aggravating process is arrested and followed 
by recovery. 

Hysteropexy. Hysteropexy is sometimes re- 
sorted to for the relief of procidentia uteri. This 
displacement may be due either to an increase of the 
forces that tend to depress the uterus, or to weak- 
ening of its supports, or to both factors operating 
simultaneously. In many cases an abnormally 
bulky and heavy uterus, on the one hand, and a 
ruptured or weakened perinaeum, on the other, are 
both present. The weaker the perinaeum the further 
the uterus descends ; the further the uterus descends 
the weaker grows the perinaeum. Moreover the 
prolapsed organs become congested and this con- 
gestion intensifies the prolapse. 

1 British Med. /., 1907, I., p. 420. 

Surgical Operations 








plate XXII. She Breaking of the Circle 
b^ Surgical Operation. 

342 Dlctous Circles in 

In severe cases neither pessary, tampon nor 
bandage retain the displaced organ, and some 
operation is called for. By the strengthening or 
shortening of the uterine supports the reciprocating 
process may be checked and the disorder cured 

(plate xxii. b). 

Colopexy, hepatopexy and nephropexy are other 
operations with a more or less similar purpose. 


Under the title organoplasty may be grouped a 
series of operations devised in order to interrupt 
injurious correlations. 

Enteroplasty. Intestinal obstruction creates 
various such conditions. There may be coprostasis, 
toxaemia, meteorism, intestinal paralysis and aggra- 
vated stasis ; coprostasis, kinking of the gut and 
aggravated stasis ; intussusception, increased peri- 
stalsis, aggravation of intussusception ; strangu- 
lation of a hernia, vomiting, aggravated strangulation; 
enteroptosis, obstruction, aggravated ptosis. Many 
of these disorders are curable by drugs. But in 
neglected cases where gangrene threatens or has 
supervened, enteroplasty is often required. The 
injured segment is removed, and the two ends of 
healthy gut are joined end to end or anastomosed 
side to side (plate XXII. c). 

Gastroplasty. Gastroplasty may be called for 
in the case of gastric ulcers when complicated with 
hyperchlorhydria, pyloric spasm and retention of 
the gastric contents. This concatenation of pheno- 
mena acting and reacting on each other leads to a 
grave condition of anaemia, malnutrition and weak- 
ness. Various operations have been devised for its 
relief, including partial resection of the stomach and 

Surgical Operations 343 

gastro-jejunostomy. By either of these operations 
the stagnation of the gastric contents may be 
prevented ; the hyperchlorhydria is arrested and 
the spasm of the pylorus subsides. Pain ceases, 
appetite returns and the patient regains the weight 
and strength that had been lost. 

Thyroplasty. Partial resection of the thyroid 
sometimes breaks a dangerous complication which 
may arise when the hypertrophied gland compresses 
the trachea and narrows its lumen, or by pressure 
on nerves excites a reflex respiratory spasm. Acute 
dyspnoea may then result from any exertion that 
calls the supplementary respiratory muscles into 
action, since these muscles, in contracting, press the 
goitre against the trachea, further diminish the 
lumen and thus increase the dyspnoea ; at times the 
glottis may be closed by spasm. Unless promptly 
relieved by operation, the victim dies self-garotted. 

Blepharoplasty is another operation which breaks 
the correlations associated with entropion and 
ectropion of the eye-lids. 


Lithiasis includes various disorders associated with 
the formation and growth of concretions in the 
tubes and cavities of the body. Such concretions 
gradually enlarge as a result of interesting circular 
reactions which have been described in former 
Chapters and need not be repeated here. 

Lithotomy. By the operation of lithotomy or 
litholapaxy the surgeon interrupts these reactions. 
With the removal of the calculus the irritation 
ceases ; the excessive deposition of salts and 
the increased production of mucus are arrested ; 
the self -perpetuating conditions are brought to an end 

(plate XXH. d). 

344 IDicious Circles in Disease 


Various channels of the body are subject to 
stricture, a self-aggravating disorder which fre- 
quently calls for surgical aid. 

Herniotomy. A striking example is met 
with when a coil of intestine is strangled in a hernia 
or a volvulus. The intestinal walls become acutely 
congested through constriction of the blood-vessels, 
while the lumen is distended with blood and gas, 
such congestion and distension in turn intensifying 
the strangulation. Frequently the tension causes 
more gut and mesentery to be drawn within the 
constricting ring, to become congested and strangled 
in their turn. By the operation of laparotomy or 
herniotomy the constriction may be relieved and 
the circulation restored (JMatC XXII. e). 

Urethrotomy. Another illustration is presented 
by stricture of the urethra associated with severe 
straining, hyperaemia of the mucous membrane and 
aggravation of the stricture. The difficulty of 
micturition may be so great as to call for urethro- 
tomy, which cures the trouble. 

Allied to these conditions are various other 
forms of strangulation, e.g. paraphimosis, con- 
striction of the prolapsed cervix uteri by the vulvar 
folds, nipping of prolapsed haemorrhoids, narrowing 
of the trachea by hypertrophied thyroid etc. In all 
these cases operative measures arrest the morbid 


Orthopaedic disorders are frequently complicated 
by injurious circular reactions which may be arrested 
by tenotomy. 

For example, various forms of clubfoot are met 
with in which adaptive shortening of the muscles 
and ligaments has led to displacement of bones and 

Surgical perattone 345 

fixation in an abnormal position. Such displace- 
ment, on the principle that performance of function 
in a wrong position leads to deformity, produces 
further distortion and shortening, and so the process 
aggravates itself. Nature, as has been said, cannot 
cure clubfoot ; it can only render the condition 
worse. With the help of tenotomy the displaced 
bones may be brought back to their normal position 
and the overstretched and weakened muscles restored 
to functional activity. 

Another illustration is afforded by acute anterior 
poliomyelitis. In the later stages of this disease 
recovery is checked by the vigorous contracture of 
healthy opponent muscles. When these have been 
divided by tenotomy, natural contractions of the 
paralysed muscles, even though feeble, again become 
possible and react beneficially on the central lesion. 
The resulting improvement in its turn promotes 
further muscular action. 


Osteotomy is resorted to for the arrest of various 
circuli vitiosi. 

Genu valgum or knock-knee frequently starts 
with a rickety bending of the femur or with some 
subsidence of the plantar arch, as a result of which 
the two tibial tuberosities no longer receive an equal 
weight from the femoral condyles, the outer tuber- 
osity receiving more than its due share. This 
extra pressure exerted by the external condyle 
retards the growth of the femoral epiphysis extern- 
ally, while the growth of the inner condyle is stimu- 
lated by the diminished pressure received. More- 
over when once the knee-joint is no longer at right 
angles to the axis of the limb the internal lateral 
ligament is placed at a disadvantage and stretches. 
This involves weakness and further mischief. Hence, 
when once started, this self-aggravating deformity 

346 IDictoue Circles in Disease 

makes steady progress, since the more the knee 
yields the greater is the difference in the pressure on 
the two tuberosities and the greater are the resulting 

By means of osteotomy the unequal level of the 
condyles is corrected, and the limb restored to the 
straight position. Knock-knee and flat-foot are 
often simultaneously present, each contributing to 
the other. 

Osteotomy may also be called for in the severe 
forms of flat-foot, a self-perpetuating disorder which 
has already been discussed on p. 333. In minor 
degrees of this disorder massage, exercises and 
supporting pads suffice. But where the arch has 
entirely collapsed, tarsectomy may be required for 
the purpose of restoring the arch and strengthening 
it by means of bony ankylosis. The most widely 
practised is probably Ogston's method of denuding 
the cartilaginous surfaces of the astragalo-scaphoid 
joint, and immobilising the two bones with ivory 
pegs. There are various modifications, all aiming 
at arresting the self -intensify ing deformity. 

Hallux valgus is sometimes cured by means of 
osteotomy. In this malformation the first phalanx 
deserts the inner aspect of the metatarsal bone and 
slips round towards its outer aspect. As a result of 
this displacement the extensor proprius pollicis, 
going straight to its insertion, lies towards the outer 
side of the metatarso-phalangeal joint and thus 
acquires increased power of aggravating the deform- 
ity. The greater the displacement the more injuri- 
ous the muscular action. By means of osteotomy 
ankylosis of the metatarso-phalangeal joint may be 
brought about and the disorder arrested. 

Extreme rickety curvature of the legs affords 
another example of a progressive lesion which may 
be relieved by osteotomy. 

Surgical 0perationg 347 


Increased pressure in the cranial and other 
cavities of the body may be a self-perpetuating 
disorder involving grave danger to life. 

Trephining. A striking illustration occurs in 
ingravescent apoplexy as has been fully described 
on p. 29. When the haemorrhage is copious, as 
frequently happens if the middle meningeal artery 
is ruptured, the patient usually succumbs to cerebral 
compression and arrest of respiration, if Nature 
is left to her own resources. The circulus vitiosus 
becomes a circulus necator. By the operation of 
trephining, however, the effused blood may be 
removed. The cerebral anaemia is relieved ; the 
blood-pressure falls ; the coma subsides. The vari- 
ous bodily functions may almost instantly be 
resumed as a result of this operation (plate XXII, f). 

Iridcctomy. Decompression is frequently re- 
quired in the case of glaucoma, a striking example of 
a self -intensifying disorder, as has been described on 
p. 175. Apart from operative interference irremedi- 
able blindness is not uncommon, while the eye may 
remain a source of severe and recurrent pain, involv- 
ing loss of sleep and impaired health. Happily 
the injurious sequence may be arrested by a success- 
ful iridectomy. Still better is an operation which 
creates a filtering cicatrix, such as a combined 
iridectomy and sclerectomy, or a corneo-scleral 
trephining. The increased intra-ocular pressure is 
relieved, the displaced lens and iris return to their 
normal position, and the self-regulating mechanism 
governing secretion and excretion again comes into 

Venesection. The relief of excessive blood-pres- 
sure may also be effected by venesection which may 
prove a life-saving operation in some cases of failing 

34 8 IDicious Circles in 3Di0ea0e 

heart associated with over-repletion and dilatation. 
As a result of the heart failure the medullary centres 
are insufficiently supplied with blood, and in response 
induce a general vaso-constriction which forces 
blood to the anaemic centres, thus imposing an 
extra burden on the already over-taxed heart. 
The cardiac failure and bulbar anaemia act and react 
on each other. Phlebotomy may under such circum- 
stances give immediate relief ; the pressure falls, 
the cardiac dilatation diminishes, the systole increases 
in force, the viscosity of blood lessens, the dyspnoea 
subsides, the cyanosis is reduced. 

Amongst other self-intensifying conditions which 
may be relieved by decompression are hydrocephalus, 
cerebro-spinal meningitis and otitis media. 


Many neoplasms owe their growth to reciprocally 
acting sequences which call for surgical aid ; a 
familiar illustration is presented by adenoids, a 
disorder which is closely related aetiologically with 
chronic catarrh of the nase-pharynx, and in its turn 
perpetuates such catarrh. 

As a result of this morbid process adenoids may 
grow so large as to block the posterior nares, in- 
volving mouth-breathing and other concomitant 
evils. Their removal interrupts the injurious se- 
quence and exerts a beneficial influence on physical 
and mental health. 

Polypi, again, frequently originate in a chronic 
catarrh, which leads to the formation of a neoplasm 
which in its turn perpetuates the catarrh. In other 
cases new growths may give rise to a Circle by 
causing mechanical obstruction. This not uncom- 
monly occurs in the intestines, as pointed out by 
Hook and Kanaval : 

" Strictures and growths, by a partial retention of 
faeces, develop a Vicious Circle of impaired function 

Surgical perattone 349 

and partial stasis that may end in complete stasis at 
any time." 1 

Removal of the polypus or new growth brings 

Amongst other examples may be mentioned 
enlarged tonsils, and polypi of the nose, middle 
ear and other regions. 


Diseases of the arteries and veins, including 
aneurysms and varices, are often self-perpetuating 

Aneurysm is usually caused either by weakening 
of the arterial coats, or by strain resulting from a 
rise of blood-pressure. The more the arterial walls 
yield the greater the tension to which they are 
subjected ; the greater the tension the thinner and 
weaker do they become. Thus the dilatation be- 
comes progressive (cf. p. 57). 

In the case of varicose veins dilatation and 
increased tension also aggravate each other. In- 
competence of the valves is a further contributing 

By ligaturing the affected arteries or veins the 
surgeon arrests these reciprocations. The tying of 
piles supplies another illustration. 


Various circular reactions are established by the 
accumulation of morbid fluids in the cavities and 
tissues of the body, e.g. effusions associated with 
pleurisy, pericarditis or ascites, abscesses and cerebro- 
spinal meningitis. The process of the accumulation 
varies somewhat in different cases and has been 
described in previous Chapters. The surgeon is often 
called in to deal with the morbid processes at work. 

Keen, Surgery, IV., p. 654. 

350 IDicioua Circles in 2>isea$e 

Paracentesis. The operation of paracentesis 
is frequently resorted to in order to remove accumu- 
lations of fluid in the pleura, pericardium and 

Sajous thus refers to paracentesis of the pleura, 
which may serve as a type of other operations : 
" Tapping may reverse the Vicious Circle into a 
beneficial Circle, viz. one in which the possibility of 
respiratory movement, and hence of the pumping 
action, having been restored, absorption has begun or 
increased in consequence. The greater the absorption, 
the greater the respiratory movement and vice versa. 
The beneficial Circle thus established will tend, appar- 
ently, to accelerate the rate of absorption beyond what 
it would otherwise have been. The fact that often 
the withdrawal of only a small quantity of a large 
effusion is followed by rapid absorption of the remainder 
might be accounted for in this way. The underlying 
absorptive power might not have improved sufficiently 
to permit of actual resorption, yet have improved 
sufficiently for resorption when aided by the respiratory 
movement restored by partial removal of the effusion." 1 

Opening of Abscess. Under the same heading 
may be placed the drainage of inflammatory swel- 
lings or abscesses which are complicated by self- 
perpetuating conditions. These have been fully 
described on p. 60. 

When an abscess is drained, a multitude of pyogenic 
bacteria and their chemical products are got rid of. 
Many beneficent phagocytes and enzymes are lost 
at the same time, but these are rapidly replaced, so 
that the ultimate gain far outweighs the loss, and 
the processes of repair are vastly strengthened. 
Thus is justified the old surgical aphorism ubi pus 
ibi evacua. 

The presence of special microbes may evoke 

l New York Medical /., 1918, II., p. 519. 

Surgical peratkme 351 

other correlations. For example, bacillus aerogenes 
capsulatus (bacillus perfringens) grows rapidly in a 
blood clot, and produces considerable quantities of 
lactic acid which in its turn checks the emigration 
of leucocytes and thus facilitates the rapid proli- 
feration of the bacilli. 

Fleming writes : 

" When the bacillus aerogenes capsulatus grows on 
blood it produces a considerable amount of lactic acid, 
and it has been shewn that lactic acid has a very potent 
action on leucocytes, preventing their emigration. 
Thus we have a Vicious Circle ; the greater the growth 
of the bacillus the more is the production of lactic acid 
and consequently the less is the leucocytic emigration. 
Unless such a Vicious Circle can be broken the result 
is likely to be disastrous." 1 

Such a complication merely emphasises the value 
of modern methods of wound treatment having in 
view the arrest of the morbid processes at work. 

These few illustrations of the applications of 
surgery to the breaking of Vicious Circles must 
be looked upon as suggestive rather than as com- 
prehensive. Further illustrations will occur in the 
practice of every busy surgeon. 

Many of the disorders referred to are of the gravest 
importance and threaten early death unless relief 
is forthcoming. In the face of such emergencies 
natura medicatrix is usually helpless ; nor are the 
pills and potions of the physician of much avail. 
Happily, however, as Hipprocrates said centuries 
ago : 

c O/cocra </>a/3/na/ca OVK i^rat, crioij/jos ITJTCU. 
" What drugs will not cure, steel cures." 2 

1 Lancet, 1915, II., p. 37. Cf. also British Med. /., 1917, 

I., p. 728 ; 1918, L, p. 369- 

2 Aphorisms, viii., 6. 

352 Dictous Circles in Disease 

All honour to the surgeon whose art can break 
the Circle at the locus minoris resistentice \ Without 
such aid it would be true of many sufferers to say : 
pax illis cum morte solum. 

The more important methods of breaking Vicious 
Circles have now been briefly discussed, although 
the subject is far from exhausted. 1 Indeed as 
Vicious Circles are closely interwoven, in warp and 
woof, with the processes of disease, so is their arrest 
intimately concerned with therapeutics. Enough, 
however, has been said to indicate to the experienced 
physician how his treatment may be adapted to the 
particular problem with which he is confronted. 

Psychotherapy is often a valuable means of breaking the 
Circle, and is discussed in " The Vicious Circles of 
Neurasthenia and their Treatment," by J. B. H. 
Cf. also Haydn Brown, "Advanced Suggestion," 
passim. Massage, balneotherapy, electricity, phy- 
sical exercises may also render service under suitable 


Conclusion 1 

E have now completed our survey of the 
operations of Vicious Circles in animal 
and vegetable pathology, and pointed 
out that this morbid process falls into 
line with other great biological laws to 
which all higher animals and plants are subject. 
The specialisation of structure and function associ- 
ated with evolution brings unquestioned benefits 
in its train, since specialisation allows a greater 
efficiency in the performance of functions. At the 
same time it involves a liability to injurious cir- 
cular reactions, when once processes of disease have 
been initiated. 

It is strange that so little attention has hitherto 
been directed to this self -perpetuating process. 
Primary reactions are the common-places of text- 
books of animal and vegetable pathology ; but the 
reciprocal effects of those reactions on the primary 
disorder are scarcely thought worthy of consideration, 
and yet such effects are of far-reaching influence on 
the natural history of disease. Only too often does 
each gyration deepen the groove, so that a restor- 
ation to normal conditions becomes more and more 

^he following Journals contain articles by the Author 
dealing with Vicious Circles in disease -.Lancet, 
1887, I. ; 1908, II. ; 1910, I. ; 1912, I. British 
Med. /., 1907, I. ; 1910, II. ; 1911, II. ; 1913, I- ; 
1914, I. Practitioner, 1910, I. ; 1910, II. ; 1912, 
I. ; 1914, I. ; 1915, II. ; 1916, I. ; 1917, II- i 
1918, II. Clinical /., 1915, I- ; I9 l8 > L J J 9i9 L 
St. Bartholomew's Hospital /., 1913, I- Medical 
Press, 1910, II. British J. of Inebriety, 1915, II. 
Royal Horticultural Society /., 1919, Feb. Veterinary 
News, 1918, I. 


354 IDicious Circles in 2>iaea$e 

This subject of injurious circular reactions should 
appeal to workers in several departments of science. 
The biologist in the widest sense of that word will 
find fresh light thrown on the great principle of 
correlation which plays so important a role in the 
mechanism of life. There is a wide field for research 
into the reciprocal influences exerted on one another 
by vital processes. 

The zoo-pathologist and phyto-pathologist are 
still more closely concerned with Vicious Circles, 
since these exert a potent influence on the phenomena 
which come under their daily observation. Their 
therapeutics are largely concerned in interrupting 
the concatenation of morbific factors. 

The central purpose of this Volume, however, 
is the narrower one of assisting the physician in his 
efforts to cure disease in man ; only to this aspect 
of therapeutics is any detailed attention given. 
No disease of lower animal or plant concerns us so 
closely as does disease of our own flesh and blood. 
Moreover organic evolution reaches its highest 
development in the human species, especially as 
regards psychical activities. On the other hand 
psycho-physical inter-dependences render man 
liable to injurious and complex reciprocations to a 
degree that is unparalleled amongst less organised 
animals and plants. 

The study of Vicious Circles exerts a fundamental 
influence on the outlook of pathology. It serves 
as a constant reminder that diseases, far from being 
entities, as our ancestors supposed, are due to ever- 
acting morbid processes in which numerous organs 
and their functions are closely concerned. 

Happily too the subject is not merely of academic 
interest ; there is profit both as regards diagnosis, 
prognosis and treatment. By promoting a deeper 
insight into the complex processes of disease a 
familiarity with these Circles renders therapeutics 
more philosophical and more successful. 


An * indicates that the disorder is illustrated. 


Abductor paralysis 203*, 206 
Abortion .. .. .. 151 

Abscess, formation of 32, 60, 

252, 350 
,, opening of . . 350 

Acapnia 281 

Acari, infection with 225, 239*, 

253, 332 

Accoutumance .. .. 285 
Achorion schonleinii . . 254 
Acid, hydrochloric . . 326 

,, salicylic . . . . 331 

trichloracetic . . 331 

Acne . . .. 231, 284 

cheloid . . . . 232 

rosacea . . . . 231 

Adam-Stokes syndrome . . 39 

Adami, J. G. . . 26f, 122, 

165, 195 

Adenoids 192, 194, 312, 348 
Adiposity, cf. Obesity 
Adrenalin . . 318, 320, 336 

Aerophagy .. 98f, 247 

.dEtiological therapeutics 302 
/Etiology of Vicious Circles i, 

Alae nasi 194 

Albuminuria . . . 285 
Alcoholism 160, 279*, 28lf 

Alkaloids, poisonous .. 118 
Allbutt, C. 6, 15, 42, 64, 93, 321 

Allen, F. M 167 

Amenorrhcea . . . MS 

Ammonia . . . . . . 323 

Amyl nitrite . . . . 321 

Anaemia 32, 37*, 62, 63, 80, 

157, 249, 275, 287, 292, 322 

,, bulbar n*, 27, 30, 43, 

267*, 274, 348 

,, pernicious . . . . 63 

Anaesthetic, danger of 26, 286 
,, Nature's . . 273f 

Anasarca 158 

Anderson, M. . . . . 219 

Andre-Thomas . . . . 18 

Aneurysm 51, 55, 57, 241, 271, 

Angina pectoris 45, 53f, 268, 321 
Anhidrosis . . . . . . 233 

Anhydraemia . . 63, 64 

Animals, diseases in the 

lower . . 237, 239* 

,, Vicious Circles in xix., 

3, 4!, 15, 237f, 239*, 353 

Anisometropia . . . . 186 

Ankylostoma duodenale . . 99 
Anorexia n*, 16, 24, 308, 324 
Anti-diphtheritic serum . . 329 
Anti-peristalsis . . . . I oo 

Anuria .. .. 64, 124 

Anus, fissure of . . .. 115 

,, prolapse at . . nsf 

,, pruritus of 116, 235, 328 

, spasm of . . nsf 

Anxiety neuroses .. I2f 

Aortic regurgitation 37*, 46f, 
293*, 296 



IDicious Circles in SHsease 

Aortic stenosis . . . . 269 

,, valve, rupture of 46, 269 
Apnoea . . . . . . 272 

Apoplexy 11*, 29f, 121, zyji, 
267*, 275, 347 
Appel on lowered 

Appetite, loss of 


89*, logf 

ii*, 1 6, 308, 

,, perversion of 99, 160, 


,, suppression of 24, 295 
Appliances, surgical 333f, 335* 
Arrhythmia . . 38, 54 

Art, breaking of Circles by 3011, 
307*, 315*, 335*, 341* 
Arterio-sclerosis . . 56f, 156 
Artificial Circles 215, 2771, 279* 

oedema . . . . 201 

Ascarides . . . . 99, 100 

Ascites 113, 125, 311, 320, 349 

Asclepiades . . . . xix. 

Aspergillus niger . . 210, 228 

Asphyxia 50, 80, 81, 202, 

204, 209, 267* 

,, neonatorum 152, 272, 


Asthenopia 173*, 186, 187, 294, 

Asthma .. 73*, 851, 324 

Astigmatism .. .. 187 
Asystolie hepatique . . 41 

Atelectasis . . 78, 155*, 272 

Athens, race to . . . . 266 
Atony of bladder . . . . 133 
Atrophy of muscles . . 34 

Aural Circles . . 2iof, 213* 
,, neuroses . . . . .216 
polypus .. 214, 348 
Auricular fibrillation 38, 319 


Auto-infection 75, 100, 116, 
225, 328 

,, -inoculation 72, 211, 228 
Autolysis . . . . . . 104 

Auto-suggestions 5, 12, i6f, 

20, 179, 187, 207, 213*, 217, 


Bacillus aerogenes 59, 351 

,, nitrifying . . . . 258 

,, perfringens 59, 351 

,, pestis . . . . 246 

Back-ache . . . . 167 

Bacteria, disorders due to 59, 

226, 228, 242, 246, 259, 262, 

263, 264, 296, 350 

Bacterium Hyacinthi 257*, 263 

,, maculicolum . . 259 

,, phaseoli . . 259 

Balano-posthitis . . . . 139* 

Baldness . . . . . . 229 

Baldwin, J. M xvii. 

Ball, C 115 

Ballenger, W. L. .. .. 197 
Ball-valve action . . 103, 132 
Balneotherapy .. 311, 352 
Bandages, elastic . . 334 

Barbier on dyspepsia . . 77 

Barie, E 36, 41 

Barnard, H. L. . . . . 95 
Basal leaf zone, turgor of 260 
Basedow's disease . . 67 

Baths, value of cold 311, 352 
Battle and Corner .. no 

Beans, disease of . . 259 

Beard, G. M 140 

Bed-wetting . . 129, 135 

Belching 98f 

Belt, value of . . . . 334 
Benzoin inhalations . . 324 


Beriberi .. ... .. 270 

Berkeley and Bonney . . 148 
Bicarbonate of soda . . 326 
Bichat on death . . . . 266 

Biliary calculus 102, in, 293*, 


disorders 100, 103, 118, 

Bing, A 218 

Binocular vision, loss of 294 

Birds, disease in 237, 244, 246, 

252, 254 

Bladder, atony of . . 133 

catherisation of 131, 133 

,, disorders of 123*, I3of, 


neuroses of . . 134 

,, over-distention of 139*, 

paralysis of . . 123* 

,, stammering of . . 135 

Blepharitis .. .. 182 

Blepharophimosis . . .. 183 

Blepharoplasty .. -343 

Blepharospasm i7if, 173*, 

174, 183, 235 

Blindness .. .. 178, 188 

Blinking, excessive 173*, 174 

Bloch on enlarged tonsils 193 

Blood, disorders of 37*, 6if, I04f 

pressure, high II*, 43, 

47, 57, 73*, 74, 266, 

267*, 269, 271 

,, pressure, low 40, 63, 267*, 
279*, 284 

vessels, Circles 

associated with 37*, S5f 
Blushing 28, 221*, 235, 236 
Boots, tight . . 61 
Botrytis Douglasii 257*, 261 
Bouillaud, J. .. 45 

Boulimia . . 94, l6o > l61 
Bouveret, L 232 

Bradycardia . . . . 39 

Brain, destruction of 240, 265 

oedema of . . 31 

Breaking of Circles by art 301, 

307*. 315*. 335*, 341* 

,, of Circles by 

drugs .. 3131, 315* 
,, of Circles by 
hygienic measures 

305*, 3<>7* 
of Circles by 

Nature . . 29if, 293* 

of Circles by 

operation 338f, 341* 
of Circles by 
surgical appliances 

333*, 335* 

Breathing exercises .. 312 

Bright's disease, cf. Nephritis 

Brocq, L. 147, 229, 231, 235, 285 

Broken wind . . . . 243 

Bromides, abuse of . . 283f 

use of 315*, 316 

Bronchiectasis * 73*, 84, 244 

Bronchitis 40, 73*, 82f, 121, 159, 

170, 243 

Broncho-pneumonia . . 276 
Brown, H. . . . . 280 

L. .. .. 329 

Bruce, M. . . 3, 54, 85, 94, 101 
Brunton, T. L. 100, 304, 306 

Buchanan, R. J 62 

Bulb, anaemia of n*, 27, 30, 

43, 267*, 274, 348 

Bulbs, disease in . . . . 251 

Bunions 224 

Burnett on trachoma . . 172 

Cabot, R. C. .. 62, 116 

Caecum, inflammation of .. nof 
Calculus, appendicular .. no 


(Dicioua Circles in Snscaec 


Calculus, biliary 102, in, 

293*, 298 

dental .. .. 88 

nasal ... .. 199 

,, pancreatic . . 103 

renal . . . . i27f 

ureteral . . 128 

urethral 136, 239*, 

,, vesical .. in, 123*, 

Callosities . . . . 224, 331 

Calories required in obesity 160 

,, wasted in faeces 162 

Campbell, H 158 

Cancer 94 

Capillary stasis . . 58, 60 

Carbolic acid . . . . 328 

Carbonaemia, excessive 64, 163 

Cardiac arrhythmia 38, 54 

,, Circles 35f, 37*, i53f, 

239*, 24of, 305, 307*, 318 

dilatation 35, 39, 42f, 

46, 71, 80, 82, 266, 267* 

,, disease, congenital 49f, 


,, dyspnoea . . . . 280 

failure 35, 37*, 41, 64, 

83, 121, 153, 155*, 156, 

161, 239*, 240, 266f, 270, 

286, 292, 299, 305, 307*, 

hypertrophy 45, 158, 
293*, 295 

,, neuroses . . 17, 53 

strain . . 42, 266 

,, tone, want of . . 48 

Cardio-gastric Circle . . 42 

Caries, dental 88, 89*, 90 

Carlsbad water . . . . 327 

Cascara sagrada . . . . 327 

Cathartics . . . . 277, 279* 

Catheter, Eustachian . . 336 

vesical 131, 133, 

335*, 336 


Cattle, disease in 237, 242, 244^ 


Cauliflowers, disease in . . 259 

Cauteries 338 

Cavities, pulmonary . . 242 

Cellular pathology . . 2 

Cerebral anaemia, cf. Anaemia 

,, haemorrhage n*, 291, 

121, 237f, 267*, 275,347 

Cerebro-spinal meningitis 3 if, 


Cerumen, accumulation of 211, 
213*, 312, 337 

Cervix uteri, strangulation of 149 
Chalybeate waters . . 323 

Chauffard and Laederich 68, 122 
Chemical Circles 8, 96, 326 

Chemosis .. .. .. 182 

Chermes laricis . . . . 263 

Children, Circles in 13, 74, 99, 

129, 135, I7if, i83f, 185, 

192, 202, 206, 2i7f, 223, 272, 


Chloral 316 

Chloride of sodium 311, 329 
Chlorine gas . . . . 78 

Chloroform . . . . 286 

Chlorophyll, want of 257*, 258 
Chlorosis . . 146, 292, 322 

Cholaemia . . . . . . 104 

Cholangitis . . . . 103 

Cholecystectomy . . . . 339 

Cholecystitis . . 89*, 103 

Cholelithiasis io2f, in, 293*, 

298, 339 

Cholera . . . . 63, 336 

Cholesteatoma . . 213*, 214 
Chondroids .. .. 241 

Choroiditis . . .. 179, 184 

Church, W. S 29 

Cilia, destruction of 191*, I97f, 
211, 213*, 323 

Ciliary muscle, over-taxed 294, 


Circles associated with 

bladder . . I2if, 123* 

associated with 

blood . . . . 37*, 6if 
,, associated with 

blood-vessels 37*, 55! 

associated with 

brain . . 1 1 *, 2gl , 237 

,, associated with 

bronchi .. 73*, 82f 

associated with 

constitutional disease I53f, 
,, associated with 

death, cf. Death 
,, associated with 

ear .. .. 2iof, 213* 
associated with eye 1711, 
associated with heart, 

cf. Cardiac Circles 
associated with 

intestines .. 89*, io6f 
associated with 

kidneys .. I2if, 123* 

,, associated with 

larynx . . 202f, 203* 

,, associated with 

liver .. .. 89*, loof 
associated with 

lungs . . 7if, 73*. 239*. 241* 
associated with 

lymphatics . . . . 5^f 
associated with 

mouth .. 87f, 89* 

, associated with 

nails 229 

,, associated with 

nervous system 9 f > "* 
associated with 

nose .. .. i89f, 191* 
,, associated with 

cesophagus . . . . 9 2 * 
associated with 

pancreas . . . . xoof 
associated with 

pericardium .. 37*. 5<>f 

Circles associated with 

pleura . . 73*, 8if 

,, associated with 

prostate .. 123*, i3of 
,, associated with 

sebaceous glands 221*, 


,, associated with 

sexual system i37f, 139* 
,, associated with 

skin 2i9f, 221*, 253, 33if, 
,, associated with 

stomach 89*, 93f, 3251 
,, associated with 

throat . . 20if, 203* 

associated with 

ureter .. 125*, I28f 

,, associated with 

urethra . . 125*, I35f 

,, associated with 

veterinary diseases . . 237f, 

broken by Art . . 3Oof 
broken by drugs . . 3131, 

,, broken by hygienic 

measures . . 3051, 307* 
broken by Nature 291 f, 

,, broken by surgical 

appliances .. 333*. 335* 
,,' broken by surgical 

operations 338f, 34 * 

concurrent Frontispiece, 8 

,, physiological 24, 324 

virtuous 24, 41, 258, 

280, 324, 325 

Circling, positive and 

negative . . 200 
Circuits, long and short 36, 41 
Circular reaction, 

definition of . . xvii. 

Circuit faclilii . . 2771, 279* 

, virtuosi 24, 41, 258, 

280, 324, 325 


IDicious Circles in SMseaee 


Circulus necator . . . . 347 
. viliosus, cf. Circles 
Cirrhosis, portal . . . . 296 

renal . . . . 124 

Clarke, E. .. 177, 182, 188 

Classification of Circles . . 7 

Clavus 224 

Cleanliness, want of . . 312 
Clothing, disinfection of . . 332 
Clouston, T. . . . . 308 

Clubfoot 344 

Cocaine, abuse of . . 281 

Codeine . . . . 303, 304 

Cohnheim, J. . . . . 58 
Coitus, difficult . . . . 148 

unnatural . . 138 

Cold baths .. .. 311 

exposure to . . . . 29 
Colectomy . . . . 340 

Coleman, F. . . . . 90 

Coleophora laricella . . 263 
Coleosporium Senecionis 258 
Colic, flatulent . . 249, 250 
Colitis .. 20, no, in 

Collaemia 70 

Collapse 276 

pulmonary . . 78 

Collier, M. . . . . 193 

Colon, dilatation of . . 127 

,, displacement of . . 109 

,, spasm of . . . . 108 

Colopexy . . . . . . 342 

Coma .. 29, 287, 347 

Comedos . . . . . . 230 

Compensation, failure of 40, 42 

Compression, cerebral 30, 32, 

238, 341,* 347 

Concurrent Circles Frontispiece, 8 
Confidence, loss of 12, 142, 163 

Congenital cardiac disease 49f, 

Congestion, pulmonary 37 " 


I 7 if 

Congressus interruptus 
Conservative spectacles 
Constipation 20, 67, 89*, 108, 
247, 298, 307*, 337 
Constitutional diseases i53f, 


Convulsions 28, 2O5f, 276, 287, 
314, 315* 

Coombs, C. F. . . 47, 270 

Coprostasis, cf. Constipation 
Cork, formation of 256, 259, 

Cornea, inflammation of 173*, 

staphyloma of 174, 178 

,, ulcer of 172*, 174, 175 

Corneo-scleral trephining 347 

Corner, E. M. . . . . 143 

Corns 224 

Coronary circulation, 

impaired 42, 157, 266, 

267*, 268, 270, 275, 293*, 


,, congestion 36, 82, 268 

sclerosis 44, 268 

Corpulence, cf. Obesity 

Corset, use of . . 106, 289 

Cough 73*, 74, 82, 202, 235, 

242, 274, 292, 296, 303, 314, 


Cramer, A. 

Creosote inhalations 
Crime and alcohol 
Croom, J. H. 
Crop, distention of 

Curvature, spinal 
Cushny, A. R. 
Cyanosis . . 
Cycle, vicious 

I 4 6 


.. 326 
. . 276 

38, 50, 65, 348 
. . 25 


1 86. 







Death from hydrothorax 



E. F. 


,, from impaction of 

Cyst, adenomatous 



2 4 6f 

retention . . '.. 


,, from influenza 


,, sebaceous 


,, from nervous 


Cystitis 123*, I3bf, 133! 

, 288 

from parasitic 
disease . . 255, 


,, from pericarditis 52 


,, from peritonitis 


,, from pleurisy 


,, from pulmonary 

haemorrhage 267*, 


Damocles, sword of 
Dasyscypha Willkommii 

1 80 


,, from respiratory 
disorders . . 267*, 
,, from ruptured 
aneurysm . . 

2 7 2f 


E. D 


,, from ruptured 


Deafness .. 213*, 2i4f, 218 

Death from aneurysm . . 271 

,, from angina pectoris 268 

,, from apoplexy 238, 267*, 


,, from asphyxia 8of, 202, 

204, 209, 244, 267, 272 

from atelectasis . . 272 

,, from beriberi . . 270 

from broncho-pneumonia 


,, from cardiac failure 43?, 
46, 266f, 270, 306 
,, from chloroform . . 286 
,, from congenital 

heart disease . . 271 
from convulsions . . 276 
,, from embolism . . 270 
,, from excessive venosity 

28, 64, 272 

,, from goitre 267*, 272 
,, from haemorrhage 238, 

,, from heart disease 43f, 

46, 266f, 270, 306 

,, from hydrocephalus 276 

,, from ruptured heart 267*, 
,, from ruptured 

intestine . . . . 245f 
,, from ruptured valve 269 
,, from sepsis 257, 263 

,, from shock 267*, 276 
,, from starvation 92, 246 
,, from syncope . . 268 
,, from thrombosis . . 270 
,, from vaso-motor 

paralysis . . 30, 275 
from venesection . . 287f 
,, from Vicious Circles 5, 

,, from violence . . 276 

,, from wind-colic . . 99 

Debility 226, 233, 249, 279* 

Dechlorinisation .. .. 3iof 

Decidua, haemorrhage into 151 

Decompression . . 299, 347 

Defaecation, neglect of .. H3f 

,, regulation of 312 

Definition of Vicious Circle xvii. 

Dench, E. B. .. 212, 217 


H)iciou0 Circles tn Bieeaee 


Dental calculus . . . . 88 

caries . . 88, 89*, 90 

,, sepsis . . 87, 90 

Depilatories . . . . 229 

Depression, mental 13, 236, 
279*, 295 

Dermodectes communis . . 253 

Desnos and Minet . . 132 

Destruction of brain 30, 240, 


,, eye 178, 265 

kidney 126, 251, 


leaves 257*, 260 

., lung 265 

,, twigs 257*, 26of 

Determann on viscosity . . 64 

D'Etiolles, L 130 

Diabetes . . . . 155*, i6jt 
insipidus 129, 151 

Diaphoresis . . . . 3 2 8f 

Diaphragmatic pump, 

weakness of . . . . 158 

Diarrhoea .. 21, 276, 285 

Digestive disorders 20, 87f, 89*, 

100, 102, 295, 297, 308, 

3 2 4 f, 326 

Digitalis 3*8* 

Dilatation of bronchi 84*, 244 
colon .. 127 

heart, cf. Heart 
,, ,, nasal tract 191, 

,, ,, cesophagus 127 

,, ,, rectum . . 114 
,, ,, stomach, cf. 

trachea . . 244 

ureter . . 129 

,, ,, urethra . . 135 

Diphtheria.. 43, 201, 203* 

Dispersal of parasites 225, 239*, 


Diseases, self -limiting .. 121 
Dixon, W. E. . . 85, 86 

Dogs, disease in . . 237, 248 
Domestic animals, disease 

in .. .. 237f, 239* 
Donders, F. C. . . . . 179 
Douching, danger of . . 289 

Doyne, R. W 186 

Drainage, arrest of . . 241 

,, value of . . 349f 

Dropsy, cf. Ascites 

pericardial 37*, sif 

peritoneal 52, 113 

pleural 52, 73*, 8if 

Drowning . . . . . . 276 

Drugs, value of . . 313^ 315* 

Drum, stretching of the 212, 215 

Dubois, P. .. 12, 1 8 

Duckworth, D. . . 1 53, 165 

Duncan, J. M. 129, 146, 150 

Duodenum, distention of 95 

kinking of 89*, 95 

,, obstruction of 247 

,, ulcer of . . io7f 

Dyschezia .. .. 89*, H4f 

Dyshidrosis . . . . 233 

Dysmenorrhcea . . . . 145 

Dyspareunia . . 145, 148 

Dyspepsia, cf. Digestive 

Dysphagia . . . . 77, 204 

Dyspnoea 78, 170, 203*, 2O7f 

Ear, disorders of the 2iof, 213*, 

Earth hunger . . 99, 100 
Eclampsia .. 68, 105 

Ecthyma . . . . -. 228 



Ectropion .. .. 173*, i8if 
Eczema 173*, i8if, 211, 2igi, 

221*, 222, 229, 286 

Edwards, F. S 116 

Effusion, pericardial 37*, $if 

,, peritoneal 52, 113 

,, pleuritic 52, 73*, 8if 

Egg-binding . . 239*, 252 

Ehrnrooth on heart . . 43 

Eichhorst on anaemia . . 63 

Elastin, loss of . . . . 222 

Electricity, value of . . 338 

Ellis, T. S. . . . . 224 

Emesis 297f 

Emphysema 83, 86, 159, 243 
Empyema .. .. 81, 274 
Endocarditis .. 48, 88 

Enemata of quassia . . 328 
Enteric fever . . 43, 287 

Enteritis 109 

Enteroplasty . . . . 34 2 
Enteroptosis 105, 109, 342 

Entropion . . 172, 173*, 183 
Enuresis . . .. 129, 135 
Enzymes 60, 69, 88, 105, 256, 
262, 295f, 342 
Epididymitis . . . . 288 

Epilation 229 

Epilepsy ii*, 28, 86, 314, 315* 
Epiphora . . . . . . i8lf 

Epistaxis . . 196, 292, 299 

Equanimity . . . 54 

Equilibration of forces, 

disturbed ' . . . . 292 

Ereutophobia . . . . 236 

Erlanger on heart-block 39 

Errors of refraction . . i84f 
Eruptions, artificial . . 284f 

Erythema 223 

Eserine, value of . . . . 33* 
Eucles .. .. 42, 266 


Euphoria . . . . . . 279* 

Eustachian catheter . . 336 

obstruction 21 if, 336 

Evans, J. J. . . . . 180 

Ewald, C. A. . . 93, 98 

Exercise, insufficient 159, 162, 
164, 221*, 233 

,, physical . . 308 

Expectorants . . . . 323 

Explosions, injuries due to 209, 


" Explosive method," the 294 

Expulsion of calculus . . 293* 

Extraordinary mechanisms 297f 

Eye, disorders of the I7if, 173*, 

265, 347 

,, strain, cf. Asthenopia 

Faecal concretions .. in 

,, stasis, cf. Constipation 
Failure, cardiac, cf. Cardiac 
Fainting . . . . . . 27 

Fallopian tube, kinking of 150 
Falstaff .... ..164 

Fat, excess of, cf. Obesity 
Faure and Siredey . . 144 

Favus 237 

Feet, tenderness of .. 165 

Female, disorders in the 144 
Fermentation of food 245, 247, 
293*. 297*. 326 
Fever, enteric . . 43, 287 

hay 200 

milk .. .. 25if 

,, rheumatic . . 48 

Fibrillation, auricular 38, 319 

Pick, A 178 

Fischer, M. H 124 

on glaucoma . . 177 


IDicious Circles in Disease 


Fissure, anal . . . . 115 

Flat-foot . . 167, 333f, 346 

Flatulence 41 f, 119, 283 

Fleas, disease in . . . . 246 

Fleming, A. . . . . 351 

Floating kidney . . 126, 342 

liver .. 1 06, 342 

Foetus, giant .. . . 151 

Foie cardiaque . . . . 41 

Folie circulaire . . 28, 306 

Food, impaction of 237, 245 

,, regulation of . . 309 

,, restriction of . . 309 
Foramen magnum, 

plugging of . . . . 276 

ovale, patent . . 49f 

Forsyth, D. . . . . 51 

Fowls, disease in 244, 254 

Fox, W 232 

Frankel, A. . . 71, 2o8f 

Frantzel, 0. . . . . 54 

Fraser, J. S. . . . . 192 

Frostbite 60 

Fuchs on deferred delivery 151 

,, ,, epiphora . . 181 

Fungi, disorders due to . . 226 

Fiirbringer, P 138 

Furunculosis . 228 

Galen . . . . . . xix. 

,, veins of . . . . 32 

Gall-stones iO2f, m, 293*, 298, 


Gangrene . . . . 59f, 342 

Gant, S. G. . . . . 21 

Gapes, the . . . . 244 

Gas gangrene . . . . 59 


Gassing by chlorine . . 78 

Gastrectasis 3, 94, 99, 119, 

127, 160, 283, 293*, 298f, 

327, 34 

Gastric Circles 89*, 93f, 245, 340 

,, neuroses . . . . 19 

,, tympany . . . . 249 

,, ulcer 97f, 342 

Gastritis 93f, 119, 248, 325 

Gastro-enterostomy . . 93 

Gastro-jejunostomy . . 343 

Gastropexy . . . . 340 

Gastroplasty . . . . 342 

Gastroptosis 89*, 95, 340 

Gaucher, E. . . . . 224 

Gentian 325 

Genu valgum . . . . 345 

Geophagy 99f 

Giant foetus .. .. 151 

Gibbons, R. A 147 

Gibson, G. A. . . 45, 52 

Gilbert, A. . . . . 69 

Gilford, H. .. 27, 166 

Giddiness . . . . 158, 163 
Glans, strangulation of 142, 344 
Glaucoma 173*, I75f, 330, 347 
Globus, hystericus . . 207 

Glottis, narrowing of . . 207 
Glycaemia . . 155*, i67f 

Glycosuria .. .. i67f 

Goadby, K. . . . . 90 

Goats, disease in . . . . 244 
Goitre 203*, 208, 267*, 272 

Gonorrhoea 135, 171, 288 

Goodell, W 149 

Goodhart, G. F 187 

Cradle, H. . . 194, 214 

Green, E 185 

Griinwald, L. .. .. 197 

Guisez, J 211 

Gull, W. W 24 


Gums, recession of 
Guttural pouches 
Guyon, F. . . 





Habit Circles .. 235, 250 

spasms . . 28, 86 

Haematemesis .. 274,314 

Haematuria . . . . 299 

Haemopoiesis, defective 62, 155*, 

315*, 322 

Haemoptysis 57, 73*, 267*, 274, 
292, 299, 314 

Haemorrhage .. 57, 62 

cerebral n*, 29f, 
237, 267* 
gastric 293*, 299 
,, intestinal . . 299 

pulmonary, cf. 


Haemorrhoids .. 115*. 349 
Haemostasis, natural . . 75 

Haig, A 7<>, 3io 

Hair, disorders of . . 228 

Halls Dally, J. F. 8, 41 

Halluxvalgus .. .-346 

Hanging 276 

Hare, F 74, "4 

Harman, B 182 

Hats, hard-brimmed . . 229 

Hay fever 200 

Headache 23, 187, 287, 295, 337 

Heart, arrhythmia of 38, 54 

block .... 39 

dilatation of 35, 39, 42*. 

46, 71, 80, 82, 158, 266,, 

disease, congenital 49f, 

Heart failure, cf . Cardiac 

,, hypertrophy of 45, 158, 
293*, 295 

neuroses of 17, 53, 321 

,, rupture of 39, 271 

,, strain of . . 42, 48 

,, tilting of . . . . 42 

valvular disease of 37*, 


Heat-regulating mechanism 164 

Heath, C. J 215 

Hemicrania . . . . 25 

Hepatic disorders 41, iO4f, 296 
Hepatopexy . . . . 342 

Hepatoptosis . . . . tosf 

Herman, G. E 23 

Herman and Maxwell 22, 146 
Hernia 89*, 109, 341*, 344 
Hetero-suggestion . . 14 

Hewlett, A. W 164 

Heymann, P 198 

Hill, L 31 

Hippocrates ax., 118, 299, 351 

Hirschfelder, A. D. 38, 47f, 50, 

67, 269, 281 

Hirsuties 229 

Hoare, E. W 249 

Holland, H 278 

Holmes, G 140 

Homer 332 

Hook and Kanaval . . 34 

Horace 5 

Hormone, production of 116 

Horses, disease in 237f, 240f, 


Horsley and Sturge . . 283 

Huchard, H 4<> 

Hiihner, M I5<> 

Hunger-pain .. 160 

psychical .. 325 

Hunter, J. . . . . 28 


IDidous Circles in Disease 



Hunyadi Janos water . . 327 


Hurst, A. F. .. ..217 

Ideation, perverted n*, i5f 

Hutchinson, J. . . 230, 235 

Immunization . . . . 72 

Hyacinth bulbs . . . . 263f 

Impetigo .. 221*, 228, 253 

Hyde, J. N 223 

Impotence . . . . 141 f 

Hydrocephalus n*, 30, 32, 179, 
238, 276, 348 

Inanition . . . . 155*, 168 
Inattention and deafness . . 215 

Hydrochloric acid . . 326 

Indolence . . 155*, 158, i6if 

Hydronephrosis 123*, I26f, 25of 

Inflammation . . . . 58f 

Hydropericardium . . 52 

Influenza . . . . 43, 276 

Hydrotherapy . . . . 311 

Injudicious treatment . . 277f 

Hydrothorax . . . . 82 

Insanity . . 28, 289f, 3o6f 

Hygienic measures break 

Insomnia 5, isf, 23, 41, 76, 140, 

Circles .. 3o5f, 307* 

187, 213*, 2l6, 222, 236, 

Hymenolepis nana . . 100 

295, 313 

Hyper aesthesia . . 23, 90 

Insufficiency, hepatic . . iO4f 

,, of nose . . 200 

Inter-dependence of organs if, 

7, 291, 354 

,, ,, ovaries 145 

Intertrigo . . 223, 312 

,, retina . . i78f 

Intestinal disorders 89*, io6f 

.. vulva . . 139*, 

2 45f 

Hyperchlorhydria g6i, 326, 342 

Hyperhidrosis 164, 221*, 223, 


Hyperkeratosis 224, 230, 235 
Hypermetropia .. 186, 337 
Hyperthyroidism . . . . 66f 
Hypertrichosis . . . . 229 

Hypertrophy, cardiac 45, 56!, 
158, 293*, 295 
prostatic 132, 340 

Hypochondriasis 20, 140, 217 
Hypodermoclysis . . . . 336 

Hypoendocrinism . . . . 320 
Hypopituitarism . . . . 163 
Hyposphyxia . . . . 320 
Hypothyroidism .. 112, 163 
Hysterectomy . . . . 339 

Hysteria .. . . n*, 23f 
Hysteropexy .. , . 340 

stasis, cf. Constipation 
,, tympany . . 249f 

Intra- venous injections . . 336 
Intussusception .. 113, 342 
Invalidism, chronic . . 259 

Iodides, use of . . . . 284* 

lododerma.. .. .. 284 

Ipecacuanha . . . . 323 

Iridectomy . . . . 327 

Iritis .. .. 88, 175 

Iron 322f 

Irons, use of . . . . 289 

Irrigations, injurious . . 288 

value of . . 337 

Isodynamic factors . . 292 

Jackets, spinal 
Jackson, H. 



Jacquet, L. 
Jeliffe, S. E. 

Jones, M 


Joyce, J. L. 
Judson on coughing 


104, 337 
.. MS 
.. 131 
.. 76 

Kaposi, M. 
Keratitis . . 
Keratoma . . 

2i9f, 292 

173*. 174 


.. 230 


Kidney, calculus of . . I2yf 

,, cirrhosis of . . 124 

destruction of 126, 251, 


disorders of the 69, 121 

movable . . 125, 342 

,, tuberculosis of . . 126 

King William Rufus . . 271 

Kinking of duodenum 337, 340 

,, ,, Fallopian tube 150 

pylorus 337, 34 

,, ureter 123*, 126, 


Klebs-Loffler bacillus 201, 203* 

Knee joints, painful . . 167 

Knock-knee .. . . 345 

Koranyi on obesity 167 

Krafft-Ebing, R. . . 16, 141 

Krehl, L. . ..162 

Kuhnt on sinusitis . . 198 

Kuschel on glaucoma . . 17 

Kiistner on abortion . . IS 1 


Lachrymal sac, excision of 340 

stenosis 180, 336 

Landolt, E. .. 1 79, 184 

Lane, A 120 

Larch, disease in . . . . 262f 
Laryngismus . . . . 205 

Larynx, disorders of 77, 2O2f, 
203*, 286 

polypus of 203*, 204 

,, spasm of 205, 286 

,, tuberculosis of . . 204 

Lassitude .. .. 233, 325 

Latham, A. 86 

Lawson, A. 174, 176, 185 

Lea, E 38 

Leaf-shedding disease . . 260 
,, -spot disease . . . . 259 
,, zone, basal . . . . 278 
Leaves, destruction of 257*, 260 
Leguminous plants . . 258 

Lens, value of artificial . . 337 
Lenzmann, R. .. IS 2 , 273 
Leubuscher on obesity . . 165 
Leucorrhcea .. MS. 289 

Lewandowsky, M. 5 39 

Lewis, B 133 

Lice .. 2251, 263, 332 

Lichenification . . 220, 234 
Liebreich on myopia 186 

Ligaments, stretching of 333, 

Ligation of vessels . . 349 

Liquids, restriction of . . 309 
Litholapaxy 343 

Lithotomy 343 

Lithotrity 33* 

Liver, disorders of 41, 69, ioof, 
161, 169 

floating .. 105*. 342 
Llewellyn and Jones . . 233 


IDicious Circles in Disease 



Lobisch on obesity .. 163 

Massage 334, 346, 352 

Longmore, T. . . . . 226 

Mastication, defective . . 91 

Lophodermium pinastri 257*, 

Masturbation 22, 137, 141 


Mathieu, A. 20, 309, 326 

Lorisch, H. .. ..162 

,, and Roux 19, 97, 99, 

Loughnane, F. M. . . 61 

108, 324 

Lousiness . . 225f, 263, 332 

Maxillae, malformation of 90, 

Lunacy . . 138, 279*, 308 


Lungs, disorders of the xx., 

Mechanical Circles . . 8 

7i*. 73*, 239*, 241, 244 

supports, abuse of . . 289 

Lymphatic pump . . 51, 81 

,, ,, use of . . 333f 

Lymphatics, pressure on 37*, 

Mechanisms, extra-ordinary 297f 

Si, 73*. 81 

Melaena . . 13, 15, 217, 299 

,, varicose . . 58 

Melancholia . . 13, 17 

Lymphatism . . . . 209 

" Memory of the body " 28 

Meningitis .. 3if, 348f 

Menorrhagia M5f, 292, 322 

Mercury, ointment of . . 328 


perchloride of . . 322 

Meteorism .. 112, 342 

Macleod, J. M. H. . . 235 

Metritis . . . . . . 145 

McBride, C. A 282 
McCallum, W. G. . . 102 

Metrorrhagia . . . . 146 
Meyer and Gottlieb . . 286 

McCarrison, R 112 

McDonald, G 196 

Migraine . . . . . . 25f 
Milk fever . . . . 25 if 

McKenzie on polypi . . 199 
on rickets . . 170 

,, stagnation of . . 252 
value of . . . . 311 

McKisack, H. L 46 
Magnesium sulphate . . 329 
Majendie, foramen of . . 3 1 
Male, sexual disorders in the 

Mineral waters . . 323, 327 
Mining moth . . . . 263 
Mitchell, W 24 
Mitral regurgitation . . 47f 

Mallophagia .. ..250 ., stenosis .. .. 47 

Malnutrition 24, 90, i68f, 204 Monod, G. . . . . 104 

Mandible, contraction of 90, 194 Monro, foramen of 25 

Mange 253 

Morison, A . . 55 

Mania 28, 270, 290, 3o6f 

Morphia 278, 279*, 28of, 3131, 

Manson, P. .. I", 270 

315*, 321 

Marasmus . . 285 

Morris, H. . . 128, 142 

M. . 220, 222 

Marathon race .. 42, z66 
Martinet on " hyposphyxia " 
161, 320 

Mors ex circulo vitioso . . 265 
Mortimer, J. D. E. . . 206 



M-shaped colon . . . . 109 
Mott, F. W. 19, 28, 33, 316 
Moullin, M .. 107, 130 

Mouth-breathing 191*, I92f, 

312, 348 

disorders of the 87, 90 
Miiller, F. C. . . 22, 137 
Mummery, J. P. .. .. in 
Muscae volitantes 163, 178, 187 
Muscles, disorders of 34, i65f, 

333, 346 
Musser and Kelly . . 103 

Muthu, D. J 74 

Mutism 209 

Myocardium, disorders of 

the 351, 37*, 157, 240, 296, 

305, 3i8 
Myopia 173*, 179, 1841, 293*, 

294, 337 

Myotics, value of . . 330 

Myxomycetes 258, 261 

Nails, the . . 




Narcotics, use of . . 



Nasal calculus 


,, catarrh 



,, dilatation . . 



,, disorders 



,, neuroses 


polypus 191*, 


I 9 8f, 


,, stenosis i89f, 



,, ulceration . . 


Nascher, I. L. 


Nasi, collapse of alae 


Naso-pharynx, catarrh of 


Nature, breaking of Circles 

by .. .. 29if, 293* 

Nausea, value of . . . . 295 

Necrosis . . . . . . 59 

Neoplasms .. 204, 348 

Nephritis 68f, 105, I2if, 123*, 

I24f, 156, 276, 310, 328 

Nephrolithiasis . . . . 127 

Nephrolysins . . . . 68 

Nephropexy . . . . 342 

Nephroptosis .. 123*, 125 
Nervous system, disorders of 

91, ii*, 1621, 237f 
Neuralgia . . . . . . 23 

Neurasthenia 5, 9, n*, 98, 106, 
115, 138, i44f, 173*, i87f, 

213*, 2l6, 232, 282f, 306, 

3131, 337 

,, traumatic . . 14 

Neuron threshold, lowered 10, 

MS, 3*3 

Neuroses, aural . . . . 216 
cardiac I7f, 53f 

,, cutaneous . . 234 

,, gastric . . . . 19 

nasal . . . . 200 

ocular .. .. i87f 

,, paroxysmal 27, 200 

sexual 22, 137, 139*, 

1 44 

,, traumatic . . 14 

Night sweats .. -.233 

,, terrors . . . . 13 

\imia diligentia .. . . 290 

Nitrites, value of . . . . 321 

Noorden, C. 154, 156, 160, 162, 

1 66 

Nose, disorders of the i89f, 191*, 

Nothnagel, H. .. .112 

Nutrition, disorders of 24, iS3f 

,, regulation of . . 309 


IDicious Circles in Disease 


Oak twigs, death of . . 260 

Obesity 53, 78, 153!, 155*, 221*, 

232f, 306, 309 

Obsessions .. 19, 21, 236 

Obstruction, biliary 104, no 

Eustachian 21 if, 


,, intestinal in, 249, 


lachrymal 180, 336 

nasal i8gi, 191*, 

312, 331 

,, pancreatic .. no 

salivary .. no 

CEdema .. 201, 318, 329 

cerebral .. .. 31 

,, pulmonary 40, y8f 

CEsophageal disorders 92, 127, 


Ofenheim, E. . . 67, 109 

Ogston's osteotomy . . 346 

Onychia maligna . . . . 230 

Onychogryphosis . . . . 230 

Onychomycosis . . . . 227 

Ophthalmia .. 171, 173* 

,, neonatorum 171, 183 

tarsi .. .. 181 

Opotherapy . . 320, 330 

Oppenheim, H. .. .. 137 

Oral disorders . . 87, goi 

Organectomy .. 339, 341* 

Organic Circles . . 8, 72 

Organopexy .. 340, 341* 

Organoplasty .. 341*, 342 

Organs, destruction of 126, 240, 

251, 256, 257*, 259, 265 

inter-dependence of 

if, 7, 291, 354 

Orgasm, cutaneous . . 234 

Orthopaedic disorders 167, 333f, 



Osteo-myelitis . . . . 88 

Osteotomy . . . . 23$f 

Oswald on thyroidism . . 67 

Otalgia .. . . 213*, 218 

Otitis . . 2oif, 212, 348 

Otomycosis . . . . 227 

Ova, dispersal of 225, 239*, 332 

Ovary, congestion of . . 22 

,, extracts from the . . 320 

hyperaesthesia of 115, 


Oviduct, distension of 239*, 252 
Oxyurides 116, 225, 229, 328 

Paget, J 135, 140 

Pain 22, 173*, 213*, 218, 313, 

315*. 326, 343 

Palpitation 17, 41, 54, 158, 287 

Panas, F 181 

Pancreas, disorders of 100, 103, 

Papillcedema .. .. i79f 

Paracentesis . . 81, 350 

Paralysis, abductor . . 206 

,, general.. .. 28 

intestinal 112, 341*, 


,, muscular 33, 317 

respiratory 238, 273 

,, spastic . . . . 34 

,, thermotaxic . . 29 

,, vaso-motor 26f, 275 

,, vesical . . 123*, 133 

Paraphimosis 139*, 142, 344 

Parasitic disorders 99f, 116, 

210, 225f, 237, 239*, 244, 

254, 256, 257*, 299, 328, 331 

Paroxysmal neuroses . . 27 




Parturition, disorders of . . isof Pine Needle-cast . . . . 261 

Pathology, cellular .. 2 Pinto, G. .. .. .. 175 

Paunch, impaction of . . 245 Plant lice . . . . . . 263 

Pavlov, J. P. .. .. 319 Plants, disease in 5, 14, 255f, 

Payne, J. L. .. .. 91 257*, 354 

Pectoris, angina 45, 53f, 268, leguminous . 258 


Plethora 161 

Pediculosis .. 225, 332 Pleurisy 73*, 8if, 121, 349 

Penis captivus . . . . 150 Pneumonia 40, 43, 7if, 88, 287, 

Pericarditis 37*, 5if, 271, 349 

Peridermium pini . . 258 Poliomyelitis 33, 345 

Perinseum, ruptured . . 340 Polycythaemia 6sf, 105 

Peristalsis, impaired 93, 98, 109, 

Polypus, aural . . 214, 349 

114, 116, 161, 239,* 245, 

laryngeal . . 203* 

247, 283, 298, 327 M nasal I9I * f I96( 198f 

increased . . 298 

,, removal of . . 349 

Peritoneal effusion .. 113 

Pompholyx . . . . 233 

Peritonitis 252, 287 Poplar ^.^ death of 26o 

Pernet, G. Portal cirrhosis .. ..296 

Pernicious anaemia . . 63 Potassium, iodide of . . 28 4 f 

Perspiration, excessive . . 232f 

nitrate of . . 324 

Pessary, use of . . 334, 342 

Pottenger, F 76 

Pessimism, evils of .. 13 

Pouch, cesophageal . . 92 

Pharyngeal spasm . . 207 

,, prostatic . . . . 132 

Phimosis 142 

,, vesical . . . . 132 

Phlebotomy .. .. 347 

Pouches, guttural . . . . 241 

Phlyctenular ophthalmia 171 Poverty and alcoholism .. 28 if 

Phobias n*, I2f, 18, 218, 234, Powe ii D S3 

236, 313 

Photophobia .. I73M74 Pregnancy, disorders of . 

Physiological Circles 24,324 PreSby Pia 
Pressure, increased mtra- 
Phyto-pathology xix., * 2S 5 f, cfania , f ^ ^ 

257 > 354 

Pritchard, E 109 

Pica . . 99 

Pick and Hecht . . 168, 274 

Procidentia of uterus 148, 340, 

Pickerill, H. P. 8, 91, 194 
Picking of nose . . . I96f 

Prolapse of rectum .. 115 
,, uterus 139*. 

Pigs, disease in . . . 244 | I4 8, 294, 340 

Piles .. ' .. "5*. 349 

Prostate, disorders of 123*, 

Pilocarpine 3 2 9 

130, 132, 340 

Pine Blister 258 

Proverbs, book of . . . . 282 

Leaf-scurf .. ..261 

Prurigo .. *. .. 235 


IDictoue Circles in ^Disease 


Pruritus, 116, 146, 211, 221*, 

234, 332 

Psilosis . . . . . . in 

Psychical disorders lof, n* 

Psychotherapy . . . . 352 

Pulmonary cavities, formation of 
76, 242 

,, congestion 37*, 7if, 

73*, 83 

,, emphysema 83, 86, 

159, 243 

,, haemorrhage 73*, 

74, 267*, 292 

,, oedema 40, 78f 

stenosis . . 49 

Pump, diaphragmatic . . 158 

lymphatic . . 51 

Punctum, eversion of 173*, 181 

Purgation, excessive . . 278f 

Pus, injury due to 60, 350 

Pylorus, kink of 337, 340 

spasm of 96f, 326 

,, stenosis of . . 94 

Pyonephrosis .. .. 128 

Pyorrhoea 90, 119, 312 

Quack remedies 



.. 277 

325, 328 


Rams, disease in . . . . 251 
Rational therapeutics 333, 354 
Rats, disease in . . . . 246 
Rayner, H. . . . . 25 

Rays, value of Rontgen . . 337f 


Rectum, dilatation of . . 114 

,, stenosis of . . 336 

Recumbency 293*, 294, 305 

Refraction, errors of 184, 337 

Regurgitation, aortic 37*, 461", 

293*, 296 

,, mitral . . 47f 

,, tricuspid . . 48 

Reichmann, syndrome of 97, 


Renal disorders .. I2if, 123* 
Renin .. .. .. 122 

Resin, exudation of 256, 258 

Resistance, lowered 4, 72, 82, 

84, 90, 124, 159, 175, 

184, 200f, 216, 255, 257*, 
263, 311 

Respiratory disorders 71, 73*, 

78, 120, 155*, is8f, 170, 

241*. 323 

Rest, excess of .. i66f, 308 
,, value of 294f, 305f, 314, 


Restraint in insanity 279*, 289 

Retention cysts 103, 230, 234 

,, of urine 123*, I3if, 

135, 335*, 336, 340 

Retinitis i78f 

Retroversion of uterus 139*, 150 
Rheumatism 48, 175, 232f 

Rhinitis i89f, I94f, 198, 200, 


Rhinolith .. .. 191*, 199 
Rhinophyma . . . . 232 
Rhythm in pathology . . 27f 
Ribary, U. .. . . 196 
Ribs, deformity of . . 170 
Rickets 155*, i68f, 272, 345f 
Rigidity, muscular 206, 286 
Ringworm . . 226, 253f, 338 
Riseley, S. D. . . . . 192 
Ritchie, J. . . . . 64 
Robin, A 119 


Robin and Dalche" 115, 147 

Romberg, E. . . 58, 125 

Rontgen ra7s, use of . . 337 

Roose, R .. 62 

Root starvation . . 3, 257* 

Roussy and Lhermitte . . 236 

Routh, A. . . . . 22, 144 

Roux on gastic ulcer . . 97 

Rufus, King William . . 271 

Rumen, impaction of . . 24$f 

Rupture of aneurysm 57, 271 

,, aortic valve 46, 269 

heart 39, 267*, 271 

Sabouraud, R. . . . . 227 
Sajoux, L.T.M. . . 303, 350 
Salicylic acid . . . . 331 

Saline injections . . . . 336 
Salivary duct, obstruction of no 
Salpingitis . . . . 150 

Salt, restriction of 124, 31 of 
Sap, arrest of . . . . 258f 
Sarcoptes scabiei . . . . 253 
Scabies 225, 239*, 253, 285, 331 
Scabs .. 191*, 197, 253 

Schafer, E. A 78f 

Schizomycetes . . 258, 261 

Schofield, A. T 24 

Schrotter, L 204 

Sclerectomy . . . . 347 

Sclerosis, coronary 44, 268 

Sclerostomum vulgure .. 241 
Scott on bronchitis . . 85 

Scybala, formation of ii4f, 312 
Seborrhcea 23of, 236, 312 

Sebum, retention of 221*, 23if 
Secretin, production of .. 118 
value of . 320 

Self-abuse . . . . i37f 

,, -consciousness . . 236 

,, -control, want of . . 282 

,, -dependence of heart 42 

-garotting . . . . 207 

,, -limiting diseases .. 121 

Sepsis, dental 87, 89*, 90 

,, intestinal 109, 112, 118, 


Septum, deflection of . . 190 

ulcer of . . 191, 196 

Sequeira, J. . . . . 228 

Serum, anti-diphtheritic . . 329 

Sexual disorders 22, I37f, 139*, 


Shattock, S. G 127 

Shaw, C. . . . . . . 295 

Sheep, disease in . . 244, 253 

Shock ii*, 26, 1 88, 209*, 284, 

317. 336 

Sinusitis .. 191*, 195, 197 

Sippy, B. W 96 

Skin, disorders of 164, 2igi, 221* 

Sleep, disorders of, cf. Insomnia 

value of . . 295, 3i3f 

Slime fungi . . . . 258 

Smegma, accumulation of 139*, 

i6sf, 312 

Smith, E. F. . . 259, 262 

.. P 175, 330 

Smuts, cereal . . . . 261 

Sodium bicarbonate . . 326 

chloride .. 311, 329 

nitrite . . . . 321 

sulphate . . . . 327 

Sophocles 338 

Sorauer, P. . . . . 260 

Spasm, habit . . . . 86 

,, of intestine 97, lO7f, 326 

larynx . . 205, 286 

,, ,, oesophagus . . 92 


UMcfous Circles In Disease 


Spasm of pharynx . . 207 

,, pylorus 96f, 326 

,, sphincter ani .. iisf 

Spasmophilia . . . . 92 

Spear, I. J. . . . . 12 

Specific Vicious Circles 4, 8, 255, 


Speech, loss of . . . . 209 
Spermatorrhoea . . 138, 140 
Spermocystitis . . . . 138 

Spicer, S 189 

Spinal curvature . . 186, 334 
jackets . . . . 289 
Spiral, vicious . . . . 18 
Splanchnoptosis 106, 109, 334 
Splenectomy . . . . 339 

Sprains .. .. .. 167 

Spriggs, E. 1 116 

Sprue in 

Stammering . . 203*, 207 

of bladder . . 135 

Staphyloma of choroid 174, 178, 

293*, 294 

Starck, H. . . . . 92 

Starvation, death from . . 246 

Stasis, capillary . . 58, 60 

intestinal iO9f, 247, 

251, 342 

,, venous . . . . 154 

Status epilepticus 28, 276, 313 

Stenosis, aortic . . . . 269 

,, lachrymal 180, 340 

mitral . . 47, 269 

nasal 1891, 191*, 

192, 194 

oesophageal . . 336 

pulmonary . . 49 

tracheal 203*, 2o7f, 

208, 267*, 272 

Still, G. F. .. .. 170 

Stocker on alcoholism . . 282 


Stomach, disorders of 41, 89*, 

93f, 239*, 2451, 2 4 9f, 337, 


,, tube, use of . . 337 

Stomatitis, aphthous . . 91 

Strain, cardiac . . 42, 266 

Strait waistcoat, abuse of 289 

Stramonium .. .. 324 

Strangulation of cervix 149, 344 

,, glans . . 142 

,, ,, hernia n6, 344 

,, papilla .. 1 80 

piles .. 116 

Stricture, intestinal . . 344 

,, lachrymal 180, 336 

,, urethral 123*, 135 

Strongylus infection 239*, 241, 


Strumpell, A 21 

Strychnine 279*, 284, 317, 325 

Sturgis on coitus . . . . 138 

Stuttering . . . . 28, 207 

Subthyroidism . . . . 67 

Suffocation, cf. Asphyxia 

Suggestibility, increased . . 23 

Sulphate of magnesium . . 329 

,, ,, soda . . . . 327 

,, ,, zinc . . . . 327 

Sulphur . . . . 285, 332 

Supports, abuse of . . 289 

,, value of . . 333f 

Surgical appliances break 

Circles .. 333f, 335* 

,, operations break 

Circles . . 338f, 341* 

Sweating, excessive 164, 221*, 

223, 232 

Sycosis 228 

Sylvian aqueduct, blocking 

of . . . . 32, 238 
Symptomatic treatment . . 3O2f 


Symptoms cause Vicious 

Circles .. 15, 303 

Syncope 268 

Syngamosis . . - . . 244 

Syngamus trachealis . . 244 

Syphilis . . . . 175, 208 

Syringing, dangers of . . 288 

Tachycardia 17, 40, 319 

Tanzi on morphia . . 280 

Tape- worm . . . . 100 

Tarsectomy . . . . 346 

Tartar, deposition of . . 88 
Teeth, disorders of the 87, 89* 
Telangiectases . . . . 231 

Tenesmus iiSf 

Tenotomy . . . . . . 344 

Terebene . . . . . . 323 

Terson on entropion . . 183 
Therapeutics, rational 333, 354 
Thermotaxis, paralysis of 29 

Thieberge, G 285 

Thirst ... .. .. 96 

Thompson, H. .. .. 133 

Thomson, H. H 72 

Thorax, deformity of . . 170 

Thorburn, W 14 

Throat, disorders of 201, 203* 
Thrombosis of heart . . 270 
Thymus, hypertrophy of 203*, 

Thyreo-globulin . . 66, 330 
Thyroid, deficiency of .. 112 

,, hypertrophy of 203*, 


preparations . . 330 

,, pressure on 203*, 207 



Tinea tarsi 


.. 28 
.. 181 
253, 338 

,, versicolor . . . . 227 
Tinnitus 158, 163, 213*, 216 
Toe-nail, ingrowing . . 230 
Tongue, retraction of . . 287 
,, swallowing . . 202 
Tonsils, enlarged .. 193, 349 
Tooth-ache . . . . 90 

Tourette on morphia . . 280 
Tourniquet, use of . . 338 

Toxaemia 25, 28, 67!', 91, 104, 

n8, 122, 123*, 163, 169, 

201, 203*, 276, 328, 342 
Trachea, dilatation of . . 244 
,, stenosis of 203*, 2O7f, 
267*, 272, 343 

Trachoma 172 

Traumatic neurasthenia 14, 283 
Treatment, aetiological . . 302 

,, injudicious . . 277f 

Trees, death of . . . . 263 
Trembling . . . . 236 

I Trendelenburg on Vicious 

Circle . . . . 93 

Trephining - .. .. 347 
Treves, F. . . . . 31,116 
Trichiasis . . . . 174, 183 
Trichloracetic acid . . 331 

Trichophytons . . 226, 338 
Tricuspid regurgitation . . 48 
Tropics, diseases of the 63, in, 
27. 336 

Trousseau, A. . . . . 292 
Truss, value of . . . . 334 
Tuberculosis 72, 73*, 74f, 77f, 

121, 204, 232, 242, 296, 308, 


Turgor, excessive . . . . 260 

37 6 

\Diciou0 Circles in Disease 

Turpentine, exudation of 

use of . . 

Twigs, death of . . 257*, 

Tympanum,, catarrh of .. 

Tympany, gastric . . 

intestinal . . 

Typhlitis .. .. .. 

Typhoid fever . . 43, 

Tyrel, Walter . . . . 



Udder, inflammation of . . 252 

Ulcer, corneal . . 173*, i74f 

,, duodenal . . . . io7f 

gastric . . 97f, 342 

,, nasal .. .. i95f 

,, pulmonary . . xx. 

,, septal .. 191*, 196 

,, varicose . . . . 220 

Unna, P. G. 50, 220, 222, 234 

Uraemia . . . . 68, 299 

Urbantschitsch on deafness 215 

Ureter, disorders of . . I28f 

,, diverticulum of 128, I3of 

kinking of 123*, 126, 


Urethra, calculus of 136, 251 

,, disorders of I35f, 141, 

239*, 288 

,, stricture of 123*, 135 

Urethrocele . . . . i35f 

Urethrotomy . . . . 344 
Uric acid, excess of 69, 310 

Urinary disorders I2if, 123*, 


Urine, diminished excretion 

of 113 

retention of I3if, i34f, 
ISO, 239*, 335*. 336, 340 

suppression of . . 64 

Urticaria . . . . 223, 

Ustilago . . . . . . 

Uterus, displacement of 

M8, 334, 335*. 340, 

fibroid of . . 

inertia of . . . . 

,, inversion of . . 

prolapse of 139*, 
335*, 340, 

,, retroversion of 139 

*, 150 

Vaccine therapy . . . . 330 

Vagina, irrigations of . . 288 

Vaginismus . . 139*, I47f 

Valsalvan inflation . . 215 

Valve, rupture of cardiac 269 

Varicocele . . 139*, 143 

Varicose lymphatics . . 58 

,, ulcers . . . . 220 

,, veins, cf. Veins 

Vaso-motor paralysis 26f, 30, 


Vegetable parasites 210, 226f, 


Vegetarianism .. .. 310 

Veins, congestion of 

coronary . . . . 268 

,, varicose 37*, 58, 93, 220, 

293*, 294, 335,* 349 

Venesection 75, 279*, 287^ 347 

Venosity, excessive 80, 2O5f 

Venous stasis .. .. 154 

Ventricles, distension of 

cerebral 31, 236, 276 

Verminous bronchitis . . 244 
Vertigo .. 16, 218, 287 

Vesical calculus 131, 133, 343 
Vessels, ligation of . . 349 

Veterinary diseases 15, 237, 239* 




Vicarious assistance 2, 72, 101, 



Ward, G. R 66 

Vice . . 28, 137, 141 

H. M 258 

Vicious Circles, aetiology of i 

Warfield, L. M. . . 56, 157 

,, ,, and death, 

Watson- Williams, P. . . 190 

cf. Death 

" Weak-heart" .. 53, 307* 

,, chemical 8, 96, 

Weber, P 294 

,, classification 

Wecker, L. . . . . 176 

of .. 7 

Weeks, J. E 183 

definition of xvii. 

Weight of body in obesity 160, 

162, 1 66 

,, ,, in animals xix., 

3, 4*, 15, 237*. 

Wells, H. G. . . 68, 104 

239*, 353 

West, C 205 

in plants xix., 5, 

S 36, 83, 268 

14, 255, 257*, 

Westcott, W 266 


"Whites," the .. ..288 

,, ,, mechanical 8 

Wilkinson, C. . . 77, 278 

,, ,, organic . . 8 

Will power, loss of 13, 282 

specific 4, 8, 255, 

Wind-pipe worm . . . . 244 

Cycle . . . . 25 

Wind-sucking . . 98f, 248 

spiral . . . . 18 

Wool-eating .. ..250 

Virgil 280 

Worm aneurysm . . . . 241 

Virtuous Circles 24, 41, 258, 
280, 324, 325 

,, nodules . . . . 244 
Worms, cf. Parasitic disorders 

Vis medicatrix .. .. xviii. 

Visceroptosis 1051, 106, 109, 


126, 334 

Viscosity, increased 64f, 69 

Yearsley, P. M 190 

Vitality, lowered 172, 187, 

257*, 261 


Volvulus 344 

Zinc, sulphate of . . . . 327 

Vomiting .. 89*, 235, 293* 

Zoo-pathology xix., 3f, 237f, 

Vulva, pruritus of 139*, 146, 332 

239*. 353 

Vulvitis .. .. 147. i65 

Zymotic disease . . 43, 321 

Printed by 


AA 000376954 4