Biological physics, physic [and] metaphysics; studies and essays

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“BIOLOGICAL PHYSICS

PHYSIC & METAPHYSICS

STUDIES AND ESSAYS BY

THOMAS LOGAN, M.D.

LICENTIATE OF THE ROYAL FACULTY OF PHYSICIANS AND SURGEONS
OF GLASGOW

EDITED BY

QUINTIN MCLENNAN, M.B., Cu.M.

SURGEON, GLASGOW ROYAL INFIRMARY; FORMERLY EXTRA-HONORARY SURGEON
ROYAL HOSPITAL FOR SICK CHILDREN, GLASGOW 5; MEDICAL EXAMINER
FRENCH, SPANISH, RUSSIAN AND ITALIAN CONSULATES; EXTRA
MEDICAL EXAMINER FOR BOARD OF TRADE, ETC.

AND

P. HENDERSON AITKEN, M.A., B.Sc., D.Lrrr.

VOL. II.
PHYSIC

Circulatio Circulationum omnia Cuirculatio

LONDON
H. K. LEWIS, 136, GOWER STREET .

IQIO

en

GLASGOW : ‘PRINTED, AT THE UNIVERSITY PRESS
BY ROBERT Beach aia AND co. ‘LTD *

CONTENTS

Circulation, in its Pathogenic Bearings - - . -

Biological Evolution, and its Influence on Pathogenesis,
and Treatment’ - ~ - m = r y

On the Jngesta, and Egesta, and the Process of Disposal
of the latter, with Observations on Therapeutics,
and Pathogenesis - - - . - - -

Health, Disease, and Death - 0 : : :

On the popular term “Sickness,” and the classical
phrase “Sick unto Death” - M : m

The Systemic Nervous System, in its Relation to the
Incidence of Disease generally, and the manner of
Evolution of its various Diseases - - - -

‘The Incidence and Development of Cystic Growths,
Tumours, and Neoplasms, as related to Arrested
and Impeded Circulation and Excretion - - -

Diseased Conditions, arising from Mechanical Interference
with the Integrity of the Inter-Meningeal and Intra-
Cerebro-Spinal Spaces - - - - - -

The Incidence of Skin Affections, Eruptive as well as
Destructive, and Mal-Nutritive, determined by the
Distribution of the Cutaneous Nervature - -

On the Exanthemata, and -how they are related to the

foregoing Views - - - = - : ‘
Vv

20

22

30

40

49

52

57

vi CONTENTS

The Relationships of the Incidence of Organic Disease
to the Distribution of the Systemic Nervous System

The Naked-Eye Detection of the Peripheral Distribu-
tion of the Sensory Nervature, and its Clinical
Importance - - - : fs = Z

A Comparison of some of the Diseases Incidental to the
Afferent and Efferent Nervatures respectively, based
on their Physiology as before described, so as to
show some of their Common Characteristics and
Dissimilarities - - - - - - -

Neural Excretion, as the Determining Factor in Fashioning
the Character and Pattern of Skin Eruptions, and
on Rodent Ulcer, Cancer, and Disturbed Materio-
Dynamic Balance - - - - - - -

Zymosis, with References to Parasitism, Contagion, and

Infection. Also on English and Asiatic Cholera, so

called - 3 : i 3 4 “ 4 <

On Smallpox ‘ 3 A : y E 4 x

On the “Vis Medicatrix Nature’”’ : ote

The Healing of Wounds by “First Intention,” and
what takes place in the Process of Cicatrisation and
Osseous Union ~ - - - - - - -

On Metastasis = - < : 7 : 2 7 .
Counter-Irritation, or Artificial Metastasis — - - -
On Vaccination - = : . 4 : : f

The: Physiological Action of Tobacco in the various
methods of its use - - - : x : zx

On Metallic, or Arsenic, and Lead, etc., Poisoning, as
seen along the lines dictated by the foregoing Views

On what is a “Cold” - Z 4 . Z “ .

On Inflammation - s : u 5 = - e

PAGE

60. |

63

68.

71

86

95
98

105
Ilo
IIl2

116

124

128
130

134

CONTENTS

Cerebro-Spinal Meningitis — - : : Bs ‘ :
Neuritis - - - : a . = z i
Neuroma- - - - A “ # ‘ P ;
Sclerosis of the Nervous System, or Scleroma - - :
Polymyositis and Myositis — - - é 2 : 3
Myopathy - - - ~ ¢ x ; ;
On the Cutaneous Condition known as “Glossy Skin” -
Keratosis and Hyperkeratosis - : : . ’ -
Hyperkeratosis of the Skin (Continued) - . : E

Atrophy, Hypertrophy, and Degeneration of Muscle and
Skin Tissues, from the point of view of Neuro-
Muscular and Neuro-Dermal Nutrition and Innerva-
tion - . - - - - - - -

_ The Origin of Colour or Pigmentation in the various

‘Textures - = ; : ; : i.
On Leprosy - : : E - : 4 P
On Tuberculosis - : 2 : ; : ;
On Cancer - - ; ; a ‘ F E .
On Biihilis and Gonorrhcea “ : 2 : z

Rheumatism, Acute, Subacute, and Chronic, with Rheu-
matic Arthritis - « 2 E = S Z

On Urticaria ; 3 ‘ : “ 2 ?
Influenza - - x . = 3 : : :
Hydrophobia - “ - 2 2 2 2
Eczema - ie = ‘ $ ‘s r
_ Acromegaly - : - “ ‘A > e ’

The Causation and Evolution of some cases of Goitre,
with Observations on Cretinism, Myxcedema, etc. -

vill CONTENTS

Coccydynia or Coccygodynia and Hemorrhoids, in relation
to the Filum Terminale of the Cord, and the Coccy-
geal Gland - : z $ “ : z ‘

The Evacuation or Discharge of Colloidal Material through
Narrow Excretory Channels, as contrasted with that
of more Fluid or Serous Materials - - -

Glycosuria and Diabetes . - 2 : : x

A Mode of Emptying Abscesses, Serous Cavities, including
the Cerebro-Spinal, etc., and the Obviating of
Pitting in Smallpox - - - - i 2

The Cell Unit as the Central Textural Element in
Organic Pathogenesis — - - 2 : z

Circulatory Stasis as a Pathogenic Factor 3 3 ‘

On Mal de Mer or Sea Sickness - : 5 : ;

PAGE

261

268

372

ate

229

he
283

I, CEINICAL.

EXTRACT I.
ON CIRCULATION, IN ITS PATHOGENIC BEARINGS.

On the progress of Medicine and Surgery.

One of the pathological and histological results of the
acceptance of the foregoing views (see Vol I.), modified by
the application of criticism and subjection to everyday clini-
_ cal experience, we hope, and we think, will be the removal
of a large part of the diseases hitherto attributed to blood
influences, to the continually increasing class of acknow-
ledged nervine diseases—such, for instance, as a large
proportion of the exanthemata, rheumatism, and gout,
and to a considerable extent metallic poisoning and many
of the bacterial diseases, including influenza, to which
may be added tetanus, hydrophobia, we might almost say,
et hoc genus omne, with many local as well as general
ailments, which have hitherto not been specially localised
or located, and a corresponding practical modification in
the application of medical and surgical curative and ameli-
orative procedure, in accordance with the changed stand-
point from which these diseases will then be regarded, and
the increased possibilities of treatment which will in con-
sequence be placed within available reach of the clinical
_ pioneer.

The great mass of diseases, moreover, except perhaps
the purely local and structural, and even many of these
cannot fail to have their true nature more clearly and
fully apprehended by a “‘light from within” being, as it

II A

2 PHYSIC

were, projected into, and upon, their inner nature, and
working, and thereby revealing it may be, in novel and

unaccustomed positionsand relief, the essence, the methods, |

and manners of attack, progress, and result of the various
morbid entities in their contentions for supremacy with
the resources of the vis medicatrix nature. Figuratively
speaking, the systemic nervous system, being the citadel
and capital, so to speak, of the body corporate, and the
habitat of its presiding ego, is liable to attack by the
enemy disease through all the channels by which it—the
central nervous system—communicates with its environ-
ment, immediate and remote; consequently it requires
these channels to be jealously guarded to prevent invasion,
and to be freely opened to expel the enemy, should it
unfortunately have gained an entrance to that citadel, and
should the forces of expulsion prove equal to the occasion.
In other words, a fluid or lymph is omnipresent through-
out the inter-spaces of the systemic nerve organisms, which
is liable to become the scene of disease when its substance
may become septic, chemically altered, or otherwise
affected in quality or quantity, thereby necessitating the
adoption of special medicinal and other measures to meet

the special circumstances, apart altogether, or almost -

altogether, from the purely nervine aspect of the subject,
which requires to be dealt with on its own lines and very
much on its own merits. In view of the facts that the
cerebro-spinal fluid cannot be called a living, organic, or
nutritious fluid, but, on the contrary, a fluid, much of
which is destined for elimination purposes, very much on
the same lines and principle that the fluid secretion of the
kidneys is, and that the bladder, or viscus, containing it
consists or is made up of the whole inter- and intra-spatial
lymph areas surrounding and inter-penetrating the systemic
nervous system, central and peripheral. It requires,
therefore, that the eliminatory mechanisms making up or
composing that viscus, if we may call it so, should be
equal, but not more than equal, to the performance of
this vital function. Should this be quite normally accom-
plished, it must follow that the enclosed nervous system,
in all its parts, is at full liberty, all other essential condi-
tions being likewise normal, to perform unhindered its

a

oath Wie ee ia ee

ON CIRCULATION 3

multifarious duties, and should the component elements
of the nervous system be likewise normal and intact
_ throughout their full extent, then it must likewise follow
that that nervous system proper will be entirely equal to
its task. That this state of things may be attained, it is,
of course, thus necessary that a state of perfect health
should prevail throughout the whole non-systemic nervous
system, and then will likewise follow that ideally perfect
state of being described by Celsus in the oft-quoted phrase :
MeNS Sana in corpore sano.

EXTRACT Ihe

ON BIOLOGICAL EVOLUTION, AND ITS INFLUENCE ON
PATHOGENESIS, AND TREATMENT.

In biological developmental progress we see the natural
history aphorism, ‘‘the survival of the fittest,” supple-
mented by the subsidiary, structural, and functional law
of the displacement or replacement of the less by the more
fit, the less fit gradually, but absolutely, disappearing with
the altering environment of the developing organism in
its successional progress by zatural selection in tissue,
organ, and organism, in part and in whole. The truth of
these observations is abundantly evident, throughout the
whole of animated nature, in the sequence of the steps of
advance characterising the whole course of evolutionary
progress, from the uni-cellular organism to the last and
most highly differentiated and endowed living being—
man. Man himself representing, in-the various consecu-
tive phases of his developmental experience, every stage
of organic evolution as it is to be met with in the whole
course and stages of the organic life of the globe, both as
it has existed and now exists; with the additional and
further evolution of great intellectual endowments and
moral attributes, which latter are his peculiar and crowning
possessions, although rudiments of intellectual superiority,
with a faint glimmering of nascent morality, are not
wanting in his higher neighbours in the animal scale.

It is by the evolution and development of nervine
structure and function that every stage of organic advance-
ment is achieved; the first, or uni-cellular, form of
organism is animated, vitalised, or energised by a sub-

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ON BIOLOGICAL EVOLUTION 5

nervine or molecular form of materio-dynamic activity
and metabolism ; and it is by the segmentation or karioki-
nesis of the uni-cellular organism that the multi-cellular
organism is built up and energised, innervated, or vital-
ised by the first rudiments of developed and differentiated
nervine structure, called, when fully differentiated and
evolved, the sympathetic nervous system—a system which
governs all organic or vegetative life processes throughout
the total flora and fauna of the globe. Also, it is from
this latter that a further evolution and nervine develop-
ment takes place, in virtue of which is ultimately added
to the attributes of organised beings, the crowning qualities
of reason, will, and moral powers.

Man is thus a double being—or even a treble, if we
regard his uni-cellular life—accordingly as we consider
his nervine history and development, and is equally
dependent for the enjoyment of his full manhood, material
and dynamic, on the two elements of his dual innervation.
Fiis last developed nervous system, the systemic, brings
him into relationship with a higher series of conditions
than it was possible for him to reach with his sympathetic
nervous system alone, and hence into a psychological and
metaphysical sphere, where he is enabled to distinguish
between the ego and the non-ego, and to penetrate far
beyond the confines of his immediate surroundings and
personal experiences, and to enter, it may be, into com-
munion with kindred existences, and with far removed,
but undeniable, realities. ,

It is a singular and striking embryonic developmental
truth that the great neurenteric canal, the first of the great
vascular arrangements to be evolved from the earliest
histological elements of the ovum, should become sub-
servient to the growth and maintenance of the two great
nervous systems, the anterior, or ventral, becoming the
alimentary canal, where the protoplasmic elements of
tissue are first elaborated, and the posterior, or dorsal,
becoming the cerebro-spinal canal, in which is laid down
and stored up the food for the systemic nervous system—
the two, even after their differentiation, maintaining a
modified union, and ministering to each other’s needs, as
material and functional wants mutually determine. As these

6 PHYSIC

two neurenteric tubes maintain an intimate material and
dynamic relationship, due to original continuity of histo-

logical elements, so do their peripheral aspects assume, in

the progress of mutual inter-mixture, inter-penetration,
and dovetailing, a condition almost of homogeneity, which
ensures a communal functional work as well as a dual
control and independent action.

The formative results of independent histological exist-
ence and inter-dependent functional activities have far-
reaching physiological consequences in the regulation of
the general bodily health, and must necessarily determine,
to a large extent, the incidence and progress of a large
part of disease entities and neoplastic textural develop-
ments, facts which should, therefore, at all times be borne
in mind, and utilised as far as possible.

The one nervous system gathers its nourishment
directly from the alimentary canal, and converts it into
protoplasm fit for its own peculiar metabolic purposes,
while the other has its peculiar protoplasm prepared and
stored for its immediate use in the cerebro-spinal canal,
each part of the original neurenteric canal, thus, continuing
to perform the common function of meeting the nutritive
wants of its peculiar nervous system and structural de-
pendencies, and, therefore, necessarily colouring the
peculiar, or essential, formative activities of that system,
as well as determining the formative results of their com-
bined or dual metabolism, besides the manner and char-
acter of their pathological formations and processes ; thus
the early progress of pathological formative processes may
so resemble the physiological as at first to elude observa-
tion, until the departures from the normal become so
unmistakably alien in character and structural results that
they compel recognition as fully established diseases.

In pathological formative processes we see the physio-
logical manner of procedure, and results lead to a reversal
of the natural findings, as elicited by science, biological
and chemical, and discover that instead of the survival of
the fittest, it is the survival of the unfittest, with the
terminal effect of the extinction of the individual organ-
isms affected, and perhaps, when widely distributed in
incidence, the species implicated. In all such eventuali-

ON BIOLOGICAL EVOLUTION 7

ties, the dynamic and formative powers of thé unal, or
dual, nervous systems are responsible for the direction
and administration of the alien influences at work, and for
the accomplishment of their final results, be they innocent
or malignant. Appeals, therefore, must be made to them
individually or conjointly, in accordance with the indica-
tions for treatment deducible in each individual case.

EXTRACT II...

ON THE INGESTA, AND EGESTA, AND THE PROCESS
OF DISPOSAL OF THE LATTER, WITH OBSERVA-
TIONS ON THERAPEUTICS, AND PATHOGENESIS.

Tue ingesta are almost entirely taken into the body by
the mouth, the exceptions being atmospheric air, with its
material admixtures, and the very uncertain quantity
imbibed by the cutaneous surface. They comprise solid,
liquid, and gaseous materials, with a conceivable quan-
tity of finely disintegrated inorganic, as well as living
organic, material, not amenable to measurement by
the most delicate methods of detection yet known to
science.

From the time these ingesta reach the stage of perfect
metabolism, they begin to assume the character and pursue
their course as egesta, and are ultimately disposed of at
the innumerable points of exit, and surfaces of exudation
and exfoliation, by the various egestive processes at work
throughout the body, as residual or waste materials. The
principal examples of these egestive processes are the
alvine, the renal, the pulmonary, and the cutaneous.
Some of the ingesta are cast out of the body directly,
without metabolic change, in a more or less solid condi-
tion, as unutilisable or harmful, by the alimentary ap-
paratus. Some, after a more or less appreciable interval
of time and use, are cast out in a liquid condition by the
kidneys, some are eliminated in a vaporous or gaseous
condition by the lungs, while some are exhaled, transuded,
or perspired in a more or less sensibly consistent condition,
by the skin, and as more or less solid epidermaland epithelial

ON THE INGESTA AND EGESTA 9

débris, after complete metabolism. ‘The materials so
egested, if we could possibly succeed in weighing them,
would exactly, of physical necessity, correspond to the sum
of the material ingested, plus, or minus, irregularity (if
any) for the time being ; the various chemical and physio-
logical changes undergone by the ingesta and egesta
would likewise represent the quantity of energy released
and expended on the total functional work of the entire
organism during the time occupied in the processes of
ingestion and egestion.

The processes of ingestion and egestion must, therefore,
balance each other, and form the counterparts of one great
integrative and disintegrative process or whole, the various
portions or parts of which, if health is to be secured and
maintained, must completely dovetail and follow each
other in unbroken succession and harmony.

Errors, therefore, in quantity or quality of the ingesta
must inevitably be followed by egestive derangement, and
consequent disturbances of the condition of health, while
active or passive interferences with the process of egestion
~ must likewise be followed by departures from the standard
condition, proportionate to the nature and amount of the
errors and interferences; thus obesity or accumulation
may follow the former, and ailments accruing from
emaciation or waste the latter. A large portion of the
whole list of morbid entities, infirmities, and sufferings of
humanity may, therefore, be said to be due to such errors
and interferences with the balance which ought ever to
exist between the quantity and quality of the food taken
into the body and the amount of waste material given out.
In pursuing the subject as thus outlined, we would take
up more especially the latter half, viz. the process of
egestion, or excretion, exudation, and exhalation, or the
methods by which the body is relieved of its encumbering,
‘or effete, materials; this process is a great compound
process, whereas the process of ingestion, in at least its
early details, is somewhat more simple. It is concerned
with the final ejection of disintegrated and effete, or worn
out, organic matter, in the forms of solid, liquid, and gas,
or vapour, and is accomplished by appropriate excretionary
agencies or mechanisms located at the most convenient

IO PHYSIC

points for its final disposal. The process itself consists
of a continuation in inverse order of the circulatory pheno-
mena which lead up to the metabolism of the ingesta by
the various tissues and organs of the body, and begins
with the first katabolic or disintegrative changes under-
gone by the organised or metabolised structural materials,
continues by the collection of these into definite excretory
vessels, glands, and hollow organs, and terminates by the
unlocking of the various eliminatory agencies, by relaxa-
tion of their proper sphincters, escape valves, or structural
safeguards. It follows axiomatically, therefore, from this
that any failure of these circulatory and eliminatory
agencies or media, or any stasis or arrest of the circulated
material must give rise to a condition of disease which,
if continued, must inevitably end in the production of a
more or less definite pathological condition, the remedy
for which must necessarily be, in all cases, primarily sought
for in the rectification of the circulatory and eliminatory
failure of the media involved, or in the overcoming of the
stasis, or arrest, of the circulated material ; hence, in what-
ever part of the egestal, circulatory, and eliminatory
economy the diseased condition is to be found, there we
must bring to bear the use of the most appropriate means
which the particular pathological circumstances indicate,
and let us hope we shall be enabled more and more to do
so with a scientific security based upon physiological
law and data, and with a warranted feeling that we are
not absolutely ‘‘ groping in the dark,” nor “‘ bowing to
the idol” of mere empiricism.

Thus obstruction of the bowel or intestinal canal must
be met by carefully adapted means, according to the indi-
cations yielded by each particular case, retention or sup-
pression of the renal excretion, by. the adoption of
appropriate means, based on diagnostic analysis of each
particular case; pulmonary excretional stasis, by appro-
priate expectorant means; closure of the sweat glands,
by diaphoresis, secured by appropriate medicaments and
mechanical unlockment of the gland ducts, and the con-
sequent allowance of the escape of the imprisoned neural
and other fluid; while retention of the septic results of
neural excretion, or the more solid ingredients of neural

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ON THE INGESTA AND EGESTA II

waste, in the shape of epidermal débris, must be secured
by the use of appropriate means, therapeutic and mechani-
cal, suitable or adapted, to the requirements of each
particular variety and form of the large family of patho-
logical conditions and more or less specific affections,
owing their origin and persistence to arrested epidermal
exfoliation or cuticular shedding.

From the point of view thus presented, we are amply
warranted in computing that disease, owing its origin to
hindered or arrested circulation of either, or both, the
ingesta and egesta, whether of mechanical, structural, or
dynamic origin, ranks first in numerical proportions in the
list of morbid conditions whose etiological evolution it is
at present possible to fathom or appreciate, consequently
we would assign circulatory inability or disability, from
mere stasis to complete arrestment of one or other of the
circulatory processes to be met with throughout the body
in texture or organ, as the principal etiological factor in
the production of diseased conditions, locally and gener-
ally, and would, in the strongest terms possible, advise

that the nature and sequence of the arrestment phenomena

in every such case should be traced back to its source, in
order that the treatment, directed to removal, should be
carried out on strictly rational principles and properly

indicated lines, so as to secure, if possible, the renewal of

free circulation, and all that depends upon it of health of
body and comfort of mind. Circulation in both areas—-
i.e. of ingestion and egestion, or throughout the whole
living organism—being essential to and constituting the
great physical work and basis of life, is responsive to every
impression from within and without that organism of a
material character, as well as to every dynamic disturbance
within and without by which its highly endowed and
sensitive nervature can be in any way influenced; it,
therefore, necessitates a continuous and uninterrupted
existence, if health is to be maintained in a condition even
approaching to perfection, and it goes without saying that
science and art, when called upon to treat its faulty be-
haviour, must endeavour to find where to begin and how
to continue the work of rectification.

Should the circulatory ‘“‘breakdown” be discerned

12 PHYSIC

within the area of ingestion, then the curative agencies to
be adopted under the particular circumstances must be
chosen, accordingly as the traffic superintendent of a rail-
way system finds out and prescribes the required emerg-
ency means in case of disaster in the area under his charge,
and if, on the other hand, the “‘breakdown” be dis-
covered in the latter half of the circulatory area—the
egestive—then the curative agencies to be adopted to
rectify that circulatory calamity must be chosen from the
appropriate category of means adapted to secure its
rectification. A true apprehension, therefore, of the
general physiological circumstances comprising the whole
phenomena involved in and constituting the processes of
ingestion and egestion, as well as of the particular circum-
stances of the cases in question, thus become absolutely
necessary, if the means directed to the removal of the
primary cause and the rectification of the deranged organic
trafiic—which here means disease—are to be accomplished
with any degree of technical precision or certainty and
scientific accuracy.

Although the principles involved in the classification of
therapeutic agencies have not been directed on such lines
hitherto, we are convinced that the remedial classifications,
which have from time to time been adopted, have con-
formed more and more to circumstances emanating from
the grafting of physiological methods and requirements
on the parent stem of empiricism and folk medicine, with
the growing result that the ultimate goal of scientific
accuracy becomes more and more apparent, and its final
attainment more and more absolutely possible. Accord-
ing, therefore, to physiological and implied pathological
law and necessity, we would primarily thus divide all
therapeutic or ameliorative and curative agencies accord-
ing as they are adapted for use in either ingestion or
egestion, or partially in both, and so simplify our still
somewhat cumbrous and miscellaneous ‘“‘ materia medica”
and associated surgical procedure. This would necessi-
tate the employment of two suitable descriptive terms,
for which we would consequently suggest ingestive, or
ingesto-provocative, and egestive, or egesto-provocative,
as likely to be more applicable, more easily understood,

ON THE INGESTA AND EGESTA 13

and less liable to misconception and misuse than such terms
as absorptive and eliminative, secretive and excretive,
integrative and disintegrative, anabolic and katabolic,
astringent and diluent, etc., and other locally applied
incidental adjectives.

A secondary and modifying therapeutic classification
would of necessity arise in connection with the dual con-
struction of the nervous system, since agents which are
esteemed neuro-medicinal quite differently affect the two
systems, the sympathetic and the systemic, and give rise
to therapeutic influences entirely determined by the
physiological and histological distinctness and independ-
ence, as well as by the mutual inter-dependence, functional
and structural, of the two systems—the terms for which
two classes of therapeutic agencies might be, neuro-
sympathetic and neuro-systemic.

Flowing out of these heterodox views, which we have
with some considerable pains, and for a long time, been
endeavouring to evolve from the orthodox materials and
views which we have possessed, the foregoing therapeutic
‘divisions seem to us to possess the elements of truth,
simplicity, and adaptability, although, did time and

classical “‘license” permit, we might do fuller justice to

' our constructive efforts and the requirements of scientific

terminology ; be that, however, as it may, to those con-
cerned, we give them for what they are worth, with the
utmost confidence that if found fit they will survive, but
if unfit their future fate will likewise be fit.

Involved in, and flowing from, the continuity of the
circulatory phenomena of ingestion and egestion is the
great principle of onward progression of the circulatory
material in all its stages, ingestive, nutritive, incorporative,
or metabolic, and egestive ; stasis or retrogression in either
of these resulting in the production of pathological pheno-
mena, in accordance with, and determined by, the nature
and incidence of the etiological factors engaged in the
evolution of the particular morbid condition. Stasis and
regurgitation in the alimentary canal produces its effects
in a particular manner and order, mesenteric circulatory
stasis and regurgitation its sanguineous circulation; its
pulmonary, its nutritive, or its metabolic, and the many

14 PHYSIC

egestive systems theirs, in accordance with the general and
particular local conditions involved. It, therefore, be-
comes a matter of the greatest diagnostic importance to
locate the position of the circulatory stasis in order to be
able to prescribe suitable means for its removal, and the
restoration of the onward progression of the circulating
ingestive, metabolic, and egestive materials, and the re-
gainment of the physiological circulatory equilibrium.
Having located the position of the circulatory stasis, it
will become possible to indicate a treatment, founded on
the recognition of the great principle referred to, with
greater scientific precision, and a greater hope of a suc-
cessful result, than can be possible on lines largely
dictated by the results of empirical experience, somewhat
in-co6rdinated observations, and individual manners of
deduction. |

Every stage of the entire intra-corporeal circulation
_ must, therefore, be ‘‘ passed in review” as we proceed to
discover the flaws in its course, and we feel assured that
the labour of the reviewer will be amply repaid by a more
or less full and definite appreciation of the morbid in-
fluence, or influences, at work in the production, character,
and intrinsic nature of the morbid condition, and by the
possible—nay probable-—discovery of the lines on which
that morbid condition can be rectified. On the accom-
plishment of this absolutely necessary preliminary diagnostic
process, with, it is to be hoped, the detection of the site,
or sites, of the circulatory derangement, amid the pan-
circulatory activities of the diseased subject, we shall
obtain the possession of a vantage ground from which to
view the pathological results effected by the particular
disease, to note the sequence of its morbid events, and
to see our way—working backwards or forwards from that
site, or these sites, as the circumstances of the individual
case require—to re-establish the arrested, perverted, or
deranged current of morbid circulatory phenomena and
contingent altered material conditions, and thereby be
enabled to cure or ameliorate the disease in question.
Accordingly, therefore, as the morbid phenomena are
observable in the ingestive, metabolic, or egestive circu-
latory areas, we must be prepared to lay our plans for the

7
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ON THE INGESTA AND EGESTA IS

conversion of a pathological into a physiological circula-
tory condition, and to work out, by whatever material
and dynamic means can be made serviceable, the benign
work of the restoration of the status quo ante with
what definiteness and precision we can.

Circulatory stasis, or arrest, within the area of ingestion,
speaking broadly, must be characterised by phenomena of
plasma deprivation or perversion; circulatory stasis, or
arrest, within the area of egestion, must, in inverse order
and manner, be characterised by accumulation and reten-
tion of katabolic or effete matter within that area; while
metabolic stasis may be defined as atomic circulatory delay,
or nutritive arrestment, within the area of tissue metabolic
change and exchange.

These three varieties of circulatory stasis, thus, must
give rise to phenomena of arrestment, and forms of
disease, differing in intrinsic nature, but resembling each
other in manner of occurrence, and requiring for their
treatment measures based on their specific differences and
resemblances, and their mutual and inter-dependent rela-

tionships, due to juxtaposition, and continuity of circulat-

ing textures and circulated materials—arrestment in one
leading to arrestment in the others, according to the
ordinary laws of statics and dynamics, modified by vital
and organic influences, the physical character of the cir-
culating media and the circulated materials.

Regarding, as we do, the various circulations comprised
within the human body to be but parts of one great and
indivisible circulation, beginning with the initial act of
ingestion and terminating with the “‘thousand and one”
acts of egestion, it follows that circulatory difficulties and
derangements must be followed by local or general effects,
in proportion to the intensity, extent, and persistency of
these difficulties and derangements, and thus that all
disease more or less is produced by, or is associated with,
altered physiological circulatory phenomena. .

A great principle, therefore, is deducible from this
manner of viewing the initiation and progress of patho-
logical phenomena, inasmuch as physiological complete-
ness of the circulatory process is the foundation on which
health is laid, and without which foundation a pathological

16 PHYSIC

incompleteness, or disease, must exist—the physiological
giving place to the pathological circulatory process, health
giving place to disease, as cause leads to effect, with the
inevitableness of ‘‘law and order,” without a break of
continuity or breach of sequence of the circulatory chain
of movements and events. On this chain of circulatory
movements and events, moreover, the whole phenomena
of life, healthy and diseased alike, from the cradle to the
grave, are grouped in successional order, the one deter-
mining the other, as its various links are run out from its
opening to its close—once more compelling the expression :
circulatio circulationum omnia circulatio.

It would be easy to cite here diseases illustrative of the
various classes embraced in the orders of ingestive, meta-
bolic, and egestive, but suffice it to say that we have
endeavoured to do this, although somewhat irregularly, in
the clinical extracts relating to particular or individual
diseases. As types, however, of the three orders of
disease due to pathological conditions of the three great
circulatory divisions, ingestive, metabolic, and egestive,
we would instance tabes mesenterica, gangrene, and
leprosy as respectively displaying the attributes of stasis,
or arrestment, of circulatory movement, more or less com-
plete, of the materials transmitted through the respective
vasculatures. These three typical affections, thus tabu-
lated together, respectively represent circulatory break-
downs within the area of ingestive, metabolic, and egestive
distribution, and are characterised respectively by struc-
tural phenomena of deprivation of nutritive pabulum,
mal- or non-nutritive disposal of tissue protoplasm, and
retention or non-excretion and non-exfoliation of effete
or. residual tissue débris.

The lines of treatment to be followed in such affections
must, therefore, naturally follow or flow from an exact
appreciation of the etiological factors at work in their
evolution, and the ability to adopt the means at present
available or at our disposal for effecting the removal of
the circulatory stasis and its dependent pathological pheno-
mena, or to supplement these by inventing new or im-
proved means to meet the indications of the particular
case, and so to aid the work of placing the knowledge of

ON THE INGESTA AND EGESTA 17
disease and its treatment, preventive, curative, and amelio-
rative, on a more exact and scientific basis.

As bearing on the course of modern research, these
deductions, moreover, point to the necessity of our
primarily possessing an exact knowledge of the pheno-
mena embraced within the area of transition from the
physiological to the pathological ‘‘state of things,” in
order clearly to apprehend the order and sequence of the
events embraced in such disease processes as are now
engaging a large proportion of professional and lay atten-
tion, as it would thus seem that many of the problems
now being regarded as primary in the causation of these
diseases are but secondary, and flowing out of or permitted
by those of circulatory stasis, or arrestment. Thus cell
mitosis, bacterial invasion, the renewal of developmental
phenomena by embryonic “survivals,” et hoc genus
omne, but represent phenomena, due to pauses, more or
less long and complete, in some part or other of the
universal process of the human corporeal circulation, with
the dependent greater or lesser suspension or modification
of the work of organic life and the invulnerability of
living tissue substance, due to its maintenance at the
normal standard by vital activity with the implied power
of vital resistance to the attack of pathological influences
and agencies—the lapses of which latter constitute the
opportunities for the successful initiation and evolution
of pathological entities and processes, or disease. The
key, therefore, by which to unlock the hiding places of
disease generally is an exhaustive knowledge of the
phenomena of hindered or arrested circulation within the
spheres of influence embraced in the great areas of inges-
tion, metabolism, and egestion, with all of pathological
change permitted or induced thereby.

In the title of this study or extract, we have included,
in particular, ‘‘the process or manner of disposal of the
egesta.” We, therefore, in addition to what has been
already said on the subject, would make a few further
observations. The egesta represent the used up and
consequently effete and sometimes noxious products of
ingestion and metabolism, and, begin to collect and to
become egestive products on their metabolic or katabolic

II B

18 PHYSIC

disengagement by the individual tissue fabrics; they may
be designed for direct and absolutely immediate discharge
from the body, as no longer necessary, or as noxious and
hurtful, to the physiological condition, or they may have
important duties, mechanical, material, or dynamic, still
to perform ere they are finally disposed of as altogether
excrementitious or used up materials, whose disengagement
and elimination have become absolutely necessary for the
maintenance of perfect health. The egesta are finally
eliminated by the alimentary channel, as more or less solid
residuum ; the kidneys, as a fluid in which are dissolved
or suspended a large amount of katabolic, saline, and other
ingredients ; the lungs, from which is eliminated as vapour
or gas a large proportion of the carbonaceous products of
chemical reactions ; the olfactory, pituitary, and coccygeal
glandulatures, and the skin, from which are eliminated
the neural lymph, and exfoliated the results of neuronal
growth and axonal extension and denudation. The three
first representing the structural displacement and elimina-
tion of sympathetic nerve elements—-with the exception
of what escapes from the systemic into the sympathetic
via the motor nervature and rami communicantes.

If the final acts of elimination, exudation, excretion,
and exfoliation of effete matter be absolutely perfect in
their performance, then it will follow that a larger pro-
portion of the morbid processes, set in operation by
circulatory stasis, will be non-existent, from the effect of
obviated pathogenic incidence, by the maintenance of exit
patency and free surface denudation.

If, on the contrary, these final acts of effete material
disposal be interrupted by influences sufficient to induce
stasis of egestive circulation, then it must likewise inevi-
tably follow that morbid processes will be evolved from
these stases in accordance with the anatomical position of
the particular stasis and the character of the arrestment
phenomena involved by it. Thus, obstruction of the
bowel, gravedo, acromegaly, and coccydynia with reten-
tion of urine, asphyxia, retained perspiration, and hindered
cuticular exfoliation, are produced, and produce arrest-
ment phenomena in accordance with the anatomical
arrangements of the circulatory media and the nature of

—_ = = -

ON THE INGESTA AND EGESTA 19
the circulating material, and entail the evolution of morbid
processes exactly in accordance with their respective
intrinsic pathogenic conditions and potentialities, neither
more nor less. It is needless to say that diseased con-
ditions, due to these stases of egestive circulation, may
vary from the slightest and most ephemeral to the gravest
and most lasting, as well as immediately fatal.

Besides stasis and arrestment of egestive circulation we
necessarily have to deal with phenomena due to perversion
and acceleration of that circulation, and, consequently,
requiring for their treatment measures of an opposite
character, but dictated on the same lines as those appli-
cable to the treatment of the first mentioned, or stasis and
arrestment. |

The subject of acceleration and perversion of the eges-
tive circulation opens up a very large and much traversed
field, to explore which, by the light of these heterodox
views, time and opportunity are both necessary. We,
therefore, in the meantime, simply content ourselves by
“broaching the subject,” and calling for it the attention
which its importance requires and its clinical adaptability
entitles it to, letting it suffice merely to enumerate such
typical examples as diarrhoea and cholera, diabetes mellitus
et insipidus, bronchorrhoea, rhinorrhcea, seborrhcea, and
hyperkeratosis, as samples of this aspect of the subject of
pathological egestive circulatory rate and character, and
diseases whose intrinsic nature may be more fully revealed
by inspection in subjection to such light as these views
can be made to afford.

EXTRACT III.
HEALTH, DISEASE, AND DEATH.

TueEse are biological titles or terms under which we may
possibly be able to say something from the point of view
created by the views embraced in the preceding pages.
Health is a term of the greatest significance to the indi-
vidual and the community, and, generally speaking, its
attainment and retainment have been more or less earnestly
sought after by the human race in all ages and in all stages
of civilisation.

A folk medicine has been practised usually in the first
place, from which professional medicine has ultimately
evolved itself as the progress of civilisation. has advanced,
the latter emanating from the former as the conditions of
society have become more complex and artificial—the
purely empirical stage being left behind as accumulating
knowledge and the growing necessity for exactitude and
a reasoned faith have made themselves felt amid the strife
of human progress and the fitful advance of man’s intel-
lectual acquirements and ambitions. Health may be
described as the condition of wholeness or ‘‘ haleness”
resulting from the faultless working of the entire struc-
tures and organs of the body, or from the existence of a-
bodily condition entirely in accordance with and emanating
from the working of physiological law and necessity ;
any departure from which constitutes a pathological con-
dition or disease. A pathological condition is therefore
a departure from the state of health due to the annulment
or negation of the state of ease characterising health, and
ee is equal to a condition of disease.

HEALTH, DISEASE, AND DEATH 21

And thus death is the complete annulment of life, with
what is implied of health and disease and the absolute
dissolution or separation of the bonds uniting the material
and dynamic entities comprising the living organism.

Health and disease are alike qualifying conditions of
life, and are more or less familiar in the experience of
every living organism, colouring and affecting its life’s
progress from inception to close, and terminating only
with its death, or dissolution. Both are the outcome of
the degree of perfection characterising the working of
the various parts of the organism, and the ease or freedom
from friction enjoyed in its entire life experience, material,
and dynamic, the one or the other predominating accord-
ing as its organic work accords with the requirements of
the organic laws possessed by the particular organism.

EXTRACT IV.

ON THE POPULAR TERM “SICKNESS,” AND THE
CLASSICAL PHRASE “SICK UNTO DEATH.”

6

Tuart the term ‘‘sickness” contains a “‘ world of mean-
ing” the human family and all animated nature, at least
the most highly organised division of it, fully appreciate,
and, stimulated by that appreciation and the fear of what
is to follow it, have endeavoured, and are still endeavour-
ing, to find out means whereby it may be mitigated or
prevented. In virtue of this continued endeavour,
medical science and art have been called into being, and,
sustained by the clamancy of the appeal, the individual
observations and experiences of succeeding generations
have been taken note of and systematised by the pre-
decessors and followers of A‘sculapius, and a more or less
scientific body of teaching deduced as the solid ground
of fact has been touched from time to time until now,
when medicine and surgery have reached a stage of
development that libraries are required to contain their
mere literature.

In the stage at which we now find it, we see arising a
belief in the truth of the necessity of means being used,
whenever and wherever possible, of preventing the exist-
ence of disease and its accompanying sickness, and thus
of allowing life to continue and be enjoyed as long as it
is possible for the individual organism to survive the
natural wear and tear of life, or, in other words, the
“natural term of existence.” Along this line it seems
reasonable to expect that the human race may reach, if
not Utopia, at least the goal of the greatest happiness

THE POPULAR TERM “SICKNESS” 23

of the greatest number, and to the most lasting
extent.

Sickness 1s a term evidently of great antiquity, and we
should suppose it has existed in a general or more or less
concrete form in every language and dialect that has been
spoken since Adamic times; moreover, it is likely, not-
withstanding the use of every means to extinguish it, to
continue to be a well-understood term, if its meaning
is only casually realised, until the physical nature of man
undergoes a radical change through the elimination of
discordant influences and the growth of such as make for
perfection.

The term sickness is far-reaching in its meaning, but
most indefinite in its true and exact appreciation, inasmuch
as every individual man and woman who is asked for a
description of it gives a different account of its intrinsic
effects upon him or her, and of the character of the

henomena, physical and mental, of which it is composed.
Although, therefore, it may be regarded as the first, and
‘more or less ever recurrent, ailment of humanity, in its
essence it is less understood than any morbid experience
from which it suffers, it would thus seem that we must
still wait for a scientifically true estimate of its nature
and incidence until the sciences constituting the founda-
tions of descriptive medicine have been placed in the
category of the more, if not most, exact.

Meantime, it behoves us, however, to endeavour to
form some estimate of what it is, however imperfect, in
order that we may be able to prevent or to neutralise its
attacks on somewhat more exact lines and principles than
those which have hitherto served us. What is it then?

Sickness, bodily, seems to us to be primarily a nervine
ailment, and to arise out of, in most cases, a disturbed
condition of the non-nervous or sympathetically inner-
vated elements and textures situated, roughly speaking,
at and around the epigastric region, where the great auto-
matic ganglionic or sympathetio-systemic nervature reaches
its most highly organised and complex functional develop-
ment, and where the phenomena of peristalsis and anti-
peristalsis radiate from and are maintained for the highest
physiological purposes and organic necessities, and any

24 PHYSIC

interference with which is consequently of nothing less
than vital importance. . ,

Primarily, therefore, it would seem to be the result of
disturbance of a most sensitive neuro-muscular mechanism,
one of whose functions is to guard against the entrance
of toxic and harmful agencies and influences into the
domain of the organic life of the body, by rejecting their
intrusion or expediting their removal by a purposive
combination of neuro-muscular phenomena. These neuro-
muscular phenomena may be experienced in all degrees
of intensity, and at times reach an extremity of develop-
ment inconsistent with the continuance of life, when the
literal truth of the classical expression ‘‘ sick unto death”
becomes an accomplished reality.

Viewed thus, sickness is the outcome and effect of the
functional working of a great safe-guarding physiological
endowment placed at the entrance to the prima via, and
so it may be regarded as almost altogether salutary in
degrees of ordinary intensity, and as a symptom vitally
injurious only in those cases of a hyper-exaggerated
character.

Situated as it is at and about the first great digestive
stage of the alimentary circulation, the safety of the
organic life processes beyond it are more or less perfectly
secured through it by its directing the avoidance of
dangerous articles of diet, and septic material generally,
by the excitation of anti-peristalsis and, it may be, peristal-
sis, and the consequent rejection or ejection of unsuitable
or injurious materials—all this being accomplished, in a
reflex manner, through the working of a very complex
series of neuro-muscular operations, very faintly control-
lable by voluntary effort, and, hence, generally successful
in their working and in their ultimate object of freeing
the gastro-intestinal tube from hostile influences and ~
agents. -

The occurrence of the sense of sickness, in its less pro-
nounced degrees, may be, and is often, rationally appreci-
ated and used by civilised man as a criterion of the fitness
of what should constitute his ‘‘ food and drink”; in savage
man and the lower animals, however, we often find that
their daily regimen in both food and drink is regulated

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THE POPULAR TERM “SICKNESS” 25

by a strict adherence to inherited and early experience,
which would do credit to the most advanced elaborators
of dietetic tables and scales and the firmest adherents to
prescribed methods of living—‘‘ Once bitten, twice shy”
thus proving successful in their rule of life.

The vis medicatrix nature, utilising the incidence of
the sensation of sickness automatically, debars the further
supply of alimentary substances, until the effects of the
occurrence on which its existence was due have been
removed and the status quo ante restored, and proceeds
gently and gradually to renew the process of alimentation,
by first allowing the use of only the most digestible
materials in diluted form and small quantity. Art, there-
fore, whenever it is called upon to interfere in the supple-
menting of nature’s work, if it is to be successful, must
carefully copy nature’s methods and adopt nature’s plans
of operation.

It would thus seem that the ‘‘forcing” of medicine,
or anything else, into an unwilling stomach may not
always be justified, nor be successful in the accomplishment
of the object of its use, if the excitement of that safeguard
—sickness—be its most prominent result and its continual
attendant. In such cases the “‘cure may be really worse
than the disease,” and the trusting of them a little more
to nature may be not only justifiable, but highly beneficial
and even curatively successful, besides certainly being more
humane to the patient, and, what is not to be despised,
agreeable to the “‘interested onlooker.” After profes-
sional acquiescence in, it may take a long time to educate
lay public opinion into the necessity of recognising, and |
acting on the truth of, these observations ; it will, how-
ever, we are convinced, be accomplished as the required
scientific knowledge, which is now the possession of the
few, becomes the possession, by early and everyday
education, of the many.

Although the sensation of sickness is a very recognisable
sensation, the scientific realisation and description of its
various phenomena become the more difficult as we
attempt to focus our indefinite knowledge in an attempt
to obtain a clear view of it, and, to some extent, to
appreciate its real and true meaning, and, if possible, to

26 PHYSIC

deduce from its teaching some indications for the guidance
of those who seek to minister to its relief or to effect its
removal. at

Being, as we have said, in most. cases a physiological
expression by the local nervature, epigastric, of a presence
of a disturbing influence or influences, generally material,
in the stomach, we must look upon the sensation of sick-
ness as a call to both the voluntary and involuntary local
machinery, nervous and muscular, to ‘work in unison”
for the expulsion or removal of the peccant influence or
influences, and to maintain that local feeling of comfort
which should at all times prevail in well-disciplined diges-
tive systems and during physiologically sound gastro-
hepatic work and operations.

Should the offending influence on which the sensation
of sickness is dependent be sufficiently powerful to rouse
the gastric nervature into supernormal activity, the pheno-
mena of anti-peristalsis may be at once initiated and the
offending presence ejected without the interference of the
systemic neuro-musculature; such an occurrence, however,
in the conscious condition, cannot take place without
arousing the latter and bringing into play the combined
neuro-muscular machinery of both systems.

In degrees of the more pronounced sensation of sick-
ness, the neuro-muscular storm thus initiated may persist
for an indefinite period, to the great discomfort, and some-
times danger, of its subject—in such cases it becomes a
matter of supreme importance to have recourse to what-
ever means will assist in stilling “‘the troubled waters”
and securing the wonted physiological calm. In the
severest forms of sickness, induced by improper or
poisonous ingesta, the disturbance engendered may ter-
minate in death from shock and collapse, or be prolonged
into local and general pathological conditions of a tem-
porary or permanent character, which may tax the highest
intelligence and the best resources of art and science.

Besides these varieties of locally induced sensations of
sickness, some of an entirely reflex and distal character
take place when pathological conditions or profound
functional disturbances ensue in various parts and organs
throughout the system, such as in occlusion of the bowel,

THE POPULAR TERM “SICKNESS” 27

in various cerebral troubles, and in many definite and
indefinite, febrile, and other systemic conditions, where
they are reflexly felt by the epigastric neuro-muscular
structures, with the result that more or less grave and
continued functional disturbance is the result. Sympto-
matically this occurrence is often of value in drawing
attention to the presence of, it may be, hitherto unsus-
pected disease, and of the consequent necessity of special
treatment being adopted as soon as its nature becomes
unmasked and its true character apprehended.

In this last variety of the sensations of sickness, with,
it may be, acute anti-peristalsis, the phenomena may occur
so suddenly and unexpectedly—‘‘like a bolt from the
blue”—that a revelation, sometimes of a startling and
grave character, is in store for its unfortunate subject,
which may then be read as the second chapter in the
history of some dangerous disease, which will, thereafter,
prolong itself to the third and even fourth chapters, and
then leave the patient invalid for life.

“Sick unto death” is a phrase in which it might at
first sight seem that its framer was using the poetic license
beyond the limits warranted by strict adherence to truth.
This, however, we are convinced, is not so, as in these
exceptional cases which prove the rule, the sensation of
sickness is so persistent and overpowering, and so unat-
tended by other disease, as literally to necessitate the use
of the phrase. What is embraced in the symptoms of
sickness and the disease ‘‘sick unto death” constitutes
the largest proportion of physical human misery, the
principal raison d’étre of the medical profession, and a
fulcrum by which the compassionate instincts of humanity
are raised into helpful activity for the benefit of the race,
as well as that of all the lower races of animated existence
liable to such infirmities. The sensation of sickness,
when physiologically analysed, is found to consist of the
more or less violent excitation and dynamic disturbance
and exhaustion of the gastric, and the associated sympa-
thetic and systemic nervatures embraced within what
might be called the sympathetico-systemic “head centre,”
where the functions of digestion begin and radiate from,
and, consequently, where shock acts on lines more or less

28 PHYSIC

parallel with those which obtain in the incidence of such
influences in central nerve areas and in the brain itself.
Thus, shock, traumatic or toxic, external or internal, may
so profoundly affect and depress the epigastric nervature
as to deplete it of nerve energy, and thereby paralyse
the organs directly dependent for innervation upon it, as
well as those, such as the cardio-pulmonary immediately,
and others more remotely, related to it. The lethal effects
of shock here are so immediate and profound, and the
sensation of sickness is so short as not to be consciously
realisable, therefore it can only be in cases of minor degree
where the sensation of sickness is consciously appreciated
by its subject—complete paralysis preventing, and partial
paralysis allowing, appreciation in the respective instances,
according to the degree of intensity of causation.

The sensation of sickness being a physiological mani-
festation of the incidence of nervine disturbance, whereby
impressions are made on the local epigastric nervature for
ordinary organic purposes, and on the sensorium for
extraordinary or systemic purposes, we must regard it as
a nervine function normally exercised for maintaining the
life and health of the body, but capable of explosive dis-
plays or neural breakdowns incompatible with the main-
tenance of health or even the continuance of life.

The comparative unprotectedness of the epigastric
neural structures lays them open to many traumatic
interferences from which the central nerve structures are
exempt, and hence to a wide range of morbid conditions
of a transitory and more or less persistent type from which
the central nervous system is almost entirely exempt on
account of its anatomical position and remoteness from
external contact and consequent liability to lethal impres-
sions.

Sickness may be described as an exaggerated form of
what is usually a sympathetic or sub-conscious sensation,
intelligible, so to speak, only to the sympathetic nervature,
and used as a guide by that system in its direction of the
organic work of the body, and is continuous, on the one
hand, with the absolutely unconscious sympathetic inner-
vation, and with conscious systemic cerebration and
innervation, on the other. In this respect it may be

————o

a

_ THE POPULAR TERM “SICKNESS” 29

classified with such sensations as those of hunger, thirst,

and pain, and be regarded as possessed of a functional

and material value as a aon influence in the organic
execution of the affairs o
misery.

life and health, happiness, and

EXTRACT V.

THE SYSTEMIC NERVOUS SYSTEM, IN ITS RELATION
TO THE INCIDENCE OF DISEASE GENERALLY, AND
THE MANNER OF EVOLUTION OF ITS VARIOUS
DISEASES.

THE systemic nervous system is, primarily, liable to attack
by a very large number of diseases, and, secondarily, to
affections invading or spreading to it from the so-called
non-nervous structures and fluids with which it is inter-
penetrated and surrounded.

The primary affections may attack the cerebro-spinal
lymph, the neural envelopes or peripheral non-nervine
elements of that system, or they may, through and from
these, invade and involve the true nerve elements which
they contain, and in many cases these affections may
involve the whole structural elements, nervine and non-
nervine, of which the systemic nervous system is com-
posed, the juxtaposition and continuity of these elements
securing a universal involvement of the nervous system,
and, in certain cases, secondary implication of the inter-
penetrating and neighbouring non-nervine elements of
the affected organism.

Each of the diseases included in the long list of purely
nervine diseases is characterised by an individuality, the
outcome of the nature of the materies morbi, the neural
element or elements attacked, and the sequence of the
morbid changes involved in the pathological process.
Thus, an attack of influenza may primarily involve the
cerebro-spinal lymph, the totality of which it may zymoti-
cally affect, and, everything being favourable, may pass

THE SYSTEMIC NERVOUS SYSTEM - 31

out of it without ‘‘leaving a trace behind” to mark its
passage, but, if not inducing secondary diseases of a more
or less fatal character and persistent nature, which leave a
wreckage, it may be of a permanent kind.

In like manner such diseases as the following primarily
incubate in the cerebro-spinal lymph, and, secondarily,
affect its surrounding, containing and contained, tex-
tures, viz. Variola, vaccinia, varicella, scarlatina, measles,
cerebro-spinal meningitis, trypanosomiasis, rheumatic fever,
eczema, a great proportion of the non-febrile cutaneous
eruptive affections, at least those of an internal microbic
origin, as well as many less definite or anomalous and
ephemeral affections, which ‘‘ come and go” comparatively
unnoticed.

These may be looked upon as types of bacterial disease
whose habitat is primarily the cerebro-spinal lymph.
Another class, however, may find an entrance to the true
nervine structures from this medium, of which we may
enumerate such affections as plumbism, arsenical neuritis,
alcoholic neuritis, and beri-beri, with those cases of
_chemico-physical origin whose manner and method of
attack and spread are still enrapt in great obscurity.

The meningeo-neurilemmar structures are liable to
attack by their own specific ailments, as well as indirectly
by those of their contained fluid, while in like manner
the true nervine structures are affected by their own
intrinsic diseases, as well as indirectly by those of their
surrounding and enclosing fluid, and outer solid or
organised envelopes.

The diseases, therefore, which affect the nervous system
partake more or less of the pathological characters of these
three elementary structural constituents, in varying pro-
portions according to the nature of the materies morbi,
its manner and method of attack, and the evolution of
the morbid phenomena constituting the various diseased
conditions. Thus one, two, or all three, may be impli-
cated in the same disease, each of which may leave its
pathological impression individually or conjointly in the
features of the particular disease, and the sequence of its
symptoms in its evolution as well as involution.

The nervous system may, from the foregoing remarks,

32 PHYSIC

be regarded as peculiarly liable to infection by bacterial
organisms and to entrance by certain inorganic substances,
and to the subsequent manifestation of pathological pheno-
mena, as these pathogenic presences or factors exercise
their baneful influence along their specific lines, by writing,
so to speak, their individual names and characters on the
nervine and surrounding textures. Its intimate and struc-
tural relationship with every organic element of the body,
and its exposure to invasion from outward or external, as
well as internal, pathogenic agencies, render it peculiarly
and constantly liable to attack, while both its material and
dynamic work or functions cause it to exercise a powerful
pathological influence on its non-nervine or containing
structures. |

An analysis of the vascular elements of the skin, we
think, will reveal that the nervous system must be funda-
mentally concerned in every, or almost every, eruptive
disease to which that structure is liable, as we have con-
tended is the case in our study of the phenomena displayed
in vaccinia and vaccination. |

Constituting the proper fibro-cellulo-vascular substance
of the cutis vera, we recognise the presence of three well-
defined vascular systems, each of which, on account of
its vascularity, takes part in the cutaneous circulatory
phenomena in its individual capacity, as a vehicular agent in
the economy of nutrition, excretion, or imbibition. These
three vascular systems are respectively concerned in the
circulation of the blood, hamal lymph, and neural lymph,
and are consequently engaged in their individual capacities
in conveying the nutritive plasma to the cutis vera, the
collection and return of the hemal or resultant lymph
from the nourished cutis vera, and the conveyance to and
discharge of neural lymph, as well as effete proper nerve

substance, from the surface of the skin in the form of —

vapour, sweat, and epidermic débris.

In the division of functional work here indicated, we
see that the nervature of the skin alone, or almost alone,
is responsible for the discharge of effete materials from the
outer surface of the body, and, therefore, since all erup-
tions represent a discharge of substance from within the
body, it must follow that the nerve vasculature must be

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THE SYSTEMIC NERVOUS SYSTEM 33

the discharging agent, responsible for the conveyance of
the material from the place of its production within the
body and its consignment to the proper delivery agencies
within the outermost layers of the cuticular envelope of
the body, inasmuch as the circulation of the blood is
constantly onward and forward, round and round, without
break in its physiological state, and inasmuch as the
hzmal lympathic circulation is from without inwards, and
consequently away from the scene of eruption or ex-
cretion.

We thus eliminate from the category of eruptive
factors, except in certain purpuric and other eruptions of
a kindred character, where manifestly the blood circulation
is primarily implicated, or where, at any rate, it contributes
more or less of its corpuscular or hemoglobin elements
to the substance and pigmentation of the eruption. In
variola hemorrhagica we have contended that the blood
circulation is secondarily invaded from the area of nervine
eruption by the breaking down of the interstitial cutaneous
elements and the commingling of the toxic and atoxic

circulatory media, and consequent re-infection of the affected

person by way of the blood circulation.

The substances erupted or thrown out of the system
by the nervine excretionary agencies must necessarily be
modified by the nature of the materies morbi, on the one
hand, and the particular nervine elements affected by the
particular eruptive disease, on the other; thus a herpes
may alone involve the cerebro-spinal lymph, and may
begin and end with mere vesiculation at the points of
exit of the tainted fluid, or an attack of hyperkeratosis
in like manner may be characterised by the eruption or
excretion of the true nervine elements, or the medullary
and axis cylinder substances, which undergo encrustation
and agglutinative changes in virtue of the coagulation of
these substances on exposure to the air; in like manner
also eruptions may vary in character in accordance with
the nature of the material erupted, as to whether it 1s
one or the other, or a compound of the two, and whether
the eruption is lethal enough to disorganise the interstitial
connective elements and surrounding cutaneous textures
and vasculatures, in which latter case the eruption becomes

II c

34. PHYSIC

a wholesale and compound exfoliation or shedding of the
entire external dermal and epidermal matrix.

All such morbid cutaneous phenomena, like all other
morbid phenomena, must, therefore, be regarded as natur-
ally determined by anatomical and histological conditions,
and physiological hydrostatics and dynamics, so to speak,
of a constant and consistent character, and hence requiring
a therapeutic and other treatment based on such founda-
tions and directed by a strictly scientific use of the laws
deducible from them by pathologists and clinicians. Thus
alone is it possible to place the almost entirely empirical
fabric of dermatological therapeutics on a sound basis,
where its practical bearings can be directed on lines capable
of leading it into the haven of something akin to, if not
entirely accordant with, exact science.

All that has been stated above applies to the sensory
neural aspect and to the afferent, peripheral, or cutaneous
terminal nervature ; we, therefore, to complete this study,
have still to dispose of the efferent or motor nervature,
and the nervi communicantes to the sympathetic.

The efferent or motor aspect of the systemic nervous
system has an equal or equivalent terminal distribution
throughout the voluntary musculature with the afferent
in its distribution to the skin, and is affected on the same
lines as determine the incidence of the morbid affections
of the latter, the difference in or between the two cate-
gories of affections—viz. the sensory and motor—being
due to their different anatomical and histological terminal
structural conditions. The principal difference, therefore,
being due to the fact that the sensory nervature sheds
itself finally from the periphery of the body, while the
motor nervature sheds itself into the voluntary muscula-
ture, and, by histological continuity along the tendons
and their sheaths, into the periosteal structures, the joints,
the proper osseous matrix of the skeleton, the medullary
substance of its hollow bones, and the systemic lymphatic
spaces generally of the cancellous osseous tissues.

This absolutely different manner of disposal of residual
efferent nerve plasma, in its continual nutritional distri-
bution to the musculature and skeleton, entails a corre-
spondingly different character and incidence in the

THE SYSTEMIC NERVOUS SYSTEM | 3 5

occurrence of the diseases to which the motor nervature
and musculo-osseous structures are liable; besides, it
introduces into the non-nervous structures, with which
these latter are anatomically related, the secondary pro-
ducts of nervine diseases, which, in turn, constitute a
pathogenic array of the most formidable order, and one,
the prophylaxis of which must be sought for on all
occasions, while the far-reaching process of morbid causa~
tion is still in embryo. |

As types of efferent or motor nerve disease, we may
allude to rheumatism and myopathy—the first, it may be,
positively involving the whole neuro-musculo-osseous
economy, the latter passively leading to negative patho-
logical results and complete atrophy of a part or of the
whole of the voluntary musculature.

Typical rheumatism, acute, subacute, and chronic,
covers a very large clinical area, and no doubt in its
causation may and must be due to a variety of pathogenic
influences ; suffice it, however, here to say that in many
cases it is of undoubted microbic origin, in which cases the
_ microbe effects an entrance into the incubatory medium of
the cerebro-spinal lymph, where it multiplies, and finally
invades the motor intermeningeo-neurilemmar spaces,
along which it finds its way into the histologically con-
tinuous intra-sarcolemmar spaces, where the lethal effects
of its presence at once become manifest in the functional
disability of the implicated musculature, the generation of
local sub-inflammatory phenomena, and more or less pro-
nounced pyrexia—these phenomena being due to the pre-
sence of the microbe, with its trail or train of toxin, formic
acid, etc., amid structural surroundings of a highly organ-
ised and functionated character. Should the zymosis end
here by retrogression and peripheral excretion of the
tainted cerebro-spinal lymph, convalescence may quickly
follow, but if progress of the microbe be uninterrupted,
the invasion, piecemeal, of the whole musculo-skeletal
structures inevitably follows, in which case the disease
presence affects in turn the whole lymph vasculature,
neural and hemal, with their contained fluids, and second-
arily the blood itself, with the whole non-neural textures
to which it is distributed—thus we see what is at first a

36 PHYSIC

local nervine bacterial invasion progress along the lines
of least resistance within the body, until the whole has

been literally leavened by the fell bacterial organisms.

The sequence, therefore, of the evolution of the sympto-
matology of acute rheumatism may thus be traced and read
along the lines here indicated, as the stages of invasion
and occupancy are accomplished, until the entire corporeal
commonwealth is overrun and subdued, when we see the
“conquering host” victorious, waiting the vis medicatrix
nature, it may be, with its allies, science and art, once
more to assert itself, and clear the affected domain of its
foreign occupants and obnoxious toxic impedimenta. It
might here be remarked that, in the most typical cases of
acute rheumatism, the materies morbi is most probably
telluric in origin, and that it effects an entrance into the
lymph spaces surrounding the nervous system by aérial
convection and contact with the escaping perspiration and
transpiration, and zymotic genetic progress or zymosis
thereafter, along the layers of that fluid, as they flow out
of the cerebro-spinal cavity into the inner recesses of the
central nervous system. Microbes, of the character here
indicated, may be supposed to abound more or less every-
where on the earth’s surface at all times, and to be con-
stantly on the alert for a suitable “breeding place”; it,
therefore, but requires to be presented to be accepted and
utilised. Insect plagues are more or less the constant
companions of man and animals; it is, therefore, not to
be wondered at that these insect plagues are accompanied,
and preyed upon, by smaller insect plagues, and so on ad
infinitum, or until the absolutely smallest living organism
closes the biological scene. In this light we have not far
to seek for the reason of the evolution of formic acid in
this insect and bacterial struggle.

It 1s most interesting, besides instructive, to trace the
‘waxing and waning” of the toxic and antitoxic struggle,
embraced in an attack of, and recovery from, acute
rheumatism, and to mark the occurrence of what are called
complications—cardiac and others—as the disease runs its
course along the anatomical and histological lines traversed
by the ordinary physiological media in the course of their
meeting the daily healthy requirements of the human

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THE SYSTEMIC NERVOUS SYSTEM 37

organism. Thus rheumatic invasion may occur in some
cases of the disease, generally or locally, along the sudori-
ferous channels from the outer world in a very brief period
of time, after which, when zymosis of the cerebro-spinal
lymph has been more or less completely effected, the
phenomena of local or general neuro-muscular involvement,
joint affection, and visceral disease begin to evolve them-
selves, as the materies morbi spreads along the lines of
least resistance into the physiologically sound areas of
texture and organ. The peculiar liability of the heart to
the incidence of rheumatic affection thus becomes at once
apparent, when we consider that the principal source of its
innervation is the pneumogastric nerve, a nerve anatomi-
cally well, indeed ideally, suited to receive and convey
the toxic agent from the cerebro-spinal cavity, or incubat-
ing chamber, to its muscular, epithelial, and endothelial
terminally connected textures, the common and _ syn-
chronous presence of certain bacterial organisms in the
central nervous system and the organs and textures inner-
vated by it, generally and locally, thus receiving an easy,
as well as a scientific, explanation.

The phenomena of metastasis, which are peculiarly
liable to be experienced in rheumatism, are also explicable
by the forward or backward movements of the microbe-
laden cerebro-spinal lymph, as they are determined by
intrinsic and extrinsic local or general systemic influences,
acting by physiological hydrostatics and dynamics along
the most patent available inter-spaces and vasculatures.
Thus a regurgitative movement of infected cerebro-spinal
fluid may take place from a part or the whole of the
voluntary musculature into the cerebro-spinal cavity, when
the central nervous system may be so profoundly nar-
cotised as soon to be affected by unconsciousness and
coma, or it may happen, in non-fatal cases, where the
sensory nervine outlets are available for the work of
excretion of the toxic lymph, that a clearance of the dis-
eased area is effected by profuse diaphoresis, it may be,
aided by artificial neutralisation of the prevailing toxis,
and timely assistance to the narcotised and failing
nervature.

Myopathy is a nervine affection of what may be called

38 PHYSIC

a negative character, i.e. an affection arising out of a
failure in the supply of nerve protoplasm to some or all
of the voluntary muscles, and a consequent atrophy of
these structures ; this failure, of course, may arise primarily
in the neuronal or cell economy of a part or the whole of
the motor areas, in obliteration of the axonal processes of
the various neurons from which the neuro-sarcous ele-
ments are derived, in a breakdown of the end-plate
structures of the motor nervature involved, or in the
inability of the affected musculature to take advantage
of the proffered neural protoplasm—but from whatever
of these causes the affection proceeds, or arises, the result
is the same, sarcous atrophy or myopathy.

The nervi communicantes, proceeding from the central
nervous system, to join and to supplement, or reinforce, the
sympathetic system, seem to establish or set up a ** buffer”
or mixed system of innervation, partaking of the characters
of both systems, and, therefore, subject to invasion from
diseased conditions or materies morbi from both, which
diseased conditions are necessarily coloured or conditioned,
so to speak, by the proportion in time, intensity, and ex-
tent of the prevalence of the disease, and whether it is
contributed by the one or the other system in a greater or
lesser proportion. This ganglionic or mixed system of
nervine structures, being enterable from both the systemic
and sympathetic nervatures proper, is, therefore, subject
to diseases commencing in either or both the neural or
hemal elements, and may free itself from them by elimi-
nation of their diseased products, through either or both
systems, along their respective excretionary vasculatures,
and through the exits provided for the completion of that
function—hence, therapeutic assistance can be directed
along one or both or on mixed lines, according to the
character of the particular morbid condition and the indi-
cations afforded. In this debatable field of innervation,
moreover, will be found the favourite locale for the origin
of much of the neoplastic structural new growth to be
met with throughout the human organism. In this field
unite the neural and hemal tissue elements; here blend
the formative energies of two systems of innervation, or,
it may be, two divisional areas of one innervation, which,

i

THE SYSTEMIC NERVOUS SYSTEM 49

conjointly, take part locally in the manipulation of both
nutritive pabulumand effete or excrementitious materials ;
here, in short, are provided both the material and dynamic
conditions and formative materials for the production,
figuratively speaking, of a “‘kirk or a mill,” and it will,
therefore, depend on the nature of the blending of the
materials, and the play of the mixed formative energies,

__ what formative results may be attained under the modi-

fying influences of the systemic hygiene and the operation
of the vis medicatrix nature.

EXTRACT VI.a.

ON THE INCIDENCE AND DEVELOPMENT OF CYSTIC
GROWTHS, TUMOURS, AND NEOPLASMS, AS RE-
LATED TO ARRESTED AND IMPEDED CIRCULATION
AND EXCRETION.

As a general principle in the initiation, and incidence, of
cystic tumours we would recognise the occurrence of
stasis within the vascular media engaged in circulating the
various fluids of those structures, or parts, of the body in
which they occur, the consequent accumulation of those
fluids within the /umina of their vessels, the also con-
sequent ballooning of these vessels, the inspissation of
their contained fluids, the quasi-organisation of the resul-
tant residua, their pseudo-material histological amalgama-
tion or blending with the surrounding textures, and the
continued or further progress of the pathological processes
thus established along the lines of tissue strata of least
resistance, and of greatest plasmic supply and re-formative
and mal-formative energy.

While this generalisation applies to cystic tumours
generally, it applies with perhaps greatest force to the
incidence of those tumours which are found related to the
excretory mechanisms of the cerebro-spinal fluid, and of
gland ducts generally ; thus a “‘ definite range” of tumours,
cystic and others, range themselves at, and around, the
great as well as the small neural lymph emunctories and
gland exits generally, claiming as their initial cause the
arrestment of lymph circulating matter or fluid excretion,
and the establishment of consequent pathological changes,
which culminate in the production of new structural
arrangements, tumours composed of retained effete

CYSTIC GROWTHS 41

materials, and ultimately of foreign bodies. All ducts are
peculiarly liable to such occurrences, but the same principle
also applies to the initiation and incidence of many tumours
in tissues and organs, apart from ducts, and in such cases
it will be found, on histological and anatomical analysis,
that the pathological changes involved arise from circula-
tory stasis in one, more, or all of the circulations of the
affected parts, i.e. in any of the three circulations, the
blood, the lymph, or the proper neural substance, such as
may be seen, for instance, in aneurysm, localised cedema
and neuroma, in each of which the arrest of circulation,
or stasis, respectively, of the blood, the lymph, or the
neural medullary substance constitutes the starting point
of the pathological changes involved. In advanced cases
of any of these diseases, stasis of one or other of these
circulations leads to stasis of another, until frequently a
general stasis of all ensues, with complete arrestment
and gangrene. Small arrestive causes’ may, there-
fore, in time produce wholesale pathological arrestive
effects, and so are liable to be overlooked in the final assign-
ment of responsibility in the ante- and post-mortem
summing up. Flowing out of stasis in structures where
the vascular walls are to any degree permeable by the
arrested circulatory materials, or where those walls rupture
and permit wholesale escape of their contents, thickening,
consolidation, and pseudo-organisation ensue in the inter-
vascular and inter-histological spaces, and a general matting
or tumour essence is the result, which may overwhelm and
modify both the original structural features of the impli-
cated parts, as well as any preceding pathological conditions
effected by the earlier stages of endo- and peri-vascular
morbid change. Stasis of circulation in vasculatures when
collateral channels are easily reached and utilised by the
circulatory agencies is, therefore, less liable to occur
than in those vasculatures in which the circulatory channels
do not anastomose, so that the systemic nervine circula-
tions are peculiarly liable to suffer from the effects of stasis,
inasmuch as each neuronal unit of circulation is bounded
by its individual unbranching, encircling structures, and
hence is incapable of overcoming stasis of its contents, save
in one of two directions, viz. forwards or backwards, and

42 PHYSIC

backward movement being prevented by the nodes of ©
Ranvier, the arrested circulating material, if not moved
forward, must collect and balloon the /umina of the neural
channels involved, and hence cause such pathological
phenomena as neuroma, which we have elsewhere con-
tended is due to arrest, accumulation, inspissation, and
pseudo-organisation of the white substance of Schwann.

While we thus claim stasis of neural circulation as one
of its specific series of vascular channels, arrest of the
forward and backward movement of the substance known
by the above name, with accompanying inspissation, sub-
organisation, and localisation of the accumulating mass as
a type of cystic tumour of neural origin, we would claim
that the operation of kindred circulatory conditions,
material and dynamic, and the action of like pathological
factors, must result in the evolution of kindred morbid
states, organic and functional. The phenomena, physio-
logical and pathological, due to vascular circulatory stasis
must depend in character to a very great extent on whether
the arrested material is potentially formative and nutritive,
or has lost its nutritive components and qualities and is on
the downgrade of vital change, or become actually effete ;
thus the character of the tumour or new growth, and the
physiologico-pathological régime set up by the circula-
tory stasis will necessarily be determined by the amount
of vital change already undergone by the arrested material,
and the nature of the histological elements amid which the
arrest has taken place, as to whether they formatively lend
themselves, so to speak, to further vital change, physio-
logical or pathological, or at once break down from material
inability or dynamic exhaustion, and cease further to main-
tain the continuity of vital change. Circulatory stasis may
be complete or partial, and, therefore, may lead to very
different pathological results, ranging from complete de-
struction and disappearance, or wholesale accumulation of
the circulatory materials, and their formative re-arrange-
ment amid the surrounding tissue elements, to the slightest
mechanical interference with the process of organic change
and functional activity or vital capacity: it may also be
local or general, and produce effects from the most minute
and transitory to the most general and persistent. Cir-

CYSTIC GROWTHS 43

culatory stasis may thus be said under such circumstances
to initiate the process of the formation of new growths and
strange tissue formations by the suspension of the normal
process of physiological growth and the substitution of an
abnormal or pathological growth, in virtue of the retained
material and unexhausted formative energies being re-
directed along abnormal lines, and determined as to result
by the survival of the strongest formative energies and the
most abundant formative materials as factors in the morbid
processes set up. Tumours thus initiated and determined,
if detected before they become invaded by the elements of
malignancy, are amenable to treatment, as clinical records
abundantly prove; it, therefore, behoves the science of
the subject to assist in every way possible rightly to direct
the application of the art of the subject.

The quality of malignancy, so often acquired by such
pathological developments, may be said to be determined
and precipitated by environment and pre-disposition, and
may, by anticipative preparation of the threatened or
susceptible subject, be averted or prevented by the elimina-
tion of exciting causes, whether these be material or
dynamic, structural, bacterial, or chemical. Malignancy
being a quality superadded to an already pathologically
acquired and determined mode of growth, it follows that
the absolute removal of such pathological structural ele-
ments will prevent the occurrence of malignancy, besides
it will follow that thus is obtained a systemic condition
suitable for the maintenance of an absolutely hygienic
physiological régime around and in the pathological
area, which will ensure immunity from future malignant
attack and occupancy, and enable the subject to live out
life to its legitimate close, all other physiological require-
ments being present. As stasis of circulation so often
initiates and determines the development of pathological
conditions, it must follow that in all such cases the reason-
able and logical procedure, curative and ameliorative, to be
adopted must be chosen with a view to meet the clinical
necessities created by such causation. In short, to make
clear and patent the devious obstructed circulatory ways 1s
what is indicated, and how, and by what means, this end
is to be achieved must be determined by the character and

44 PHYSIC

extent of the pathological changes already effected, the
ability of the subject to ‘‘respond” to the application of
the necessary means, medicinal or surgical, and the range
of ‘‘choice of means” available in each particular case.
Thus in stasis, or overcomable obstruction, of alimentary
circulation of opposed renal and vesical outflow of
hindered pulmonary expectoration and cutaneous excretion
the therapeutic means to be chosen are aperients, diuretics,
expectorants, and diaphoretics respectively, classes of
remedies first determined and set aside for regular use by
the progenitors of Aésculapius and Hippocrates, many
of which still continue to afford an almost unimpaired
satisfaction to the latest exponents of scientific medicine.

Stasis of blood, lymph, and neural circulation within
definite portions of their individual vasculatures, individu-
ally and combined, represents a much more complex
problem, or series of problems, in pathologico-biological
physics (statics and dynamics), and requires the use
of a much larger series of medicinal agencies, as well as (it
may be) assistance from whatever mechanical and materio-
dynamic means which can be brought to bear in their
clinical solution. Massage and other mechanical con-
trivances for the breaking down of intra- and extra-vascular
inspissated and pseudo-organised arrested material, the
promotion of renewed circulation, proper or direct and
collateral, and the maintenance of the regained physio-
logical régime by whatever can conduce to its permanency,
are all here indicated. But if, unhappily, pathological
changes have so affected the original vasculatures as to
render their renewed functional activity impossible, then
the character of the means to adopt to meet the clinical
requirements becomes still more modified and problemati-
cal, until a limit is reached, when the “‘relief of symp-
toms” is all that can be achieved or even attempted by the
most heroic treatment.

All which but proves, pathologically and clinically, the
truth of the physiological finding: circulatio circulationum
omnia circulatio, and that, without it, vitality, local as well
as general, is impossible, physiologically and pathologically
alike. .

Within the apparently almost homogeneous structures

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CYSTIC GROWTHS 45

of the body we must, therefore, find, as a result of the
universality of circulation, that the occurrence of stasis,
or arrest of the continuously moving materials of which
they are composed and by which they are inter-penetrated,
is the starting point of structural change, and that the
new formative procedure so initiated is finally dependent
on the survival of the fittest amongst the struggling
physiological and pathological factors, material and
dynamic, the new growth or neoplasm so begotten affect-
ing the health and the length of life of its host, in
accordance with its specific character as to anatomical
position and relationship to innocence or malignancy, and
to the resisting powers of that host.

Circulatory stasis, or arrest, from the pathological point
of view, may be regarded as proceeding primarily from a
change in the physical consistence of the material circulat-
ing, due, it may be, to the effect of material or dynamic
causes, or the occurrence of obstructive conditions in the
circulating vasculature or tissue inter-spaces, through which
the phenomenaof nutrition are effected and the stages of for-

- mative activity determined and regulated, morphologically

and functionally,and both physiologically and pathologically.

A body, mobile in mass and in molecule, and continually
changing under the influence of vital and other energies
its physical and chemical constituents in certain vitally
determined directions, must necessarily be subject to the
disturbing influences, material and dynamic, flowing out
of its subjectivity to the laws of matter and energy, and,
consequently, must be liable to the modifying influence
of every change, material and dynamic, which impresses
it, and as these changes are innumerable, and to be “‘ met
with at every turn,” a special prohibitive and rectifying
force is self-produced in every organism, by which the
disastrous effects of these changes are neutralised, called
the vis medicatrix nature.

This power it is which renders the continuance of life
possible to the extent that it is, and which, under patho-
logical conditions, enables the affected organism to throw
them off and to renew the status quo ante, or the reign
of physiological law and order ; a study, therefore, of this
power, and the manners and methods of its beneficent

46 PHYSIC

procedure, becomes a matter of paramount necessity if
we would seek to aid it in its continual attempts at curing
disease and healing the injuries to which humanity 1s subject.

We would, therefore, hazard a brief contribution to its
study as it seems to manifest itself in the.removal of
circulatory stasis, and the pathological effects due to it.
Thus, in simple stasis of the blood circulation, a simple
appeal to the vaso-motor nervature may be sufficient to
effect its removal, by altering the /umina of the affected
vessels, in lymphatic stasis the vis medicatrix may be
exerted both a fronte and a tergo, while in neural stasis
it may operate variously, but especially a tergo, according
to which of the nervine circulations is the seat of stasis.
If the stasis, however, be more than simple, and if con-
solidation and pseudo-organisation have ensued in the
elements intra- and extra-vascular, the vis medicatrix pro-
ceeds to break down or disintegrate, to move on, and to
cause absorption of arrested and effused material, to unlock
the closed vasculatures and to re-start the arrested circu-
lation by means of molecular disturbance and movement,
cell activity, leucocytic and phagocytic, lymphogenesis and
vascular absorption, hemal and lymphatic, the clearing of
the intra-vascular channels and the restoration of the circu-
latory activities of the implicated vasculatures, hzmal,
lymphatic, and neural. All which procedures indicate that
if we are to render scientific and practical assistance in the
process of cure, we must seek for inspiration and guidance
by an appreciation of what nature has got to do in it, and
how she is doing her work.

For example, if she is breaking down adhesions and
obstructions, we must assist her mechanically and otherwise
to do it, if she is trying to remove débris, we must help
her surgically and medically so far as we can, and if she
is engaged in the work of regeneration and repair, then
we must remove conditions inimical to her procedure and
supply others which will conduce to a successful issue to
her beneficent efforts. If there be perforation, rupture,
effusion, or exudation, superadded to, or consequent on,
stasis, then art and science may both be brought to bear
in the securing of a favourable issue.

The symptomatology of circulatory stasis must vary

a ee me) Rel on i a

wand te

ew.

CYSTIC GROWTHS 47

according to the structural character of the part or parts
affected, the vasculatures implicated, and the degree and
extent of the pathological changes effected ; but in most
are displayed, to some degree, the classic or Celsian tumour
or swelling, and, it may be, dolor, or pain, with a varying
number of other subjective signs determined by the
mechanical and other effects of the pathological changes
produced, locally and generally. The character and
amount of the swelling varies indefinitely, usually within
certain structural visceral limits, but is always the most
pathognomonic symptom, as it has been the one which
has given rise to the generic name of tumour. Pain is
also a very variable quantity, as observed in the origin
and progress of tumours, and is evoked very often by
merely mechanical causes, such as pressure on and stretch-
ing of nerve structures, or by direct implication of these
in the matrix of the tumour, with stasis of the nervine
circulations, complete or partial. The character of the
pain is somewhat tell-tale, however, and sometimes very
plainly reveals what structures are implicated directly in

_ the pathological process, and what parts are indirectly or

reflexly involved in the neural nexus amid pain “‘ storms” ;
the sympathetic nervature from this point of view
yielding information, more especially from distant internal
parts, of the most valuable character to the diagnostician.
Moreover, pains emanating distinctly from the systemic
nervous system are usually strangely contrasted to those
of the purely sympathetic or the mixed or dual class, and
proclaim themselves, as a rule, within the matrix of the
cutaneous envelope of the body, being referred to or
realised at some portion or portions of that structure by
the sensorium. Besides, it is found that a series of sen-
sations, varying from a desire to sneeze, through the many
degrees of pruritus to acute pain, are found to locate
themselves with the precision of cause and effect at and
around the areas engaged in the function of cerebro-spinal
lymph excretion, i.e. in the Schneiderian mucosa, in the
pharyngeal mucosa, in the peri- and endo-anal structures,
and at the orifices of the individual and grouped sweat
glands, or in reality wherever that fluid is eliminated from

the body.

48 PHYSIC

Stases, therefore, of all degrees in the vasculatures and
circulatory inter-spaces, from the largest to the most
minute known to anatomy and histology, are the causes
of pathological conditions ranging from definite structural
new formations or neoplasms to the most minute and
ephemeral arrestive circulatory phenomena.

The occurrence of circulatory stasis, strictly speaking,
must apply to, and can only take place, where circulation
exists, i.e. usually along definite lines or in the vascu-
latures and tissue inter-spaces, in other words, in the
canals, ducts, vessels, and inter-communicating channels,
where the alimentary, the hemal, the lymph, and the
neural materials are conveyed to their respective destina-
tions; it must, at the same time, be recognised that the
cells, to which these vasculatures convey their contained
materials, and from which they again receive them, must
of necessity suffer in some degree from the incidence of
the same biological statics and dynamics in their reception,
intra-cellular disposal, and return of these materials. It
must, therefore, follow that cell circulatory stasis must also
be regarded as a causative influence in the incidence of
those diseases due to the arrest of movement of the
materials concerned in the vital processes of metabolism
and physiological hygiene. A cell or a group of cells
may thus be the centre or the point from which many
of the diseases referred to are to be traced, and, conse-
quently, may, if discoverable, be made the stepping stones
to the obtainment of indications for successful treatment.

Circulatory stasis, therefore, however minute or limited,
if associated with perturbed formative physiological
activity, may lead by pathological continuity to the pro-
duction of new growths and strange forms of tissue evolu-
tion, both innocent and malignant, without, in the first
instance, the presence of other than normal conditions and
physiological influences, these latter changing by degrees
into pathological by regular and continuous formative
sequence—the same physiological materio-dynamic expen-
diture, as dispensed by pathological means, ultimately
leading to the production of foreign and alien results.

EXTRACT VI...

ON DISEASED CONDITIONS, ARISING FROM MECHANICAL
INTERFERENCE WITH THE INTEGRITY OF THE
INTER-MENINGEAL AND INTRA-CEREBRO-SPINAL
SPACES.

Iy the normal condition of these inter- and intra-spaces a
continuity of /umen is maintained, by which the gross
quantity of cerebro-spinal fluid is secured and maintained
in proportion suitable for the internal support and external
protection of the central nervous structures, and for keep-
ing open a means whereby its circulation is secured from
end to end of the brain and cord; and that the quantity
of fluid can be increased and diminished indicates the
existence of means of escape and of entrance to the canal ;
but as we have elsewhere described these means, we merely
recall that a choice of exits is provided, whereby local and
general intra-pressure can be lessened and also increased,
according to the exigencies of intra- and extra-cerebro-
spinal hydrostatics.

In certain pathological conditions, these facilities for the
equalisation of intra-cerebro-spinal pressure become non-
operative, and such untoward diseases arise in consequence
as acephalism, hydro-cephalism—the former during fcetal
life, the latter also then, but more especially in early post-
natal life—hydro-myelia and syringo-myelia—the last-
mentioned usually in adult or advanced life.

Acephalism usually arises from preceding hydro-
cephalic conditions, rupture of the surrounding, or cor-
tical, and non-nervine cephalic structures, and escape of
contents, with shrinkage of the brain substance, but does
not necessarily interfere with the growth of the body ;

Il D

30 PHYSIC

hydro-cephalism results from non-escape and consequent
accumulation, or from over-production, of cerebro-spinal
fluid, with consequent cortico-cerebral ballooning and over-
development of the cranium to meet the increased skeletal
requirements of the condition. :

To a certain extent hydro-myelia may be said to consist
of like increase of fluid in the central canal of the cord, and
to represent a mechanical distension of its lumen, with
mechanical interference with its nutrition and functional
powers, which may ultimately assume proportions incom-
patible with the maintenance of life; it is also conceivable
that it may precede and initiate the condition known as
syringo-myelia, in which case the over-distended central
canal limiting structures finally give way, and allow the
surrounding neuroglial elements of the cord to be inun-
dated with the imprisoned cerebro-spinal fluid, and to be
thereby disintegrated and finally washed out of it, reduc-
ing it to the condition of a hollow tube, bereft of the
nutritive plasma whereby the spinal neurons are enabled
to live, and of the physical supports to which they have
been accustomed to attach themselves, until they perish
from inanition and mechanical disturbance.

In cases of syringo-myelia not preceded by hydro-myelia,
we may infer that the endothelial lining of the central
canal suffers a solution of continuity from some intrusive
cause and fails to resist the insinuation of the cerebro-
spinal fluid, with the attendant vital and mechanical
changes, due to admixture of a more or less toxic medium
with the neuronal pabulum, and the incidence of nervine
changes, due to the destructive progress of the disease
created, in accordance with local neuronal implication,
until the spinal cord, at and below the seat of attack,
becomes more or less completely hollow and functionless,
and the structures innervated thereby become degenerated
and, in many cases, entirely removed.

Of course, for such occurrences there must be an array
of original and acquired etiological factors of a formidable
order, both predisposing and exciting, the determination
of the manner of whose working can only be dimly
guessed at, but a knowledge of which, if not utilitarian,
should be scientifically interesting and very informative,

THE INTER- AND INTRA-SPACES g1

and a means of assisting “‘ elimination” in symptomatically
allied morbid entities in the processes of diagnosis and
treatment. |

Thus, from the point, or points, at which the cerebro-
spinal fluid effects an entrance into the matrix of the
neuroglia of the cord, a process of softening and dis-
integration of its amorphous elements, followed by a
breakdown of the neuroglial reticular framework of sup-
porting and innervating texture takes place, leaving the
local neurons unprovided with nutritive pabulum, and
bereft of mechanical support for their cell bodies and
attached dendritic and axonal processes, in which condi-
tion they collapse and disappear, causing the paralysis and
degeneration of their peripheral or histologically continu-
ous neuro-musculature, and, to some extent, affecting the
related sympathetically innervated structures. Its sympto-
matology, therefore, must vary according to the rate of
incidence of the destructive effects of the neuroglial break-
down on the local neuronal structures, and can thus be
made to measure the progress that is being made in the
syringo-myelic process.

Moreover, the destruction of the neuronal textures is
usually realised by the myopathic degeneration and dis-
appearance of the sarcous elements of the dependent
musculature, with, frequently, the appearance of whitlows
or cold abscesses, which represent in such circumstances the
passive accumulations of the resultant muscular débris,
and the final stage of neuro-muscular paralytic breakdown
and sarcous degeneration.

These accumulations of neuro-muscular débris usually
take place on the outer surface of the bones, to all appear-
ance from a too consistent condition to pass through it,
on account of the lymphatic vasculature being overwhelmed
with, and unable to absorb and pass on for excretion, so
much semi-solid waste material, and to the non-connection
of that material with any other vasculature capable of
effecting the formidable work of its removal; hence, it
must either remain pseudo-encapsulated or effect its escape
by the aid of ulceration or necrosis of the overlying
tissues. The condition must, therefore, be regarded as
one of complete and melancholy hopelessness.

EXTRACT VII.

THE INCIDENCE OF SKIN AFFECTIONS, ERUPTIVE AS
WELL AS DESTRUCTIVE, AND MAL-NUTRITIVE,
DETERMINED BY THE DISTRIBUTION OF THE
CUTANEOUS NERVATURE.

Tuat the exanthemata, febrile and non-febrile, are nervine
in origin, with very few exceptions, we are convinced there
can be no doubt, and that many of the non-exanthematous
diseases, involving the structural elements of the skin,
are nervine, we also think there is ample evidence to
prove ; thus such diseases as perforating ulcer and rodent,
or cancerous, ulcer of the skin, leucoderma and _ sclero-
derma, exactly coincide with certain areas of sensory
nerve distribution, and certain points where the cuticular
or afferent nerve trunks debouch on the under surface of
the skin, to traverse the thickness of the dermal layers
and areas, and, therefore, where nerve energy and nerve
protoplasm are circulating with a greater combined in-
tensity than at the remote terminal arborisations, where
dissipation of both energy and protoplasm are more easily
and safely effected, amid the general terminal and sur-
rounding structures, or in non-fulminating proportions.
The two first-named ulcerative processes belong to the
former category ; while the two latter, which may be said
to implicate the cutaneous textures in a non-disintegrative
way, may be regarded as affecting the peripheral expansion
of the involved nerve trunks, and producing alterations in
pigmentation and terminal histological arrangement only.
The anatomical and histological distribution of the cutane-
ous nervature renders the occurrence of these somewhat

‘

INCIDENCE OF SKIN AFFECTIONS 53

o

local diseases orderly in character, and does away with the
apparent element of chance or accident as a determinant
factor, making the operation of like causes, under like
circumstances, to be followed by like results, and intro-
ducing into the work of diagnosis, prognosis, and treat-
ment a method of exactitude which has not hitherto been
conspicuous, but which may be pregnant with great possi-
bilities when the subject comes to be studied in proper
detail, and becomes fully systematised. In studying in
only slight detail the manner and method of the patho-
logical evolution of the two first of these disease entities,
viz. rodent and cancerous ulcer, we have been struck with
the thought that the processes involve the operation of
both material and dynamic factors in a more definite way
than can usually be discovered in pathological processes
generally, and that, in the two alike, the disintegrative, or
dynamic factor, predominates over the material, thereby
determining the incidence of abnormally active whole
tissue disintegration, as distinguished from the normal or
physiological disintegration. We have elsewhere argued
that this pathological or abnormal tissue waste is due to
the escape into the extra-systemic neural textures of nerve
energy, with the resultant blighting and final destruction
of these textures, and the involved and systemic neural
textures themselves, when they become exposed to the
traumatic and neurolytic influence of the escaping nerve
force. If this be so, as we have little doubt it is, then
we have also reason to believe that the nerve energy is
being discharged from within, and, therefore, must reach
the scene of its destructive work along the afferent chan-
nels or sensory nerve trunks, or by ‘“‘reverse currents ”’-—
this latter circumstance explaining the destructive effects
of the lethal discharge of nerve force through a receiving
or sensory instead of a delivering or motor terminal nerva-
ture. It is thus a self-destructive influence, exercised by
the involved nervature on itself and its surrounding and
neighbouring non-nervous structures, during the pre-
valence of which the destroyed and disintegrating tissue
elements may become a prey to bio-chemical change,
bacterial invasion, and pathogenic influence of other
kinds, the morbid process supplying materio-dynamic fac-

54 PHYSIC

tors ideally adapted for invasion of neighbouring sound
textures and the propagation and perpetuation of disease.

Nerve influences, emanating from the systemic nervous —

system, are thus destructive to that system itself, and
irresistible in their disintegrative effects on the sympathetic
nerve areas, which everywhere surround and support it,
by the intensity and continuance of their neurolytic
powers. A way, therefore, must be sought to prevent
this nerve force escape or leakage, to redirect it aright,
and to erect barriers to prevent the recurrence of its escape.
Into the therapeutic bearings of the subject, however, it is
yet premature to enter; we, therefore, content ourselves
with reiterating that a very large number of diseases, which
are still looked upon as emanating from hemal quarters,
are none other than nervine in origin and progress, and
that they require to be studied anew in the light of neural
pathology. ,

Altered pigmentation, a principal feature in the two
last-named of the group of diseases mentioned above,
viz. leucoderma and scleroderma, we elsewhere traced
to an origin in the central nerve structures of brain, cord,
and ganglia, in the nerve cells of which all physiological
colour phenomena of skin, hair, and cutaneous appendages
generally are determined and effected, where the pattern
is designed, and the material and energy provided by which
the design is peripherally carried out. Thus the nerve cells
elaborate the neuroplasm, which, when circulated to the
peripheral nerve terminals and shed into the dermic tex-
ture, produce, in conjunction with the modifying influences
of the environment, the pattern originally determined by
the trophic hierarchy of the united nerve commonwealth,
and accomplished by dynamic influences emanating from
the same quarter. Leucoderma seems to depend on the
central failure of the elements, material or dynamic, or
material and dynamic, of pigmentation, and represents a
condition of central negation or peripheral neural incapa-
bility of trophically dealing with the physiological neces-
sities of the situation. Scleroderma involves a greater
or lesser departure from the standard of normal pigmen-
tation, combined with what seems very like a pathologically
aggravated discharge or shedding of the neural elements

INCIDENCE OF SKIN AFFECTIONS 55

of lymph and plasm, or cerebro-spinal medullary and axis
cylinder substances, into the areas embraced within the
spheres of attack, plus the modifying influences of the
pathogenic factors which may happen to come on “‘the
scene of action” to modify the course of events and
determine final results.

The lines of junction of the ‘spheres of influence” of
the two nervous systems, the systemic and sympathetic
respectively, seem to afford a more or less debatable area,
along which there is at times a possibility for leakage of
intra-nerve elements, material and dynamic, and where the
unwonted and unrestrained play of nerve energy on non-
inhibited structures leads to their neurolysis and to inter-
stitial distinctive changes, whereby the definitive elements
of both nervatures and their material belongings are
reduced to pathological waste, to be removed by systemic
hygiene or to become a prey to pathogenic vagabondage,
by which they are finally disposed of, or remain a more
or less permanent menace to the health of the surrounding
physiologically sound structures.

he pain associated with these ailments, the solutions
of tissue continuity involved in their progress, the shorter
or longer continuance of the diseased condition, and the
ultimate results, locally and generally, of the morbid pro-
cesses, are one and all meted out by the leaking nervature,
while the intensity of the intercalated and dependent,
secondary and concomitant, destructive tissue phenomena
conform to the local conditions imposed by the anatomical —
and histological relationships of the affected parts, or
areas, and the individual resisting powers of their subjects.

Viewing as a whole the réle of the nervous system in
its widest sense in the incidence of disease generally, it
would not be too much to say that it has more or less
to do with every morbid process entitled to be called a
disease, either of structure or function, and that without
the dynamic influences exercised by that system in every
_ physiological process, and by continuity in every patho-
logical departure from physiological standards of action,
disease itself, and premature death, would disappear, and
leave the race to run its life-course free from the limitations
imposed by its present vulnerable conditions and its con-

‘

56 ' PHYSIC

stant exposure to pathogenic agencies from within and
from without.

In other words, the nervous system, being synonymous
with life and responsible for the conversion of dead or
inorganic matter into living protoplasm or bioplasm, and
the fashioning and moulding of that bioplasm into the
various tissues and organs of a composite human body,
continues to maintain the vitality of that body, to guard
it against the influences of morbidity, and, where unsuc-
cessful in its battles with these, it continues the use of
its best endeavours to neutralise the effects of every
morbid influence, which has attained a temporary ascend-
ency by opposing it with its utmost physiological vigour,
until it perishes in the attempt or comes out the victor.

EXTRACT VIII.

ON THE EXANTHEMATA, AND HOW THEY ARE
RELATED TO THE FOREGOING VIEWS.

THE exanthemata constitute an order of diseases of a
conspicuous and very important character, and have from
the very earliest period of scientific, as well as folk,
medicine, given rise to the greatest interest—the eruptive
symptoms with which they are accompanied, and the
febrile disturbance to which they generally give rise, alike
claiming the attention of the patient, his friends, and his
medical attendant.

Their nature, genesis, and after effects have been keenly
observed and discussed, and classifications made according
to, sometimes the intensity of the fever and sometimes
the appearance and character of the eruptions, the length
of time of their endurance, and the many other features
by which they are known.

According to the most modern teaching they are
regarded as all but entirely bacterial in origin, and the
view is all but universally held that the zymotic or
microbic poison on which their production depends, incu-
bates or grows in, and is finally thrown out of, the blood
by eruption—each eruption differing from another accord-
ing to the behaviour of its specific virus. In this process
of eruptive excretion it is taken for granted that the
capillary blood circulatory mechanism somehow effects the
expulsion of the zymotic organisms, and leaves on the
various surfaces, cutaneous and membranous, an impress
according to their varying nature and character.. This
we confess our inability to see in, we may say, a large

58 PHYSIC

proportion of the eruptive diseases, inasmuch as the type
of the eruption seems not to depend on the surface distri-
bution of the blood capillary circulation, but on that of
some other surface textural element—what then can that
be? In our opinion, it can only be the nerve terminal
arborisations, their distribution determining the position,
shape, and duration of the eruption, or rash. This occur-
rence would and could, of course, only be the pathological
outcome of a previous invasion and sepsis of the cerebro-
spinal lymph cavities, and the subsequent outflow along
the nerve trunks and their terminal distributions of the
resultant microbe-laden fluid—the primary infection taking
place from the blood streams communicating with the
brain and nervous system, or by direct transit into the
cerebro-spinal lymph circulation via the neural lymph
channels. |

The process of eruption is attended by more or less
profound disturbance of the peripheral or distal ends of
the sensory nervature, with an appreciable subjective
experience of motor involvement, in many cases followed
sooner or later by a “‘sense of relief” and gradual de-
fervescence. :

In diseases in which the nerve terminal textures are
simultaneously affected with the blood capillary circu-
latory vessels, as in hemorrhagic variola, the prognosis iS
always grave, ‘the apparent reason being the re-invasion and
sepsis of the blood by a fresh culture, so to speak, under-
going excretion from the cerebro-spinal septic lymph
spaces.

The presence in the cerebro-spinal lymph of a microbic
organism undergoing the process of more or less rapid
erowth and decay, with the resultant accumulation of
toxinal matter, explains much of the intellectual and
nervous disturbance so frequently associated with exanthe-
matous disease, and affords a clue by which its future
course and conduct may be anticipated and its progress,
- to some extent, guided—thus the preliminary flushing of
the excretory apparatus, most involved in the process of
eruption, assists in determining and accomplishing it, as.
we observe when we succeed in setting up a free aa
phoresis.

ON THE EXANTHEMATA 59

The phenomena constituting the early stages of the
exanthematous diseases vary greatly in the degree of their
intensity, their manner and sequence of manifestation, and
the length of time occupied in their development and
evolution, the period of incubation, as it is called, occupy-
ing the time stretching from the date of infection to that
of eruption, and coinciding with the growth, reproduction,
and expulsion of a particular microbic organism. The
number of diseases now included in the class of exanthe-
mata is very large; that number, however, we think, is
likely to increase as we gain a more precise knowledge
of the etiology and pathology of many of those diseases
familiar to the dermatologist ; moreover, many of the
diseases, undoubtedly exanthematous at times, fail to
manifest themselves in their usual eruptive character and
manner, and thus elude inclusion in their proper category,
hence the necessity for maintaining broad views in relation
to classification, and the consequent therapeutic and
hygienic action indicated therein.

EXTRACT IX.

THE RELATIONSHIPS OF THE INCIDENCE OF ORGANIC
DISEASE TO THE DISTRIBUTION OF THE SYSTEMIC
NERVOUS SYSTEM.

WE have already traced the incidence and manner of
manifestation of exanthematous and skin disease generally
to the manner of the terminal distribution of the systemic
nervature in relation to the other structural elements of
the skin, and have satisfied ourselves that it is almost all-
important therein, and we have now become satisfied that
the incidence and distribution of many affections of the
voluntary musculature, as well as of much organic disease
throughout the viscera, but more especially of the tissues
belonging to these viscera that are to any extent inner-
vated by the systemic nervature, are similarly determined.

Thus the muscular system generally, owing to its
intimate materio-dynamic relationships with the central
nervature, is necessarily dependent for the origin and
progress of the main part of the disease to which it is
liable, to interferences with the processes of neuro-muscular
nutrition and neuro-muscular innervation, varying from
the extreme of the complete negation of myopathy to the
extreme of muscular hypertrophy in incidence, and from
the affection of single muscles to the wholesale affection
of the entire musculature.

We mean to allude here more especially to the incidence
of organic disease of the heart and its dependence on
interferences with the neuro-muscular and central connec-
tions of the brain, cord, pneumogastric nerves, and heart.

INCIDENCE OF ORGANIC DISEASE 6,

In this connection we have already traced the bacterial
relationships of various septic conditions of the cerebro-
spinal lymph, and the simultaneous or immediately sub-
sequent appearance of similar pericardial or endocardial
bacterial involvement, in which alone the element of the
cerebro-spinal lymph is primarily involved, and which, by
the continuity of its presence along the nerve trunks,
secures the spread of the disease, from the cerebro-spinal
cavity to the cardiac cavities and structures—covering,
lining, and interstitial.

The incidence of disease of the muscular structure of
the heart in like manner may be traced to materio-dynamic
interferences with the nutrition of its fibres and their
consequent innervation, by mechanical, chemical, or bac-
terial causes owning a central nervine origin, and acting
along histological lines of continuity vid the pneumogastric
nerve trunks, stretching from the cerebro-spinal structures
to the dependent cardiac musculature; thus atrophy,
hypertrophy, fatty degeneration, and other associated and
consequent heart conditions owe their origin and incidence
alike to interferences with the distribution of neuro-
muscular plasma, and the consequent lapse or perversion
of neuro-dynamic influence or energy, with the subsequent
evolution of disease entities, according to the particular
etiological combination of disease factors.

Of course the heart, being beholden for its innervation
and nutrition to both nervatures, can be sustained in
functional wholeness and comparative health when failure
threatens from either side, and will only yield when both
sources fail; we must, therefore, in estimating the probable
etiology and pathology of any disease of the muscular
structure of the heart, allow for this organic duplex nutri-
tion and innervation, so as, if possible, to adjust our
unfortunately usually only ameliorative treatment with the
greatest scientific precision. The various diseased con-
ditions named above may be due primarily to non-over,
or perverted, production of neuro-muscular plasma by the
central neuronal elements, to faulty neural conveyance
from the scene of production to the scene of delivery, or
to imperfect powers of assimilation of the receiving
organic or muscular structures, in whole or in part, and

62 PHYSIC

to subsequent mal- or non-assimilation and complete struc-
tural and functional breakdown.

We thus see that the central nervous system determines
the incidence and particular local manifestations of a wide
range of disease, spreading over both aspects of distri-
bution, sensory or cutaneous, and motor or muscular, and
that the full recognition of this etiological principle, as a
diagnostic assistance, should always be taken advantage
of, as well as its use in affording indications of treatment.

Moreover, many other allied diseases owe their origin
to the spread from the muscular terminations or attach-
ments to the bones of morbid materials and agencies,
which have already done their best and their worst during
their neuro-muscular transit, such as periostitis, ostitis,
abscesses, acute and cold, joint disease, perversion, and
destruction of skeletal developments, et hoc genus omne—
all of which circumstances are inseparable from the great
laws of neuro-cutaneous and neuro-musculo-osseous evo-
lution and nutrition, and the origin in the great cerebro-
spinal cavity, and its contents, of a host of etiological
factors, which, let loose on the dependent structural ele-
ments, progress and eventuate on the lines of histological
continuity and materio-dynamic affinities, with the common
end of leaving in their track the history of structural
impairment and functional curtailment to mark the various
forms of morbid evolution proceeding from this little
suspected region of “cause and effect.”

EXTRACT X.

ON THE NAKED-EYE DETECTION OF THE PERIPHERAL
DISTRIBUTION OF THE SENSORY NERVATURE, AND
ITS CLINICAL IMPORTANCE.

Ir must be conceded here that the naked eye is often
baffled in tracing the peripheral distribution of the cuta-
neous nerve terminals in many individuals, as well as in
many parts of those individuals in whom in certain areas
it is conspicuous—thus, in many infants, but particularly
in the healthy and ‘“‘thriving,” we can easily see, in the
“ dappling” of their skin, a more or less obvious differ-
entiation of the neural and hemal structural elements,
the former, or neural, being represented ‘‘in bulk” in the
pale ; the latter, or hemal, in the pink, spots composing
the dappling, both, however, dovetailing and blending to
constitute that variegated “‘ivory” or “‘ pearly” appearance
so often characterising this condition of the infantile skin.
As age advances through youth, adolescence, and decline
the relative disposition of the two principal vascular ele-
ments of the skin undergoes considerable change, ‘* wax-
ing and waning” and fluctuating somewhat rhythmically
and regularly with the changing phases of life and altering
environment. At one stage of life, and under the com-
bined influences of certain environments and internal
conditions, the neural element may be most in evidence,
while at another the hemal element may be in like manner
most conspicuous.

Paleness of surface, in normal conditions, may be said
to mark the presence of the neural vasculature locally as
well as generally whenever present in conspicuous pro-

64 PHYSIC

portion, and, when locally observed in thin skinned indi-
viduals, the paleness may often be seen to be confined to

one or more terminal arborisations, to a group of associ-—

ated peripheral nerve expansions, or to the specially
distributed terminal nervature of the skin_ generally.
Thus, on the more exposed surfaces of those who show
this anatomical peculiarity, each nerve terminal displays
its final histological breaking up in the form of single,
dual, triple, or multiple, circular, oval, or irregular, but
distinctly outlined, ivory coloured, glistening or faintly
transparent, ring-like shapes showing in slight relief above
the prevailing more rouge hemal vasculature. 4t first
this surface marking has to be carefully looked for, even
ina good specimen, but when once seen, and when the eyes
have been familiarised “‘to the sight,” there is very little
difficulty in detecting, even in the worst specimen, traces
of this manner of the terminal distribution of the sensory
nerves and blood vasculature respectively. That the
power to observe the manner of the terminal distribution
of the sensory nervature of the skin can aid us in diag-
nosing a neural from a hemal eruption goes without
saying, as the most elementary scrutiny, by the initiated,
of the cutaneous disposal of its details, will show whether
the eruptive display conforms most to the outlines of the
neural terminals or to the more indefinite capillary ele-
ments of the blood vasculature, or whether it involves
both.

As we have said before, we are convinced, from our
analysis of the eruptive phenomena displayed by the
exanthematous fevers and the non-febrile eruptive dis-
orders generally, including many forms of neuritis and
dermatitis, that differentiating the neural from the hemal
varieties will enable us to dictate a treatment at once more
scientific, and likely to be successful, than that only based,
at the best, on the sifted empiricism “‘of the ages”:
moreover, justified by this analysis, we claim once more
that a much larger proportion than is usually supposed
of the eruptive diseases will be found to have been incu-
bated in, and to have secondarily invaded, the so-called
non-nervous structures of the body from the cerebro-spinal
cavity, and that, therefore, it will be found that their

rs

——

THE SENSORY NERVATURE 65

eruptive displays have been moulded on the structural
lines of the cutaneous or peripheral nervature—anatomical
necessities, therefore, determine their manner and method
of evolution and development, as they must be acknow-
ledged to do in every definite diseased condition.

The terminal distribution of the peripheral sensory
nervature being thus generally more or less traceable,
lends itself to the more or less graphic illustration of the
“condition of things” within the central nervous system,
and publishes, for the information of those able to trans-
late the messages, what is transpiring in these cryptic
regions, and what response, if any, to return.

The naked-eye features of the skin generally, and those
relating to the sensory nerve terminals particularly, as we
have remarked, are continually undergoing change as age
advances, each phase of life being characterised by its own
particular features; thus its creasing or wrinkling, its
smoothness or roughness, its own pigmentation and that
of its appendages, with many other less prominent, are
rhythmically responding to the plastic and colouring or
de-colouring touch of the ‘‘hand of time,” and “telling
the tale of life,” whether it may be smooth and joyous,
rough and careworn, or wild and tumultuous.

The truth of these observations must be tested by the
study of the living subject, however, because post-mortem
changes frequently obliterate those which have been the
work of a lifetime, thus smoothing out the grosser mark-
ings of time, throwing an air of peace and rest over
countenances which have long been strange to them, and
leaving, it may be, a uniform pallor alone to mark, or mask,
the history of the individual.

The deeper and unseen relationships of the peripheral
nerve terminals, to the well-defined and anatomically traced
nerve trunks and fibres, have an important bearing on the
surface disposition of the terminal nerve markings, inas-
much as every such marking, when it has become the
scene of eruptive phenomena, will, on being traced back
to its parent nerve, reveal the path by which the neural
discharge has been effected, and give a clue to the discovery
of its true etiology and nature. The cutaneous sensory
nerve terminals seem to be disposed on and in the surface

II E

66 PHYSIC

of the skin, and the sympathetic nerve terminals in the lining
membranes, very much in the same manner as the leaves

of a tree—say a sycamore—are disposed on its terminal

branches, which, when looked at from the outside or from
above, show an almost complete continuity of-leaf surface
distribution and arrangement, giving to the tree an appear-
ance of solidarity, which is only appreciated at its true
value when subjected to scrutiny from underneath or
within—then it is realised that the disposition of the
individual leaves is such as completely to “‘slate” the
trunk and its branches, the natural seasonal leaf shedding,
revealing the same truth negatively. On pursuing the
comparison, we become aware that at certain points of the
leafy envelope of this sycamore a group of leaves shows
a disposition to wither, change colour, and are finally shed,
leaving a mark more or less evident amid the prevailing
green, which may become a permanent scar should the
leaves not be renewed. Very similar phenomena are
observed in the disposition of the sensory nerve terminals
of the skin, as they lie closely tessellated in its neuro-hemal
layer when attacked by eruptive and destructive morbid
forces and materies morbi from within the central nervous
system, or, if the eruptive displays involve the lining
membranes of the body cavities, the same may be said of
the sympathetic nervous system.

The phenomena of diversity of appreciation of sensory
stimuli by different areas of the skin and by different
points within any one area, in view of the comparative
light thrown on the subject by such observations as these,
would seem explicable by the varying degrees of intensity
with which the various component parts of the nerve
terminal expansions are reachable by the stimuli; thus
the outer or peripheral surface of the neural tubules, com-
posing the terminal arborisations, must be reached, and
respond more quickly and readily than those surfaces
representing the sides and under aspects of the same
tubules, and hence the explanation of the apparent con-
tradictoriness of the results obtained by experimental
stimulation: of these sensory nerve terminals, and the
unsatisfactoriness of the conclusions which have been based
on the results.

ow he ss

THE SENSORY NERVATURE 67

As proving that the peripheral or sensory terminal
nervature must necessarily be the most superficial element
of the true skin, we may point out that the sense of touch
is resident in the most acute degree at the parts of the
cutis vera nearest the surface, and, therefore, that it is the
first vasculature met with in the usual manner of per-
forming vaccination, where it is best not to “‘ draw blood,”
and to avoid the hemal vasculature; hence the nerve
terminals usually lie above or outside of the capillary
vessels of the skin, except in the red or more deeply
tinged areas referred to in describing the more conspicuous
cutaneous naked-eye features for the detection of the
peripheral distribution of the sensory nervature.

EXTRACT XI.

A COMPARISON OF SOME OF THE DISEASES INCI-
DENTAL TO THE AFFERENT AND EFFERENT
NERVATURES RESPECTIVELY, BASED ON THEIR
PHYSIOLOGY AS BEFORE DESCRIBED, SO AS TO
SHOW SOME OF THEIR COMMON CHARACTERIS-
TICS AND DISSIMILARITIES.

Tue afferent and efferent, or the sensory and motor nerva-
tures or nerve fibrils, are histologically alike, in that they
are both axonal processes of nerve cells, that embryonically
they are projected into, become amalgamated with, and
innervate the skin and voluntary musculature, respec-
tively, and that they grow from the nerve cells towards
the textures, which they innervate, and not from the tex-
tures towards the nerve cells, of which they form the
axonal processes, the possibility of this latter occurrence
being absolutely precluded from the non-existence at the
periphery of either nervature of a neuro-genetic cell
mechanism, and because a cell process can only grow from
a cell. They are alike, also, in that, besides being merely
axonal processes connecting nerve cells with sensory and
motor agencies respectively, they convey, along with nerve
energy, material pabulum for the growth and maintenance
- of these agencies in skin and muscle elements respectively,
by capillary circulation along the fibrillary /umina, so to
speak, of the axis cylinder and medullary containing
membranes or tubes; the dual protoplasmic elements of
the axis cylinder and medullary substances thus constitut-
ing the material pabulum,*on which the processes of
growth and maintenance of much of the muscle and skin

i ee ee

mee

—,

—
ie

< 4g 2? ye se a vt

AFFERENT AND EFFERENT NERVATURES 69

textures proper depend. ‘Thus far the characteristics of
the two systems of innervation, sensory and motor (i.e.
so far as their histological development and structure are
concerned), are entirely parallel; at this point in their
comparison, however, there ensues a distinction, which
amounts to an absolute difference, because nerve stimuli
are transmitted from without inwards to the cell by the
one, and from within outwards to the muscles by the other.
It cannot be said, therefore, that nerve stimuli are always
transmitted in the line of growth of the transmitting fibre
only, but according to the direction of incidence of the
functional transmission or circulation of nerve impulse or
energy. An exception, however, to this latter rule is
claimed to the extent that, in certain physiological as well
as pathological conditions, a nerve fibre can and does
transmit a duplex current, i.e. an afferent fibre can be made
the vehicle of transmitting an efferent impulse, as in
herpes zoster, and an efferent fibre can be made the vehicle
of transmitting an afferent impulse, as it may be conceived
to do in connection with the phenomenon of the “sixth”
or “‘ muscular sense.”

In contending for the truth of these assumptions, it is
necessary to reiterate that a nerve fibre, instead of being
a solid and homogeneous texture, is composed of two
keratinous tubes, through which run, or are circulated,
the medullary and axis cylinder substances, these sub-
stances being the products respectively of the cell and its
nucleus, from which they are poured into the /umina of
their respective tubules and circulated to their remotest
terminals, where they are disposed of as skin ingredients
and sarcous tissue elements. Instead, thus, of the nerve
fibre being a stationary non-mobile strand of neural sub-
stance, histologically attached by its two extremities to
nerve cell and innervated texture, it is composed of two
telescoped tubes, an outer and an inner, transmitting
neuroglial substance, known as medullary and axis cylinder
substances, from brain, cord, or ganglia, to the limits of
the systemically innervated tissues, peripherally and cen-
trally, of the entire organism. aa

Being, if this be true, active agents in the distribution
of neural tissue pabulum, as well as the transmitters of

70 PHYSIC

nerve impulse, these fibres, therefore, become the most
important vehicular agents in the economy of nutrition

of skin and muscle, especially in the so-called trophic |

work and oversight of certain nerve centres, which physio-
logy persists in assigning to some hitherto ; ill-defined
nervine areas, in conjunction with the distributive agency
of the blood circulation and subsequent metabolism ; and,
consequently, interference with this nutritive work in the
way of increase, diminution, or perversion, becomes a
pathological factor of the most vital importance. Thus
increase of the peripheral or afferent nerve terminal
exfoliation, excretion, or shedding, is followed by hyper-
trophy of the cutis and cuticular textures, while increased
motor excretion is in like manner followed by hypertrophic
changes in the sarcous elements of the voluntary muscular
textures; in like manner, also, decrease in the afferent
nerve fibre pabulum leads to the production of “glossy
skin” or dermal atrophy, while decrease in the efferent
nerve fibre pabulum leads to the production of myopathy
or muscular atrophy, the determining cause in both cases
being abnormal supply of nervine pabulum or inefficient
metabolism on the part of the affected structures.

In conjunction with these pathological factors is often
associated a pathological condition of the cerebro-spinal
lymph circulation, whereby diseased conditions of the
above order are modified according to its extent and
intensity, and so such conditions as neuritis and myositis,
local and general, become evolved, and pursue a course,
it may be, at first simple, but gradually becoming more
complex as it involves associated non-systemic nervous
textures.

—

EXTRACT XII.

ON NEURAL EXCRETION, AS THE DETERMINING
FACTOR IN FASHIONING THE CHARACTER AND
PATTERN OF SKIN ERUPTIONS, AND ON RODENT
ULCER, CANCER, AND DISTURBED MATERIO-
DYNAMIC BALANCE.

In alluding to the causation and incidence of the exan-
themata, we advanced the opinion that they represented
neural excretion consequent on incubation of the microbic
viri or organisms in the cerebro-spinal lymph, and were
to be regarded as primarily diseases implicating the neural
rather than the hemal system. On the continuation of
our studies along this line, we have become convinced that
these views apply as well to very many of the more slowly
progressing cutaneous affections manifesting themselves
by eruption, or in other more or less conspicuous alteration
of the cutaneous textures and surface, and owing their
production to such very various morbific agencies as
metallic, chemical, and bacterial viri, but eventuating in
common in excretion through nervine channels in the
great external area of final disposal of effete and noxious
residual nervine materials. The cutaneous eruptions here
alluded to usually conform to the configuration of the local
terminal peripheral nervature, appearing in discrete or
confluent proportions according to whether one or more
terminal arborisations are involved in the work of
excretion, and whether one or more of the con-
stituent neural fibral elements of the implicated arbori-
sations are shedding their residual contents, and in
what proportions these elements are represented in the

72 PHYSIC

rash, and consequently responsible for shaping its specific
features and determining its local incidence and char-

acter. Thus a simple miniature dermatitis, with only

the slightest surrounding hyperemia, may be all that is
visible in arsenical or alcoholic neural elimination, or the
most acute and destructive changes may mark its rapid
progress over larger areas, a papular thickening, a vesicular
elevation, or a pustular invasion, may mark the points of
excretion of a bacterial organism, a bulbous accumulation
of neural lymph may represent arrested perspiration and
subcutaneous accumulation, a crusted and piled-up heap
of escaped medullary substance may be recognised in the
rash known as pemphigus, and the more sebaceous spots of
acne and the comedones of xanthelasma as admixtures of
the whole exuvial and excrementitious fibro-neural ele-
ments. When we add this large class of the more slowly
progressing eliminative ailments noticeable on, through,
or over the skin to the exanthemata proper, and when we
bring into the same category many of the diseases of the
olfactory apparatus, the glosso-pharyngeal area, and the anal
orifice of the intestinal canal, besides, it is conceivable, a
considerable proportion of the diseases attacking the
visceral parenchyma and limiting membranes within the
body, we must become aware of the great importance of
neural circulation and excretion in the incidence and evolu-
tion of the morbid entities to be met with in the human
body, and of the consequent necessity there is for a con-
tinual recognition of that fact in the everyday work of
diagnosis, prognosis, and treatment, both on account of
its inherent, immediate, and utilitarian value, and its
purely scientific bearings on the progress of medicine and
surgery locally and generally.

Moreover, the incidence of cutaneous tuberculous affec-
tions, such as rodent ulcer, and even cancer itself, seem to
_ be to a great extent determined by neural distribution and
excretion, and the consequent effects of tainted neural
materials amid the textural elements undergoing malignant
change, hypertrophic growth, and degenerative removal,
in all which morbid phenomena it is warrantable to sup-
pose, and even to contend, that a subtle and destructive
poison 1s being distilled, and, it may be, a dynamic leakage

a |

i ee? poo jen Ae? A eer. th are aod «5

ON NEURAL EXCRETION 73

taking place, from the central nervous system into the
textures involved by the local nervature ; this being so, we
shall in such cases have to look for their causation away
back in the central regions and lymph caverns of the
systemic nervous system, where, it may be, traces will be
found of the presence of a bacterial organism or other
materies morbi, which had found its way thither, and
finally been expelled along the intra-neurilemmar channels
of the locally involved nervature of the diseased textures
and areas.

The character, therefore, of the specific morbid elements
or effects locally discoverable in any particular instance of
these affections, at least of those whose origin is not
absolutely local, must to a great extent conform to the
nature of the specific and determining cause, which has
been at work in the distant central nervous system, mould-
ing and evolving the particular or specific virus, and the
character of its pathogenic influence on the structures
involved locally must be likewise so determined—it may
thus well be that the various schools of pathology now
engaged in research on this subject may find a justification
for their respective beliefs in this matter ; as according to the
manner and method of their diverse procedure in arriving
at them, so necessarily will they be; hence mutual respect
and forbearance will be required to enable each and all
to have their particular views passed through the crucible
of final determining search and criticism.

These statements relate to the incidence of disease in
the areas innervated by the afferent or sensory nervature,
and, therefore, to the peripheral or external aspect of the
body, a similar, but necessarily modified, morbific inci-
dence must characterise the motor or efferent nervature,
when, amid the functionally active elements of the entire
voluntary musculature, the toxic or disease-producing
elements of the central nervature are liable to be deposited
by their “‘end plate” fibral distribution. The diseases
thus caused are no less numerous and important than those
which emanate from the sensory aspect of the nervous
system, and, generally speaking, profoundly differ from
them, inasmuch as the textures involved in the respective
categories of sensory and motor are fundamentally dif-

74 PHYSIC

ferent ; thus the diseases affecting the tissues in which the
sensory nervature ends spread themselves by histological —
continuity along and amongst the elements of these tissues
free from overlying mechanical hindrance, while those —
involving the voluntary musculature are necessarily
moulded by surrounding structural limitations, direct and
indirect, and conform more or less exactly to the topo-—
graphy of that musculature and its textural environments.
To make this plain, it may be sufficient here to refer to
two classes of disease, affecting respectively the sensory
and the motor areas of the systemic nervous system, with
the textures to which they are distributed, viz. the exanthe-
mata and the “‘ morbi rheumatici.” ‘These two classes of
ailments are both typically illustrative of morbid agencies,
hatched in the remote intricacies of the central nervous
system, and finding an exit for their resultant toxic débris
along the channels of exit and least resistance into their
attached and innervated textures and organs, cutaneous
and muscular—in both, although the results are so dif-
ferent, the manner of their evolution is the same. Kindred
agencies, working along different lines, producing different
effects, in accordance with the operation of the same laws,
on different structural elements. It becomes conceivable
here that the grouping of diseases generally, and their
classification, may be determined on simpler and more
scientific lines than those in use hitherto, and that valuable
indications for the application of curative and ameliorative
means may become more readily and rationally available.
Another group of diseases of very large proportions is
embraced in this classification, in virtue of its nervine
origin, and becomes conformable to the same laws of
nervine distribution and evolution, viz. the nervine affec-
tions of the viscera generally; in these, however, the
influences derivable from association with the sympathetic
_nhervature exercise a modifying influence on their inci-
dence; nevertheless, it is essential to bear in mind that
the central nervous system is the fons et origo of these
maladies, and requires to be appealed to in any practical
measures that may be adopted for their removal or relief.
This group of diseases may be typified by the affections

known as the sequele of many of the affections of the

f ¢ s

ON NEURAL EXCRETION 7

systemic nervous system, such, for instance, as heart com-

plications in rheumatic fever, and pneumonia in influenza,

where the specific neural virus travels along the pneumo-
gastric nerve trunks into the, parenchyma and _ proper
structural elements of lungs and heart respectively, after

incubation, in the lymph spaces of the cerebro-spinal

cavity. Other viscera, innervated by the solar plexus,
coeliac axis, and other sympathetic ganglia, conform to the
same laws in relation to the incidence of those diseases
which spread to them from the systemic nervous system,
and serve as channels through which morbid or toxic
agencies find an exit from the sympathetic system, on the
same principle which characterises the excretion of an
exanthematous virus or chemical poison from the cutaneous
surface of the body. |

From all which we may infer that these varieties of
disease processes and phenomena associated with neural
excretion are the active curative agencies or means exer-
cised by the vis medicatrix nature for the maintenance of
the health of its subjects, and that, generally speaking, all
that science and art are called upon to do is to “‘put no
obstacles in the way,” and, if possible, to “‘lend a helping
hand” in the work which the natural history of the
particular disease in question usually more or less clearly
indicates.

Before departing from the subjects of neural terminal
distribution and excretion as the determining factors in
fashioning the character and pattern of skin eruption, and
affecting the incidence of diseases belonging to the sensory,

motor, and sympathetic terminal nerve distributions, we

would call attention to the possible, and, we think,
probable, occurrence of an order of diseases, due not to
the action of neural material poisons on the structures to
which the nerve terminal fibres are conveyed, but to the
modifying and, it may be, destroying influence of intensi-
fied, perverted, or alien nerve energy finding an exit
through these terminal nervatures into the histologically
related, if not continuous, non-nervous or sympathetically
innervated textures. The leakage of nerve energy in
small or large amounts into or out of sensory and motor
and sympathetico-systemic nerve terminals is an occur-

+6 PHYSIC

rence felt and seen in the experience of every observer, in
such affections as herpes zoster, epilepsy, and certain forms
of gastralgia, together with many other forms of neuralgia,
of particular nerve trunks or fibres, where absolutely no
material change can be traced in the structures implicated,
but where, of necessity, there must be the passage of nerve
energy, with its implied molecular disturbance of the
proper nerve and related substances. This disturbance,
as we have already said, consists often, if not always, of a
reverse current of nerve energy, i.e. the passage of an
efferent current along an afferent nerve trunk or fibre,
and, it may be, the passage of an afferent current along
an efferent nerve trunk or fibre. The tracing of such
nervine phenomena, amid the fibral intricacies of the
sympathetico-systemic nervature, may be possible, but is
transcendentally difficult ; suffice it to say, therefore, that
the two forms of nerve energy, afferent and efferent, being
different in genesis and manner of conservation, must be
different in their influence on the various nerve elements
concerned in their conveyance and distribution, the two
being 1n a sense comparable to negative and positive in
the kindred domain of electrical phenomena. Herpes
zoster, for instance, according to this view, consists in
efferent discharge of nerve energy through an afferent nerve
trunk and terminal fibres into structures not designed to
discharge, but to receive, hence the neuritis ; while epilepsy
consists in the discharge of nerve energy, efferently, it
may be, of the whole of both cortical and deep-seated
‘nerve centres,” cerebral and spinal, hence wholesale and
inco-ordinated character of the muscle spasm and the lapse
of consciousness which characterise such seizures. The
phenomena characterising the mixed sympathetico-systemic
pains and pure neuralgias are of less evident order in
causation and sequence, but, nevertheless, traceable to
some extent on these lines ; their careful study will, there-
fore, we are convinced, repay the expenditure of whatever
attention may be given to this department of the subject
in a more intelligent “‘grasp of the situation” and an
increased power to deal with it practically. *

The lethal discharge of nerve energy from peripheral

nerve endings, more especially on the sensory or afferent

ON NEURAL EXCRETION 77

aspect of the systemic nervous system, seems to us to fall,
or to operate with the most deadly effect, on the textures
innervated by the sympathetic system, amid which the
systemic terminal nervature is distributed, destroying, it
may be, their vitality, and leading to solutions of their
continuity, in proportion to the continuance and intensity
of the discharge. These solutions of continuity may vary
in extent from the merely molecular and minute to the
somatic and general, and may be sudden or prolonged in
regard to the time occupied in their production, and
temporary or permanent in their destructive results, ac-
cording to the completeness of the textural destruction
effected. Thus a herpes zoster may be of such a slight
and ephemeral character as scarcely to be noticeable, or so
severe as completely to incapacitate its subject, entail great
suffering, and the destruction of more or less of the skin
and subcutaneous tissues involved in the herpetic process.
The destruction here indicated is ‘‘on all fours” with that
effected by “‘rodent ulceration” wherever existent, and
seems to us to depend on molecular or somatic death of the
involved tissue elements by the lethal discharge of nerve
energy from the peripheral extremities of the systemic
afferent nervature into the sympathetically as well as the
neighbouring systemically innervated tissues; hence the
microscopic appearances of the resultant tissue débris must
depend on the nature and texture of the tissue under-
going destruction, and the character of the particular
microbic organism which may have gained access to the
scene of destruction, and whose function for the time
being may be that of scavenger and innocent assister in
the performance of organic hygiene, phagocytosis not being
here necessary, the removal of molecular débris, the result
of neurolysis, being the pressing desideratum, and the
raison d’étre of their presence.

Viewed from this point, “‘rodent ulceration” is usually
confined to a particular nerve or nerve fibre terminal
arborisation, and manifests itself, as its histological posi-
tion necessitates, in the involved arborisation, thence
spreading, it may be, horizontally or laterally to neigh-
bouring arborisations of the same nerve trunk, «branch,
or fibre, and perpendicularly, or at right angles, along the

78 PHYSIC

receding and decaying nervine and other structures in the
line of its destructive progress, regardless of obstruction,
however resistant, until it reaches the dividing line, or
nervine ‘‘ watershed,” where its progress ends, or con-
tinues, into the central nerve centres, where it may
terminate in the death of its subject, or be reflected along
some neighbouring or histologically continuous nerve
structure on the same side, or, it may be, by symmetrical
extension on the opposite side, to continue its rodent
progress, and reduce the citadel of life to complete capitu-
lation by continued devastation of its vital defences.
Thus sometimes, after years, it may be, of molecular
‘““sapping” and ‘‘mining” or neurolytic activity, the
strongest and heaithiest body inevitably crumbles, and
finally perishes, from the attacks of its own forces, de-
livered against its own defences with inexorable precision
and sustained determination; an occurrence only com-
parable to that of lethal and fatal systemic autotoxis and
devitalisation, to be met with in certain conditions of
vitality and body hygiene. Applying this method of
etiological analysis to the explanation of the origin and
progress of cancer or malignant disease proper, we are
struck with its applicability and the manner in which it
can be made to clear up many of the obscure problems
involved in mastering its pathology and genesis; thus,
whether cancer in any particular instance is to be regarded
as a disease of external or internal origin, of microbic
descent or dependent on the pre-existence of tumour germs,
we see it deliver its malignant attacks along lines often,
if not generally, marked out and differentiated by nerve
distribution, indicating that in such instances it has ob-
tained an entrance into the cerebro-spinal cavity, and
delivers its attacks along lines secured by nerve distribu-
tion on the areas and structures involved; whence it
_ follows that the materies morbi may circulate along the
inter-neurilemmar spaces in the cerebro-spinal lymph, or
along the true nervine elements, the medullary or axis
cylinder substances, as a material virus, into the substance
of the involved tissues or organs, or that the cause of the
attack may be due to discharge of nervine energy on or
amongst the molecular elements of the affected tissues,

:* tr bree r

ON NEURAL EXCRETION 79

in which latter case the cause may be called dynamic, and
not material.

In this way we shall realise that the several observations
and conclusions of those engaged in the work of research
in this obscure department of pathological investigation
are entitled to the greatest respect, inasmuch as each and
all engaged in making them have been giving a true
picture of their impressions and conceptions of what they
have seen, and have each and all described an actual
instance or instances of the many characters which cancer-
ous disease assumes, according to the nature of the struc-
ture or structures chosen or attacked by it. The recondite
theories which in these modern times have been advanced
in explanation of its etiology and genesis, as well as its
progress, will to some extent, we hope, be beneficially
influenced by information obtainable along somewhat dif-
ferent lines, lines which, we claim, flow from the belief
that the physiology of a structure, or of the whole organ-
ism, is the main determining influence in the shaping of
its pathology in each and every diseased condition ; altered
structure, leading to altered function, in unbroken and
graduated continuity, from the benign to the malign, from
the ephemeral to the persistent, and from the slight to the
fatal. The earliest possible pathological moment, with
what it displays of pathological change in structure and
function, must, therefore, be laid hold of, in order that
the true etiological factors may be apprehended, their lethal
work prevented, and effectual barriers raised against their
further progress. In this way, we may hope, by a union
of the physiological and pathological forces scouring this
field of research, and the consequent strength derivable
from united action in a common work, to obtain a clue to
the discovery of what cancer, as a morbid entity, really is,
as a means of accomplishing its prevention or effecting
its cure. It seems to us that here both time and effort
are being to some extent dissipated in a comparatively
futile attempt to obtain a knowledge of the cause or
causes of this most destructive disease, amid the structural
ruins left by its agent or agents, after the work of destruc-
tion has been accomplished, and the real culprit, or culp-
able agency, had disappeared from the scene ; viewed thus,

80 PHYSIC

it would appear that what is discovered of the etiology of
the disease is not its real cause or essence, but the remains
of some of its weapons of offence, bacterial developments, |
embryonic survivals, and others, amid the surroundings
of pathological débris and debased function. |
Underlying and determining the fell work of cancer, as
well as rodent ulcer, we are deeply impressed with the
idea that primarily altered and disturbed dynamic equili-
brium is operative in bringing about the material pre-
pathological or preparatory conditions necessary for the
operation of the specific etiological factors, whatever they
be, and whenever they ‘‘ assume the aggressive” ; without
this preparatory, disturbed and altered, dynamism, local
or general, we are strongly of opinion that no mal-forma-
tive or pathologically organic departure can take place in
any tissue or. organ, and that no disease process can be
permitted to exist, so long as the physiological condition
of the organism, locally and generally, is maintained.
The conditions of tissue or organ, known as physiological
and pathological respectively, insensibly merge into each
other, and which, being taken as axiomatic, it follows that
in Our investigation of diseased conditions such as cancer,
we must be prepared, along the debatable lines of structural
union, to turn over, first to one side and then to the other,
the structures involved, and to view them alternately as
physiological and pathological entities, in order that we
may arrive at scientifically justifiable, if not absolutely
correct, conclusions. It is an interesting but somewhat
disconcerting deduction to make from the theory of dis-
torted and altered dynamism, as a disease factor, that man
—as well as all living organisms—bears daily about with
him the elements of his own destruction, the letting loose
of which leads to the production of disease, and its con-
tinuance to death. Man is thus heir to two methods of
self-destruction, viz. autotoxis and auto- or neuro-
cution, to coin a term, depending on conditions, flowing
respectively from his material and dynamic component
parts in both their independent and related aspects and
bearings. The physiological working of vital energy on
organic plasma results, in the state known as health, in
normal growth and tissue sustenance, while the patho-

ae aa ee er eS PS ee Oe

= TELE PA Se > oe ee
Tos fo 7 ~ t)

ON NEURAL EXCRETION 81

logical working of vital energy on organic plasma results,
in the state known as disease, in waste, decline, or atrophy,
or in increase or hypertrophy, according to the formative
proportions of the pathogenic elements of growth, both
dynamic and material, or by the perversion of these
elements of growth into a condition known as hetero-
genesis, in which come to be displayed, in one form
or another, organic structures of greater or lesser malig-
nancy, according to the position and character of the
structural elements involved, and the length of time to
which the diseased process has extended. By the degree
of normal inter-action on each other of the formative ele-
ments of vital energy and organic raw material, a normal
or healthy tissue is involved, while the want of that normal
inter-action results in the evolution of an abnormal or
unhealthy tissue, in proportion to the character and dura-
tion of the abnormal condition, which may be either
atrophic, hypertrophic, or heterogenetic and malignant, and
may consist in, or arise from, want or superabundance, or
the perversion of either or both elements—the dynamic or
the material.

The heterogenetic or malignant, therefore, emanates
from the normal tissue elements, on conditions entirely
dependent on the formative elements, plus the influence
of altered metabolism, due to the departure from normal
inter-action of these elements—the physiological giving
place to the pathological, along lines defined by histology
and anatomy, and, therefore, necessarily conformable to
existent morphology in each and every instance.

~The human body par excellence, composed as it is of
two distinct systems of dynamic and organic machinery,
so to speak, actuated and operated by the sympathetic and
systemic nervatures respectively separately and in con-
junction, is liable to break-downs emanating from one or
both of these systems ; hence it becomes a scientific neces-
sity to discover the ‘‘ sequence of events” constituting the
particular example of disease on which attention for the
time being is being bestowed, in order to arrive at definite
and correct conclusions, on which to found a treatment by
which it may be possible to rectify the faulty working of
these organic machineries, so far as it is possible to do it,

II F

82 PHYSIC

by the adoption of scientific means, intrinsic as well as
extrinsic, medical as well as surgical.

The neuro-organic dual control here indicated, although
an element of safety for the preservation of life in its daily
occurring and recurring exigencies, may be conceivably an
element of danger, as, for instance, where the lethal in-
fluence of systemic neuro-dynamic outflow, along un-
accustomed paths or in unaccustomed quantity, may
destroy the integrity of the textures invaded, whether
they belong to that system, or whether, as most likely,
they belong to the other partner, the sympathetic; thus
epilepsy, from its very intensity, may absolutely destroy
life almost at once, and thus rodent ulcer may destroy
molecularly or piecemeal the combined or dual structures,
both diseases being self-centred, if not self-initiated.
Much the same may be said of cancer, with the addition
that, instead of destruction and immediate dissolution and
outcasting of texture, it keeps in pathological being and
textural continuity the various structures and organs
attacked by it, their final dissolution being thereby delayed
until the physiological barriers opposing it are absolutely
broken down and levelled, as a mass of pathological débris,
amid a scene of dynamic confusion and chaos—an example
of the morbid siege and ultimate reduction of the human
citadel, by one of its fellest enemies, of the most tragic
and complete description known to medical science, and
surely deserving of the utmost efforts of philanthropy
and sympathetic humanity to mitigate and, if possible,
remove.

Under such circumstances it behoves us to keep fast
hold of first principles as guides along the dark and un-
illumined way open to the pioneers of research in this
‘“‘dark continent,” where lurk the felt, but unseen, and
malignant foes of humanity, and if these first principles
are but rush-lights in a darkness intense as midnight, it
further behoves us to replenish the supply from whatever
source is available. We, therefore, feel warranted in pro-
ducing what we think may become one of these, and
offering it for use, so far as it will go, and so long as it
will last, in order that the work of exploration may
be even fractionally assisted. This rush-light of first

ON NEURAL EXCRETION 83

principle is the recognition of the fact that there can only
be in malignant disease, as in all disease, the collision or
friction of two factors, the material and dynamic, and a
resultant pre-pathological disturbance of, and disparity in,
the working of physiological organic statics and dynamics,
which may, or may not, lead to a sustained pathological
working of certain structures and organs, and to the estab-
lishment of fully evolved malignancy. The recognition,
therefore, of the circumstances constituting this premoni-
tory disturbance, disparity, and friction in the material and
dynamic working of the human organism, is the great end
to be aimed at primarily by research, as the prevention, and
not the cure of the disease, will then only have to be
dealt with, while the way to remedial success may simul-
taneously be brought into clearer view, if not practical
realisation.

From all which it follows as axiomatic that, if the
physiological material and dynamic balance in the working
of the human organism can be constantly maintained, no
disease, innocent or malignant, can exist, and that, if
unhappily that balance is but temporarily impaired or
lost, it equally follows that disease is beginning, or has
begun, and that the incidence of that disease will depend
on the nature of the influence or influences by which the
balance has been destroyed, while the later stages of the
disease so commenced must be evolved by the vital con-
dition of its subject, and the character of the accessory
morbid influences and agencies, material and dynamic,
active and passive, live and dead, which are then naturally
present at, or subsequently determined to, ‘‘the scene of
operations.”

In the evolution of disease it must never be forgotten
that the two usually co-operating agencies, dynamic and
material, have for the time being ceased to work in har-
mony, with the result that the scene of their combined
operations ceases to be characterised by functional and
organic order and normal material disposition, and assumes
an appearance of spasmodic effort, in-codrdinate and pur-
poseless, as to function and destruction of material or
structural integrity ; we will thus, on coming critically to
examine the “‘condition of things” brought about by this

84 PHYSIC

morbid occurrence, be necessarily confronted with only
the material remains of the catastrophe on which to expend
our pathological acumen and to elicit the nature of the
disease process—the dynamic factor in that process having
disappeared, as the electric discharge does in the thunder-
bolt, which is afterwards only known by the wreckage it
leaves behind. Remembering this, it will necessarily be
found that microscope and crucible have their limitations
as instruments of discovery, and that they require to be
strengthened, supplemented, and corrected by a ceaseless
appeal to physiological aid and clinical support, in order
that the factors of morbidity may be discovered and seen
at work, their respective powers for evil appreciated,
restrained, and neutralised, and their continuance pre-
vented.

In accomplishing this, it will be perceived that the prin-
cipal partner in the combination of disease factors must be
the dynamic, which is at once the arranger and admini-
strator of the vital business affairs, so to speak, in a work
in which the capital of the sleeping partner becomes the
subject of the firm’s operations, and which, if prodigally
used, in time will literally fail.

In this work outside influences, such as science, may, if
called upon to indicate and supply, do something to pre-
vent the inevitable collapse, which must overtake the
working of all such firms by the adoption of means to
correlate the working and conciliate the amour propre of
the partners, so as to give a fresh start, and literally a “new
lease of life”? to the firm, which here signifies the restora-
tion of a diseased body to a state of health. In accom-
plishing such a great work, our scientific efforts must be
dominated by a strict adherence to indications, based on as
true a knowledge of nature’s ways as can be obtained from
the strictest scrutiny and the use of not only the keenest
observation and best directed experiment, but the most
liberal application of “‘common sense.” If it be found
that the material, or sleeping partner, has suffered in what
he has contributed to the firm’s work, by shrinkage, or
depreciation of capital, the restoration of that capital to
its original proportions and quantity must be sought for
by every legitimate means, and if the quest be successful,

ON NEURAL EXCRETION 85

good and well, but if, after every legitimate effort towards
that end, it fails, then it behoves the directing partner no
longer to attempt the impossible, on the principle of
‘putting new wine into old bottles,’ but to accept the
inevitable and become accustomed to work in ‘‘reduced
circumstances,” which, in other words, means that a failing
material capital must not be destroyed at the expense, or
by means of, an artificially strengthened and accelerated
dynamic expenditure.

We must, therefore, regard it as a sound principle not
artificially to overstimulate a failing brain and nervous
system by infusing into them alien dynamic influences, or
over-increasing the crippled output and exercise of ordinary
nerve energy, but rationally to slow down, husband, and
regulate the currents of physical and nervine work, in
accordance with the necessities of reduced organic ability,
by courses of graduated mental massage, so to speak, and
the dynamic influence of restricted nervine effort and
modified cerebration—in other words, ‘‘spur not a done
horse,” but give him food and rest first, and exercise
afterwards.

EXTRACT XIII. a.

ZYMOSIS WITH REFERENCES TO PARASITISM, CON-
TAGION, AND INFECTION. ALSO ON ENGLISH
AND ASIATIC CHOLERA, SO CALLED.

PaRASITISM, contagion, infection,—what a combination
of living pests is here grouped! Yea, it is sufficient to
make the strongest thinking member of the human
family shudder and shrink! Yet we get accustomed and
callous, it may be, to our future avoidable, but now
inevitable, companionships, and can bear critically to
regard them as no doubt possessing some necessary, but
at present undetected, raison détre, which consequently
it becomes our duty to discover and turn to proper
utilitarian account.

Parasites, in gaining a human home, are usually im-
planted or swallowed in embryo, contagia attached, by
adhesion to, and penetration of, the peripheral and inner
surfaces of the body, and infections wafted into its in-
terior in contaminated air, each mode of entrance originat-
ing an organic pathogenic agent possessed of specific living
qualities, enabling it to live a life of dependence on its
host, and to perpetuate its species, according to the laws
of heredity and the battle of life.

In pursuing the subject, we shall mainly regard it from
the point of view of the general subject of zymosis.

By this term, if it be permissible to use it, we mean that
morbid etiological process, which is continually exhibited
as a health disturbing and destroying factor throughout a
large extent of the better understood morbid entities of

ZY MOSIS $7

life generally, and in a constantly increasing number of
the diseases affecting the human organism in particular,
as they become better known in their nature and essence,
as pathological research is brought to bear on them. The
process implies that a more highly organised body may
become tenanted by another body of a more lowly organ-
ised order, the latter multiplying itself and procreating
its species at the expense of the former, thereby affecting
its health, and sometimes even destroying its life.

The diseases thus affecting the human species are
numerous, widespread in their incidence, and often most
fatal in their consequences. They embrace a wide range
of morbid conditions, febrile and non-febrile, local and

eneral, and are due to the invasion of a part or the
whole of the infected organism by a microbe or bacillus,
which lives and multiplies according to its generic and
individual character and nature, and whose incubation,
growth, and continued presence or expulsion synchronise
with certain conspicuous features and well-marked stages
of the resultant zymotic condition. The natural history
of many of these disease-producing organisms is now well
known to science, and has given a name to a department
of biology known as bacteriology, the future of which
seems likely to be fraught with eminently beneficent results
to the human race, and its immediate lower relatives, in
the very possible and highly probable additions which are
likely to accrue to preventive as well as curative medicine
from the continuance of its progress along definite and
scientifically dictated lines.

_ The first diseases to be understood, described, and
classified as zymotic were the fevers, exanthematous and
non-exanthematous, but others have constantly been added
as bacteriological knowledge has increased and become
more exact, until now they have become one of the largest
groups of classified morbid conditions amongst the
authentically proved and accepted category of human
ailments. Moreover, besides the, what may be called,
systemic constitutional or general zymotic diseases, a
large class of local diseased conditions may be dominated
local zymotic, as distinguished from the grosser parasitic,
or non-zymotic, ailments, as respective types or illustrative

88 PHT

examples of which we might adduce erysipelas and
scabies. .

The primary or immediate effects of zymosis consist —
of those resulting from the foreign organic or microbic
invasion, and its destructive and disorganising influence
on the living textures, the vital properties of which become
impaired and perverted, the secondary effects being those
due to the continued presence in the affected textures of
the bodies attacked, of the toxines, to which the growth
of the zymotic or microbic agencies give rise. ;

The zymotic germs or organisms may attack their
human hosts in many ways and along numerous paths,
in fact, along every inlet to and outlet from their bodies ;
they may thus be air-borne, water-borne, or hidden within
the articles of food and drink consumed, or they may enter
by every chink in the external covering and protective
envelopes of the body, as well as through the linings of its
hollow viscera ; but however the invasion be effected, and
whether by foraging scouts or a whole army corps of the
‘locust brood,” the overrunning and occupation of the
invaded structural territories become the final result.

A few of the main lines of zymotic invasion and attack
may be enumerated and considered in more or less detail,
and first, we, following our last paragraph, would refer to
the air-borne microbes, which effect their entrance by way
of the respiratory organs—and by the respiratory organs
we mean the whole mucosa lining these organs, from the
nasal passages and accessory pneumatic cavities of the face
and head, to the minutest pulmonary vesicular spaces. In
the extent of assailable surface included in this area, there
are abundant points where invasion can be accomplished
with a minimum of difficulty, and we find that these points
are taken advantage of by the bacterial invading forces ;
thus the nasal fosse, with their communicating air spaces,
_ offer an ideal surface to which air-borne spores can adhere,
and, if not molested or removed, grow and develop, by
continuity of medium and pabulum, along the olfactory
inter-neurilemmar spaces into the inter-meningeal spaces of
the cerebro-spinal cavity, and by the intra-olfactory pas-
sages into the associated lateral ventricles and other intra-
cerebro-spinal spaces. Thus, also, the glosso-pharyngeal

a er

eR om Seite i wae ea

ZY MOSIS 89

mucosa affords a wide area for the growth of microbic
organisms, and a ready means of reaching a channel of
entrance to the cerebro-spinal cavity and third ventricle by
the pituitary apparatus.

hus, moreover, but not directly through the nervous
system, does the laryngeal, tracheal, and pulmonary mucosa
lend itself to the passage of hostile organisms into the
blood circulation with which it is overspread and inter-
penetrated, and where, especially in the calm vesicular
pulmonary recesses, in which rests the residual air, a fitting
repository is found for the lurking and breeding of unsus-
pected lethal bacillary organisms, in “‘ miliary” proportions,
which are destined in the future to break their barriers,
join their contingents, and overrun and annihilate their
host.

From the above it will be seen that air-borne bacteria
attack primarily the nervous system in the first two
methods of invasion, and the blood in the third and last ;
it must, therefore, follow that the organic media first over-
run must be the cerebro-spinal lymph and the blood
respectively, and that the germinal pioneer broods incubate
there, and thereafter traverse the invaded organism along
the lines of least resistance, and finally effect an exit by
eruption into neighbouring not yet invaded areas, or on
to the limiting or ‘“‘bounding” surfaces of the body,
external and internal. The lines of invasion, the media
of incubation and growth, and the means and places of
exit of the peccant organisms, are, therefore, determined
by anatomical structure, physiological affinities, and histo-

logical continuity of circulatory facilities—moreover, the

characters of the resultant morbid phenomena are conse-
quently moulded by the same genetic conditions, together
with the differing zoological, botanical, and other features
of the various bacteria. In this way the viri of such
varying diseases as influenza, diphtheria, and tuberculosis
effect an entrance into the systems of their victims, incu-
bate, develop, and remain, or are thrown out, according
to definite genetic conditions.

Water-borne bacterial organisms have a more limited
‘sphere of influence,” but yet one sufficiently wide to
enable them to effect dire injury on whole populations

90 PHYSIC

where the indispensable element of water becomes con-
taminated and where its choice is limited. Drinking water
thus becomes the principal representative of the media
by which such organisms are conveyed within the bodies
of their victims, and its most lethal microbic organism is
the comma-bacillus, or cholera germ. The manner and
methods of its attack have been described so fully that a
great literature is now claimed by it, and yet it cannot be
said that it is satisfactorily understood—thus its geographi-
cally determined varieties are sometimes not founded on
generic differences of bacterial organisms, but on climatic
and other influences affecting the growth, virulence, and
septic qualities of, in all respects, identical organisms.
We, therefore, sometimes find that a local outbreak of
British cholera, or summer diarrhoea, is in no way dis-
tinguishable from Asiatic cholera in the fatality of its
influence, the character of its materies morbi, and the
symptoms to which it gives rise. —

In illustration of the truth of this statement I would
adduce the following personal experiences in which my
own services as Medical Officer of Health were completed
by those of Professor Klein, Bacteriologist, and Dr.
Bulstrode, Inspector of the Local Government Board.

The findings of Professor Klein, after an examination
of the excreta of the first and last cases, were to the effect
that the bacillary organisms discovered were *‘indistin-
guishable from those of Asiatic cholera.”

This outbreak proves that the disease can be self-
renewed in the same individual by the preservation of
septic cultures from a patient’s own excreta. Moreover,
from this point of view we may be warranted in inferring
that the dried residue of choleraic diarrhoea might be
spread atmospherically, might remain dormant for a period,
or until the required conditions of heat and moisture being
renewed a re-growth is effected, by which the disease may
again be spread.

This is the experience referred to which I take the
liberty of quoting from my final report on the subject to
the Local Government Board.

i ae Teri rs

.

oR PY Ser eee

= RE et We en gg ©
_" b — _—

1 2] hate lgley Be

De DNS tae Ayr gee:

ZY MOSIS gI

14th November, 1893.

To the
Secretary of the Local Government Board.

SIR,

In continuation of my report of date October 4th, relative
to an outbreak of “Choleraic Diarrhoea”? at Low Moor, North
Bierley, I have further to report, that the outbreak seems now to
be at an end—no case having occurred since the death of Mrs.
Law, Morley Carr, on the gth of October.

Altogether, six cases of the disease occurred, and six deaths—
the names of the victims being as follows:—Edmund Wood,
aged 20 years; Mary Wood, about 42; John Wood, 42; Jane
Stocks, 39 ; Mrs. Lockwood, and Betty Law, 71—the first three
were son, mother, and father, the next two were sisters of Mary
Wood, and the last was a neighbour, who assisted in nursing.

In arriving at a solution of the etiology of the outbreak, I have
been unable to trace to any Asiatic source, or to contaminated
water, milk, or food supply, neither have I been able to make out

‘its connection with any preceding cases of the disease. I have,

therefore, been led to believe that there has been something like
““cause and effect” in the following circumstances: I am informed
that Edmund Wood, the first to be affected, was the subject of
“Chronic Diarrhoea,” or what his friends called “ consumption of
the bowels,” and that he sought relief for this in a “ change of air”
to Southport. On leaving he took with him (and this seems to be
the point of origin) a quantity of napkins, or diapers, to prevent the
accidental soiling of his clothes, or of the bedding in the lodgings
to which he resorted.

‘These napkins, or diapers, when they became soiled, instead of

being destroyed, were returned to the box from which they had

been taken, and brought home with him on his return—meanwhile
the contents of the box were no doubt the scene of the growth, or
“culture” of organisms (comma-bacillus), which simply required a
suitable soil in which to develop and perpetuate themselves, and
this was supplied by the lad himself and his immediate relatives,
whose office it was to wait upon him.

The opening of this box, thus, seems to have originated the
outbreak, and appears to demonstrate that our own country can
grow a “ materies morbi” as lethal and destructive as any that can
be bred in Asia.

I am, Sir,
Your obedient servant,

(sd.) THOMAS LOGAN.

.

92 PHYSIC

In view of such common characteristics, clinical, bac-
teriological, and general, we think we are warranted in
insisting on the adoption of a classification and nosology ~
which will more strictly accord with the requirements of
science, and be less misleading in its bearings om the choice
of the preventive and curative lines of treatment most
likely to be successful in obviating the occurrence of epi-
demics of the disease and securing its extinction on its
earliest appearance.

The retention of the terms Asiatic and British, as indi-
cating two different diseases, is not warranted by fact, and
can consequently not be continued without violating an
essential necessity of all scientific progress, viz. truth.
We would, therefore, urge that our nomenclature here
requires overhauling and modification in order to bring
it up to “‘the requirements of the times” in both a
utilitarian and scientific respect.

Zymosis, besides typically delivering its attacks on these
main lines, invades the human body by “‘sapping and
mining” through every loophole or vulnerable point pre-
sented to the outer world, and many a disease owes its
origin and development to the stealthy invasion of a
single channel, or, it may be, a few lymphatic spaces and
associated vessels, as, for instance, hydrophobia, where it
attacks its victim through a single opening into the cuta-
neous tissues, through which its virus finally reaches the
cerebro-spinal lymph cavity, either by way of the nerve
vasculature directly, or by way of the lymph vasculature
into the blood vasculature, or by way of the blood vascu-
lature into the cerebro-spinal cavity and contained nerve
structures indirectly. According, therefore, to which of
these lines may be traversed singly or in combination by
the virus, the time of the manifestation of specific symp-
toms is determined, and the time for prophylactic treatment
‘regulated. Zymosis here seems to be effected by a com-
paratively limited and slowly progressive bacterial growth
along definite anatomical and histological lines, neural,
lymphatic, or hemal, and to manifest itself in the produc-
tion of the characteristic symptoms in consequently most
irregular fashion and at most uncertain intervals, according
to the length of distance traversed by the poison and the

ad

MR a le

ZY MOSIS 93

extent of the initial tissue and vascular invasion. The
fundamental necessity for the final delivery of the specific
attack is that the cerebro-spinal lymph should be zymosed,
so to speak, by the hydrophobic bacteria, and tainted by
their toxins to such an extent that the encircled and inter-
penetrated neighbouring brain (but especially ‘‘the
medulla”), cord, and nerves become literally saturated and
intoxicated with the specific virus. On this occurrence
nothing but the preparation of the subject of the microbic
invasion for withstanding the attack and development of
the terrific phenomena of this fell disease, by the renowned
method of Pasteur, can offer any specific hope of averting
its inevitably fatal termination. We, however, now have
every reason to rejoice that science even here is offering
such well-founded hopes for those unfortunate enough to
contract such a fearful disease, and to the world generally
that there is a possibility that it may in time “‘ cease to be.”

Zymosis may confine itself to a single structure, or
series of structures, may begin and end there, or may, by
continuity of the involved textures with neighbouring
textures, continue its destructive course indefinitely, as,
for instance, in certain lupoid affections and ulcerative
processes as well as “‘fungating” surfaces. Zymosis may,
moreover, begin and continue a local invasion along a
single line into the blood or lymph streams proper, or
by nervine channels into the cerebro-spinal lymph, there-
after effecting an exit along the same or other local lines
without producing more than a minimum of constitutional
disturbance or more than a local effect or an entirely local
discomfort. Zymosis is, therefore, a process varying in
the intensity of its effects from the most ephemeral and
mild to the most prolonged and malignant, according to
the media and textures invaded, and according to the
character of the invading organism, as to rapidity of
growth, reproduction, and spread, and the intensity of
the virulence of action of its toxines on the structures and
physiological processes involved.

The parasitic, contagious, and infectious agents now
known to science represent a wide field of natural history,
and comport themselves in their pathogenic work in a
great variety of ways, and deliver their specific attacks on

94 PHYSIC.

almost every individual tissue and organ. Thus the
parasites sometimes live in common with their hosts on
the elements of the common food supply, while sometimes
attaching themselves for sustenance to particular struc-
tures or organs, the contagious taking more or less general
possession of the total liquids and solids of the body, and
the infectious comporting themselves according to their
local and general likes and dislikes; they thus attack
among them, in general or in detail, the whole organic
elements, either in organic mass, in structural division, or
cellular unit, and hence, roughly, they are divisible into
fully developed and differentiated organisms, cellular com-
munities, or uni-cellular organisms, and organised particles
capable of intra-cellular life and development, and so, indi-
vidually, they are able to annihilate en masse or reduce
in detail the strongest body and the most resistant struc-
tures, the last mentioned being able to effect the process
of absolute disintegration of organised matter, plastic or
solid.

Zymosis and sepsis are thus to a considerable extent
identical in meaning, and signify, in preventive and cura-
tive medicine, an extent of area of ever rapidly increasing
and widening proportions, but an area, nevertheless, which
the rapidly progressive march of bacteriological knowledge
and research are coping with in the most hopeful manner,
and demonstrating that the trend of progress in medicine
is ever towards prevention of disease, through the dis-
covery of its causes, and the application of scientifically
devised means of prohibition and neutralisation. There-
fore, we feel warranted in holding the opinion that as thus
much of the disease and suffering to which “‘ human flesh
is heir” is likely to be eliminated from its long category,
and finally, barring accident, that there is, or will be, a
chance given for man to live to the full extent of his
attainable existence before yielding to the incidence of old
age and final dissolution.

Pat hy aN

he ~~

agak.

EXTRACT XIII. zs.

ON SMALLPOX,

Tuis is a disease of a typically contagious and infectious
character, and as an example of the acute varieties of the
exanthematous and zymotic diseases it might appropri-
ately be appended to our general treatment of the subject
of zymosis.

It will be noticed that it is both contagious and
infectious, being able to effect an entrance to the bodies
of its subjects through the media of the air they breathe,
the liquids and solids they consume, and by direct surface
acquirement through personal contact with the materies
morbi.

The disease is so well known, and has been so much
and so long in the public and professional eye, that any
allusion to its clinical character and treatment will not be
here necessary; we, therefore, merely venture to refer to
a few of the aspects of the subject so far as they relate

to the views we are promulgating ; and, in doing so, it

may best meet our requirements if we recapitulate the
main features of a case with which we are familiar. The
case is as follows: —J. D., a young commercial gentleman
of splendid physique and athletic attainments, in the course
of business was ushered into the room of a gentleman
who had been but a short time unwell, but who, as it
turned out, was at the time developing an attack of
variola, and who, as is generally the case in severe confluent
smallpox, was profoundly “‘poorly.’ He talked for a
short time with his affected host, and on bidding him
good-day and leaving, he suddenly became aware of a

96 PHYSIC

peculiar and, to him, very disagreeable odour, which
seemed to emanate from the bed, which he had not
touched, or from the gentleman himself, whom he had not
been near. ‘This odour continued to “‘ haunt him” and
to draw his attention to its probable source or cause, when
he remembered he had seen the gentleman turn in bed at
the time he felt it, and, in the movement, that the bed-
clothes were tossed about, and he became satisfied that that
must have originated it ; meantime, while trying to forget
the circumstances, he became aware of unusual feelings of
discomfort, and ‘‘sickened” so as to be compelled “to
take to his bed,” learning, at the same time, that his friend
on whom he had called had developed a severe attack of
smallpox. For some time he continued ‘“‘better and
worse,” but ultimately became the subject of a dangerous
attack of the same disease, which also became confluent,
and, after running a protracted course, subsided, leaving
him deeply pitted, but otherwise absolutely well.

e now enquire, whence came the infection in this
case? and we are satisfied that the answer should be, ‘‘ from
the gentleman on whom he called”; nevertheless, it may
be best to advance our reasons for the belief, seeing that
absolute certainty in such matters is impossible. And
these reasons are the following: The subject of this record
was, at the time of infection, in the best of health, and
had not been, so far as he could discover, in the neighbour-
hood of the disease ; he had not touched the body or the
immediate belongings of his friend who was unwell, but
he had breathed a “‘ fetid air”? which emanated from him,
and which made in reality a deep impression on his
olfactory mucosa, and here is the fons et origo of his
attack of variola, the factors operating in some such way
as this—the subject, from whom the infection emanated,
had begun to throw off a brood of variolous microbes in
the perspiration of his skin, which was on the eve of
showing their presence by unmistakable eruption, and
these had ‘‘ taken wing,” so to speak, in the vapourised
or insensible transpiration, and, floating in the atmosphere
confined under the bedclothing, waited their chances of
freedom, which arrived at the time and by the means
mentioned, when, ‘‘as luck would have it,” a ‘‘ new start

ON SMALLPOX 97

in life” immediately presented itself to the disengaged
microbes, on which they were ‘‘not loth to seize,” and
in which they perpetuated with unabated vigour and
renewed strength a further brood of young pathogenic
organisms. ‘These are the ‘‘ main facts of the case,” and,
we think, there is little doubt but what they prove the
whole sequence of cause and effect.

The nasal mucosa, being the main route by which the
microbes reached the cerebro-spinal cavity, where they
incubated and grew, in the medium of the cerebro-spinal
fluid, renewing their journey into the outer world along
the lines of least resistance, which were those of the inter-
neurilemmar spaces, and finally succeeding in destroying
beyond repair the tissues composing and surrounding the
peripheral sensory ‘‘nerve endings,” thus leaving both a
continuous internal record in secured immunity from
further attack and a legible external record, which not only
variolous microbes, but the human species can read and
‘“‘take note of.”

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EXTRACT XIV.
ON THE “VIS MEDICATRIX NATUR.”

Tuis phrase must be of considerable antiquity, and its
origin would be of some interest to know, inasmuch as it
points back to a time when the educated man had begun
to differentiate between the various agencies responsible
for the restoration to health of the diseased and maimed,
and to a period in the history of medical science when the
deeper aspects of biological processes and things generally
were beginning to present themselves for solution and
practical appraisement and application. It, moreover,
indicates a growing belief in the minds of thinking men
in the powers of nature, not only to cause disease, but to
effect its removal, to produce the bane, and to provide
the antidote.

Nature, in evolving living forms from inert matter,
made each form perishable and ephemeral, embodying in
it the co-working of the principles of life and death, both
of which principles are absolutely essential in the great
evolutionary processes of advancement of type of organi-
sation, and the effacement of imperfect adaptation to
altering environment.

In the process of organic evolution, the vis medicatrix
nature may be regarded from two different standpoints,
according to the two aspects from which we may study its
operations throughout the broad field of animated nature,
the one aspect being the origin and perpetuation of livin
forms, the other aspect being the limitation of individual
living forms to more or less exactly defined periods of
time and areas of space.

;
}
}
.
i.
i

ON THE “VIS MEDICATRIX NATURA” 99

The origin and perpetuation of living forms may be
regarded as the dynamic aspect of organic evolution, while
the disappearance or cessation of living forms, as they
make room for the appearance of others, may be regarded
as the adynamic aspect of organic evolution. The two
processes are complementary of each other, and must be
regarded as equally necessary and essential in the great
process of organic evolution as it unfolds itself in “‘ the
struggle of life” by the ‘survival of the fittest.”

The “survival of the fittest” is the result of every
organic struggle, whether it takes place in the evolution
of the various individual forms of life or in the evolution
of the members, organs, and structures of the individual
organism within itself, and represents on all such occasions
the occurrence of an exhausted or adynamic residuum of .-
degenerate or “‘used up” organic units. This degenerate
or used up residuum, which results from every such organic
struggle, becomes a source of danger to the surviving
organic units and individual organisms, if retained within
or in close proximity to them or their living and function-
ally active structures; it, therefore, becomes a necessity
that a machinery should exist by which all such residual
material can be removed from the “‘scene of the struggle,”
to provide an unincumbered “‘ field,” if “no favour,” for
the continuation of this perpetual organic warfare.

Within the individual organism this machinery exists
as, and is actuated by, the vis medicatrix nature, with the
intent that the life of that organism may last to its utmost
possible limit—the operation of that force, if unopposed,

being just able to prolong it to that extent, so as to obviate

the loss or waste of that organism before it has accom-
plished the work of which it is capable.

This machinery and power, although existing in every
vital organism, cannot definitely be separated from its other
vital machinery and powers, and subjected to such separate
scrutiny and experimental testing as will enable us to make
use of it definitely in the treatment of the many “‘ills to
which human” and all ‘‘flesh is heir,” nevertheless, we
are warranted, and called upon, to make use of every
fragment of inductive evidence we can obtairi on the
subject, and every fact which in any way can be said to be

100 PHYSIC

‘

deducible from the study of it, to enable us not to “run
counter” in our attempts to aid the operation of the vis
medicatrix nature, but to mould “‘our line of conduct”
with an eye to combined action and co-operative influence
with it. The vis nature having done its work abso-
lutely well or physiologically correctly in vitalising and
moulding into organic form the protoplasmic elements of
the fecundated ovum, and in superintending the various
stages of embryonic, foetal, and pre-adult growth by the
aid of the vis medicatrix natura, it lays the foundation
of a future health which, if unassailed by morbific agencies,
is calculated to last, in the human species, to “*three score
and ten years,” and, according to the experience of every
generation, to ‘four score,” or even “‘ the round century.”

This result is frequently obtained by the unassisted
operation of the combined vis nature and its constantly
associated vis medicatrix, and may be regarded as the
natural goal which all humanity is legitimately entitled
to aim at gaining, by these agencies alone, but, if required
from any cause or combination of causes opposed to it,
then by the assistance of science and art.

The vis natura, as the fountain of organism or forma-
tive force, and the author of vitality, utilises almost all
the known forces, combining and opposing them, and har-
nessing them to the machinery of life in the accomplish-
ment of the great organic work of evolution. Should
these forces suffice for the ends of life and health well and
good, but should they not, then the vis medicatrix is called
in to meet the difficulty and to arrange for bridging over
the temporary impossible by the addition or substitution
of other and perhaps exceptional modes of force. The
organic vis nature being a compound of mechanical,
chemical, and physiological modes of force, with that
specific residuum of force or forces known as vital, requires
for its ‘‘field of operations” a combination of organic units,
material and dynamic, specifically adapted and mutually
arranged so that their inter-dependence and co-operation
will result in “‘life,” ‘‘organism in action,” or that which
answers to any other definition of the phenomena called
‘‘ vital,” known to science. It operates by trituration of
the solid materials of the food, admixture of these with

ON THE “VIS MEDICATRIX NATUR” 1to1

the juices of the mouth and fauces and fluids imbibed,
mechanical agitation by intestinal peristalsis, and_ still
further admixture, chemical action and reaction, with re-
sulting changes of composition, physiological or vital,
including those of metabolism or nutrition, and resolution
or disintegration, secretion, and excretion.

When the sequence, mechanical, chemical, and physio-
logical, of these factors and their work becomes faulty, the
vis nature takes to its aid the vis medicatrix, in order to
re-establish the status quo ante and maintain the conditions
of health and continuity of life, hence we find, under such
circumstances, that a change of alimentation is effected, a
modified digestion is accomplished, an improved aération
is introduced, and that such improvements are wrought
in the details of metabolism that physiologically perfect
nutrition is once more in evidence in all its details, with
its usual concomitants of health of body and soundness of
mind.

In the performance of this work of aiding the vis nature
to re-establish the condition of health, it is most interesting
and highly instructive to notice the methods of procedure
of the vis medicatrix, and the agencies it employs in its
beneficent work. ‘Thus, it may be noticed to appeal to
merely mechanical force, as when it excites hyper-peristalsis
or anti-peristalsis, as suits it best, to altered methods of
the use of chemical force, to modified forms of the use of
metabolic energy, and to a modification and redistribution
of the secretory and excretory physiological forces, in order
to meet special wants and necessities. Its methods of
procedure are necessarily determined by the necessities of
the individual occasion, and may require for their carrying
out the single or combined use of one or more mechanical,
chemical, or physiological agencies, such as increased
muscular action of the intestine and blood vasculature,
improved oxygenation, local or general, increased phago-
cytosis, toxicity and anti-toxicity of body fluids, with im-
proved organic hygiene and the procurance of freedom of
exit for all excretionary matter from the intestinal canal
in its whole extent—lungs, kidneys, and skin. The vis
medicatrix having tried one agency, or set of agencies,
and failed to procure the needed effect, tries another and

102 PHYSIC

another until it does succeed or is finally baffled, leaving
“no stone unturned” in its beneficent procedure, and only
yielding to compulsion.

In this latter dilemma, if science and art come to its
aid, it behoves, in the first instance, that the natural history
of the “‘occurrence” in which it has been engaged should
be as fully mastered as possible, in order that the proffered
aid should come to its assistance in the way and by the
method best adapted to help its always beneficent inten-
tions and actions. In this way alone is it possible for the
ameliorative, curative, or preventive measures dictated by
science and ‘applied by art to be made available for the
assistance of the vis medicatrix in its supervision and
maintenance of the health of the individual and the com-
munity, and for the attainment of that complete immunity
from disease, which has been the dream of the sanitarian
of every age, to be made a final reality over the whole
surface of the globe.

It must also be borne in mind by the ardent student
and the conscientious busy practitioner, that “credit must
be given to whom credit is due,” and, therefore, that the
vis medicatrix should be credited oith performing the
major part of every operation and medical procedure havy-
ing for its object the removal of disease and the restoration
of health, and that it is the most arrogant and faulty
conduct to assign to science and art the entire credit on
the principle involved in merely post hoc, ergo propter hoc,
reasoning on, and estimation of, facts.

Reasoning on, and estimating, the facts embraced in the
study of any morbid entity and its elimination on these
lines, we are persuaded that a much higher position will
be given to the influence of the vis medicatrix nature than
has hitherto been assigned to it, and that the interests of
medicine and surgery will be best served by their devotees
being saturated with a humble spirit of imitation and
subserviency i in all their efforts to enlarge the boundaries
of their respective callings, both scientific and practical.

It would, therefore, many a time be better were the
surgeon and physician to sit with “‘ folded arms” as intelli-
gently watching as he possibly can the progress of events
than by haphazard to venture into “‘the arena,” where a

;

ARE VI CR gk, SR ete Sm
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ON THE “VIS MEDICATRIX NATURE” 103

closely-contested combat is being waged between the vis
medicatrix nature and a very obscurely visible and subtile
morbid foe, at a time of crisis, or when the palm of victory
is on the point of being awarded, perchance, to the
beneficent combatant, lest the tide of battle should be
turned in favour of the malevolent combatant, and the
efforts of the beneficent undone. Be that as it may,
however, we firmly believe that, ‘‘ given a fair field and
no favour,” the vis medicatrix nature will, in the great
majority of its contests with disease, be found the van-
quisher, and that it is alone in those cases where the
position of the opposing forces can be descried that medical
and surgical relief can be most successfully offered, and
where the results, if good, can be claimed as well won
victories, and added to the undoubted and properly con-
ferred laurels of applied medicine and surgery.

We must, therefore, at all times ally ourselves with the
vis medicatrix nature, seeking light and guidance from
the arrangements made for the conduct of its engagements
with the enemy disease, and the disposition of its forces,
so as to be able to assist it where weak and liable to suc-
cessful attack, and to guard it when and where possible
from defeat. Doing this, and using aright our medical
and surgical armamentaria, we may, and will, do great
things in the limitation of mortality and the prevalence of
disease, besides adding greatly to the sum of human happi-
ness and longevity, or to the extent attainable under the
present life conditions in their relationship to the competi-
tion and battle which must ever be waged, and, if possible,

won, individually and communally.

A word of confession may also sometimes be made, and
that is when we at first sight feel inclined to credit our-
selves with the recovery of a certain patient, and begin to
analyse it in all its details, we discover that the patient
has recovered, not in virtue, but in spite of our best
directed efforts. We, therefore, hold that, from whatever
point we view the subject, we are fully entitled to mete
out to the vis medicatrix nature the major share of the
credit in the work of successful treatment of disease and
amelioration of suffering: nevertheless, we are far from
decrying or pooh-poohing the magnificent work done by,

104 PHYSIC

and in the name of, scientific and practical medicine and
surgery, but, on the contrary, claim that in these latter
days both have advanced with ‘‘leaps and bounds,” and

bid fair, in the near future, to be the greatest influence for ©

physical good that humanity has known.

In still further tracing the nature and mode of action of
the vis medicatrix nature, we have been ‘‘impressed with
the idea” that it, the vis medicatrix, is necessarily only
a mode of force possessed by, or combined with, the vis
nature, to be exercised in the supervision and accomplish-
ment of organic hygiene and police, so to speak, and that
it resides in, belongs to, and is operated by, the sympa-
thetic nervous system; thus, should a stasis of forward
or onward circulation, or a regurgitation of the circulated
substances, take place anywhere throughout the organism,
with a consequent admixture of the effete and fresh tissue
pabulum, or a pathogenic crisis of any other character,
take place, or should the organic continuity of any texture

or organ be disturbed by traumatic or other agency, we ©

observe sooner or later the play of medicatricial force on
the pathological conditions, and sooner or later the restora-
tion to physiological order of the disturbed organic ele-
ments—in other words, the natural cure of the pathological
conditions so created. ‘The systemic nervous system,
under these circumstances, acts a completely neutral part,
taking absolutely nothing to do with the problems of
restoration to order of disturbed circulation, or with the
repair of traumatic destruction. In many cases, in fact,
the systemic nervous system is absolutely suspended from
its work of conscious innervation by sleep or coma, leaving
the sympathetic nervous system entirely alone to effect the
organic operations required for the accomplishment of her
never-ceasing functions of repairer and vitaliser of shat-
tered and substituted tissue elements. In this work it,
the vis medicatrix nature is engaged from first to last in
every living form, sometimes, as in vegetable, and the
lowest forms of animal, life, by a solitary nervous system,
and sometimes, where associated with a systemic nervous
system, aided by reason and intelligence.

EE ————— ee —————

Se ee ae

_—— —— «=

DEM IRACT XV.

ON THE HEALING OF WOUNDS BY “FIRST INTENTION,”
AND WHAT TAKES PLACE IN THE PROCESS OF
CICATRISATION AND OSSEOUS UNION.

Wownps are of daily occurrence throughout both the
vegetable and animal kingdoms, and are usually left to
the management and oversight of the. vis medicatrix
nature, aided, it may be, sometimes, by the efforts,
conscious or unconscious, of the subjects of them.

In arriving, therefore, at an understanding of the sub-
ject of the natural and unaided healing of wounds, it
might be well if we could gain some definite ideas with
regard to the manner of nature’s procedure, and the instru-
mentalities or agencies she uses, so as, if possible, to
become better able ‘‘to lend her a helping hand,” without
interfering with her plans, when called upon to do so.

We would, therefore, begin by asking, what constitutes
a wound? A wound, according to our received teaching,
is a “solution of continuity” of a texture or textures,
usually the latter, inasmuch as, if it be ‘“‘but a scratch,”
several textures must be involved in the traumatic occur-
rence, and, hence, we may describe a wound as compound,
although it may be called simple.

The textures, or texture, wounded necessarily determine
the character of the wound, or “solution of continuity,”
each texture showing a different manner of behaviour under
the influence of traumatic violence, and making arrange-
ments for the process of its healing on its own lines and
according to its particular anatomical and histological struc-
ture. In every instance of wound, in whatsoever structure

106 PHYSIC

or structures it may have occurred, the “solution of con-
tinuity,” according to the distance separating its sides, the
amount of interstitial injury, and the presence or absence

of foreign matter in the wound, nature’s plan seems to be -

to obtain in the shortest possible time the apposition of
the severed textures, and this, when all is favourable, she
does by “‘first intention,” but if unable from any of the
above or other unfavourable conditions to do so, she first
removes these, and then proceeds to accomplish the process
by second, third, or continued intentions.

When all the conditions for healing are present, she
proceeds by obtaining, as nearly as possible, the exact
apposition of the separated surfaces, and by renewing the
continuity which has been dissolved by the traumatic

influence by interpolating into the wound an organisable

plasma or ‘‘ mortar,” so to speak, which develops into a
bond of organic union, which more and more approximates
the separated textures while it itself proportionately dis-
appears. This organisable ‘‘ mortar” or intra-traumatic
plasma we would regard as largely the product of nervine
exudation, sympathetic and systemic, because if sanguine-
ous matter be exuded into a wound, it has to be removed
or absorbed, minus, it may be, its organisable material,
before the process of healing can go on, in the essential
reparative matter or cicatricial elements, in which takes
place the work of tissue reorganisation and restoration.
Moreover, we are of opinion that the reorganising agency
is none other than the sympathetic proper fibro-cellular
texture immediately surrounding or entering into the
traumatised area, and that it proceeds to the accomplish-
ment of its benign work by sending out into the inter-
polated and enclosed or intra-traumatic plasma a series of
proliferating cell organisms, which vivify and organise it,
and by it readjust the separated and disorganised tissue
elements—spider cells appearing in reality, and weaving
into organised cicatricial tissue a medium of textural union
so complete and lasting that its duration, with a few ex-
ceptions of pathological breakdown, is conterminous with
the traumatee’s life. This immediate union of traumatised
textures may be taken as representative of healing by the
best, if not absolutely the “‘first intention.”

ON THE HEALING OF WOUNDS _ 107

The other manners of healing, such as by granulation,
may be generally classed as effected by a process of growth
from the surface, or surfaces, of the traumatised area, or
by what is called ‘‘second intention.” Granulation may
be described as a process of new growth, by which any
loss of substance suffered by the traumatised parts is
replaced by a cicatricial texture, usually of a lower type
than the lost texture, but yet of such an order as to meet
the functional requirements of the reunited parts, although,
it may be, on a somewhat restricted scale. The process is
effected by the reconstructive powers of the sympathetic
nervature exercised in arranging and licking into organic
form the exuded intra-traumatic plasma by a growth and
proliferation of its cell elements with their uniting and
anastomosing processes, and secondarily, by the interjec-
tion of vascular or blood-vessel agencies and the laying
down of a fibrous groundwork of uniting tissue, with the
concluding organic act in the regenerative developmental
process of a more or less complete renewal of the cutaneous
external enveloping texture.

On closely observing the character and _ histological
elements of cicatricial tissue, it will become apparent that
they are composed almost entirely of materials derived
from the growth of the sympathetic nerve cellulo-fibrous
reticulum into the intra-traumatic plasma by the prolifera-
tion of its cell elements and the anastomosis of the pro-
cesses thrown out by the evolving cells. This description
may be accepted as axiomatic when applied to the cicatricial
results of healing by less than first intention, that is, by
granulation, but as less axiomatic, or modified, when ap-
plied to those of healing by first intention, in which cases
the sympathetic cicatricial elements are, to a more or less
complete extent, inter-penetrated by the reunited systemic
nerve and, it may be, neuro-muscular elements ; functional
as well as structural continuity being effected in the latter,
while in the former, although structural continuity be
effected, it is not followed by renewal of function, on
account of the absence in the cicatrix of the systemic nerve
elements and related musculature. The sympathetic
nervature must, therefore, be recognised as the agent,
material and dynamic, in the process of “healing of

108 PHYSE.

wounds,” and the production of cicatrisation in all cases
of trauma, and should be allowed a “‘ fair field,” and as
much ‘“‘favour,” as can be afforded, under the manifold
conditions of its vital work, on the reunion, restoration of
divided and more or less destroyed texture, and the new
growth of substitutional tissue.

It may be remarked here that after excessive burns,
where the systemic sensory nervature has been completely
destroyed, and where, therefore, the new skin or scar tissue
matrix is absolutely due to sympathetic materio-dynamic
agency, the texture of that skin is irregular in outline,
delicate and thin in histological character, sensitive to
irritant influences, apt to contract and liable to suffer from
ulcerative breakdown and keloid growth, all of which
negative circumstances accentuate the importance of the
presence of the peripheral systemic nervous system, as an
external histological blend, for the sympathetic peripheral
neuro-dermal elements to ally themselves with in all
renewals of dermal tissue.

The restoration of function must be sought after in
every case of trauma by the exact apposition, as far as
possible, of the divided ends of the disunited textures,
be they skin, nerve, muscle, or bone, organ or viscus, and
the renewal of material and dynamic continuity: as far as
possible, we say, because in the union of systemic nerve
ends especially, there exist often insuperable difficulties,
nevertheless, even then there seems a power inherent in
or begotten of the materio-dynamic compact between the
two nervous systems of passing nerve impulses across
neutral barriers of cicatricial tissue laid down in the tracks
of traumatism by the ever-watchful and inventive vis
medicatrix nature through the materio-dynamic agencies
of the sympathetic nervature, dovetailing, if not uniting,
with those of the systemic nervature.

In the union of fractured long bones it has been
observed that when the systemic nervature has suffered
irreparable injury, it does not take place with the char-
acteristic rapidity and completeness of unaffected innerva-
tion, and in some cases that it has not taken place at all.
This observation is at first sight puzzling, but when we
consider the physiology of the process of ossification in the

ON THE HEALING OF WOUNDS | tog

light of the preceding views, it becomes apparent that the
“missing link” in the process of union is the absence of
neuro-musculo-osseous plasma, due to the destruction of
the systemic nervature of the fragments involved, the
ossifying or earthy matter being wanting in the callus or
material matrix of union supplied by the unassisted
sympathetic nervature.

EXTRACT XVI.
ON METASTASIS.

MerastTasis is a term used to signify transposition or
removal of disease from one region, organ, or structure to
another. It has been in common use in medical literature
for a long time, but its existence as a pathological occur-
rence has been objected to for various reasons, and it has.
been held by some to be an impossibility. Be that as it
may, we persuade ourselves that it is a term of great
convenience, and contains, in however limited a sense, a
truth and relevancy of a remarkably cogent character when
applied to the description of certain well-known character-
istics of gout and rheumatism, for instance.

Thus, in the latter of these diseases inits most acute form,
we have witnessed some of the most appalling occurrences.
which fall to the lot of the medical practitioner to observe,
the most typical example of which is the sudden and
complete cessation or disappearance of all local and general
pain and distress, the immediate or subsequent and liter-
ally intoxicated belief of the patient in his entire recovery
and safety from his late sufferings, and his confidence in
the future of his case, culminating in the immediate or
gradual development of intellectual paralysis, coma, and
death ; the whole of which occurrences succeed each other
with the rapidity and in the manner of a lethal toxis from
an over-dose of a powerful narcotic poison. How to
account for these pathological occurrences we confess our-
selves unable to discover on any other principle than that
of metastasis or transference of the materies morbi of the
_ rheumatic disease from the peripheral motor structures of

ON METASTASIS 1II

the body to the central neural textures of the nervous
system, and, therefore, we hold that the whole series of
such untoward events is due to, and determined by, the
existence of circulatory channels and facilities along which
the rheumatic virus and toxins are transferred from the one
to the other of the involved areas. In other words, we
hold that in such cases the materies morbi is in the mean-
time located in the external fibro-muscular developments
of the body, whence it is usually eliminated by the lym-
phatics and other excretory provisions, but which, in such
instances, have for the time being become occluded from
some cause, and so have necessitated the escape of the
rheumatic materies morbi, with its containing toxic culture
and toxins, along the other lines of least resistance, which
here are the intra-neurilemmar spaces of the proximal
motor nervature connected with the involved musculature,
into the cerebro-spinal cavity, where its neuro-cerebral
toxic qualities are immediately, and with almost uni-
versally fatal effects, demonstrated.

In like manner the metastasis of gout is observed when
an external manifestation of that disease gives place to, or
is immediately followed by, an acute gastric attack, in
which case the sequence of the metastatic events are
retirement, or regurgitation, of the gouty materies morbi
from its external seat, its invasion of the cerebro-spinal
lymph cavity, and its ejection through the pneumogastric
neurilemmar lymph inter-spaces into the gastric terminal
extensions of these nerve trunks and related non-nervous
structures.

Many other instances of metastasis might be mentioned,
but these may suffice to prove that it is still necessary for
us to retain the term as absolutely required to express and
describe a pathological occurrence which is not uncommon,
and which it would be difficult to define by any other term
or combination of words.

EXTRACT XVII.
ON COUNTER-IRRITATION, OR ARTIFICIAL METASTASIS.

THE term counter-irritation is of considerable antiquity,
but to whom we are indebted for its origination we have
not as yet satisfactorily discovered, nor have we yet very
clear ideas of its true nature and therapeutical application
to the relief and cure of certain diseased conditions ;
nevertheless we think we are warranted in obtruding some
of the views of which we have become possessed on the
subject on the attention of those interested in such matters,
in order that empiricism in its use should become tinctured
somewhat more with scientific precision and warranty.
What, then, is counter-irritation? Before answering this
question, it seems right to ask, what is irritation? in order
that we should more clearly understand the rationale of
counter-irritation. Irritation then, as a scientific term,
must be understood as applicable only to a condition of the
nervous system, or part of the nervous system, which ends
in eliciting or inducing involuntary contraction of muscular
fibre in its motor aspect, or disagreeable sensation in its
sensory aspect, and as dependent on the existence of an
exciting or provocative agent or functional stimulus, which,
if intense enough or long enough continued in its applica-
_ tion, may produce disease of a local or even general
Ma acter

Irritation is thus a thing of nervine origin and essence,
and, therefore, requiring for its relief or removal an appeal
primarily to the nervous system. That the nervous
system by direct or reflex agency can transfer the product
of irritation, be it sensory or motor, from the actual seat

=a

ae Oe

:
2

ON COUNTER-IRRITATION 113

of irritation to a distant part, or distant parts, of its area,
is a truth patent to every observer, and now generally
acknowledged, and therefore, capable of being taken advan-
tage of in dictating the line of treatment in certain diseased
conditions, the origin of which is due to the existence of
a removable irritant cause or stimulus. Hence we think
we are consequently further warranted in concluding that
the long since empirically established conclusion, that the
application of a counter-irritant to a free and easily reach-
able or accessible surface or peripheral area, can determine,
by the attraction of its superior and overmastering, albeit
artificially induced nervine influence and persistence, the
removal of naturally induced irritation to the scene of an
artificially produced irritation, and, therefore, by counter-
irritation, in which the latter must act on the former by the
exercise of a preponderating and neutralising influence
through the prevailing vital principle of ubi stimulus ibi
fluxus, as regulating the. circulation, or movement, of
both vital energy and matter. Thus the use of the term
counter-irritation is a defensible, as well as a most happy
and intelligible, one, and one, nevertheless, which can
claim a scientific permit, or authority, by reason of its
completely 4 propos applicability to the circumstances and
occurrences involved; moreover, the warrant for its
therapeutic use is based on the fact that it is used by nature
in carrying out many of the curative processes adopted
by the vis medicatrix in removing pathological conditions
and maintaining the even balance of health—it may be
said, with equal truth, in both the bodies corporate and

politic.

Who that has observed his own sub-conscious ways of
feeling and realising sensory irritations, from the faintest
degree of psora to the most intense degree of neuralgia,
and of neutralising, or abating, their importunity and
provocativeness by sub-conscious or reflex means? and
who that has witnessed and analysed the apparently aim-
less and mostly reflex movements of the suffering infant,
but has been struck with the manifold ways in which
nature has endowed the sub- and un-conscious neuro-
muscular agencies to meet such oft-recurring -nervine
troubles? Thus the sensory inconvenience or irritation

II H

114 PHYSIC

is removed or neutralised by the application of peripheral
counter-irritation in a degree of proportionate intensity,
according to the manner and nature of the objectionable
sensory experience, by gentle, or more or less vigorous,
apposition, or contact of cutaneous surfaces and append-
ages with the irritated area. In the case of the adult
irritatee, this subconscious application of counter-irritation
may, and does, often end in conscious realisation of the
irritation, and the conscious and intelligent application of
the means of counter-irritation.

Moreover, throughout the higher animal world, we may
every day observe the more or less conscious and intelli-
gent use of the principle of counter-irritation by the
systemic nervous system possessed members in removing
and neutralising the thousand and one irritations to which
they are constantly exposed, and from which they so often
suffer. Such phenomena may, therefore, be regarded as
amongst the inherited, transmitted, or innate protective
and beneficent qualifications for meeting the “‘ills of life,”
and bafHing some of the many disturbing agencies to
which it is continually exposed, and so of rendering its
survival possible and, to some extent, enjoyable and desir-
able. The counter-irritant may vary in intensity of appli-
cation from the faintest touch, contact, or impact, to the
most violent, in proportion to the degree of intensity of
the irritant to be removed or neutralised, and will be
sub-consciously or consciously used, according to the
degree of mental attention attracted to it, and the nature
of the being affected. Thus the tickle may be neutralised
or removed by a gentle touch or contact, or a more
emphatic scratch, the fainter degrees of pain by more pro-
nounced pressure and rubbing, the more severe degrees
of pain by more severe application of these, and the
absolutely intolerable varieties of pain by a frantic appeal
to the involved nervature, overwhelming in its insistence
and violence to the degree of self-destruction. The appli-
cation, therefore, of artificial methods of utilising the
principle of counter-irritation in the removal or modifica-
tion of sensory nerve irritation is abundantly warranted,
and will often justify its adoption as a mode of treatment
in many of the ills to which human flesh is heir. The

ON COUNTER-IRRITATION 11s

use on empirical lines, 4 a ‘* similia similibus curantur,” of
counter-irritation has brought into the medical armamen-
tarium a series of agencies differing very much in character
and manner of use, but possessing a common curative
effect and quality ; thus the emplastrum, the liniment, the
unguent, the seton, and the cautery, et hoc genus omne,
have been at one time or another in use by the older
practitioners of medicine and surgery, and still have to be
resorted to by the most modern generalists and specialists
in their everyday practice; hence, we may conclude,
that these facts warrant us in claiming the principle of
counter-irritation as a “‘survival of the fittest” in the
progress of empirical experience and research—a survival
to which we hope present day scientific research, with its
modes of mechanical and electrical percussion, its sham-
pooing and massage, may be able to do full justice by
placing it on a reasoned basis, and utilising, when indicated,
its beneficial influences in the relief and cure of disease
and suffering.

EXTRACT XVIII.
ON VACCINATION.

VaccinaTion—the title of the following remarks—has,
from familiarity, come to be mentioned by a somewhat
large number of the lay population, and a very small
number of the members of the medical profession of these
Islands, with contempt, and the subject by them has
obtained a sinister character, which necessitates its removal
from the list of the ‘‘resources of civilisation.”

That it has been possible for this to occur in the country
where, more than a century ago, the great and philan-
thropic Jenner observed and formulated, and where the
strength of his convictions enabled him to form and sway
a public opinion which initiated and established the greatest
movement in the preservation of the public health of the
world that had hitherto been witnessed, is one of the
greatest enigmas of our time, and an occurrence which
brings a “‘blush to the cheeks” of his countrymen, when
they hear and see with what reverence his memory is
cherished in every country of the globe which has entered
on the race of hygienic advancement and the solution of
the great problem of preserving the lives and health of
its people.

As the explanation of this enigma becomes clearer,
perhaps it will be found that its causes have been com-
paratively insignificant and quite removable, and that it
behoves the nation which first demonstrated the nature
and value of vaccination to cling to it and to vindicate
its claims to retention on the statute book of the state

———————— =

im _ l NeaaM acam il —

—————————

ON VACCINATION 117

as the great corner-stone of the modern fabric of pre-
ventive medicine and beneficent legislation.

Vaccination, as its name implies, signifies the introduc-
tion into the system of a non-vaccinated person of a virus,
the operation and influence of which, on that system,
confers immunity from, or protection under, the invasion
and attack of variola or smallpox. It is probable that
we have already succeeded in isolating its specific bacillus,
but we can scarcely as yet claim that we have identified
it or established its claim to recognition as the bacillus of
vaccinia.

In the materies vaccine are discovered several bacterial
organisms, one or other, if not all, of which may play
the part, or a part, as the case may be, in the production
of the vaccine disease, and, hence, in the conferring of
immunity or protection from the major disease variola,
it, therefore, still behoves us to regard this question as
sub judice.

Vaccination may be regarded as the type and herald
of what is now called serum therapy, and as the foundation
on which is being erected the modern beneficent institution
of ameliorative and preventive medical principles and

ractice. Dr. Jenner may, therefore, be aptly named the
“John the Baptist” of the great modern forward move-
ment of militant and beneficent medicine alike, and to
represent a ‘“‘man crying in the wilderness” or amongst
the arid but quickening places of medical thought and
action of the eighteenth century, and, like his great proto-
type, it should be claimed for him that he “‘ lived for the
future,” and that his name will be, or ought to be, retained
as a living influence amongst the latest generations of
mankind.

The pre-Jennerian or natural vaccination was effected
by the entrance of the vaccine virus into abraded or open
surfaces on the hands, or other exposed surfaces or parts
of the persons, of dairymaids and others engaged in the
milking of cows, and had done its work of protection
against the lethal effects of smallpox or variola, no doubt,
for generations. Of the protective value of this acci-
dental occurrence nothing was known or dreamt, so far
as we know, by the profession of medicine until the

118 PHYSIC

observant mind of Jenner was attracted to the subject,
and his inductive acumen was exercised on the problem,
when lo! a means was devised by which the scourges of
the most loathsome and mortal disease of the time were
to be lightened and lessened almost to the vanishing point.
His strength of faith in the correctness of his inductions
led him to adopt the means which Nature had indicated
and carried out in the dairymaids of his district, and he
artificially followed her lead, introducing by the lancet the
vaccine serum or lymph provided from its natural source,
and afterwards from ‘“‘arm to arm.”

The good results of the procedure in conferring im-
munity against, or so far modifying the progress of,
smallpox soon showed themselves, and he felt himself
warranted in urging its adoption in place of “inoculation,”
which was then in favour. The subsequent experience of
the ameliorative influences of the procedure won public
confidence to such an extent that a measure enforcing its
general adoption was added to the statute book.

The rationale of the process of vaccination is as yet
somewhat obscure, and although a great deal has been
thought, said, and written on the subject since the immortal
Jenner’s introduction of it, we can scarcely, with all the
comparative light that has been shed on the problems
involved in its elucidation, say much more of “‘light and
leading” than he did. Nevertheless, and so much more
in consequence of this, it behoves everyone who can add
a ‘‘mite” of thought, experience, or deduction, to do so,
trusting that aid, although infinitesimal may thus be
afforded in the interesting and important work.

The vaccine virus, having been introduced into a sus-
ceptible child or individual through a sufficient “‘ solution
of continuity” of its surrounding skin, passes into its
internal fluid-containing parts, and there incubates, pro-
ducing meanwhile more or less febrile and general dis-
turbance according, we may say, to the intensity of the
action of the specific poison germs on the various impres-
sible and responsive body constituents, and the range to
which the multiplication of these germs attain and the
degree of toxicity to which they may reach. The period
of incubation passed, a more or less slow but definite

ON VACCINATION 11g

return to the status quo ante takes place, accompanied or
preceded by the appearance at the point or points of
entrance, but now of exit, of a more or less well-defined
vesicular spot or spots, which indicate the exanthematous
nature of the morbid process thus artificially produced.

In the imbibition of the virus, one, two, or all of these
channels must have been used or entered in the process,
viz. the hemal lymph, the blood, or the nervine lymph
circulatory channels. If the hemal.lymph channel had
been the one used, then we would have expected that the
‘solution of continuity of the vascular walls involved would
have been made good or closed by the vis medicatrix
nature before a process of regurgitation, were that pos-
sible, and exudation could have ensued after the processes
of absorption and incubation had been run; in like
manner and for like reasons the same may be said of the
blood channels, besides, it might be mentioned that the
walls of the hemal lymph and blood capillary vessels are
made up of organised structures which are eminently
prone to heal, and, hence, would have prevented the occur-
rence of ‘“‘eruptive” exudation. We are, therefore,
reduced to the necessity of entertaining and maintaining
the opinion that the vaccine virus enters the system by
the nervine lymph circulation, that it invades and multi-
plies in the fluid with which that system is inter-penetrated
and surrounded, and that, on the cessation of the morbid
processes set up there, a small quantity of the tainted
fluid or culture, as it might be called, is extravasated at
the still open or thinned walls of the originally traumatised
- nerve terminals, which do not circulate further, but excrete
their contents there.

Vaccinia, and consequently variola, are, therefore, dis-
eases primarily of the nervous system, and it is through
the impression made and left on that system by the
artificial, or natural, effects of their respective viri that
immunity or protection is conferred; but no doubt the
secondary effects of these diseases are experienced through-
out the whole organism, non-nervous as well as nervous.

Were it possible to analyse the changes wrought in the
minute structure of the skin involved in the vaccine
trauma and succeeding vesiculation, we are convinced that

120 PHYSIC

the truth of the above assertions would be abundantly
proved. Moreover, we are convinced that many of the
exanthematous diseases, as well as skin eruptions gener-
ally, with the many anomalous “‘rashes” observed by the
practitioner from time to time, are alike, primarily, diseases,
or the outcome of diseases, of the nervous system. This
may be said to hold good also of many of the diseases of
the muscles and the various structures and viscera of the
body, or, in fact, wherever nerve structures, motor, sen-
sory, or sympathetic, are distributed. The key which
thus opens to us a way into the intricacies and labyrinths
of the nervine circulation is also, we venture to think, the
key which shall open the door of the therapeutic situation
in dealing with the whole family of the exanthematous
diseases.

Eruption in its primary and simple varieties seems only,
or principally, to occur by the natural sweat ducts or the
rupture of the nerve terminal coverings and the escape
of their contents, fluid and plastic, together with the sub-
sequent subaérial changes which these latter are liable to
undergo in the production of definite papules, vesicles,
pustules, and crusts, as well as cuticular complications of
a desquamatory and inflammatory character. Cases of
variola, of a purely nervine variety and non-pustular, ter-
minate well and without pitting, but purulent cases, or
when the non-nervous elements of the skin are implicated,
less satisfactorily, while cases of a hemorrhagic description
terminate almost universally fatally, all which may be
regarded as pointing to the well-known methods of pro-
gress of the prevalent varieties and their natural history
along nervine lines. |

A vaccine or variolous vesicle may, therefore, be re-
garded as a limited or defined accumulation of tainted or
specifically poisoned cerebro-spinal fluid, plus the more
_ plastic contents or elements of the containing membranes
respectively, of the medullary and axis cylinder substances,
of the nerve terminals involved, together with the non-
nervous texture of the parts outlying the vesicle, which,
being almost entirely epidermic, do not necessarily touch
the blood or lymph textures.

In the process of vesiculation in the eruptive stage of

a Pere en wee eee

Poe

ON VACCINATION 121

vaccinia the neuro-keratine walls of the recently trau-
matised or abraded nerve terminals, we may assume, give
way or rupture at the seat of trauma under the disruptive
influence of the vis a tergo set up by, or due to, the retro-
gression of the tainted lymph or vaccine, and discharge
it, with the effect that the neurilemmar sheaths of these
terminals are disorganised or necrosed, so as to permit its
intermixture with and possible destruction of more or less
of the surrounding non-nervous texture, and afterwards
of the formation of escharotic tissue from which the
cerebro-spinal nerve elements are absent or sparsely
present, and where only the trophic nerve elements are
left to preside over the processes of nutrition and renewed
development.

In this connection it might further be assumed that
destruction, traumatism, and necrosis of the sensory ter-
minal nerve arborisations are not followed by their renewal
or re-growth in the substituted cicatricial tissues. The
truth of this assumption is verifiable by testing the sensory
condition of the vaccinal cicatrices and the “‘ pits” result-
ing from smallpox. The depressed surfaces and “‘ pits”
seem, in fact, to be respectively due largely to the non-
presence in them of the cerebro-spinal nerve elements
consequent on their destruction during the continuance
of the vaccinal and variolar lesions and to their imperfect,
or non-renewal.

The manner of the performance of the operation of
vaccination must be regarded as a matter of importance,
and is a subject on which much diversity of opinion pre-
vails. Since Jenner’s introduction of it, it has been
performed by all manner of persons, lay as well as pro-
fessional, and at the present day we have living and
smallpox-proof individuals amongst us who owe their
immunity and protection to the services of one or all of
these. In its performance, therefore, we may take it that
its manner does not embody any great or insuperable
difficulty. The introduction of the appropriate virus or
lymph, destitute of any admixture with other viri, into
the system of the unprotected is the desideratum, and
this can be effected perfectly safely in mostly all of many
manners affected by the initiated and other vaccinators,

122 PHYSIC

provided the introduction of foreign disease-producing
viri be avoided, and the specific virus, or viri, allowed a

free and untrammelled opportunity of effecting the benign

mission on which it is sent; this, therefore, necessitates
the guarded use of bactericidal agents in case, perchance,
they act too literally on the principle embraced in the old
saying, ‘‘set a thief to catch a thief.” In short, purity,
simplicity, and the avoidance of unnecessary detail in the
performance of an operation which was first successfully
performed by nature would seem to dictate the manner
of its performance. :

A few more thoughts on the subject of vaccination
have suggested themselves since the above study was
closed, and, lest they should be forgotten, they had better
be recorded here. The vaccine vesicles or “‘ spots,” as
they are popularly called, as well as the vesicles of small-
pox, are, we contend, nervine in origin and almost entirely
nervine in the extent of tissue involved, and affect,
secondarily only, the other tissues of the skin, as can be
plainly seen on examination and analysis of the process
of vesiculation. Thus the mature vesicles, when they
may be said to have ‘‘reached their height,” are semi-
transparent, non-vascular, raised areas of cutaneous tissue
loculated—and why? because they are determined by the
disposition and arrangement of the terminal nervature—
and filled with an unstained serum, containing the specific
virus of the disease, which may be drawn off free from
blood or left to undergo a process of inspissation and,
finally, shedding, without, except in hemorrhagic cases of
smallpox, invading the blood circulatory structures or
vasculature, the surrounding hyperemic vesicular areole
subsiding with the declension of the specific pathological
neural changes, when the scabs or crusts are shed as the
collective nervine necrosed elements of the affected areas,
hence the scars left are found to be devoid of the ordinary
peripheral nerve terminal extensions, these having been
destroyed, and the skin consequently left to that extent
anesthetic. , |

In closely observing the sequence of the pathological
events displayed in the evolution, maturation, and sub-
sidence of the rash of vaccinia or variola, we are struck

a ee

“ 2) “a ee

ON VACCINATION 123

with the very marked process of differentiation which
manifests itself in the diseased areas in regard to the
involvement of the nervine and non-nervine structures
respectively ; thus, as the process of exudation or excretion
of the specific serum and nerve plasma advances, the areole
of hypergmic cutis surrounding the areas of vesiculation
widen and retire before the forming or growing vesicles
until the stage of maturity of these is reached, when the
fully formed vesicular units stand out clearly defined and
quite anemic amid a now scarcely visible but increasing
halo of hyperemia, which halo in turn widens, culminates,
and finally subsides, leaving the involved nervine textures
and contained inspissated specific serum and connective
tissue to be detached and shed. This differentiation is
effected through or by the eruptive material raising the
cuticle from the underlying cutis and overflowing a more
or less definite area of that tissue, where it ultimately
“sets” or dries, and is thrown off.

The term eruption here, we think, is a very expressive
one, as very exactly describing the final pathological
phenomena occurring in the extravasation and exudation
of exanthematous materies morbi generally, or at least
when the peculiar habitat and incubating media are found
within the nervous system. From the nerve terminals,
distributed to the areas of eruption, the vesicular contents
are thrown out by the sweat ducts of the nerve terminals
through cracks or ruptures, and, in the case of artificial
vaccinia, through unhealed traumatic channels in the
nceurilemmar walls, where they push aside or submerge
the adjacent structural elements, leaving plateaux, cones,
or elevations of erupted or ‘“‘volcanic” material, so to
speak, as monuments of subtextural or intra-neural pres-
sure and morbid activity—the ‘‘vents” or passages by
which or through which these acts of eruption are effected
being the peri-neural lymph inter-spaces of the peripheral
terminal nerve tissues. Secondary toxis of the blood and
hzemal lymph is thus averted, save in the almost constantly
fatal complications of hemorrhagic variola, where the
interposed limiting structures being broken down, and
the circulation of the materies morbi being no longer
confined within the neural lymph channels, overflows into

124 PHYSIC

and invades the contents of the non-nervous surrounding
areas, where secondary zymosis or auto-toxis results, and
the most disastrous consequences ensue.

It might, moreover, be questioned whether many of
the cases of exaggerated inflammatory and erysipelatous
complications arising in the course of some cases of vac-
cination do not arise from the operation of the same
causes, and, consequently, not from the introduction of
extraneous morbific organisms or the non-avoidance or
overlookment of preventable causes. In explanation of
the shapes and manner of occurrence of the individual
“spots” in vaccinia, varicella, and variola, as well as in
many, if not all, of the exanthemata, we would offer the
opinion that it is dependent entirely on the histological
distribution of the cutaneous terminal nervature, which,
being that of individual and associated groups of ultimate
fibrils devoid of peripheral blending or anastomosis, lends
itself to the occurrence of single and of grouped papules
and vesicles, whereas, in the cases of hamo-vascular erup-
tions, the manner of the eruption is general over the
affected surfaces, as we might expect, where anastomosis
occurs throughout the entire blood circulatory structures
involved, and where capillary communication is universally
present and actively operative. We are, therefore, called
upon to observe further, that the diseases under discussion
and the exanthemata generally must be primarily largely
diseases of the sensory nervature, and of the cutaneous
and other textures with which it is related. Their symp-
toms, however, point to general involvement of the
affected organism, while the lasting impression of im-
munity left behind them is the legacy of an anti-toxinal
influence of a temporary or permanent character, which
we are warranted in referring to the existence of a universal
sepsis, the leaving of a general impress, and the peripheral
expulsion of the resultant spores, microbes, and toxins.

ee

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EXTRACT XIX.

ON THE PHYSIOLOGICAL ACTION OF TOBACCO IN
THE VARIOUS METHODS OF ITS USE.

We have already advanced—in a former study in con-
nection with the pneumatic or air spaces of the face and
head—that these spaces constitute what may be called the
lungs of the head and face, inasmuch as an interchange
of gases seems permitted by diffusion and chemical action
or interchange through their thinly lined cavity walls, in
which the blood capillaries are distributed in much the
same manner as they are in the ultimate bronchial passages
and pulmonary vesicles of the lungs.

The recognition of a provision near the great centre of
life, the brain, of a supplementary means ts keeping pure
the blood circulating in its immediate vicinity and basal
neighbourhood, and within its supporting structures, if
not to a limited extent within the passages leading to and
from itself, may be regarded as of great importance on

account that these somewhat neglected spaces would conse-

quently be brought within the circle of the more vital
parts, and so have their condition as to soundness and
patency more enquired into by those engaged in their
clinical oversight, and their therapeutics, prophylactic and
curative, placed on a more definite and scientific basis.

Flowing out of our study of this subject, the rationale
of the physiological effects of one of the most all-pervad-
ing habits of modern life and times, viz. smoking, and
inferentially all other ways of using tobacco, seems de-
ducible or, at any rate, more apparent.

We have on many occasions asked devotees of the habit

126 PHYSIC

for an explanation of its physiological effects on their
minds and bodies, but have not hitherto been gratified to
receive an answer which would satisfy non-smoking curi-
osity; in the dim light, therefore, of our inexperience, —
and what might, therefore, be called our unsuitability for
the task, we would very cautiously venture to say that
our own ideas, as above deduced, are somewhat as follows:

Tobacco, belonging as it does to a narcotico-sedative
class of vegetable substances, charged, it may be, with
essential oils and other elements of a diffusible nature,
requires, for its full enjoyment, that it should be burned,
vaporised, and diffused throughout the air passages of
the head and body, including more especially the spaces
under consideration, and absorbed by the structures lining
these passages or spaces—the absorption being accom-
plished by direct diffusion of the gaseous part of the
smoke, by liquefaction and osmosis of the more solid part
of the smoke, and by the infiltration of the mucous lining
of these passages and spaces, and the direct invasion of
the underlying blood and lymphatic vessels and nerve
terminals by what of the residuum has not been already
disposed of.

The slow burning of the tobacco, effected by the many
fashionable methods in use for accomplishing that process,
lends itself to the correspondingly slow and gradual intro-
duction of the nicotine and other volatile and absorbable
constituents of the drug into the system of its votary,
and so to the gentle and more or less complete saturation
of those parts of the system amenable to its narcotic
influences, and thus to the production of a more or less
complete narcosis with the accompanying feelings of more
or less full enjoyment of the effects, physical and mental.

Thus produced, the effects of tobacco are experienced
over a wider area of the organism and with more intensity
than can be possible in the cases of the snuffer or chewer
of the article.

A somewhat fine drawn, if not quite exact, method of
differentiating and estimating the height and depth, the
length and breadth, of the possibilities of extracting the
real and full enjoyment of the weed by the three classes
of its uses may be possible as follows: The smoker may

7. re

PHYSIOLOGICAL ACTION OF TOBACCO 127

be said to present his “‘ burnt offering” to his brain and
nervous system, his blood, his lungs, and his digestive
organs ; the snuffer his ‘‘ pinch” mainly to his brain and
nervous system; while the chewer of the coveted article
presents his ‘‘ plug,” with the “benefit of the doubt,” to
his whole system.

EXTRACT. XxX.

ON METALLIC, OR ARSENIC, AND LEAD, ETC., POISON-
ING, AS SEEN ALONG THE LINES DICTATED BY
THE FOREGOING VIEWS.

WE think we see here the lines along which we can most
successfully pursue our observations of this momentous
problem if we are to arrive at a scientific explanation of
the presence of arsenic and lead in such unusual but
specific situations as the shafts of the hair and the extensor
muscles of the fore-arms respectively.

The discovery of arsenic in the hair or other parts of
a person who has imbibed it medicinally or otherwise
through the walls of the alimentary canal, points to its
absorption through these walls by the blood vessels or
lacteals, its conveyance thence to the neuroglial matrix
along with the nerve nutrient elements with which it is
imbibed and conveyed to the nerve terminal areas by
which the implicated hair and other parts are innervated,
or to its exudation with the elements of the cerebro-spinal
fluid from the pia mater, and its distribution by that circu-
lation to the parts affected, or to its direct absorption or
passage from the blood vessels supplying them. ‘The first
of these views we prefer to believe as being most in
accordance with the teaching of the acknowledged affinity
of nerve structures for arsenic and other inorganic poisons ;
in which case the poisonous agents must first be supplied
to the affected nerve structures, and thence, by histological
continuity, to the hairs and other parts by being deposited
from the blood of the pia mater in the neuroglial matrix
or blastema.

—

METALLIC AND LEAD POISONING $129

This view holds good, of course, only in cases of the
internal and, consequently, general poisonous effects by
the substances in question, and not in such cases as “‘ drop-
wrist”? in painters, where the local pathological condition
is due to the cutaneous absorption of lead through the
open sweat ducts, and its passage thence through the sweat
glands proper along the inter-neurilemmar spaces of the
sensory or peripheral nerve fibrils, terminating in the
glands from which these ducts proceed to points high
enough in the course of the common nerve trunk or trunks
to enable it to pass up to and regurgitate or turn back
into the inter-neurilemmar spaces of the accompanying
motor nerve or nerves, along which it retrogrades or
returns, or rather passes forward, into the sarcolemmar
intra-spaces of the affected muscles, where its poisonous
effects become apparent in the production of paralysis
through its deleterious influence on their sarcous elements.
Thus, moreover, we account for the confinement of the
pathological characteristics of this disease—drop-wrist—
within strictly defined and local limits, these changes being
due to and consequent on the liquefaction of the lead by
the sweat, it may be, its subsequent passage through the
sweat glands, and thence along the peripheral or efferent
nerve fibre inter-spaces and textures to the points in the
common neurilemmar nerve sheaths, where the efferent
or implicated motor nerve fibres leave, to be distributed to
the paralysed muscles, and whence the poison finds its
way into their intimate substance along the nerve terminal

fibrils supplying them.

A local preference or affinity, we think, is thus demon-
strated, due to progress, it may be, along the lines of
least resistance between the invading mineral poison, the
motor nerve fibres, and the sarcous elements of the affected
muscles, as compared with the neutral influence exercised
on the sensory nerve fibres and the local sensory pheno-
mena. We think, moreover, that an analysis of the
effects of general lead poisoning will demonstrate the same
inference and lead to a similar conclusion as to the existence
of the same affinity generally between lead and motor
nerve textures, including cells, and fibres, and- muscle
elements.

II I

EXTRACT XXI.
ON WHAT IS A “COLD”?

Tue disease or pathological condition called a “cold,”
‘‘catching a cold,” etc., is a clinical entity known popularly
all over the world, but which has not received, we think,
that critical notice from the profession to which its import-
ance entitles it on its own account, if not on account of
the part it plays—the very large and important part—in
the causation of disease generally.

Adopting the name “‘cold,” by which it is popularly
known, in lieu of one based on a clear knowledge of its
true scientific meaning and apprehension, and proceeding
to analyse its pathological elements in the light of the
views we have advanced in relation to “‘nervine circu-
lation,” etc., we shall try to make clear a subject which
literally has been in everyone’s mouth for, it may be,
centuries, and which still passes current in our everyday
literature and our daily converse.

To begin with the simplest example of what is called
a “cold,” or “‘ catching a cold,” let us choose the following
as representing its most ephemeral and passing form or
variety—for it can be studied and felt in endless grades
of intensity and duration—and let us follow the sequence
of events, one by one, in order to, or until we, grasp the
meaning of the united whole or pathological entity.

Thus, a man, during the course or process of sleep,
exposes a portion of his person, or has occasion to get
out of bed, when a portion of his cutaneous surface
becomes exposed to a draught. On awaking in the former

ON WHAT is"-*A COLD”? 131

instance, and after retiring to bed in the latter, he is
“taken with a desire to sneeze,” and, yielding to the
impulse, does so, with the effect or result that his nose
“begins to run,” and he finds himself the subject of a
‘“cold in the head.”

How is this? It is thuswise—the exposed cutaneous
surface suffers a chill, the peripheral sensory nerve fibres,
in association with the sympathetic ganglionic corporeal
advance-guard, determine and cause the contraction of the
muscular structures of the skin, producing, it may be,
cutis anserina, when the local and cutaneous or peripheral
nerve structures, with their surrounding sheaths and con-
tained cerebro-spinal or nervine fluid, become in turn
compressed, with the result that their fluid contents, their
outward or cutaneous points of exit being thus closed, are
pushed forwards or, if you like, backwards until more or
less escapes into the cerebro-spinal cavity like railway
“rolling stock pushed into a ‘lie,?” which suddenly
increasing the volume of the contents of these already
sufficiently full intra-spinal and intra-cranial spaces and
inter-spaces, the situation thus created is relieved by an
overflow into the nasal cavities, preceded by the required
act of sneezing or “‘open sesame” determined by the dis-
charge of the necessary reflex motor impulses to the
necessary muscular organisms.

A “‘cold”—a “‘ simple cold” in this case—thus becomes
the type of that class of diseases which have for their
origin and cause the operation of a purely mechanico-
nervous influence, and, therefore, into the consideration
of which chemico-zymotic problems do not enter.

From thus following one by one the various occurrences
in the “‘sequence of events” characterising and making
up this pathological entity, and obtaining a clear insight
into the causation and progress of the ailment, we are
warranted, after searching for “‘ indications for treatment”
and ‘‘prescribing” on simple and purely scientific lines,
in saying that, if our opinion were sought in this or such
a case, “‘trust the operations of the vis medicatrix nature.”

In pursuing our enquiries a little further in this twilight
or dawning region of medical science, where the ‘scene of
the growth of modern descriptive medicine and pathology

132 PHYSIC

just begins ‘‘to strike the view,” we should further say,
about the subject of ‘‘a severe cold,” that some symptoms
of it, such as the ‘‘feeling of pains and aches all over,”
seem to arise from the disturbance of innervation, due to
violent and irregular distribution of the nervine or cerebro-
spinal fluid, and to the consequent interference with, and
impairment of, nerve force production and circulation, and
that the feeling of ‘‘exhaustion of strength,” which is
experienced in the more severe cases, seems also to depend
upon and be traceable to the same causes. Moreover, on
such and other anomalous circumstances depend the many
“indescribable” feelings and symptoms that are yet
required to fill up the picture of a “‘ bad cold.”

At this stage, when the subject of the attack realises
that he has caught a ‘“‘bad cold,” we, if consulted, per-
ceive that disturbances of the blood circulation begin to
play an important, but still secondary, part, and that the
time is rapidly arriving when convalescence must declare
itself, or further pathological changes of a more or less
far-reaching description will follow ; such, for instance, as

characterise the progress of acute visceral disease, the con-_

sideration of which, so far as we can continue it, will
follow more conveniently under proper clinical titles.

Nevertheless, we might consistently remark here that,
if spontaneous cessation of the phenomena of “‘cold” has
not taken place, then a simple appeal to diaphoresis or
cutaneous excretion should be at once made in order to
effect its arrest.

Diaphoresis, however induced, may be understood as
a flushing—so far as the nervous system is concerned—
of the peri-neural inter-spaces from their origin in the
cerebro-spinal cavity to their termination in the peripheral
terminal nerve structures, and of the ejection, of a portion
at least, of the cerebro-spinal fluid with, it may be, a
proportionate relief to ‘“‘nerve tension,” besides intra-
cranial and intra-spinal pressure.

Should this process not be successful by ordinary and
simple means, then it should be effected by an agent or
agents, which will at once relieve this pressure and rectify
chemical disturbances of the cerebro-spinal fluid or clear
it of microbic organisms in the more intensely pathological

EE —

CC eee eS
a s

eT ON WHAT IS “A COLD”? 133
conditions, and then a great experimental work of research
will have been performed in clinical medicine and some
important problems solved in ameliorative and curative
therapeutics.

EXTRACT XXII.

ON INFLAMMATION.

Tue subject of inflammation has held the premier position
in interest and in the everyday practical experience of the
professors of the healing art since the days of Hippocrates.
We, therefore, approach its discussion with mixed feelings,
with one of great respect for those who have laid the
scientific foundation for truly apprehending its character
and nature, and another of strong desire to penetrate still
farther into the secrets which lie at its foundation, and to
place it, if possible, in a still more favourable position for
being completely apprehended, and its clinical importance
fully appreciated.

Its symptomatology, as given by Celsus, has not yet
been materially departed from, being only supplemented
by a few additions, as the progress of knowledge dictated.
Its pathology, however, although of recent growth, has
made great and notable progress, until now we can appre-
hend much of the true meaning and significance of the
manifold processes involved in its initiation, progress and
subsidence. Fortunately for us, we have been able to
view by the aid of the microscope typical examples of it,
_ and to study them in detail, in their elementary manner of
evolution and involution, and have thereby become
familiarised, as we have with few pathological problems
or entities, with some of nature’s ways of maiming and
mending, of making ill and making well, and of working
out the intimately related and continuous physiological and
pathological processes constituting disease, which are so

ng a

ON INFLAMMATION 135

much in evidence in the daily life of every organised
creature and of every medical practitioner.

Engaged, as we have been, in the study of the nervous
system in many of its less familiar aspects for many years,
we have, when coming to consider the subject of inflamma-
tion in the light of the views of which we have become
possessed, been much struck, in the perusal of its litera-
ture, with the absence as a factor in the production and
evolution of the process of inflammation, of any but the
merest inferential reference to the nervous system and the
local nerve elements. This omission will, therefore, we
think, warrant us in endeavouring to supply whatever
information and data we can, in order to call attention to
the circumstance, and, if possible, to broaden and deepen,
and make more exact, the entire rationale of this complex
foundation and far-reaching morbid phenomenon.

As a rule, we say we have noticed little or no importance
attached to the influence of nervine factors in the produc-
tion and course of inflammatory phenomena, and for this
we can only, or mainly, suggest as a reason that the micro-
scopic research to which it has been so searchingly and
continuously subjected has failed to reveal the nervine
influences at work in the regulation of the blood circulatory
behaviour, so engrossingly interesting to the novice as
well as the veteran observer.

It has thus, we think, been too much taken for granted
that the visible phenomena comprise the whole phenomena
of which this diseased process is made up, and hence the
natural curiosity of the observer has been appeased, and

the necessary still further research been prevented.

The behaviour )of the blood vasculature and its con-
tents has thus been most exhaustively observed, and the
observations have been repeated and tested for every
generation of physiologists and pathologists during many
years, until we now take for granted that research in this
field is no longer necessary, and are almost called upon to
believe that the last word has been said on the subject.

The classical experiment on the web of the frog’s foot
demonstrates a succession of vascular vaso-motor and
blood circulatory changes of a most apparent and con-
sequential character, which have only to be seen to be

136 PHYSIC

realised, and which afford a biological picture seemingly
complete in tout ensemble and minutie of detail; but
underlying all this, we contend that we have hitherto
failed to recognise the chief factor in the origin, progress,
and decline of the processes involved in the experiment.
The stages of circulatory acceleration, retardation, oscilla-
tion, stasis, and thrombosis are preceded by what is usually
described as a momentary contraction of the local arterioles,
‘“a thing,” or phenomenon, we are assured, that is ‘‘ of no
known significance” (the italics are ours) in connection with
this series of events. This thing of ‘‘ no known significance”
we claim to be the most significant of the whole series of
events comprising the experiment, inasmuch as it clearly
(to us) indicates, if it does not show it microscopically,
that the etiological irritant first appeals to, and is realised
by, the nervous system—albeit both systemic and sym-
pathetic—and that the nervous system throughout rules
and regulates the evolution of the entire sequence of
experimental events and results, and, by inference, those
of all idiopathic inflammations as well.

This momentary contraction of the involved arterioles
is the lethal or traumatic result of nerve irritation, or
shock, however produced, and is followed by what is
equivalent to a paralysis of the musculature controlling the
lumina of these arterioles, in proportion to the intensity
and duration of the influence of the irritant; if that irri-
tant be mild and short in the manner and time of its
application, or intense and prolonged, we should expect the
respective results to be quite in accordance with the nature
of their cause, and, therefore, that these results would
afford an exact measurement of the intensity and duration
of the inflammatory seguele and irritant causation.

Holding the opinion that every so-called non-nerve cell
is controlled by sympathetic nerve influence, and that it is
related to, and, in fact, continuous to some extent histo-
logically with the processes of the true, or so-called proper,
nerve cells, or, in other words, that it is in reality a true
nerve cell, we have in all cases to deal with it in the inflam-
matory as well as all other diseased processes. We con-
tend that, therefore, we have primarily and throughout to
recognise the fact that we have at all such times to deal

ON INFLAMMATION £27

with phenomena, largely or principally nervine in origin,
and sequence, in the evolution and involution of physio-
logical as well as pathological phenomena.

Thus the preliminary arteriolic contraction within the
area of the experiment or disease is due to vaso-motor
influence, emanating from the primary irritation or shock,
acting through the controlling nervature of the blood
vessel musculature concerned, while the succeeding dilata-
tion, and consequent hyperemia of the local vasculature,
are due in turn to a temporary paralysis succeeding the
violent contraction of the vessel walls, with a consequent
temporary acceleration of movement of the now less
opposed inrushing blood streams. The subsequent pheno-
mena of hemal or circulatory retardation, oscillation,
stasis, and, it may be, thrombosis are very much due to
the altering hydrostatics of an increasingly viscous fluid,
plus the modifying influence of the vital structures—
necessarily nervine—involved, by which the further pheno-
mena of exudation of more, or less, or all of the blood
elements take place, and are followed by a subsequent
series of modifying, destructive, absorptive, and cell pro-
liferative processes, eventuating in the restoration, as nearly
as possible, of the textural conditions existing in the pre-
inflammatory state, and exhibiting one of the most
complete and impressive pictures of the benignant working
of the vis medicatrix nature in the spontaneous and suc-
cessful treatment of a diseased condition.

Directing and accomplishing all these phenomena, etio-
logical, pathological, and curative, is an unseen but potent
vital agency, the sympathetico-nervine, the originally
formative agency, and the nutritive medium in all organic
vital processes, the sustainer of life and averter of death.

The vascular paralysis alluded to, as consequent on the
hyper-contraction of the traumatised arterioles, produces,
through the enlargement of the lumina of the vessels
concerned, a collateral separation of the endothelial cells
lining their walls, a consequent facility for leakage of the
component parts of their hemal contents, according to
their respective mobility and fluidity, first, therefore, of
the liquor sanguinis ; second, of the white corpuscles ;
and third, in some cases only, of the red corpuscles. These

138 PHYSIC

hemal elements being already highly vitalised, and some
of them highly organised, enter into new combinations
and arrangements with the local organic elements, with
which they find themselves in contact after their exudation,
through the controlling influence and formative power of
the sympathetic nervature, in virtue of which a continuity
of the traumatised histological elements and a structural
completeness of the affected parts is effected and main-
tained, thereby securing, as nearly as can be, the status
quo ante.

We feel that it would be both instructive and interest-
ing to follow, analyse, and describe, the succeeding stages
in the process of evolution and involution involved in
inflammation, but suffice it to say that this has already
been over and over again most clearly and successfully
accomplished, and that we only here insist on the primary
and essential instrumentality of nervine influence in the
incidence and course of all inflammatory as well as some,
and, it may be, all other diseased conditions. We shall,
therefore, in short and general terms, describe the succeed-
ing stages in the extra-vascular phenomena of inflammation,
and the re-attainment by the affected part, or parts, of
the status quo ante, as a series of health and tissue restora-
tive nervine operations, comprising the breaking down and
rebuilding into permanent organic form of the extra-
vasated materials, and the absorption and removal of the
unused residuum, along with all the absolutely destroyed
tissue elements resulting from the traumatic or morbid
blood invasion of the tissue matrix. This manner of
termination constitutes what may be called resolution by
cellulitis, in which the peri-vascular cellular tissues, or what
may be called sympathetic connective tissue cells, are the
active agents in the conversion of the effused blood con-
stituents into cicatricial tissue, or normal texture, by virtue
of the all-controlling formative powers inherent in that
part of the nervous system, through its self-contained
ability to effect new growth and repair injured tissues by
cell proliferation and connective fibre extension.

Should the inflammatory process here described termi-
nate, instead of by resolution, in suppuration, ulceration,
or gangrene, we but observe a continuation and accentua-

a On a - eae

2 RE a Se ee

ON INFLAMMATION 139

tion of the truly nervine manner of progress of the
inflammatory phenomena. ‘Thus in suppuration we find
that the effused blood elements, along with the traumatised
structural elements, of the invaded and inflamed textures
are broken down, and developed by the process of suppura-
tion into pus, in which form they are eliminated, through
extension of the disintegrative and destructive, or necrotic,
activity of the pus cells, through every overlying obstacle
or texture, leaving the surviving or living tissues by cell
proliferation and connective fibre process development,
mainly of their connective tissue elements, to take up and
complete the work of cicatrisation and repair. Should
suppuration end in ulceration, which is in reality a con-
tinuation of that process, or should the inflammatory
process primarily end in ulceration, then we have demon-
strated the extension by histological continuity of the
piecemeal necrosis of the invaded and devitalised tissues
surrounding the diseased or traumatised area by the con-
tinued extension of the suppurative process, and conse-
quent textural disintegration and molecular decay, along
connective fibre processes and their parent cells.

If the vital condition of the affected and neighbouring
parts be low from any general or local cause, the untoward
occurrence of gangrene, or somatic death of the affected
tissues, may be witnessed on a smaller or larger scale, in
proportion to the intensity and extent of the incidence of
the exciting cause of the inflammation ; in this occurrence
absolute necrosis ensues, with or without the gradual
extension of the processes of suppuration or ulceration,
and under favourable circumstances for recovery the
slough, or gangrenous tissue, is shed by the still
vital and healthy neighbouring tissues, and the result-
ing structural hiatus made good by the substitution of
fresh or cicatricial tissue, the result of new growth from
the proliferation and expansion of the sympathetic nerva-
ture, cellular and fibrous, and the overgrowth inwards of
a new cuticular texture or epidermis, which becomes a
good substitute for a true skin, though void of its
distinctive organic textures and appendages.

Thus we perceive that the reputedly morbid phenomena
of inflammation may be recognised as distinctly restorative

140 PHYSIC

agencies, initiated and dominated by nervine influence,
under the guidance of the vis medicatrix nature, and
exercised on every individual occasion with an “‘eye to”
the accomplishment of the best results by the removal of
excitant causes, the neutralisation of the effects of injury
and disorganisation, and the accommodation of the affected
organism to the altered structural conditions and circum-

stances.

EXTRACT XXIII.
CEREBRO-SPINAL MENINGITIS.

CEREBRO-SPINAL MENINGITIS is another disease of the
nervous system which may be considered with profit by
the light of the foregoing views.

Sporadically or epidemically, simply or in connection
with other diseases, such as pneumonia, it seems to be
explicable to a larger and clearer extent than has been
possible hitherto.

To begin with, it appears that we must regard this
disease as almost universally microbic in se reserving,
however, the possibility of the occurrence of non-microbic
cases.

The disease being diagnosed to be cerebro-spinal menin-
gitis, and consequently microbic, and it being believed
to be due to the presence of a pneumococcus, diplococcus,
or what may more truly be described in this case as a
neurococcus, it behoves us to find out how it has come
here, how it gives rise to the disease, why it is accom-
panied sometimes by certain diseases, such as pneumonia,
and why it is followed by its peculiar sequele and fre-
quently, or generally, fatal termination.

Aérial convection, it would seem to us, is the most
likely method of its communication, most probably on
the lines described as those followed in the dissemination
of epidemic influenza; that is, the spores of the neuro-
coccus are suspended in the atmosphere or other medium
and find an entrance into the cerebro-spinal cavity through
the nasal mucosa and the peri- and endo-neural canals of

142 PHYSIC

the olfactory nerves, bulbs, and tracts, as well as through
the glosso-pharyngeal pituitary. tracts, and thence by con-

tinuity into the cerebro-spinal fluid, where they grow and

flourish and perpetuate themselves, as in a prepared cul-
tural medium, until the whole fluid becomes invaded,
contaminated, and used up, so to speak, by the succeeding
generations of this rapidly multiplying organism and its
toxins.

During this process we may take it that the germina-
tion, growth, and decay of the neurococcic bacilli, and
the accumulation of their consequent toxinal lymph ele-
ments, are effected at the expense and to the detriment
of the proper lymph contents of the cerebro-spinal cavity,
and that the toxins resulting from the manifold activity
involved therein accumulate and attach themselves to the
peripheral or meningeal surfaces of the cerebro-spinal
cavity, or gravitate to or towards its most dependent parts,
there setting up pathological changes or mechanically
blocking more or less entirely the various intra-spaces
and inter-spaces into which they are divided, and destroy-
ing the continuity and patency of their canals.

What, therefore, have hitherto been regarded as exu-
dates must thus be looked upon as deposits, and the more
or less turbid, muddy, or consistent character of the fluid
withdrawn as a diagnostic expedient by lumbar puncture
of the cord may be used to determine the greater or lesser
degree of microbic development and decay undergone in
the particular case and at the particular stage of the disease
at which it has been withdrawn.

It may here be observed that the state of things above
described may begin and end within the brain and cord
and the meninges, terminating, in a small minority of
cases, favourably, but, in the great majority of cases,
fatally.

However the cases may terminate, whether fatally, as
is their wont, or favourably, as it is just possible they
may do, we see that, in the course of a great many cases,
the pathological process extends itself in other directions,
and that these other directions will be found to coincide
with the direction or course of the greater and lesser nerve
trunks.

ee” ee

CEREBRO-SPINAL MENINGITIS 143

Thus herpetic eruptions manifest themselves at the
peripheral endings of some of the lesser nerve trunks on
a level with the particular spinal area of the central nervous
system involved, or a pneumonia will display itself on
the invasion of the pneumogastric trunk, or an endo-
cardial ulceration may appear, or a gastro-enteric catarrh
may assert itself, each affording or providing outlets
“along the lines of least resistance,” for the escape of the
over-compressed and contaminated cerebro-spinal fluid,
with its toxins and live disease germs.

We would, therefore, premise that if the course of
individual cases of this disease be carefully analysed and

studied from this point of view, it will be found that in

almost every instance of complication the complication
so called succeeds, or apparently only synchronises with,
but does not precede; in other words, it will be found
that the primary disease was, and is, the cerebro-spinal
meningitis, all which is determined, we hold, by an orderly
sequence of pathological events.

At the same time, in our process of analysis and study
of individual cases, we must not lose sight of the possi-
bility of the sequence of these pathological events being
reversed, and of our finding that the pneumococcus—dquite
appropriately named in this case—of pneumonia found
its way from the pulmonary terminal ends or endings of
the pneumogastric nerves, or other nerves involved in
particular cases, along the surrounding neurilemmar inter-
spaces of these nerves into the cerebro-spinal cavity.

Thus we may conclude that in the absence of nasal,
pharyngeal, cutaneous, or other discharges, overpressure,
arising from the continually swelling contents of the
cerebro-spinal cavity resulting from the rapid growth and
accumulation of its pathological contents, must be relieved
by a passage or passages being found for their evacuation,
and thus, also, we find that the particular paths or nerve
trunks alluded to afford the next easiest exits to the
natural great cerebro-spinal lymph exits.

The pulmonary points of exit being, not on to a free
surface externally, but into the texture of vital organs or
the lining membrane or surface of partially closed or
narrow tubes, we are forced to recognise that the difficulty

144 PHYsICc

and dangers of evacuation of toxic material thus is very
great, and that the proneness of the disease to a fatal

termination is only too well founded or established.

Nevertheless, it would seem that early surgical interference
in the shape of lumbar puncture or otherwise affords a
hope that we may be able to cope with a condition of
things, now recognised as well nigh hopeless, if we be
able to establish our diagnosis promptly, and are at liberty
to use the appropriate measures before the cerebro-spinal
fluid has reached the state of too great turbidity or too
diminished fluidity to be withdrawn.

The above narrative at once suggests that the cause of
cerebro-spinal meningitis is none other than the presence
of the mneurococcus in the congenial medium of the
cerebro-spinal fluid, the growth and decay of this organism,
and the consequent intoxication, so to speak, of the con-
tents of the cerebro-spinal cavity, liquid and solid, with
the result that the free surfaces of the involved meninges
and neural elements proper become pathologically affected
with the organism, its toxins, and residual products.

The meningeal inflammatory process, with its conse-

uences, may thus be regarded as secondary, and, there-
ree that the greater part of the solid admixture or
turbidity producing constituents of the cerebro-spinal
fluid may be credited to the primary microbic invasion,
growth, and decay, with its resulting deposition, the
remaining part only being due to an inflammatory exuda-
tion from the affected meninges and the deeper seated
structures.

In this connection we are warranted in inferring that
the great intra-cranial and intra-spinal lymph spaces, as
represented by the ventricles and central canal, cannot fail
to be also subsequently, if not simultaneously, invaded
by the common microbic enemy, with the result that intra-
spatial pressure and toxic action will be set up, together
with the secondary inflammatory consequences alluded to,
in the discussion of what we may call the extra-spatial form
of the disease.

The same sequence of events may, therefore, be looked
for in the latter—the intra-spatial—as were found to occur
in the former—the extra-spatial—with the exception that

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CEREBRO-SPINAL MENINGITIS 145

the difference in environment must, to a corresponding
extent, affect the results.

We would here remark that the more or less plugged
condition of the central canal may frequently have its
origin in this morbid process, and that the occurrence of
hydro-myelia and syringo-myelia may, in many cases, have
indirectly to be attributed to it.

Moreover, the similarity of the consistence and sub-
stance of the deposits or exudates to be found in the
intra-spinal spaces, and especially in the lower termination
of the cerebro-spinal cavity in some cases of cerebro-spinal
meningitis, and in the central canal in some cases of
syringo-myelia, lends suspicion, to say the least of it, to
the supposition that they owe their existence to an almost
common cause, and are produced by similar conditions
eventuating in obstruction of the central canal and rupture
of its walls, with consequent invasion, obliteration, and
dissipation of the proper or neuroglial substance of the
cord.

II K

EXTRACT: XXIV.
NEURITIS.

NevriTIs, or nerve inflammation, is commonly regarded
as a distinct disease of the nerves, and in systematic
treatises on the practice of medicine is defined as such.

To this we would take exception, and would state
broadly that there is no such disease as neuritis, and that,
from the anatomical composition of the structures in
question, its occurrence as a primary disease is impossible,
inasmuch as the purely nerve structures, i.e. the axis
cylinders and white substance of Schwann, with their con-
taining sheaths, are devoid of blood vessels, and, conse-
quently, cannot suffer primarily from the inflammatory
process.

We, therefore, think that the term neuritis is applicable
only, strictly speaking, to the secondary effects of the
inflammatory process initiated, it may be, in and spreading
from the outer envelopes of the nerve structures, and
that it is, or can be, consequently only secondary ; because
purely nerve structures must be regarded when considered
in relationship to diseases of the blood circulatory system,
such as inflammation, in the light of being non-hemo-
vascular tissues, such as, for instance, the keratinous, as
well as the proper nervine elements—hair, nail, epidermis,
and epithelium.

Neuritis must, therefore, so far as the nerve substance
is concerned, be looked upon as entirely a secondary
morbid process or disease, and a change of the involved
nerve substance, due to the existence of a previous disease,
interfering in some way with its peri-neural sheaths and

—a

NEURITIS 147

textural relationships and soundness; or, in other words,
it is a disease of the envelopes or neurilemmar sheaths
surrounding the sheath of the white substance of Schwann,
and primarily involving the peri- and endo-neurium, the
tissues representing and continuous with the membranes
of the brain and spinal cord.

The sheath of the white substance of Schwann and the
axilemma of the axis cylinder substance, being each com-
posed of a non-vascular layer of neuro-keratine, are
impervious to even the minutest capillary blood vessels,
and are, hence, exempt from the initial changes involved
in the inflammatory process, consequently we must repeat
that we regard neuritis, so called, as a disease primarily
of the non-nervous elements of the nerves or nervous
system.

Its etiology must, therefore, be considered, primarily,
in relation to the non-nervous enveloping and supporting
structures of that system. As thus involving the non-
nervous structures, it seems to us that we must look for
its inception in the invasion of the intra-neurilemmar
spaces by a materies morbi which finds its way from the
cerebro-spinal cavity along the neurilemmar inter-spaces
by the natural movement of. excretion or outflow of the
cerebro-spinal contained lymph; this outflowing lymph,
therefore, being contaminated by chemical or other admix-
ture, or by the growth therein of bacterial organisms, may
be regarded as the most usual and important cause of the
primary stage of neuritis, and, consequently, as the main
origin and cause of what is understood as fully developed
neuritis.

The invasion by disease-producing agents of the intra-
neurilemmar spaces of the nerves may also be accomplished
by the process of imbibition of the toxic agents through
the nerve terminals in the sweat glands wherever they
may be distributed on exposed areas of the skin, while
the manner of their transmission from these points to the
structures for which they have an affinity, or between
which and them there is a mutual affinity, is still a ‘‘ moot
point.”

However introduced, and whatever the nature of the
poison, be it chemical or bacterial, the result is the same,

148 PHYSIC

viz. the irritation of the nervous structures involved, an
increased blood supply to their surrounding non-nervous
structures, the disturbance of the textural condition of
these structures, as well as the neighbouring cellular and
connective tissues, with the consequent and subsequent
disturbance of the functional and textural integrity of the
true nerve elements of the nerves involved.

The violence, the frequent repetition or the long con-
tinued incidence of these morbid phenomena determine
the nature and extent of the attack and its probable
termination.

Thus the attack of neuritis may be acute or chronic,
local or general, and it may be characterised by all degrees
of intensity between acute and chronic, and with a distri-
bution varying between, local and general, the general
being usually recognised as polyneuritis, a condition of
highly complicated disease, which is very often associated
with the nerve phenomena of alcoholism, arsenicalism, etc.,
and other toxic conditions of the blood, and consequent
disturbance of its circulation amid the proper nerve ele-
ments. Besides the instances of neuritis due to toxis of
the cerebro-spinal lymph, and consequent irritation of the
dermic structures and musculature into which or through
which that toxic lymph is passed, we find that the purely
nervine elements of the nervous system also become
saturated with the toxic agent, in certain cases, with the
effect that such affections as dermatitis and hyper-keratosis
may arise on the afferent or sensory aspect of the systemic
nervous system on the one hand, and disturbances of the
nutrition and function of the voluntary musculature or
afferent aspect on the other.

The forms of neuritis emanating from central nervine
toxis may thus be divided into extrinsic and intrinsic in
accordance with the order of involvement of the cerebro-
spinal contents or. elements, the fluid or lymph elements
representing the former, and the proper nervine elements
the latter. 7

ro ere

EXTRACT XXV.
NEUROMA.

Nevroma is a disease of the proper nerve structures as
distinguished from the cerebro-spinal nerve adventitial
sheaths, which can be more fully, more easily, and more
intelligibly explained, than has been possible hitherto, by
the application of the principles for the truth of which we
have been contending.

Inasmuch as it stands pretty much outside the great
subject of tumours, and is conditioned by laws emanating
for the most part from within the nervous system, it
occupies an exceptional position.

Thus a true neuroma is not due, primarily, to circum-
stances connected with the neural blood circulatory system
proper, but to interference with one or other of those
inner or nerve circulations, which in this case begins
within one or many of the sheaths and contained columns
of semi-consistent or semi-fluid substance, called the
“white substance of Schwann,” or the insulating covering
of the axis cylinder, hence the results of inflammatory
action are conspicuous by their absence, except when they
may have been accidentally induced by mechanical irrita-

tion or pressure.

Neuromatous growths, or neuromata, must thus,
primarily, be developed within the nerve sheaths or neuri-
lemme, and conform to their environments by “‘ growing”
or passively collecting in the direction and along the course
of these sheaths and the nerve trunk or trunks; thereby
causing a bulging or varicosity of the sheath or, sheaths
involved, which may attain a size varying, roughly speak-

150 PHYSIC

ing, according to the literature of the subject, from that
of a plum-stone to an oval tumour, in some cases little
less than a foot in longitudinal diameter (one was eleven

by ten inches). |

The contents of the tumour, which are comparatively
homogeneous, may thus be regarded as the inspissated
and quasi-organised white substance of Schwann collected
into masses, due to the failure, on a large scale, of the
nodes of Ranvier of the affected nerve fibres, and the
yielding of the primitive or containing sheaths of that
substance, together with that of the overlying layers of
the endo- and peri-neurium.

The initiating and determining cause of the tumour may
be a more or less temporary or persistent local stasis of
the circulation of the white substance of Schwann within
its containing sheath or sheaths, which becomes permanent,
and ends in more or less local or general tumefaction at
one or several different points throughout the whole or
part of the involved nerve trunk or trunks.

The size of the tumour or neuromatous enlargement, we
may take it, is determined by its shorter or longer con-
tinuance and its greater or lesser solidarity from the more
or less complete exosmosis of the more fluid parts of its
contained materials.

The unvarying character of the contents of the so-called
growths or tumours may also be regarded as almost a proof
that their formation has taken place within, and the
materials of which they are composed have been drawn
entirely from, the proper nerve structures or elements, and
characteristically moulded by the peri-neurium, this view
holding good in the solitary and multiple varieties of the
disease alike.

The consistence of the contents of these tumours, it
ought to be added, varies between that of a thin jelly
and ordinary gristle; hence an analogy to the formation -
of gristle in joints and osseous development histologically.

The disease may be regarded in most cases, more
especially of the multiple variety, as due to a constitutional
predisposition or susceptibility, and the contemporary
incidence and influence of exciting causes—the predis-
position or susceptibility being or consisting of a too

OR OE Re eT Oe FE Sere a

NEUROMA 151

yielding primitive sheath, an imperfect provision of the
nodes of Ranvier, or a perhaps too fluid condition of the
white substance of Schwann, either or all of which may
suffice, along with an exciting cause, to initiate and con-
tinue the neuromatous growth by allowing passive
accumulation of that substance within the peri-neurium of
the implicated nerve trunks, in obedience to the influences
of local anatomical conditions and histological environ-
ment. Thus, for instance, is determined that the long
diameter of the tumour is universally parallel with the
direction of the affected nerve, which circumstance is due
to the escape and deposition of the tumour material along
the lines of least resistance.

Neuroma is, therefore, not a “‘new growth” in the
strict acceptation of the phrase, but an accumulation of
the material being locally circulated through the interstices
of the neural tubules in certain definite areas, where the
operation of local conditions secures its conversion into
definite nodules and larger masses. Generally speaking,
these neuromatous nodules and masses may be regarded
as due to stasis of the medullary circulation and substance
alone, inasmuch as the axis cylinders of the involved nerve
fibrils remain intact, and capable of transmitting nerve
impulses; therefore, we have here to deal with, in the
main, an arrest of medullary circulation and subsequent
accumulation of that substance within the neurilemmar
coverings of the affected nerve trunks, and, consequently,
with the insulating media and the transmission phenomena
of innervation, as they in turn become affected by these

altered environing circumstances.

EXTRACT XXVI.

SCLEROSIS OF THE NERVOUS SYSTEM, OR SCLEROMA.

In dealing with the subject of neuroma we assigned as its
cause local over-accumulation or production of the intra-
neural or white substance of Schwann.

In relation to the pathological disposition of the white
substance of Schwann within the neurilemmar coverings of
the nerve trunks, it may be observed that sclerosis appears.
to us to be due to a condition the opposite of that of
neuroma, i.e. the white substance of Schwann is conspicu-
ous by its more or less complete absence, according to the
stage attained by the particular case of the disease in which
it is observed.

In other words, neuroma is the pathological increase
and local accumulation or ballooning within the primitive
and neurilemmar sheaths of the white substance of Schwann,
and sclerosis is its decrease or disappearance—the sclerosed
nerve tissue being reduced to the shrunken containing
sheaths of both the white substance of Schwann, and, it
may be, the axilemmez of the axis cylinders (should the
axis cylinders have also disappeared, which they usually
have done in advanced cases) and the overlying peri- and
endo-neurium.

The neuro-keratinous material, of which these two
sheaths—the primitive or medullary and axilemmar or
axis cylinder—are composed, being comparatively inde-
structible, yet elastic, yields to pressure from within, and
expands indefinitely or to the vanishing point in the case
of neuroma, while in the case of sclerosis it shrinks and
hardens ; hence the meaning of the term sclerosis, harden-

SCLEROSIS OF THE NERVOUS SYSTEM 153

ing; the two conditions respectively representing, as it
were, the positive and negative aspects of the intra-neural
disposal of the white substance of Schwann, and generally,
or at least in sclerosis, that of the axis cylinders.

These sclerosed sheathings, with the remains of their
former contents altered by pathological changes, together
with their encircling endo- and peri-neural coverings, com-
prise, therefore, the only vestigial remains left by the arrest
of the intra-neural circulation, and constitute but the pas-
sive or inert structural survivals of once functionally active
mechanisms and most highly endowed material organisms
—dead, yet alive! They are dead so far as the systemic
nervous system is concerned, from which their separation
is permanent, but alive in virtue of their supply of sympa-
thetic nerve energy and the retained power of the restricted
nutrition and metabolism possessed in common by all
so-called non-nervous or sympathetically innervated struc-
tures.

Sclerosis, moreover, befalls other structures, more
especially of the muscular character, but also of the
cellulo-fibrous varieties, and points to the incidence of
involutionary change, comprising that of failing nutrition,
lapse of function, and textural retrogression, with accom-
panying and consequent structural and functional failure
and breakdown, such as is seen in premature senility,
where the arterial structures are peculiarly liable to partici-
pate, and show that the initial stage of involution has
begun, and that, generally speaking, it inexorably continues
until the process is complete and the continuance of life
impossible.

There are those who think that we should always look
here for the earliest symptoms of sclerosis, and if means
of preventing the threatening breakdown can be devised,
the greatest chance of their doing good is secured at this
stage, or before structural degenerative change has fairly
set in, i.e. before neuro-muscular nutritive failure and
shortage of neuro-muscular dynamic supply have become
established realities.

In relation to incidence, this affection seems to fall
entirely, as we have said, on structures innervated by the
systemic nervous system, 7.e. the musculo-osseous struc-

fee St PHYSIC

tures, as well as the muscular coatings of the blood vessels
and other structures endowed with muscular elements.
The explanation of this would seem to be that the involved
muscular structures have been deprived of the nutritive
plasma necessary for the maintenance of their sarcous
tissue, the supply of which is due to their related nerva-
tures, and that degeneration and removal of their existing
sarcous elements takes place, resulting in the collapse and
agelutination of the muscle fibre sheaths and the inter-
stitial muscular substance.

Accompanying or following this process may take place
the formation of a degenerate species of organisation,
consisting, apparently, of the union of the formative ele-
ments on which the evolution of cartilaginous, osseous, or
calcareous growths in physiological developments and
pathological production are alike due.

As the notochord produced the vertebral isiegee by
intermixture of tissue plasma and earthy salts, as the
skeleton was produced by leakage of cerebro-spinal fluid
into the membranous or cartilaginous matrix at the skeletal
points or centres of ossification, so have the leaking neuro-
musculatures concerned init eee and continued the patho-
logical processes of the conversion of sclerosis into ossific
and, by continuation, into calcareous structures by an
unbroken series of malformatae changes.

This mal-formative procedure may be the outcome of
specific predisposing and exciting causes constitutionally
evolving themselves, or it may be due to traumatic and
other influences rapidly or more slowly initiating and
determining the phenomena in the seat of injured neuro-
musculo-skeletal structures and associated non-systemic
nervine tissue elements.

EXTRACT XXVII.
POLYMYOSITIS AND MYOSITIS.

Po.ymyosirTis, as described by Sir W. Gowers and others,
seems to us to be secondary to, or to be in many cases
a continuation of polyneuritis (motor), which in turn is
often due to a rheumatic or allied condition, emanating,
as in Sir W. Gowers’ case in the British Medical Journal
of date January 14, 1899, from repeated exposures to
damp, repeated chills, want of nerve and muscle rest, and
to the effects of living amid continuous insanitary
influences.

The nightly chills to which the patient, whose case is
described by Sir W. Gowers, was for a long period subject
gave rise to nightly checks and stasis of the cutaneous
exhalations and excretions, with corresponding increases
of cerebro-spinal and intra-cerebro-spinal sepsis and pres-
sure, and, consequent, backflows along the channels of
least resistance, these channels being, in this case, along the
continuations of the sub-dural and sub-arachnoid spaces,
into the motor nerves generally, and by continuity through
their fibrils and nerve terminal plates into the substance
of the muscles to which they were supplied, and in whose
substance they were finally distributed.

If we may be permitted to say it, the case was thus
one of auto-toxis, due to the repeated invasion of the
intra-neurilemmar spaces of the motor nerves, and sub-
sequent inundation of the intra-sarcolemmar spaces of the
muscles to which those nerves were distributed by a
regurgitated cutaneous and, consequently, effete and
noxious excretion, with accompanying inflammatory

156 PHYSIC

changes in the non-muscular textural or interstitial ele-
ments.

We may here remark that the chemistry, as well as the
bacteriology, of sweat, so far as known to us, do not seem
to have been as yet exhaustively investigated, and that,
therefore, to us, as holding the view that it (the sweat)
may come from both a blood circulatory and a nerve
circulatory source, it would appear to be of a consequently
variable character, according to which of these sources
contributed to the greater extent towards its production
for the time being. Moreover, we think it will be found
in such investigation work that a considerable exhalation
of gaseous material must be reckoned with.

The stasis of sweat excretion or perspiration, if only
local and of short duration, does not necessarily make
itself felt pathologically, and, consequently, may pass un-
noticed; but if, on the other hand, it be general and
sustained, or often repeated, as in Sir W. Gowers’ case,
a vague feeling of “‘aches and pains” is experienced, which
may result in rheumatism, more or less acute, neuritis,
local or multiple, or myositis, local or general (poly-
myositis).

Rheumatism, acute, subacute, and chronic, has elsewhere
been described, neuritis has also been referred to, it, there-
fore, now remains for us to explain further the causation
and pathological changes observed in myositis and poly-
MY OSitis.

Myositis, however, except for its localisation, being in
no way different from polymyositis, it will suffice for us
to confine our remarks to the latter disease.

The cause or causes of polymyositis have almost ex-
clusively been attributed to and sought for in the blood
supply of the muscles involved, that blood supply being
supposed to introduce into the muscular substance or fibre
a toxic material or agent, which initiates and perpetuates
inflammatory changes sufficient to lead to the destruction
and removal, or the disintegration and obliteration, of the
muscular discs and fibres, or the sarcous texture proper,
accompanied, it may be, by an apparent increase in the
fibrous and connective tissue proper of the implicated
muscles. Why do we say apparent? Because we believe

POLYMYOSITIS AND MYOSITIS 157

that what remains consists simply of the exact number
of sarcolemmar sheaths representing the muscle fibres
involved, minus their former sarcous or proper contents,
and because we think that nature must not be here held
responsible for the performance of redundant work in this
evolution of pseudo-hypertrophy from the residual dis-
organised and amorphous sarcous materials, together with
the non-sarcous muscle elements.

If these views are to be accepted as a ‘‘ working theory,”
so to speak, it seems to us that a very large problem in
what may be called pathological bio-chemistry, connected
with the disease under discussion, awaits solution, and, it
further seems to us, that if a simple and yet scientific
method of escape can be provided whereby the necessity
of finding the solution on the old lines can be averted and
fruitless efforts and, it may be, precious time saved, it is
desirable that it should be made available for the purpose.

We have, therefore, to state that, feeling our inability
to find the solution of the problem referred to, as well as
many kindred problems on what may be called the “‘ old
lines,” we have felt ourselves compelled to renew or con-
tinue the task on new and, we think, or, in fact, are
convinced, more promising lines, and, hence, we have
been constrained to substitute a nervine theory, which
seems to us shortly and simply to explain the nature and
sequence of the pathological changes involved, and, to
some extent, to indicate the methods or lines along which
the treatment of the disease, therapeutic and. otherwise,
may most consistently and hopefully be conducted or
_ directed.

Polymyositis thus regarded seems to us to be due to
the invasion of the muscle sheaths primarily, at which
stage it is not an inflammation, and, secondarily, of the
individual muscle fibres, by a virus circulating along the
intra-neurilemmar spaces from the cerebro-spinal cavity
in which it has been incubated or produced, and from
which it has passed along the lines of least resistance in
such wise as this:

A chill or succession of chills having been experienced
by the subject of the coming attack, a stasis or series of
stases of the cutaneous excretion and exhalation are pro-

158 - PHYSIC

duced, whereby a damming back of them takes place,
which damming back leads, of necessity, sooner or later
to regurgitation of them into the cerebro-spinal cavity
along the intra-lemmar spaces of the peripheral nerves,
which, accordingly, and in proportion to their quantity,
increases the intra-cranial pressure, and which, if not
relieved by discharge from the nasal and pituitary channels
anteriorly, or the peri- and endo-anal apertures posteriorly,
or other channels, finds its way from that cavity along the
lines of least resistance, which are the peri-neural inter-
spaces surrounding the motor nerve trunks.

This having taken place, the cerebro-spinal fluid, which
has now become charged with an effete, and, consequently,
toxic sudorous material, is injected or run into the intra-
muscular textures, with the consequence that ‘‘ rheumatic,”

and not necessarily ‘‘inflammatory,” pains are produced, —

with more or less stiffening and, it may be, swelling,
which, if repeated and continued, may finally result in
complete loss of the power of contraction or contractility
of the affected muscles, with destruction of their sarcous
material or muscle discs—myopathy.

The pains, stiffening, and loss of contractile power,
result from the disturbance of the motor nerve energy
supply of the affected muscles, arising from the loss of
response to the usual motor nerve stimuli, the disintegra-
tion and absorption of the sarcous and contractile sub-
stance of the proper muscle fibres, the final displacement
of the sarcous elements, as well as sclerosis of the muscle
fibres proper.

The materies morbi is thus, so to speak, ‘‘ produced on
the premises,” and leads, consequently, to auto-toxis by,
most likely, a series of chemico-physiological and patho-
logical changes, due to its invasion of, and incorporation
with, the muscle substance, and to associated inflammatory
changes in the non-sarcous elements of the affected muscles
_——a secondary pathological process. Moreover, and we
must reiterate the statement, it seems to us that the non-
sarcous structures of the affected muscles are not neces-
sarily increased in pseudo-muscular hypertrophy by hyper-
proliferation of their connective tissue cells, but that this
matrix, after the removal of its accompanying and con-

POLYMYOSITIS AND MYOSITIS 159

tained sarcous material, only represents the empty
sarcolemmar sheaths, with more or less remaining sarcous
débris and interpolated materials from the motor nerve
fibres, and, it may be, from the blood vasculature, through
inflammatory exudation and through the deprivation or
loss of lateral pressure on its component vessels, by the
withdrawal of the true sarcous matter from the affected
muscle fibres, and the consequent increase of local blood
pressure from passive hyperemia.

By continued pathological changes along these lines the
sarcous elements may disappear altogether, leaving only
more or less of the sclerosed sarcolemmar investments to
represent the original muscular structure, which may be
said to constitute the last stage of muscular atrophy. or
myopathy, these latter affections following on, so to speak,
the asphyxiating influence of the inflammatory processes
and altered neuro-muscular metabolism.

EXTRACT XXVIII.
MYOPATHY!

Musc e tissue, including the fibre or sarcous material
and its interstitial or non-sarcous elements, represents a
structure whose growth is due to nutritive materials
supplied from two different sources, the physiological
balancing of which represents the condition of proper
tone and health of the muscular substance, and the dis-
turbance of which produces such ailments as atrophy and
hypertrophy of its dual structural elements. The nutri-
tive materials are supplied from the nervine and hemal
circulations respectively, with both of which the affected
muscles are structurally connected or continuous.

Muscle fibre, or the sarcous or fleshy part of muscle,
is isolated and insulated from its interstitial and surround-
ing non-sarcous structural or connective elements, and,
therefore, is cut off from direct hzemal nutritional relation-
ship and cast upon nervine sources of supply, not only
for functional impulse and tonus, but for the material
renewal and structural nutrition of its fibro-sarcous ele-
ments, this being effected and the nutritive materials
conveyed to it by an unbroken circulation through the
motor nerve axons from their parent neurons or cells in
the central nervous system, brain, cord, or ganglia. The
medullary and axis cylinder substances respectively of
these motor axons at their distal terminations, where they
are exuded by the terminal nerve plates, represent the
nutritive sources of supply of the manifold muscular

1 Vide Sir W. E. Gowers’ Lecture, British Medical Journal, July
12th, 1902.

Sn Me

— =o

ee

= -; =

MYOPATHY 161

developments of the voluntary musculature, and the
muscle plate or terminal motor nervature, the nutritional
medium or vehicle by which these sources of supply are
made available for the material wants of that musculature,
each of the muscle discs or sarcous units of which it is
composed having conveyed to it, along with the necessary
functional energy, the material elements on which it lives
and by which it acts; the functional energy and activity
and the material nutrition of the muscular system thus
owing a common origin in and emanating alike from the
inner recesses of the central nervous system, and exhibiting
an indissoluble blending of functional intent and structural
contrivance.

This intimate blending of the systemic motor nervature
and voluntary musculature in structure and function is due
to the persistence of an epi-blastic continuity of texture and
a oneness and sameness of functional réle, and represents an
inter-dependence of an absolutely essential and unbroken
nature for the complete realisation of voluntary and reflex
mobile necessities between the nervous and muscular
systems. :

We may take it, also, that a like intimacy of union
characterises the blending of the involuntary or sympa-
thetic nervature with its related involuntary musculature
in structure and function.

Moreover, we are, we think, further warranted in infer-
ring that a like, or at least a kindred, blending subsists
between the related, but in some respects independent,
systemic and sympathetic nervous systems. We would

remark still further that the central nervous system, with

its related peripheral, motor, and sensory nervature, 1s
united centrally, as between its two halves, by a somewhat
like bond of union in structure and function.

A continuity of histological development and an inter-
dependence of function, therefore, may be said to prevail
throughout the entire nervous system, with its related
voluntary and involuntary musculatures, by which is
secured a reliable tenure of the lease of life, by the har-
monious working of its varied but component parts along
the lines of least resistance and consequent minimum
expenditure of force, and the obviation of overlapping in

II L

ie PHYSIC

the spheres of production and results, intellectual and
physical.

The interstitial substance or texture of the various

muscles, on the contrary, derives its nutritional supplies

directly from hemal sources through the systemic blood
vascular circulation of the mesoblastic area, with which it
is inter-penetrated, and is, therefore, influenced by entirely
different formative and nutritive conditions, in virtue of
which, not sameness, but reciprocity, characterises the
relationship with its enclosed and surrounding sarcous or
fibro-muscular substance.

Muscular tissue may, therefore, be regarded as a com-
pound of two structural elements owing their origin to
two different formative and nutritional sources, viz. the
epi-blastic and meso-blastic, and maintaining their structural
individuality and distinctness, while collaborating in and
contributing to the performance of a common function ;
hence the disturbance of the nutritional balance existing
between the two may lead to unilateral or lop-sided trophic
results, with consequent proportional functional disturb-
ance, which may result in the abrogation of, or serious
interference with, the performance of co-ordinated muscle
functions, and, finally, to complete atrophic degeneration
and myopathic obliteration of its entire sarcous structural
elements.

Myopathy occurring thus would seem to be dependent
upon a faulty motor “‘terminal plate” materio-dynamic
distribution, as the remaining central motor nerve struc-
tures have usually not been found involved, resulting in
the deprivation of the involved musculature of the nervine
or sarcous nutriment, as well as nerve energy supplied to
it by the central nervous system, or of that combination
of matter and energy which is responsible for the main-
tenance of the true muscular fibre, as distinguished from
the interstitial substance, which we have said is derived
from hemal sources. Myopathy, of what we may call
the first degree, consists alone of atrophy, and degenera-
tion of the muscular fibres, with occupation or overlapping
of the vacated or shrunken intra-fibral spaces, by the yield-
ing collateral interstitial element, which, being deprived
of its accustomed lateral sarcous support, fills up the vacua,

RS EES ss el

eT

MYOPATHY 163

and succeeds for a time in “‘maintaining the outward
appearance or semblance of healthy muscle.” Deprived,
however, of its raison détre, and no longer able to assume
the functional réle of true muscular tissue, this structural
substitute succumbs in turn from inertia and disuse, leav-
ing scarcely a trace behind, which constitutes the second
and final stage or degree.

By thus regarding the sequence and nature of the
pathological events which lead up to and are concerned
in producing the diseased condition known as myopathy,
and which constitute and characterise its two degrees, we
persuade ourselves that we obtain a clearer insight into
the “manner and method” of the working of the various
factors responsible for its production, and alas! we also
realise the limitations of the curative powers of therapeutic
agencies and the futility of the most skilful efforts of
manual and electrical assistance. Nevertheless, we per-
ceive that however this diseased process is brought about,
remedial measures, to be even to a limited degree success-
ful, must be applied simultaneously with the commence-
ment of the shutting off of the nervine nutrient protoplasm
from the recipient muscular fibre discs, or before the
involved muscular structures have undergone degenerative
change beyond the hope of recovery, or while there is
still the possibility of renewing the continuity of neuro-
muscular tone and contractility with full voluntary func-
tional subserviency and potentiality.

In relationship to what is claimed for myopathy in
connection with failure or non-degeneration of the more

proximal, as well as distal, nerve elements connecting the

affected musculature with the central nervous system, we
would remark that that claim gives good ground for

retaining a hope that it may still, after all, be possible to

devise remedial measures, which will suffice to renew that
material and functional connection of the divorced nerva-
ture and musculature which disease, histological accident,

or failure has brought about, and that these measures are

most likely to be discovered along the lines indicated by
the local and general histological and physiological struc-
tural connections and continuities.

We would further remark, regarding the general subject

164 PHYSIC

of muscular atrophy as compared with the restricted
_ subject under discussion, myopathy, that the latter, from
the immediateness of its cause—nerve terminal distribu-
tion—should be more amenable to treatment than the
former, which is often due to central and distant structural
changes altogether beyond the possible reach of the best
devised remedial and even ameliorative measures.

It need scarcely be added that the occurrence of muscular
failure in all its varieties is a concrete subject of a most
far-reaching character, and one which, next to mental
sanity, is of the greatest importance to the individual and
to the world at large, inasmuch as the power of self-
support of the individual and the united individual con-
tributions to the coffers of the commonwealth are alike
at stake, and affected by it, hence its interest becomes a
matter of the greatest moment to the medical profession,
as well as the administrators of the State. That muscular
failure is usually, primarily, due to nerve failure, may be
regarded as axiomatic, except in those rare cases where
failure of muscular power is due to intrinsic failure of the
purely muscular structure elements, apart from failure of
any of the nervine structural elements with which the
affected muscle textures are supplied. Hence, we must
almost always be prepared to search for and to find, if
haply we can, the cause of the muscular breakdown in
some part of the nerve textures joining the affected muscu-
lature with its affiliated central nervature, i.e., in either
the parent nerve cell, its axonal process, or its terminal
nerve-plate extension, as in the case of the disease under
discussion, myopathy and muscular paralysis. In all forms
of muscular failure, irrespective of the Jocale of the original
breakdown, it is thus essential to recognise the universally
underlying fact that that failure is primarily due, except
in the rare cases of intrinsic muscle failure, to non-delivery
of the nervine nutritional protoplasm from failure of the
nervine vehicular agencies or nerve capillary circulatory
media to supply the muscle discs of the implicated muscle
fibrature. All this, therefore, is a matter entirely belong-
ing to the economy of the nervine circulation, as connected
with the nutritional phenomena involved in the growth
and maintenance of the sarcous elements of muscular

MYOPATHY 165

tissue, and does not at all primarily belong, in the remotest
degree, to the hemal circulation or nutrition of the non-
sarcous or interstitial elements or the non-contractile parts ;
secondarily, however, follow pathological changes in these
latter, dependent on the progress of pathological changes
in the former, and as the closing phase of a long retro-
gressive or degenerative process, resulting in annihilation
-more or less complete, of the involved musculature.

EXTRACT XXIX,

ON THE CUTANEOUS CONDITION KNOWN AS “GLOSSY
SKIN,”

Turis condition of skin is observable in and constitutes
a very conspicuous feature of many diseased conditions
of that structure, but, at the same time, and in the same
individual sometimes, it may be observed as a histologico-
physiological feature due to and ‘‘ marking time” in the
process of evolution, or rather involution, of the structural
changes or natural decadence: as displayed i in the surface
covering of the gradually ageing body.

In hemiplegia, paraplegia, and general sensory paralysis,
as well as in cases of extreme senile decay, this condition
of skin is seen gradually to develop itself until the glossi-
ness completely overtakes and obliterates the ordinary or
normal features and markings of the cutaneous surface
textures and appendages.

It is dependent strictly and eminently on a retrograde
and atrophic nutritional movement, having for its causes,
amongst others, a failure of the cutaneous nervine plasma,
due to scanty, or non-, production on the part of the
neuronal secretory mechanionn and to nervine non-circu-
latory ability to transmit to the peripheral nervature the
necessary nutritive material if, and when, it has been pro-
duced, or to the non-efficient supply of the requisite
neuroglial elements by the blood or hemal circulation to
the central nerve plasma-producing machinery. The plas-
mic failure responsible for the genesis of pathological
glossiness of skin is but an accentuation of the physio-
logical glossiness of skin of extreme age, and represents in

“GLOSSY SKIN ” 167

unusually intense degree the working of those nutritional
influences and processes which are daily at work from the
cradle to the grave ‘“‘ writing down” the impressions of
time on the human physique so plainly that ‘‘ he who runs
may read”—for are not the dappled skin of the chubby
infant, the ruddiness of youth, the finished growth and
nutritional completeness of adolescence, the nascent de-
clinature and wrinkling of active workaday life, and the
wholesale shrinkage of old age, but impressions left by
fleeting time to mark the stages of the journey of life?

The cutaneous features and characteristics of these
various stages of life are, to a great extent, produced by
the varying peripheral disposal of the sensory or afferent
neuronal plasma, consisting of the medullary and axis
cylinder substances, and the surrounding neurilemmar
lymph by the nervine circulatory media and forces, regu-
lated by the altering conditions of vitality as determined
by age and environment. Moreover, and as a matter of
course, the appendages of the skin, comprising hair, nails,
etc., have their tell-tale feature impressed upon them by
time and determined by the operation of the same genetic,
formative, and nutritional laws on the same, but variedly
disposed, materials, together with the addition of altered
pigmentation in the manifold stages and degrees of com-
plexity between the “‘ positive and negative.”

The atrophic changes displayed in “‘glossy skin,” in
origin and character, are identical with the atrophic changes
displayed in myopathic muscle, at any rate in the first
stage, while in the second, or final, stage the respective
atrophic changes are determined on the same lines, but
modified by the somewhat different structural conditions
existing between skin and muscle tissues. In like manner
the atrophic cause must be. sought for in faulty hemo-
neuroglial supplies, in breakdown of the neuronal struc-
tural developments of cell, nerve fibre, and terminal
extensions, one or all of which may be found faulty in
individual instances of the ailment, but one of which must
have been primarily responsible for the induction of the
pathological state and its consequences.

‘“Glossy skin” thus represents faulty dermal nutrition,
due to nervine breakdown in one or other of the structural

>, i 9
ae

- ‘ S —- ‘
+

168 4 PRY SIe | in.

elements responsible for the conveyance of nervine plasma
from the central nervous system to the dermis, or the
failure of the pial circulation to store the proper plasma
in the matrix of the neuroglia within neuronal reach—
generally or locally.

=

eee ae ee ee ee ts

EXTRACT XXX.

ON KERATOSIS AND HYPERKERATOSIS.

Tue first of these terms seems to us to be applicable to

the definition of a natural process always in evidence on

the general surface of the skin in greater or lesser degree,

and consisting of the formation and exfoliation of horny

or epidermal material, the term keratosis being, therefore,

used to designate the physiological, while the latter,

hyperkeratosis, in like manner applies to the pathological

manifestations of the process.

Keratosis thus used signifies the ordinary proliferation
and evolution of the epidermal cell elements, their corni-
fication, so to speak, and their final exfoliation from the
cutaneous surface as used up and functionless or withered
structure. Hyperkeratosis, as thus used, signifies in like

manner an exaggerated degree of the natural process of.

keratosis or the premature cessation of the final stage of

exfoliation, by which the local or general accumulation of

more or less of the keratosed material is allowed to take
place on the epidermal surface, with the result that the

involved cutaneous areas are said to be thickened or

hyperkeratosed, or to present the pathological conditions
known in so many morbid cutaneous processes and diseased
states by such names as lepra vulgaris, ichthyosis, etc.
Keratosis, as a physiological occurrence, is represented
by or consists of the conversion of the proliferating dermal
into the fully developed epidermal cells, the gradual con-
version of these into epidermal scales, and the final
shedding of the scales by peripheral exfoliation in regular

and uninterrupted structural succession, and, therefore,

170 PHYSIC

constitutes a process of peripheral excretion—albeit mainly
systemic nervine—of the exhausted and effete or dried-up
protoplasm of the peripheral nerve terminals, admixed
with a proportion of hzemal and sympathetic nervine
excretionary débris.

Keratosis being thus an excretional process, it is, there-
fore, liable to stasis, arrest, and accumulation, local and
general, of the epidermal exuvie or excretionary materials,
with the result that a pathological disposal of these takes

lace on, within, or under the epidermis on lines deter-
mined by the consistency of the excretory materials and
the histological character of the peripheral cutaneous ele-
ments, nervine and hemal, amid which that material is
arrested or deposited and keratosed, and ultimately hyper-
keratosed by continuous accumulation and cornification.

A long list of skin diseases owes its genesis and exist-
ence to mal-excretion, or to epidermal retention or stasis,
and pathological arrangement or organisation of the epi-
dermal debris, which becomes cemented by the more fluid
elements of that débris, together, it may be, by the more
solid elements of the sweat, and is thereafter held by
continual mechanico-structural continuity in histological
union with the living textures.

The pathological juxtaposition, union, or fusion of
retained excretional material, with physiologically active
tissue, leads to the evolution of diseased conditions of
great variety, each of which is determined by the operation
of specific morbid influences, bacterial, chemical, mechani-
cal, and others, and to combinations of these in different
orders and intensities ; all of which, operating in differing
constitutional conditions and under powers of resistance
of the most varied order, necessarily determine and secure
the evolution of diseased entities in accordance with the
laws of what may be denominated functional and struc-
tural survival of the strongest, but, unfortunately, not of
=" the fittest.”

The generalisation here made applies to the evolution
of diseased conditions generally, as well as to that depart-
ment of dermatological morbidity embraced in the term
hyperkeratosis with which we are now concerned.

The consistency of the excretionary material on its

KERATOSIS AND HYPERKERATOSIS 171

release from its histological attachments, and the part of
the body from which the detachment is being effected in
relation to facility or difficulty of shedding, necessarily
afford the starting points and procure the conditions for
the maintenance of hyperkeratosal evolution. It behoves
us, therefore, to give warning that the process of keratosis
must be prevented in all cases whenever a tendency is
evinced towards hyperkeratosis, on the principle that
‘“ prevention is better than cure.”

As illustration of the truth of this observation and the
success of its practical application, we would give a short
résumé of a case which lately came under our observation.
The subject of the following clinical remarks was in
advanced middle life, and had for years, during winter
and spring, suffered from chapped hands and hyperkera-
tosis of the dorsal aspect of the carpal and metacarpal
portions of thumb and forefinger of both hands. The
condition of things, when first observed, consisted of a
series of slight chaps over the dorsal aspect of the hands
and fingers generally, with a dried and roughened feeling
of the skin, and locally, over the region particularised as
affected by hyperkeratosis, was a well-marked area on
both hands, the right in particular, of irregularly but
definitely raised epidermal exuvie, which to the finger
- gave the well-known sensation of “‘ sand paper,” and which
looked to be determined in pattern by the peripheral
terminal nervature. This exuvial epidermal upheaval
was evidently determined by non-detachment of the
external epidermal layers, and their continued adherence
to the epidermal matrix, due mainly to the absence of the
moisture of perspiration, determined by the repressive
influence of the winter cold on the sudoriferous economy
of the involved areas of the frequently exposed extremities.
This state of things having occurred from year to year,
and having as often disappeared, naturally gave rise to
the idea that it was a seasonal phenomenon, and only
required the use of preventive means to be entirely obvi-
ated, and if, unfortunately, by oversight allowed to
develop, that the use of curative means indicated by the
clinical condition were equally likely to be successful in
removing it.

172 PHYSIC

Thus the curative treatment in this case, which was most
successful, consisted in the softening and removal of the
hyperkeratosed epidermal exuvie by the local emollient
and detaching influence of glycerinated skin lotion, assisted _
by simultaneous friction and the immediate removal of
the softened epidermal impedimenta. This, together with
the local protection of the affected parts after treatment
and recourse to the same treatment when required, has.
resulted in the restoration to a perfectly healthy condition
of the areas involved, and to a ‘much pleasanter con-
dition” of the whole hands, in fact, equivalent to their
summer or normal condition.

On analysing this pathological condition, if we be war-
ranted in the use of the phrase, we become aware that it
is entirely of mechanical origin, and that it requires for
its cure and prevention means of a mechanical character 3
but who will say, if it be entirely neglected and allowed
to evolve its undoubtedly pathological or pathogenic con-
sequences, where it will or may end, and what actual
disease or diseases it may initiate and foster? Verily we
have here afforded the etiological foundation for the origin
and progress of chemical, bacterial, and other ailments of
the most varied and extensive order, and sometimes most
repulsive and even fatal character—‘* desquamative derma-
titis,’ ‘‘dermal tuberculosis,” et hoc genus omne, and
“leprosy,” according to the prevailing bacterial life and
local morbid environments.

ee a eT a |

3
|

EXTRACT XXXI.
ON HYPERKERATOSIS OF THE SKIN (Continued).

Keratosts being a physiological process of growth and
devitalisation, and the last of the series undergone by the
solid or organised textures of the skin, it must naturally
follow that unless every step of that process follows the
normal course or direction an interruption or stasis will
be the result, or an altogether perverted course will be
initiated and continued, it may be, to a pathological
termination or hyperkeratosis. In other words, the shed-
ding of the skin is the final stage of the katabolic activity
of the natural vital growth or disposition of that portion
of the organised plasma and resultant egesta which reach
the periphery of the body, and necessarily, therefore, a
vital hygienic function of the very greatest moment to
the health of the body, and an occurrence, any interference
with which must lead to pathogenesis, in proportion to
the extent with which it interferes with the continuance

of the physiological work of life and health.

Keratosis consists in the devitalisation, shrinkage, and
detachment of epidermal cells as they become proliferated
from the cutis vera and enter the stratum of overlying and
protecting epidermis, and that proliferation is rendered
possible only, or largely, by the presence in the proliferat-
ing dermic materials of a proper amount and proportion
of solid and liquid or plastic elements in order to the
maintenance of the succession of the cell outgrowth and
the double function subserved by the skin of affording a
containing and protecting wall to the body which it
encloses, while allowing at the same time organised free-

174 PHYSIC

dom for the external disposal of the effete and noxious
matter resulting from devitalisation and detachment.

In the normal and healthy condition of the skin these
processes are accomplished with absolute perfection, the -
cell proliferation and succession proceeding with vitally
determined precision ; so soon, however, as the-age of the
individual or his environment, or both, leads to inter-
ference from within or from without with the regularity
of this process, so soon will appear the first indications
of the evolution of the phenomena of hyperkeratosis, it
may be only in the form of thickening and hardening of
the epidermis, with more or less consequent blunting of
the involved afferent nervature ; the condition, however
it may be, ultimately waxing in pronouncement until the
consistence of ‘‘sand paper” has been reached, or great
flakes and areas of accumulated epidermal débris mark the
affected parts. Such processes do or can only occur where
the skin is liable to be affected by changes in the environ-
ment of the body, as on the face and hands, or where the
development of pathological changes in the vitality and
texture of the skin elements have led to the occurrence
of stasis or arrest of cutaneous transpiration, perspiration,
or dermal cell proliferation and progression in one or all
of the dermal and epidermal strata.

In the former or local the occurrence may hence be
seasonal or climatic, in accordance with the existence and
play of atmospheric change and condition, and the indi-
vidual susceptibility to such influences and pathogenic
incidence, while in the latter or general occurrence it may
be developed at any or all times, or whenever and wherever
the structural and functional conditions of the skin become
affected by an internal pathogenic influence, localised in
its power of action to a particular area, or spread over the
general surface of the peripheral covering and the cutaneous
excretionary machinery of the body.

The substance, therefore, composing the hyperkeratosed
epidermis represents an exaggerated degree of the physio-
logically produced epidermal elements, and may be due
to defective shedding or aggravated production, which,
once initiated, may become the host of organisms dele-
terious to the health, and, it may be, fatal to the life of

HYPERKERATOSIS OF THE SKIN 175

the body on which it forms, as, for example, in leprosy,
where we contend that the prevention of hyperkeratosis
will banish from the human family that long-dreaded and
familiar scourge.

It is eminently here where want of parallelism between
structure and function applies, and where the removal or
detachment of devitalised and functionless materials be-
comes a matter of vital moment if the preservation of
health is to be maintained, and where, if nature is unable
alone to accomplish the work, she must be aided by art,
medical as well as surgical.

“Cleanliness,” in the strictest sense and the completest
form, externally and internally, ‘‘is next to Godliness,”
and must, consequently, be the aim of everyone anxious
to live out his or her days to their natural end, and to
take out of this life all of comfort and happiness he or
she possibly can. It, consequently, becomes the bounden
duty of the individual and, therefore, of the State, so to
educate public opinion that it will be strong enough to
enforce the laws of public health, as well as to influence
the character of the legislation necessary to this great end.

EXTRACT XXXII.

ON ATROPHY, HYPERTROPHY, AND DEGENERATION OF
MUSCLE AND SKIN TISSUES, FROM THE POINT OF
VIEW OF NEURO-MUSCULAR AND NEURO-DERMAL
NUTRITION AND INNERVATION.

CoNTENDING, as we do, that nerve and muscle, and nerve
and skin, are structurally and dynamically one in their
neuro-systemic relationships, and that they are indissoluble
in function as well as in histological continuity in physio-
logical evolution and development and in sources of
nutrition, we shall endeavour to apply these doctrines to
the elucidation of the phenomena involved in the above
conditions, and so prepare the way for, if possible, their
more scientific and effective obviation and treatment.

The key to the situation thus created is what we should
call the great physiological law that nerve and the true
sarcous elements of muscle and the neuro-dermal elements
of skin alike owe their nutrition to the neuroglia provided
by the hemal circulation in the brain cord and ganglia,
where or from which the neurons primarily take up from
the neurological matrix the pabulum on which they feed,
as well as that on which all textures innervated and also
nourished by them are supported, and to which they by
growth or circulation convey it through their axons.

This key provides, we think, the means by which the
etiology and evolution of the conditions known as atrophy,
hypertrophy, and degeneration of muscular tissue and
dermal texture respectively can best be realised and
appraised, and indications provided both for preventive
and curative treatment.

Adis

DEGENERATION OF TISSUES 177

Thus, when it is fully understood and appreciated that
every texture innervated by the systemic nervous system
is likewise nourished by it, it will at once become obvious
that any interference with either of these phenomena will
of necessity be followed by altered innervation or nutri-
tion, or both, of the textures involved, and will show
the same, whether it be by deprivation, exaggeration, or
perversion, of one or either, or both. It, therefore,
follows from this that an entirely healthy condition of the
factors engaged in systemic innervation and nutrition must
of necessity be followed by an absolutely physiological
fulfilment of these functions, while a disturbed or patho-
logical condition of them will in like manner be followed
by a pathological or imperfect manner of functional per-
formance, which will manifest itself by the evolution of
one or other of the structural states known as atrophy and
hypertrophy, and, it may be, degeneration, which latter,
however, may occur primarily or follow as a consequence
of either atrophy or hypertrophy. Atrophy thus must
follow neuro-plasmic failure in proportion to the complete-
ness of the latter, and may vary in degree, consequently,
according as the plasmic deprivation is partial or complete,
therefore, the affected musculature and the implicated
cutaneous areas will show by their trophic behaviour the
extent of the neuro-plasmic failure, and so indicate to us
whether the existent condition is partial and curable or
complete and incurable. Moreover, it may be possible,
by close observation of the incidence and sequence of the
phenomena of atrophy, to determine to some extent
whether they have originated in the affected muscular and
dermal structures and areas or whether they have been
initiated by central or connective changes, implicating the
dendronal cell or axonal elements respectively, and thus,
consequently, it may be possible for us to prescribe a
remedial or ameliorative treatment on more scientific lines
than those of the best directed empiricism.

Hypertrophy, like atrophy, follows the trophic disposal
of neuro-plasm, but, unlike it, is due to its exaggerated
distribution, circulation, and assimilation, which latter—
the assimilation—being in excess of the spatial capabilities
and requirements of the affected musculature and neuro-

II M -

178 PHYSIC.

dermal tissues respectively, manifests itself as structural
exaggeration, but on and within the normal lines of natural
histological arrangement and development. Thus the arm

of the blacksmith and the whole muscular physique of —

the athlete undergo trophic increase exclusively along the
naturally existent lines of histological continuity and
developmental evolution of neuron and muscle fibre,
determined by voluntarily increased neuro-dynamic dis-
charge and insulated circulation of neuro-plasm or nerve
matter and energy, whereby, by repetition, the constantly
accentuated supply of neuro-muscular protoplasm becomes
‘piled up,” as it were, in the muscle discs at the terminal
extremities of the actively vehicular nervature, with the
result that local or general hypertrophy is evolved in the
“upper limb” of the former, and the fully developed
‘“classic style” in the latter." Moreover, it may be claimed
that the “‘horny handed” brotherhood of labour display
on the same natural lines of evolutionary development
the exaggerated dispatch and assimilation of neuro-dermal
plasma, and its local ‘‘piling up” or storage, amid the
dermal structure and appendages of their much exercised
manual ‘‘organs” or extremities, all which shows once
more the truth of the old aphorism, ubi stimulus 1bi
fluxus, and its applicability to the explanation of neuro-
muscular and neuro-dermal circulatory and nutritionary
phenomena in their absolutely physiological condition ;
and foreshadows its corresponding applicability to the
decipherment of related pathological phenomena, further-
more, we claim that underlying what we have here
advanced are alone, or almost alone, the great principles
of the neuro-plasmic material circulation and the neuro-
dynamic or force regulation, or the formative disposal of
neuro-dermal plasma in the normal or physiological aspect
of the subject, the pathological aspect of it emerging by
continuity from the physiological. Systemic musculo-
dermic, as distinguished from sympathetic structural,
textural, or sent degeneration, follows as a pathological
phenomenon from a lapse or modification of the physio-
logical control of the formative or organic impulses, and
the consequently irregular plasmic dispositions of the
neuro-muscular and neuro-dermic organic materials on the

DEGENERATION OF TISSUES 179

part of the trophic machinery of the systemic nervous
system or organism, and manifests itself in the production,
by the substituted chemical and physical energies conse-
quent on the lapse of neuro-dynamic or vital energy, of
textural changes, called degenerative, or what may be
regarded as analytic or dissolutive plasma or material
dispositions, leading to atrophy and ultimate textural
disappearance.

Degeneration may, therefore, present itself in all degrees
of development and completeness according to the nature
of the structures involved, the length of time since their
trophic paralysis ensued, and the celerity of the chemical
and physical changes undergone by the paralysed textures,
besides what may be determined by the possible invasion
and modification of the degenerating materials by bacterial
organisms and materies morbi and their consequent con-
version into pabulum fit for new organisation on patho-
logical lines, and, it may be, for the evolution of definite
morbid entities, some of which may have the most far-
reaching influences on health and even life.

Degeneration, arising from neuro-plasmic and neuro-
dynamic failure, may be regarded as a phenomenon of
constant occurrence in the economy of nutrition generally
in certain states of health and at certain stages of life in
even its physiological condition, where the analytic forces
begin to overtake and overwhelm the synthetic or forma-
tive forces, and to initiate changes which turn the healthy
metabolism of the tissues to pathological purposes or uses,
substituting by degrees a morbid for a healthy formative
régime, which ultimately, it may be, completely asphyxiates
normal growths and vital action. This applies equally to
the trophic phenomena characterising the nutrition of both
the systemically and sympathetically innervated structures
and organs, and to tissue metabolism generally and par-
ticularly.

Degeneration, in the latter sense, is synonymous with
the disintegration, which “‘waiteth” on and followeth
integration in the process of nutrition, and becomes the
lot of every particle of integrated material or tissue fabric,
and, therefore, is physiological, while degeneration in the
pathological sense consists of the premature devitalisation

180 PHYSIC

and breaking up of tissue material into its simpler chemical
and physical constituents, and, thereafter, into its ultimate
inorganic elements.

Pathological degenerations may thus often precede ~
atrophy of structure and organ, and afford the material and
dynamic basis for the evolution of diseased entities and
for their extension to the degree of ultimate complete
usurpation of physiological dominion and vital supremacy
in the material disposition and formative work of the
affected organisms—it may, therefore, be regarded as a
prematurely aggressive ally of the natural forces of involu-
tion which, at one time or another, assert themselves as
the ‘‘natural span of life” lengthens out to its close and
as the processes of innervation and nutrition, or the
material and dynamic vital activities, fall into abeyance
and ultimate cessation. Disease and death are, therefore,
both indebted to degeneration for the accomplishment of
much of their inevitable destructive work, and vital
involution for the hurrying forward of its accomplishment
of the duties of organic reduction and dismantlement.

EXTRACT XXXIII.

ON THE ORIGIN OF COLOUR OR PIGMENTATION IN
THE VARIOUS TEXTURES,

Tue occurrence of pigmentation or the deposition of
colouring matter in the various textures of the body
during the process of pathological changes in the course
of disease seems to be dependent on the ‘chapter of
accidents,” and to be regulated by no law. Such, we are
led to believe, is not the case, and, indeed, it would be
contrary to all experience were we to look upon the
phenomena displayed in the colour relicts of disease as
representing nothing but the chaos of the battlefield, so to
speak, in which the agents of disease have been struggling
with those of health for the ‘‘ mastery of the situation,”
and in which the alterations of colour may be recognised
as so much wreckage.

Before referring to the subject in its pathological aspect,
our explanatory efforts will be devoted to its physiological
bearings, in order to make more clear the foundations on
which we propose that the pathological superstructure and
its clinical outcome of deduction and guidance should be
built.

Physiologically, we think we are warranted in stating
that all methods and varieties of animal colouration in
living animal nature are due to the initiative and selective
agency of the nervous system, by virtue of its manifold
“tastes,” and through the various fashions and modes of
its working or operating throughout the whole of the
animal kingdom, and, also, that nature operates by a pro-

182 PHYSIC

cess allied to but, so far as yet known, without the agency
of a nervous system, unless it be a rudimentary sympa-
thetic, in determining and producing the magnificent array

of colouration displayed throughout the vegetable king-—

dom.

The superficies of each animal is vitalised by the peri-
pheral nerves, the texture of that superficies being deter-
mined and its colour resolved upon and fixed in settled
perpetuity, so far as the individual animal is concerned,
by the inherent determining and selective powers of the
nervous system, reacted upon by the conditions of its
environment, and the chemical and physical nature of the
pabulum with which it is supplied, by the pervading and
related hemal vascular system and nutritional mechanism ;
in other words, by the laws of natural selection, which here
operate with great conspicuousness and continuity of pur-
posive design—-the colour of the deep-seated, as well as
the superficial parts, must necessarily be determined and
perpetuated by. like agencies.

In the embryo are laid the foundations of the colour,
shape, and general characteristics of the future organism,
and the molecular arrangements, cellular development, and
the manner of unfolding of its component parts, organs,
and appendages foreshadowed and determined. In early
and mature age are wrought out the designs formed in
the embryo, while in old age we witness their modification,
involution, and obliteration to meet the altered and alter-
ing circumstances of the individual organism and _ its
environment.

Colour, being not a property of matter, but the outcome
of its molecular arrangement, the causes of its changes
and disappearance in the living body, must, therefore, be
sought for amid the incessant activities and processes of
vital synthesis and analysis of integration and disintegra-
tion, growth and decay, which repeat themselves in regular
succession during the course of life. Continuity and
regularity, in these conditions and processes, must be
followed by sameness of result, and, consequently, same-
ness of colour, while discontinuity and irregularity must
be followed by difference of result, and, consequently,
difference of colour, which latter occurrence must be quite

——"

ON THE ORIGIN OF COLOUR 183

consistent with physiological necessities, and, therefore,
not necessarily a pathological condition or development.

The alteration in the colour of the hair, as the process
of ageing advances, affords a good example of the physio-
logical modification of the function of pigmentation, while
the sudden blanching of the hair observed under the
influence of great mental shock or emotion might be
recognised as an example of the pathological variety of
the alteration, although on strictly physiological lines.

Pigment, as observed physiologically in the human
body, is detected in a large number of textures, both
superficial and deep, and histologically it may be said to
be almost consistently related to nerve textures—mainly
terminal, both proximal and distal—as, for instance, in the
skin, retina, Schneiderian mucosa, the otic muscular tex-
tures, and the smaller and larger pigmentary deposits to
be found scattered up and down it. It may, therefore, be
inferred that the nervous system, as has already been
remarked, is mainly instrumental in its production and
deposition, and that the play of nerve force on the material
constituting the pigment under normal as well as abnormal
biological conditions eventuates in a molecular transmuta-
tion or re-arrangement whereby the impression of colour
is given and the pigmentation secured—the existence in
some nerve cells of colouring matter and the occurrence
of pigmentation in connection with the terminal ends of
some nerve fibrils being thus accounted for by histological
continuity.

As it is in the physiological state so it is in the patho-
logical state, in which latter a morbid excitation or dis-
turbance of the nerve terminal textures or a solution of
continuity of nerve fibril investments takes place, whereby
a leakage or escape of nerve substance and force is per-
mitted into the surrounding structures, and there occurs
the production of more or less pigmentation—"‘ negative
or positive,” fainter or more marked, according to the
site, the structures involved in the lesion, and the con-
tinuation and intensity of the morbid processes involved.

Associated with the subject of pigmentation of the skin
is that of the life-long modification or changing textural
proportions due to evolution and involution of its external

184 PHYSIC

layers. This modification, we have observed, is a life-long
one, stretching from the earliest development of the
embryonic “‘limiting membrane” and feetal skin to the
most wrinkled old age, and determined by the circum-—
stances of environment and the altering conditions of life
and work. Thus the respective proportions ~in regard
to fulness of development and complexity of textural
arrangement of the nervine and blood circulatory media
change *‘ with the changing years.”

4

EXTRACT XXXIV.
ON LEPROSY.

Leprosy is a disease unique in the national and individual
interest it has attracted all along the historical ages of the
human race, its conspicuousness and esteemed infectivity
securing for it the adoption of isolative and preventive
measures more or less by all races in proportion to the
intensity of its incidence in, and the degree of civilisation
attained by, the particular race.

Many opinions have from time to time been advanced
and held since its nature has been subjected to more or
less expert consideration and analysis, but it cannot be
said that any one of these has yet been generally recognised
as absolutely believable and capable of leading to more
than an empirical mode of meeting the hygienic and
therapeutic necessities of the case; therefore, we feel that
the advancement of another opinion will be quite con-
sistent with the past history of this perennial subject.

Our opinion then, shortly stated, is this: We have in
leprosy to deal with a disease primarily of arrested
cutaneous exfoliation, transpiration, perspiration, and the
consequent suspension of the other functional activities of
that most important structure, the arrestment, beginning
with temporary stasis of the eliminatory phenomena of
the skin, continuing to increase by daily and yearly
accumulation of effete dermal products, and culminating
in the production of more or less gross collections of
exfoliated but retained débris in the form of nodules,
tubercles, and plaques, or pseudo-‘‘armour plates,” which
ultimately may, and sometimes do, undergo. disintegra-

186 PHYSIC

tion and removal, leaving the overspread and involved
cutaneous and subcutaneous structures bereft of many of
their histological elements, functional, material, active and

passive, and, in short, in a state of “‘ wreck and ruin” —

more or less complete, in accordance with the intensity
and duration of the disease. ;

The process of arrestment of cutaneous elimination, and
the consequent local or general formation of more or less

ross collections of effete but unshed dermal materials,
lay the foundation conditions and provide the required
pabulum for the invasion and support of armies of bacterial
organisms, which “‘batten and fatten” at the expense of
their host, and generally succeed, with intercurrent allies,
in completely undoing him, but not always, when mark
the result! is it not a “‘living death”?

Underlying and lending itself to the production and
evolution of these lethal events is one main structural
peculiarity and histological arrangement of the elements
comprising the skin, viz. the co-existence in it of three
circulations, or rather systems of circulation, which are,
respectively, sanguineous, lymphatic, and neural.

The first two may, we contend, be eliminated from the
list of possible primary etiological factors of leprosy, so
far as the principle of circulation and its arrestment is
concerned, inasmuch as these are concerned in the circula-
tion of fluids not likely to be primarily concerned in the
initiation of such disease, although they may, and do,
become secondarily involved by invasion and contiguity ;
moreover, they circulate their fluids mainly from the
periphery, and consequently away from the scene of the
disease, the exception being the pure arterial blood, which
cannot be looked upon as conveying to the peripheral
capillaries an effete and impure, and, therefore, excretional,
product. That being so, we are left alone with the neural
_ circulation, to find, if possible, in it what we are in search
of, i.e. the etiological factor, which has in it a power and
cogency sufficient to explain the initiation and sequence
of the morbid events or phenomena characterising and
constituting this long familiar, hideous, and fell disease,
leprosy.

That the neural circulation or system of circulations is

EE

ON LEPROSY 187

a great histological and physiological reality, we have
already attempted to make plain; therefore, it is not here
necessary to re-describe it in detail, or to do more than
claim for it that power and cogency, which we hold it
possesses, to unlock the secret of the true nature and
incidence of leprosy.

Thus the neural circulations one and all conduct to
the neural periphery wherever situated, either internally
or externally, and externally, of course, as in this case, they
must necessarily end in the skin, to which they convey or
circulate whatever of neural lymph may find its way along
the inter-neurilemmar spaces, and whatever of plastic
nervine substance is elaborated in and passed out of, or
excreted by, the afferent or sensory neuronal common-
wealth or sensory nerve cell community, whether situated
in brain, spinal cord, or ganglia.. The excrementitious
matters here must, therefore, be neural lymph, in the
form of sweat, and axonal process substances consisting of
neuro-keratinous or containing membrane material, with
the medullary and axis cylinder substances or nervine
substance proper—truly, a series of devitalised and shed-
ding materials abundantly and naturally able to take on
ageglutinative action, hardening and accumulative accretion,
ideally adapted to the formative growth and prolonged
cuticular adherence or dermal retention of leprous encrus-
tations—the cemented and solidified equivalent of the
total dermal débris of the surfaces involved.

That leprous skin developments are primarily due to
such accumulations we deliberately believe, and that the
‘bacterial or microbic organisms discovered in the accumu-
lations and permeating the connected tissues are secondary
we further believe ; therefore, we are prepared to assert
that without an initial stasis and more or less permanent
-arrestment of the neural circulations with local effete
accumulations, we could not have leprosy nor the develop-
ment of the leprous bacillus.

Such views necessitate the further belief that leprosy is
essentially a disease primarily of the nervous system in
relation to the non-patency and debarred function of its
cutaneous, excretional, and exfoliative apparatus, and, there-
fore, that it is a disease of “‘dirt and uncleanliness,” with

188 PHYSIC

super-added microbism, to be dealt with rigorously from
the preventive point of view, the principles of which should
almost at once and spontaneously be indicated or present

themselves. That leprosy has been geographically limited

in incidence, racially somewhat locally circumscribed in
spread, and, as to individual cases, that they generally have
been surrounded by somewhat questionable sanitary con-
ditions, and, it may be, personal neglect of bodily cleanli-
ness, with the continuous use of questionable articles of
diet, as has been from time to time contended, give a
warrant to the assumption that it is a disease absolutely
capable of extinction by properly directed preventive
measures and the education of public opinion as to the
great possibilities underlying and flowing out of the con-
tinued and world-wide influence of the rigorous adminis-
tration of the needful preventive and other measures.
We have claimed leprosy as a disease primarily of the
nervous system, and we are quite aware that the claim is
founded on nothing more or less than rank heterodoxy ;
nevertheless, we are prepared, we think and say, to demon-
strate that, on anatomical, histological, pathological, and
clinical grounds, we are warranted in making the claim
and in rejecting the others, so far as we have been able
to gather from available literature on the subject, as
coming far shorter of the requirements necessitated than
that which we now and here advance. The universally
cutaneous sites chosen by the disease, the years long
incubatory progress characterising it, the greater or lesser
neural destruction wrought by its pathological incidence
and influence, the consistence and composition of the
leprous exuvia, the frequent symmetrical distribution of
the morbid phenomena, and the correspondence in locale
of the cutaneous involvements, with the anatomical distri-
bution of the peripheral sensory nervature, all proclaim
its nervine origin and incidence. These facts, in conjunc-
tion with the bacterial invasion of the resultant neuro-
dermal exudations, give the key, therefore, in our opinion,
to the true pathology of the affection, provide indica-
tions for a more hopeful treatment, preventive, curative,
and ameliorative, than has hitherto been possible, and
bring the disease into the category of affections of which

7

ON LEPROSY 189

it is the bounden duty of the profession of medicine to
undertake the treatment to satisfy its amour propre, as
well as to reclaim from abject misery and hopelessness the
unfortunate outcasts of, at the best, a barbarous and
melancholy survival of ancient folk-medicine.

Pursuing the subject of the nervine origin of leprosy
a little further, we are brought face to face with examples
of undoubted neural circulatory stasis, accumulation of
neural substance, lymphoid and plastic, in the lumina of
the neurilemmar tubes, and the nerve tubes proper, with
regurgitation along them and consequent enlargement,
and sometimes varicosity of the implicated nerve trunks,
occurrences which have hitherto ranked as nerve hyper-
trophy from neuritis and accompanying hyperplasia. At
a glance we see that these cases of the disease, and kindred
others, conform to the formative conditions and evolution-
ary requirements necessitated by nervine origin and
progress, and that the whole sequence of morbid events
constituting their clinical history and progress is deter-
mined by nervine conditions, plus, ultimately or later,
the addition of bacterial influences, which to some extent
modify the later and latest stages of the disease. The
bacterial invasion cannot take place unless a suitable local
culture medium is provided for the growth and increase
of the organisms, and the continued maintenance of their
malign brood, and this medium, we hold, is provided in
the accumulating and unhygienic neuro-dermal débris ;
it follows, therefore, that the absence of this culture
medium must be followed by bacterially negative results
on every occasion, and that the universal non-supply of
these media must inevitably be followed by the non-
existence or extinction of the peccant organisms. We
must assert, moreover, that the part of the nervous system
_ primarily involved in the leprous process is the systemic,
whose excretional exits on its afferent or sensory side are
entirely on the skin, where the obstructing influences of
external dirt and the accumulation of neuro-dermal im-
pedimenta or exuvie ultimately effect the blockage of
these exits, with the consequent damming back of the
outflowing and outgrowing neural elements, and their
piling up, so to speak, amid the wreckage of breaking

190 PHYSIC

down. and perishing dermal and sub-dermal tissues, and in
some cases the regurgitant accumulations in, and the
ultimate so-called pseudo-hypertrophy of, the involved
nerve trunks.

Leprosy may, therefore, be defined as a disease primarily
initiated by purely mechanical causes, evolved by the com-
bination of these with bacterial influences, and closed by
the devitalisation and disintegration of the tissues in-
volved, ending, it may be, spontaneously in sorely maimed
recovery, but generally in exhaustion and death—consti-
tuting altogether one of the most tragic and melancholy
morbid spectacles to be met with in the whole range of
human disease.

As thus defined, its evolution proceeds somewhat on the
following lines, according to the geographical locale and
climatic conditions in which it may happen to arise—being
due, as we contend, to initial arrest of cuticular desquama-
tion and retained dermal or peripheral excretional products,
leprosy is evolved by accumulation of this epidermal débris
on the functionally active and proliferating dermal tissues,
where it undergoes a process of gradual thickening by
continued accretion and cementing, which effectually pre-
vents the process of normal desquamation and bars the
exits of the sweat glands, and thus leads to greater and
ereater upheaval of the involved epidermis, and the
damming back of the arrested sweat, with its consequent
and compelled regurgitation along the neurilemmar inter-
spaces of the implicated peripheral terminal nervature and
nerve trunks, with, it may be, induced peri-neuritis and the
development of pseudo-hypertrophy of the involved or
connected nerve trunks. As this process proceeds, and
where sufficient foothold, so to speak, is presented to the
lurking lepra bacillus to effect an entrance on the scene,
we see commenced the concluding stages of that long
drawn-out morbid process and that physiologico-patho-
logical conflict between the original and acquired phagocytic
agents of the human organism represented by the host of
leprosy in all its usually unmitigated hideousness and
‘long-suffering ” endurance.

During this physiologico-pathological conflict, if the

fortunes of war be on the side of the original and against

ON LEPROSY 191

the acquired phagocytic hosts, the result, if the conflict has
been long continued, is a scene of wreckage and spoliation
of its subject almost as formidable as death itself, the
immediately adjacent and the histologically continuous
structures being usually left waste and desolate by the
waxing and waning of battle and the continued cumbering
of the battlefield by broken and useless impedimenta.
Generally, however, the conflict becomes unequal, the
acquired or invading gaining an overwhelming influence
over the original or protecting phagocytic hosts, whereby
cessation of hostilities, capitulation, and annihilation are
finally secured. All this sorrowful conflict waged in the
persons of unfortunate lepers, we say again, is absolutely
preventable, and, if the requisite treatment be but initiated,
soon ought to be curable, or, if unhappily fairly in pro-
gress, mitigable, by means plainly indicated in the fore-
going résumé of the subject ; we, therefore, reiterate the
opinion that research, instead of dwelling on the effects,
should turn its attention to the elucidation of the absolutely
initial causes of the disease, which are usually to be found
in that debatable organic region or buffer zone occupied
in common by the frontier physiological agencies or forces
of health, and the marauding or invading pathogenic
scouts and advancing forces of disease. This debatable
zone may be said to be non-existent in the absolutely
physiologically healthy body and its individual tissues and
organs, and, therefore, no pathological opportunity pre-
sents itself for the inroads of the disease; under such
circumstances, consequently, the maintenance of an un-
broken hygienic wall of healthy protective texture around
the citadel of life must be constantly sought after as the
only means effectually to resist the invasion of such an
enemy.

Hygiene of the person universally, combined with the
scientific use of germicide therapeutic agencies under all
threatening circumstances, and with a world-wide indi-
vidual and national co-operation in working out the
destruction of the lepra bacillus, promises to rid the planet
of a disease which has been one of the greatest scourges
of humanity since the beginning of history, and, by
inference, from the beginning of the race. Weer

EXTRACT. 2X ae
ON TUBERCULOSIS.

Tue term tuberculosis is here chosen in preference to the
terms consumption, phthisis, or tabes, as having a generic
signification and adaptability which the latter terms do not
possess.

Tuberculosis, as a generic term, includes a very large
array of specific varieties of the disease, each of which is
due to the growth of a, or the, specific bacillus tuberculosis
—a near relation of the bacillus lepre—in a structural
medium, capable of determining its particular manner of
growth and pathological development, and the evolution
of the particular form of the disease. Thus, according to
the incidence of its etiological factors, it attacks the pul-
monary tissues, the parenchyma of particular organs, the
free surfaces of lining membranes, and the textures of the
skin, manifesting in each instance its specific characteristics
modified by the medium in which it is developed, and the
textural nature of its environment. This classification is
now rendered possible and necessary by the discovery that
they are each and all due to the growth and influence of
a common microbic organism, and that they are each and
all dependent for their individual and distinguishing
character on the operation of local modifying influences
and factors on their common pathological evolution from
one variety of microbic organism.

Being thus evolved from the growth of a common
pathogenic micro-organism, it must follow that the organ-
ism must obtain access to, and become supported by, some
available nutritive material possessed in common by the

a ~

:
.
}

ON TUBERCULOSIS 193

various textures of the bodies which, for the time being,
become its habitat, and where it develops and perpetuates,
and is communicated seriatim to other, or all, available or
suitable localities and organs within these bodies, until it
usurps and finally secures complete possession ; the physio-
logical yielding to the pathological régime, amid a scene
of material and dynamic exhaustion altogether sui generis.

We are inclined to think that, like its relative leprosy,
it at first finds a lodgment in and a foothold on inert and
devitalised materials or substances undergoing exfoliation
and removal from the system of the individual attacked,
such as are afforded in the situations usually chosen by the
bacillus in its first attempts at invasion ; as, for instance, in
the vesicular cavities of the pulmonary parenchyma and the
surface layers of the skin, where, in particular, its presence
is usually first observed after the influence of its patho-
logical presence has become manifest.

In its origin, therefore, we see the operation of etio-
logical factors conducted along kindred lines to those which
can be traced in the evolution of zymotic disease generally,
and perceive to some extent the operation of the particular
etiological factors in the evolution of the individual
tubercular manifestations.

If the infection be air-borne, we would naturally conclude
that the terminal air spaces of the lungs, where, from the
“calm and repose” of the residual air, the bacillary spores
could be dropped, deposited, or ‘“‘sown” on the already
prepared soil of the exfoliating endothelium, would be
‘ideal places” for the rearing of such organisms and the
propagation and distribution of their ripened seed. But,
on the other hand, if the infection be transferred in more
or less fluid or solid form from person to person, we
likewise see that the skin would most readily lend itself to
“culture of the organism, and could propagate and convey
it to the deeper-seated parts, along which it would ulti-
mately reach and overrun seriatim by contiguity and
histological continuity the various vulnerable structures
and organs to which it might find access.

_ The intestinal canal is another situation from which the
microbe secures admission into vulnerable regions by pass-
ing, along with articles of food and drink, through its

Il N

194 LPHESIC

lining mucosa, and attacking the agents of nutrition,
destroying their functional powers, and disseminating

toxins, until mal-nutrition and inanition “‘ prove superior

to the powers of life.”

In relation to the intra-corporeal distribution of the
tubercle bacillus, we are convinced that the invasion of the
cerebro-spinal cavity, and the subsequent tuberculous
tainting of the streams of cerebro-spinal lymph issuing
therefrom, becomes a principal, and perhaps the greatest,
means of carrying into the most remote regions of the
body the seeds of the disease, there to become fresh centres
for its further dissemination and the spread of its patho-
genic influence.

Amongst the phenomena of tubercular infectivity is one
most remarkable, we would say, almost unique, feature,
viz. the harmless retention for long periods of the bacillary
organisms, in spore, or germ, or adult condition, within
the invaded structures, without their giving rise to more
than passive symptoms or attracting the attention of their
host. In such circumstances the enemy, so to speak, lies
low until the time arrives that, from an attack of inter-
current disease and a lowering of the power of resistance,
with most likely the accumulation of adynamic and more
or less devitalised material, it is enabled to supply itself
with the means of renewed development and pathological
progress, and to engage with renewed vigour in its work
of destruction and ‘“‘consumption,” not usually to be
stopped until it has become completely victorious over its
now helpless victim. |

The local incidence of the disease, its methods and
manner of development, the pathological changes it effects
in individual structures and organs, and its ultimate
results all conform to the character and nature of its
microbic origin and essence, which enables it first to effect
a lodgment in, or take possession of, its victim at any
time, and to wait the ‘‘current of organic events,” until
the time arrives for it to take action, when it will its lethal
‘tale unfold.” In this it is but too frequently successful,
but not always, as clinical experience has told, and as
modern research is now demonstrating in its beneficent
work of prevention and cure.

*

ON TUBERCULOSIS 195

We may regard it from this point of view as axiomatic,
that no disease germ can develop at the expense of
absolutely healthy and physiologically active tissue, and
that, therefore, the immunity of absolutely healthy people
is thus secured, even though they be exposed to the attack
of infectious tease: if they but unremittingly attend to
the removal from their bodies, externally and internally,
of the effete materials on, and in, which such organisms
can alone live and move 28 have their being.

Consistently with this view of the genesis and progress
of tuberculosis, we, therefore, find the period of incuba-
tion of the diveise to vary according to the condition of
health and the character of bodily hygiene of its subject
at the time of infection and during an indefinite period
thereafter ; moreover, we find that the infection frequently
proves Ebotiive. as whet the pathogenic germs are success-
fully resisted by an impervious wall of physiologically
perfect tissue structure and perfectly dynamically endowed
tissue elements, or when these germs have been mechani-
cally removed or therapeutically destroyed or neutralised
by proper systemic hygienic agencies by, or in, conjunction
with properly devised artificial means ; in other words, by
the rational and commonsense union of natural and arti-
ficial agencies, climatic and therapeutic, such as changed
environment, improved ingestion, and facilitated egestion,
whereby the vis medicatrix nature is assisted in resisting
and overcoming the onward progress of pathogenesis or
pathological cell proliferation at the expense of the normal
or physiological metabolism.

__ Pulmonary tuberculosis, or the most prevalent form of
the disease, is, we may conclude, generally due to air-borne
infection, the germs of which by inspiration are carried
into the temotest recesses of the vesicular textures of the
lungs, and deposited on the surrounding exfoliating
endothelium, or in the exfoliated and unexpectorated
débris, to which it adheres, and in which it grows, forming
by subsequent accumulation and arrested removal, it may
be, caseated or calcified particles or masses, or miliary
saberclen and ultimately, it may be, attacking the now
somewhat imperfectly vitalised surrounding endothelium
and adjacent pulmonary inter-vesicular textures, which it

eee PHYSIC

gradually disintegrates, and, with the aid of a cough,
succeeds in expelling, leaving a cavity behind, which in
time is joined by other such cavities, due to similar patho-

logical processes, and converted into the fully developed

‘tubercular pulmonary cavity,” such as is met with in the
advanced or concluding stage of the disease.

This pathological sequence of events is generally slow,
but it must be remembered that it is not necessarily always
so, because cases are sometimes met with in which the
whole phenomena are so hurried, and the progress so rapid,
that from the first a fatal issue is inevitable, the assistance
of hygiene and therapeutics being alike futile. ,

In many of the slowly progressive cases, however, the
phenomena of metastasis are to be observed; thus when
the peculiar cough of pulmonary phthisis becomes estab-
lished, and the disintegrative changes, due to advancing
growth of the bacillary organisms of the miliary tubercles
and the consequent breaking down of contiguous lung
textures begins, we observe, and may trace, the invasion
of the central nervous system, by zymotic growth of the
specific bacillus, along the pneumo-gastric terminal fibres,
and their connected trunks and inter-neurilemmar spaces,
into the cerebro-spinal cavity. Having reached this
cavity, and overrun its contained lymph and nervine
elements, the bacillary organisms are conveyed far and
wide by the distributive agency of that lymph, as it 1s
continuously excreted, along the inter-neurilemmar spaces
of the entire cerebro-spinal nervature, sensory as well as
motor, hence the secondary invasion of the skin and the
joints, as well as the textures and organs more directly
innervated by the sympathetic nervous system, by way of
its rami communicantes.

Moreover, there are cases of tuberculosis or tabes, in
children especially, where the invasion of the intestinal
canal is effected primarily by imbibition with the food or
drink, and secondarily from the lungs by the expectorated
tubercle, laden with pulmonary detritus, which conveys the
bacillus along the secretory paths by which the chyle is
conveyed into the blood streams, leaving en route in the
mesenteric glands sufficient organisms to produce, through
destructive changes and mechanical blockage, a more or

— ws

ON TUBERCULOSIS 197

less complete stasis of the lacteal circulation, and ultimate
inanition of the dependent body structures, with con-
sequent withering and death of the entire organism.

Other causes there are whose initiation is dependent on
primary cutaneous invasion, facilities for which are afforded
in the exfoliating epidermis, where the bacillary organisms
find a soil and pabulum ready prepared for their specific
mode of growth, progress, and distribution, and where
the morbid phenomena displayed resemble in many respects
those of leprosy. In this, we may take it, we have not a
resemblance only, but a close relationship, in specific
origin, character of infective organism, and morbid changes
wrought in the dermal and epidermal structures.

Tuberculosis, therefore, in whatever phase or form
observed, conforms in manner of origin and evolution
to the laws of xymosis, to use a concrete phrase, i.e. being
due to the growth and spread of a living organism within
a living organism, it parasite-like incubates or takes root
in totally or partially inactive or adynamic materials or
structures within its host, lives for a time passively or more
actively, and, according to the resisting power and physio-
logical impermeability of the living materials and struc-
tures, doggedly and steadily waits the advent of favourable
‘conditions for its further morbid progress and pathological
domination, locally and generally ; when it usually sooner
or later effects its fell purpose with a gradually declining
opposition, and ultimate capitulation and annihilation,
material and dynamic, of invaded structures and host
alike.

The indications for treatment in such morbid or diseased
conditions must be deduced from a study mainly of the
natural history of the tubercle bacillus, together with a
close observation and study of the circumstances and
conditions of health of the subjects of its attack, and will,
we are persuaded, be found, shortly speaking, to resolve
themselves into a destruction of the organisms—tuber-
cular—root and branch hygienically, and by the withdrawal
of the susceptible from its sphere of influence, or the
fortification of the susceptible against its attack, the
neutralisation of its destructive influence, and the adop-
tion of therapeutic measures to meet its various manners

198 PHYSIC

and methods of pathological development and progress.
The details of these measures have already to a consider-
able extent been thought out and adopted with greater
or lesser success, but it yet remains to render thoroughly ©
effective the means of absolute prevention of the disease,
and its banishment to the region of extinct morbid entities
and stamped-out plague spots.

EXTRACT XXXVI.
ON CANCER.

AFTER the study of leprosy and tuberculosis, but more
especially of leprosy, we find, on approaching the subject
of cancer as a morbid entity, that a certain suggestiveness
of, in some respects, similarity between the affections of an
etiological and intrinsic character presents itself, and gives
us a clue, which, if we can follow it, seems to promise
some, we hope, good result; at any rate, we think no
harm can be done to the subject or ourselves by a short
indulgence in amateur detective exercise, even should it
turn out no more than fiction.

Thus, having endeavoured to prove that leprosy is a
disease primarily of the nervous system, and that it is due
to mechanical and bacterial interference with the excretory
economy of the systemic nervous system and to the morbid
after-effects accruing therefrom, we would, therefore, take
up the clue suggested by our study of that disease, and
endeavour to unravel, as far as we can at least, some of the
profoundly important and no less interesting problems
involved in the study of cancer. The disease now called
cancer, or malignant disease proper, has not so long been
a subject of lay, as well as professional interest, as leprosy
has, though, no doubt, it has entailed quite as much study,
and has given rise to even a greater modern desire on
the part of the profession and the educated public to
fathom its true nature, in order to the devisal of appro-
priate means for its relief and extinction. So far as results
can be computed, we have only’as yet attained a distant
view of some of the salient features of the terra incognita

200 PHYSIC

surrounding the stronghold of the dreaded monster cancer.
It seems, however, to pursue the metaphor, that we are
approaching a vantage ground from which, if we can
possess it, we can command a fuller view of said monster
in “‘full prospective and perspective,” and be enabled
thereby to “‘take fuller advantage of the situation.”

Cancer, then, to our mind, consists primarily of, or
originates in, a disparity or want of parallelism, between
the functional or dynamic and the structural or material
elements of the textures involved in and associated with
the morbid process, the physiological status quo ante
gradually, and at first imperceptibly, giving place to and
merging in the status quo post; the local conditions of
health of the affected part or parts being gradually usurped
by those of disease, the healthy physiological régime being
called upon to yield and meet the material and dynamic
requirements of the pathological, whose lethal emissaries
and agencies convert the chemico-physiological machinery
or plant and organised material into formative instruments
and raw material for its own fell purposes and terrible
ends.

As suggesting this view, it will be observed by those
engaged in the work of cancer research that the structures
primarily attacked, and from which, when subdued, the
disease usually delivers its furthest invasive movements in
its further work of spoliation and reduction, are those
whose functional activity is being, or has been, temporarily
slowed or stopped, and whose consequently more or less
disused or obsolete material impedimenta have not yet
been removed or otherwise physiologically employed by
the functionally active surrounding structures, and which,
therefore, become the material bases for the forces of
morbid activity, and easily lend themselves to the posses-

sion of malignant as well as more innocent pathological )

agencies and organisms.

A nidus is thus presented by every tissue and organ
whose functions are ‘‘ giving out,” and whose materials are
being left more or less derelict and exposed to the tender
mercy of the resident and surviving cosmopolitan non-
hygienic “‘rats” and adventurous parasites by whom they
may be discovered amid the organic traffic still maintained

——

ON CANCER 205

by the active tissues and organs before it is ‘‘ choked” and
turned into the channels prepared by or evolved from the
formative activities of the encroaching and overwhelming
disease. Cancer is thus primarily, like leprosy, a disease
of arrested egestion, i.e. arising through delayed removal
of functionless organic substances, which, from imperfect
organic hygiene, are allowed to cumber the body, thereby
becoming a prey to bacterial and other morbid agents, as
well as, it may be, forming a material basis for the destruc-
tive display of chemico- -pathological energy, or allowing
the devitalising influences natural to all organic matter,
whether active or passive, vitally incorporated or physically
attached, to exercise their disintegrating powers.

In contrast to leprosy, however—and herein lies the
great difference in etiological evolution between the two
affections—cancer primarily manifests itself or begins its
morbid work in structures belonging to or innervated by
the sympathetic nervous system, and if it does synchron-
ously involve the systemic nervous system and systemically
innervated structures, it does so by progression along
anatomical and histological lines, determined by mutual
continuity and contiguity, therefore, we usually find by
carefully directed enquiry into individual cases, that the
first symptoms of the disease have manifested themselves
in such organs as the mamma, the uterus, and any particular
organs or structures whose functions have been from any
cause ceasing to be exercised on their accustomed scale,
and whose idle machinery or asthenic and adynamic
material parts, are being left for removal by hygienic

phagocytes and other scavengers, or for morbid utilisation
_ by any microbic or other wandering disease agencies which
have gained access to the scene of dismantlement and
textural disintegration, and are permitted to begin the
work of disease production—the same deduction applies
to traumatised textures.

It follows from this, therefore, that cancer evolves itself,
or is evolved, from health, that the physiological state on
the affected structures suffering from stasis of katabolic
material gradually gives place to the pathological, and that
there is no absolutely true dividing line, or “‘line of
demarcation,” between them, a conclusion which may

202 PHYSIC

likewise be applied to the evolution of organic disease
generally.

Being a disease of nervine origin, and involving
primarily the sympathetic neural elements, it is necessarily
dependent for the manner of its evolution and progress
on the structural conditions imposed by the histological
disposition and functional work of the sympathetic nervous
system. ‘These structural conditions of the sympathetic
are fundamentally different from those of the systemic
nervous system, at least on its sensory side, where, for
instance, the nerve terminals end in the skin, and are there
provided with a means of direct, entire, and final disposal
of effete or excrementitial matter, the stoppage of which
leads to the production of such diseases as leprosy ; on its
motor side, however, we find a greater analogy or resem-:
blance between the two systems in their terminal distri-
bution, inasmuch as these so-called motor terminals end in
muscle, and thereafter pursue a further course along the
lines of least resistance, or until the highways of the proper
vascular and lymphatic circulation are once more reached.

Lapse of function, traumatism of texture, and retention
or non-removal of the functionless tissue in molecule and
mass become thus the foundations on which the initiation
of the morbid entity known as cancer, or malignant disease,
as of many non-malignant diseases, rests, and from which
its succeeding stages are by continuity evolved, and the
life of the subject, if that continuity be allowed to proceed
unbroken to its usual close, sapped and destroyed.

On this foundation the future stages of malignant
growth are laid, and from this point begin to spring the
chemico-physiological phenomena, the phases of cellular
mitosis, morbid developments and changes, and the more
evident signs of bacterial workings in the forms of struc-
tural monstrosity and toxinal impregnation, which make
up the sum of the pathological circumstances and pheno-
-mena comprised under the generic term cancer.

The first stage of cancer, and, of course, the initial
influences essential for its establishment are comprised
herein ; from here, therefore, we must necessarily begin to
trace the disease, and become familiar with the conditions,
material and dynamic, on which the quality of malignancy

ON CANCER 203

depends, and from which also the diseases known as new
growths and tumours, innocent as well as malignant, pro-
ceed, and are evolved into the distinctive morbid éntities
known to medicine and surgery.

It goes without saying that, without some preliminary
mastering of the situation, it is impossible to appreciate
in anything approaching its fulness, the evolution and
true nature of cancer, and even with this it is impossible to
realise the real proportions of the many material and
dynamic problems that present themselves to the diligent
researcher along the unfamiliar lines of tardy progress and
patient scientific conquest. |

We would advise, therefore, after microscope and test-
tube, and other accessory research means have somewhat
exhausted their powers to penetrate the many secrets wrapt
up in this fell disease, that “‘a general survey of the
situation” should be indulged in, with a view to the
focussing of all information attainable, from whatsoever
source available, on the subject, to the end that a really
intelligible estimate of its true nature should be made,
and thereby a possible basis for treatment laid down for
its prevention, cure, or amelioration.

When this has been done, it may haply be found that
what we are now in search of as the first cause of cancer is
already within our range of vision, and that what we are
now inclined to regard as its first etiological factor or
cause is but the consequence and sequel of interrupted
parallelism between the functional and material conditions
of transitional or perishing textures and organs, and con-

sequently but a secondary result of a former cause, as well

as, in turn, a secondary cause of succeeding pathological
phenomena, and, therefore, only a connecting link in the
chain of causation and evolution of the disease. If such
a dénouement to the expenditure of intellectual energy
now and for many years so persistently exercised all over
the world ever should become an accomplished fact, we are
persuaded that a more hopeful outlook for the unfortunate
sufferers from cancer will be the result, and that science
and art will alike be the gainers.

On non-removed functionless material, whose involu-
tion has not been effected in due time from faulty materio-

204 PHYSIC

dynamic parallelism, we have an ideal nidus for the de-
velopment of bacterial organisms; it is not, therefore,
required that embryonic cellular organisms, belated amid
the physiologically active cell communities of the adult
and ageing body, should become the hosts for the develop-
ment and growth of the generic cancer organisms, neither
is it necessary nor consistent with the laws of nutrition
for their evolution into malignant growths, that other
formative materio-dynamic agencies should come into
existence beyond those already existent and active in all
developmental processes, whether physiological or patho-
logical, evolutionary or involutionary, to initiate and per-
petuate the fell process of cancerous conversion, or per-
version, of healthy texture into that of usurping malignancy
and destruction, with all the train of consequences
entailed. Here we may find in the disturbed relationships
of the dual nervatures in their related nutritive and forma-
tive functional réles in the structures affected, the materio-
dynamic factors to work out, with the aid of involutionary
tissue elements, the whole sequence of morbid events,
from inception to close, from the primary invasion of
healthy structure until its complete disappearance in and
incorporation with the altogether foreign elements of
malignant disease. All the characteristics and factors of
malignant disease are, or may be, therefore, purloined,
so to speak, from the innocent materio-dynamic belongings
of the physiologically healthy body, and converted or per-
verted into those of the pathological occupancy of that body.

Thus the characters of malignancy are impressed on
physiologically normal, but, it may be, adynamic, struc-
ture, and become the ultimate pathological and lineal
representatives of that normal condition in structure and
function, each and every structure so affected, giving a
character to the malignancy in accordance with its own
structure and function, and transferring its materio-
dynamic methods to it to become the pathological pattern
of procedure until frequently all trace of the original
becomes merged in its malign counterpart. Natural, if
not normal, structure, therefore, is the matrix in which
cancer begins to develop and on which it thrives, the
materies morbi becoming fixed, and converting to its own

ON CANCER 205

use the forces and materials which it finds belonging to
the structure selected, which it ultimately overruns and
perverts from innocency to malignancy, to the entire
undoing of its ultimately powerless host. What that
materies morbi may be is a question no doubt of the very
greatest interest and importance, but the work of depriv-
ing it of the means of support and propagation is a work
of proportionate and even greater importance, and one
which, in these days of the conferring of immunity, should
not be beyond the powers of properly directed effort and
the combined working of the agencies now employed on
the problem.

Whatever the materies morbi of cancer be, whether
microbic—and the weight of evidence favours that view—
or not, it seems to gain access to the seat of attack through,
in the first instance, permeable layers of tissue, reachable
from the most accessible inner or outer coverings of the
body, such as the sub-mucous and sub-cutaneous, through
their overlying epithelial and epidermal structures respec-
tively; and, in the second instance, by invasion of, or
metastasis to, deeper-seated structures and organs by lines
of continuity, histological and vascular, and by sepsis of
the fluids, lymphatic and sanguineous. Here, moreover,
the virus, besides meeting little textural opposition, finds
ready to hand for its mal-nutritional purposes quantities
of dead and de-vitalised materials in the act of being shed,
which meet its immediate wants and supply it with the
required opportunity to invade and convert to its increas-
ing materio-dynamic demands the elements of the physio-
logically living and active tissues. Having effected a
footing thus, by introducing into the hitherto normally
working sympathetico-systemic formative and nutritive
régime the element of materio-dynamic discord and per-
version, it finally usurps and takes possession, to the
ultimate and entire spoliation and undoing of its host—
the physiological becoming gradually merged into the
pathological, structurally. and functionally.

This finding brings us nearer to the point and manner
of origin of the disease, where it seems to make, at any
rate, clearer the various factors at work and the parts they
respectively take in initiating and continuing the patho-

206 PHYSIC -

logical process of cancer evolution. The factors can only
be two, viz. material and dynamic; the age incidence, ~
the character of the tissues first involved, and their obedi-
ence and adaptability to the presiding formative and
nutritive impulses of the local nervatures, afford.a means
of departure from the physiological methods which have
hitherto prevailed, and an opportunity for the introduction
of pathological methods of dynamic arrangement of the
somewhat devitalised tissue elements and the ordinary
alimentary materials, which, together with the collabora-
tion of chemical and bacterial agencies ‘‘in wait” for an
opportunity to take in hand the work of involution which
at all times sooner or later has to be taken in hand by
such emissaries, and so the required malignant parasite
or influence is found and put in possession to perform the
work of spoliation by the production of those tissue
changes characterising the disease so long familiar to us
under the dreaded name of cancer. All which ought to
be preventable to the extent that every human being ought
to be in possession of the undisturbed power of reaching
the legitimate ‘‘length of his or her days” without sub-
jection to the danger of such occurrences.

A proof or an evidence that muscular fibre is nourished
by or from nervine sources is that the nerve-plate endings
enter within the sarcolemmar sheaths and pass between
the sarcous discs filled with nerve substances and sur-
rounded by cerebro-spinal lymph, while the blood vascu-
lature is only spread out within the inter-musculo-fibral
spaces amid the interstitial substance and non-muscular
elements of the muscle substance, the one merging in
the proper muscular elements, while the other expends
itself in the maintenance of the non-muscular or inter-
stitial tissue. The blood circulation thus never reaches
the proper sarcous substances or contractile elements of
the voluntary musculature, leaving the systemic nervature
to effect the double function of materio-dynamic provider
and distributor, a view of the subjects involved which
brings into physiological line and order several at present
very obscure and somewhat contradictory problems bearing
on the subjects of nutrition and the etiology of certain
neuro-muscular diseases. |

ON CANCER 207

The reason that the two lobes of the pituitary body
remain histologically separate while enclosed in a common
capsule, and constituting one excretory organism, is, that
they belong to different embryonic structural elements,
and owe their nourishment and innervation to different
sources, viz., neuro-systemic and neuro-sympathetic, or
the ecto-dermal and the hypo-dermal, because we see
throughout the body generally a well-marked distinctness
maintained, a fact alone due to distinctness of innervation
and sources of nutrition, and therefore dependent on
physiological *‘law and order.”

Mr. Bland Sutton, as reported in the Lancet of date
May 18th, 1907, gives a most informative and clear
exposition of the subject of cancer up to date, and
amongst many very interesting conclusions, he draws one,
with regard to the structural incidence of primary cancer
to the effect, that the systemic nerve tissue, voluntary
muscular substance, and fat cells, are the only tissues
unaffected—secondarily, they of course come in for attack
and suffer in common.

This conclusion appears singular and at first sight inex-
plicable, but, on considering it in the light of the dual
organisation of the nervous system, it seems to be
dependent on certain histological facts of pathogenic
relevancy and resolvent power to explain the problem.
Thus the structures named comprise those composing the
systemic nervous system, or the true systemic nerve
elements, and the only sympathetic structural element
devoid of a proper nuclear and nucleolar body within its
intra-cell substance ; hence in the former, or primary, the
formative impulse or materio-dynamic phenomena of
malignancy are initiated and administered by sympathetic
nerve agency, while in the latter, a stored substance, the
absence of a neuro-dynamic or formative nuclear agency
renders the fat cells non-responsive to the primary genetic
incitements to malignancy.

From this point of view cancer would seem to be
determined primarily by a materio-dynamic disturbance
of the law of parallelism amongst: the sympathetically
innervated tissue elements, whereby the metabolic and
formative energies of the affected cells take on strange or

208 PHYSIC

pathogenic modes of growth and proliferation, at first
differing little, it may be from the normal, but ultimately
altering so completely as to assume the character of an

altogether abnormal structure, with the superadded char-

acter of malignancy, and incompatability with the main-
tenance of life. ;
Primarily the structures named escape on account of
histological peculiarities as to their position and character,
but fall a prey to the secondary invasion and pathogenic
intensity of the disease with equally dire results, and, if
possible, with less power of resistance to the influences
of malignancy than those displayed by the primarily

affected sympathetically innervated structures.

EXTRACT XXXVI.
ON SYPHILIS AND GONORRHEA.

Tue former of these diseases, syphilis, is one of the
greatest scourges to which modern civilised man, and from
him barbaric man, is liable; we say modern because, so
far as investigation of the incidence of the disease in or
amongst ancient civilised races has been carried, it is not
possible for us to assume beyond doubt that it had any
existence ; at any rate, archeologically we come across no
particularly definite trace of it, unless we extract a hidden
meaning referring to it and other diseases of an allied
nature Fes such Biblical expressions as that “‘the sins of
the father” shall be transmitted to or visited upon his
offspring ‘‘to the third and fourth generation ””—and this,
no doubt, would very exactly express our experience and
present state of knowledge on the subject. We, however,
forbear from entering into a discussion of its historical
bearings, and would rather advance some views emanating
from our study of the disease in the light of the ideas of
which we have become possessed in relation to its neuro-
logical bearings.

The view that the disease is bacterial in origin is now
largely held and taught, it behoves us, therefore, while
investigating the subject of its materies morbi, to study
and discover the lines along which it delivers its attacks,
so as to be prepared to devise a rational and scientific
prophylaxis, as well as a successful curative treatment.

The inoculation of the specific disease having been
effected, and absorption of the virus having taken place,

II O

210 PHYSIC

we may be prepared to find that the textures involved in
the inoculation and absorption are undergoing a more or
less complete necrosis and disintegration at the affected

points, and that the disease is evolving from a local into

a general pathological condition, the prevention of which
latter occurrence ought, therefore, to be the aim of all well-
directed treatment.

Should this unfortunate occurrence, the change from a

local to a general affection or disease, have been overlooked
or neglected, and the changes dependent on the further
development of the pathological phenomena constituting
the disease having been allowed to begin to display them-
selves, we shall now observe that the absorbents, as repre-
sented by the lymphatics, begin to display symptoms of
involvement, it may be, along the course of the nearest
lymphatic vessels and in the glands to which they lead
by a process of inflammatory engorgement and thickening,
a brawny swelling of the peri-lymphatic textures, and a
more or less conspicuous enlargement of the glands first
interposed in the lines of invasion. This condition is
known as bubo, and is due to the invasion of the matrix
of one or more of the lymphatic glands, of the groin by
preference, owing to the prevailing manner of infection.
Should this bubonic barrier arrest the progress of the
materies morbi and secure its removal from the system
before it has had time and opportunity to infiltrate and
infect it, then we are warranted in expecting an avoidance
of the long sequence of untoward events, consisting of
the secondary, tertiary, and consequential transmitted or
inherited stages of the disease.

Should, however, this desirable arrest of the disease not
have been effected, and an entrance have been secured
into the body proper by the virus of the disease, then we
may expect the invasion in detail of all its parts, organs,
textures, and fluids, and the sapping of its health to its
‘very foundations.”

The line of attack of the disease in this instance has
been by way of the lymphatics through imbibition of its
poison by the open mouths of its vessels or spaces, where
they lie exposed in the depths of the primary sore, and
where the culture of the lethal organisms or specific virus

a

ON SYPHILIS AND GONORRHEA air

is secured, and thence finding its way along the lines of
least resistance, it reaches, by way of the lymphatic vessels,
the gland or glands, where its further progress is chal-
lenged and, it may be, arrested, but where, if allowed to
pass, it secures an entrance into the lymphatic circulation,
and subsequently into the circulation proper and the
textures of the body generally.

But, while this may describe the usual line of attack of
the disease, we are persuaded that the invasion of the
system may be accomplished by, at any rate, one other
direct route, and this route we would describe as nervine,
and thus the primary sore in its processes of destruction
and disintegration of the textures involved in the area of
infection lays open not only the lymph spaces and vessels,
perhaps with the blood vessels, but the nerves distributed
to the part with their inter-neurilemmar spaces, into which
and along which the virus filters or develops by the growth
of its specific microbe in the medium of the cerebro-spinal
fluid into the interior of the cerebro-spinal cavity, where
it is at liberty to repeat itself in endless generations or
until its pabulum is exhausted and immunity attained.

An entrance having been thus effected along the nerves
leading from the scene of the primary sore by the specific
virus, the cerebro-spinal fluid having afforded it a ready-
made culture medium, it is at liberty to attack not only
the nervous system, for which it is said to have a peculiar,
we might say, morbid affinity, but every organ and tex-
ture of the body with which that system is connected,
whether by its afferent, efferent, or association trunks and
fibres, ganglionic cells and processes, systemic and sympa-
thetic.

In the quasi-enclosed region in which the cerebro-spinal
fluid is formed, contained, and circulated, we see a con-
geries of conditions ideally adapted for the growth,
preservation, and dissemination of such a specific microbic
poison, and where it is at liberty to attack directly and
at first hand the meningeal coverings of the brain, cord,
and nerves, with their enclosed nervine contents, and to
give rise to the very various pathological changes follow-
ing the invasion of this region, whence, passing from
this region along the nerve trunks and fibres, it readily

212 PHYSIC

finds its way into the matrix and parenchyma of organ, of
texture, and viscus throughout the entire body, injuring
and destroying in its malign progress, and leaving in its

wake an amount of wreckage scarcely to be paralleled in

the whole category of disease; here, moreover, we per-
ceive the operation of the vis medicatrix nature along
certain lines indicated and determined by histological and
anatomical continuity, as, for instance, in the peripheral
eruptive displays manifested at the various stages of the
disease, where the terminal arborisations of the cutaneous
nerves constitute the scenes of the elimination and exodus
of the specific virus on the secondary and tertiary attempts
to ‘‘clear the system.”

The spots and patches of eruption will be found,
primarily, to conform to the arrangement and form of
the final distribution of the cutaneous nervature, and to
involve, secondarily, the neighbouring cutaneous textures
in which pigmentation and perhaps destructive changes
may follow, the pigmentation being due, most probably,
to the influence of neurolysis on the haemoglobin of the
surrounding blood elements.

In this disease it would seem as if ‘‘ brood after brood ”
or ‘‘hive after hive,” so to speak, of bacterial organisms,
as they have become deposited and hatched in the depths
of the cerebro-spinal lymph, become released and, over-
flowing or breaking their barriers at their weakest points,
overwhelm the neighbouring regions of what may be
called the neutral structures, infiltrating and leaving de-
posits of pathological débris here and there throughout
the areas of disturbance, these occurrences synchronising
with the secondary and tertiary stages of the disease.
Moreover, such outlets from the cerebro-spinal cavity, as
the nose and pharynx, represent or coincide with the scenes
of the most destructive activity of the secondary and
tertiary manifestations of the disease, the determination
and incidence of which are due to the anatomical and
histological disposition and physiological functions of the
parts affected, i.e. being the eliminatory outlets of the
antero-central regions of the cerebro-spinal cavity, they
are naturally made to bear or feel the full brunt of the
destructive changes wrought by the discharging bacterial

a

ON SYPHILIS AND GONORRHGA 213

organisms and toxic débris resulting from the growth and
discharge of their repeated generations, the same condi-
tions entail very much the same consequences in coccygeal
elimination.

Such seeming coincidences as these latter occurrences
display are, therefore, due to the progress of this fell
disease along definite lines, anatomical, histological, patho-
logical, and clinical, and represent the natural history and
evolution of a morbid entity as clearly and as explicitly
as that of any disease to be found in the whole family of
the exanthematous affections. We, consequently, claim
that the etiology, morbid anatomy, and clinical phenomena,
of this disease find a clearer explanation along these lines
than along any other lines with which we are acquainted.

Gonorrheea, although usually classed from its manner of
causation with syphilis, is a disease of an entirely different
character in manner of attack, symptoms, complications,
and clinical behaviour. Instead of beginning with a
primary chancrous sore or sores, it is usually ushered in
by urethritis with more or less consequent painful mic-
turition and muco-purulent discharge, which, after running
a more or less acute course for a somewhat indefinite
period, eventuates in complete recovery without the occur-
rence of secondary or consequential symptoms or compli-
cations.

This, however, does not always characterise the course,
behaviour, and decline of the disease, as there are cases
where it is usually accompanied or followed by affections
of a rheumatoid character, involving the limbs and joints,
which run a more or less acute or continued course, and
terminate, in many cases, in synovitis, which may display
the presence of the gonococcus or microbe of gonorrhcea.
It may further be remarked that it is a disease of a much
less malign character than syphilis, and that in a large
percentage of cases it terminates without leaving any
wreckage behind, but, nevertheless, it is one which, if not
arrested by what may be called ‘“‘nature’s police” on its
entrance of the system, will give rise to severe and well-
defined morbid processes: these latter, as we have said,
are generally of a rheumatoid character, and evince them-
selves in the manner customary to those affections by the

214 PHYSIC

occurrence of more or less acute pains, confined principally
to the muscles and fibrous structures of the limbs, with
intercurrent or subsequent involvement of the joints of
these limbs, accompanied by considerable febrile and
general disturbance.

How the gonococcus in this disease reaches the muscles,
fibrous structures, and joints, is a question very dificult
to answer, whether it reaches them by way of the blood
piren wiion through the entrance of the gonococcal bacillus
into its stream and its subsequent deposition in the tex-
tures of these parts, or whether it effects an entrance, like
syphilis, into the cerebro-spinal fluid or lymph, and there-
after enters the motor nerve sheaths from the cerebro-spinal
cavity, where its multiplication and growth have been
effected, or, as is most likely, in both ways. The latter
method, however, deserves study, and we may take it that
the virus effects an entry into the nerve terminal distri-
bution of the urethral nervature through the inflamed
and traumatised mucosa, and pushes its way, by a process
of continuous sepsis or contamination of the neural
lymph and microbal growth, along the inter-neurilemmar
lymph paths into the cerebro-spinal lymph cavities, where,
incubating anew, it is diverted into and along the motor
nerve inter-neurilemmar lymph spaces, between which and
the gonococcus there apparently exists a mutual affinity,
where it progresses in like manner until it reaches the
muscles and other susceptible textures, as well as the joints,
where the vitality of the microbic brood is found to be
as robust as when its progenitors left the urethral canal.

Thus these two diseases, syphilis and gonorrheea, have
a somewhat similar line and manner of attack, and a some-
what analogous method of invasion, but a very dissimilar
after history as regards their respective temporary and per-
sistent after effects on the affected individuals, as well as
on their progeny.

The frequency with which these and other kindred
diseases enter the system, either directly or indirectly by
invasion of the neural lymph and lymph inter-spaces and
paths, becomes more and more apparent as we look more
deeply into their etiology and manner of development ;
we, therefore, cannot help thinking that valuable htore

ON SYPHILIS AND GONORRHEA 215

mation must flow from their study in this light regarding
their prevention, amelioration, and cure.

A clinical Lecture has just been delivered by Sir W. R.
Gowers at University College Hospital (vide Lancet,
Dec. 1, 1905), entitled “‘A Metastatic Mystery,” in his
usual most lucid style, and effectively illustrated. The
title of the lecture is transparently honest and brief, and
no doubt expresses the high-water mark of special know-
ledge on the subject ; yet the case, as viewed in the light
of our expressed views and personal knowledge of the
subject, resolves itself into one of belated manifestation
of tertiary syphilitic symptoms confined to the motor
cerebro-spinal nervature and part of the musculature of
the right side, and to the lateral aspect of the meninges
overlying the mid brain, all manifestly due to the localisa-
tion of the basal tumour described to the antero-lateral
aspect of the pons. We would assign as the place of
origin of this tumour, which we are satisfied is the fons
et origo of the attack, the locally involved sub-arachnoid
surface, where we may suppose a gummatous growth
originally evolved itself, and increased to the size men-
tioned, sustaining itself by a pseudo-encapsulation, and
succeeding in keeping itself stationary as to further growth
by the process of discharging from within or passing away
from its external aspect a continuous flow of epithelial
and other material due to its local presence and disturbing
influence, which found its way along the lines of least
resistance, which were the antero-lateral aspect of the spinal
cord, to the motor nerve roots, issuing at the points
indicated by the vertebre affected, the trunks of the
nerves distributed to the muscles implicated, the periosteal
coverings of the bones, and the deeper osteal structures
where they were inserted. Likewise ensued the upward
cephalic progress from the scene of the tumour’s irritation,
the tainted fluid causing, evidently, from the illustration
supplied, an opaque and thickened condition of the
meninges, and spreading laterally, to some extent, but
ultimately finding a means of exit for the tainted material
through one or more of the Pacchionian bodies and the
tables of the skull into and under the periosteum or
peri-cranium. Each of the abscesses and periosteal inflam-

216 PHYSIC

mations was, therefore, due, secondarily, to the progress
of the outflowing fluid along the lines of least resistance
leading from the tumour, and were owing to the sustained

flow of that fluid, a circumstance which, moreover, explains

the stoppage of the growth of the tumour and the cessation
of the evolution of head symptoms. The-other local
visceral involvements seem to us due to the distribution
by the pneumo-gastric nerves to the pulmonary and
hepatic structures respectively, and not to distribution by
the blood circulation, which, we would suppose, had not
been called upon at all to distribute the etiological material
agencies to any of the parts affected.

We must now, therefore, recognise the great fact that
a third vasculature, viz. the nervine, has to be added to
the two mentioned by Sir W. R. Gowers, viz. the blood
and lymph, and that it, in fact, seems the most prolific in
the conveyance of disease-producing materials, the great
cause of metastatic phenomena, and the medium by which
much of the mystery involved in such occurrences can
find a clear and scientific explanation, because an explana-
tion founded on anatomical and histological truths, and,
therefore, absolutely consistent and decipherable.

It 1s thus most interesting and instructive to observe
that that chameleon-like disease, syphilis, manifests its
symptoms not haphazard, but strictly in accordance with
structural anatomy, and that an explanation can be afforded
of such contradictory external manifestations of it as
appear on the skin, on the one hand, and the muscles and
bones, on the other, these being the structural areas to
which the sensory and the motor systemic terminal nerva-
tures are respectively distributed, and where the “‘ shape
and form” of the secondary and tertiary morbid phenomena
are respectively determined.

EXTRACT XXXVIII.

RHEUMATISM, ACUTE, SUBACUTE, AND CHRONIC, WITH
RHEUMATIC ARTHRITIS.

In taking up this large and varied subject, we feel our-
selves unable to deal with it systematically, or to do more
than touch on a few of its aspects which dovetail with or
bear on our views of the nervous system and the pathology
of some of its diseases.

We shall not, therefore, attempt to consider whether its
materies morbi is bacterial or chemical, or both, or neither.

Whatever its nature, wherever it may have come from,
whether from within the body itself, as in autotoxis, or
from without, from some septic source of infection, we
shall not wait to enquire, as the literature of these very
far-reaching problems is so voluminous that we have been
unable to do more than touch it, besides, it is now so
highly specialised that it must, necessarily, be left to the
criticism and appraisement of experts.

On thus refraining from dealing with the very technical
and highly interesting department of clinical research
embraced in that congeries of pathological likes and dis-
likes, that agglomeration or gallery of contradictory
morbid entities known as rheumatism, we are reduced to
the necessity of expressing only a few thoughts suggested,
as above indicated, from their neural bearings on the
practical, clinical, and therapeutical sides of the subject.

Guided by these limitations, we would begin by saying
that the main theatre for the observation of the manifold
phases of the disease known as rheumatism is the muscular

218 PHYSIC

system, with its aponeurotic coverings and interlying
fibrous, fibro-elastic, and connective layers or processes of
bounding and supporting tissue, its tendons, with their

sheaths and more or less lubricating surrounding material,

and their final attachments to the bones, where the peri-
osteum and ends of insertion of the tendons become so
intimately blended as to make the union as complete as
is possible or compatible with the junction of two histo-
logically different structures, besides the periosteum, by
continuity along the shafts of the bones of the limbs, its
reflection over the epiphyses of these bones, its junction
and blending with the ligamentous structures of the
joints, and its ultimate association with the joints through
contact with their cartilages and synovial membranes.
From this statement we want to make it clear that a bond
of union is effected or exists between the structures named
by continuity and contiguity of texture of such an intimate
character that a passage by capillary and osmotic circulation
is possible, and not only possible, but in more or less
constant operation through the implied inter-textural
spaces, lacune, and channels.

On to the nervous system we shall now tack all this
complicated array of highly organised structures, indeed,
we must recognise that all these structures belong to and
constitute, so to speak, an appendage and part of the
nervous system, and that the nervous system is as inti-
mately blended with the muscular system as the muscular
system is blended with the skeleton through tendons,
periosteum, ligaments, and joints.

This association and interdependence of the nervous
system, the muscular system, and the osseous system,
constitutes the basis on which we must elaborate our
contribution to the literature of that far-reaching subject,
rheumatism.

Rheumatism must be regarded as an affection, ranging
- from the slight and almost imperceptible ‘‘rheum” of our
forefathers to the acute rheumatism of the present day,
ranging also from the absolute helplessness, fear, and
dread, of acute rheumatism to the unyielding stiffening
and deformity of chronic rheumatic arthritis.

These two varieties of the affection may be looked upon

tind

RHEUMATISM 219

as the extremes of the train of rheumatic conditions and
the pathological entities known as rheumatic.

Rheumatism once initiated there is a great danger of
its progressing through more than one of its recognised
stages, and it becomes our bounden duty, if consulted
early enough, to devise a treatment so as to arrest the
disease at the earliest stage possible, in order to prevent
its progress towards its succeeding and permanently dis-
abling stages.

It is allowable, consequently, to conclude that, when an
attack of acute rheumatism is imminent, that attack may
be averted or modified by a smart appeal to the excretory
functions of the skin through the peripheral nerve-endings
and sudoriferous glands, which may, in this case, be con-
sidered the easiest and safest exits from the nervous system
of the cerebro-spinal fluid occupying the spaces and inter-
spaces, in which we hold the materies morbi of the attack
is lodged, and whence it invades the muscular system and
associated parts in order to prevent it forcing itself along
the motor nerve trunks or structures into the muscular
tissues.

By anticipation we may thus prevent the occurrence,
shorten the duration, or mitigate the severity of an attack
of acute or sub-acute rheumatism by inducing free dia-
phoresis, combined with physiological rest of the entire
muscular and nervous systems, and the use of the other
subsidiary therapeutical and dietetic desiderata necessary
in the particular case.

The toxic matter, which, at this juncture, is stored in
the nervous system, and, it may be, in the act of invading
the muscular system or individual groups of muscles, will
thereby find a natural exit through the cutaneous sweat
organisms on to its outer surface, leaving only that which
has found an entrance into the motor nerve inter-spatial
channels, nerve terminals, and sarcolemmar sheaths and
sarcous elements proper of a greater or lesser number of
the muscles to be dealt. with.

This latter, the toxic matter, the ‘‘real element of dis-
cord” or exciting cause of acute rheumatism and, it may
be, other forms of the disease as well, must also be medi-
cally dealt with in such a way as that it will be neutralised

6

220 PH YSICi}

in situ or dislodged, and eliminated from the sarcous
elements of the muscles involved through the lymphatics
leading from the muscular system into the circulation of
the blood proper.

If this procedure, the use of our artificial aids along
the lines on which nature is working, prove successful, the
result will be the restoration of the mechanism and con-
tents of the cerebro-spinal and muscular circulations to
their normal and aseptic condition.

Thus will the disease be cut short and cured, and thus
will be prevented the occurrence of more prolonged,
though less acute, rheumatic processes or diseases, with
their accompanying loads of suffering and their greater or
lesser degrees of attendant or permanent crippling.

Thus, also, will be averted such fatal “‘ turns and twists”
as sometimes mark the progress of cases of this disease,
and which those in charge often regard as absolutely
beyond their control, such as metastasis to the cord and
brain, including the entire cerebro-spinal cavity, with its
other contents, liquid and solid, or to the muscular sub-
stance of the heart, with its covering and lining membranes
and valvular structures.

We, perhaps, ought here to remark that it seems to us
that the phenomena of metastasis can find an explanation
in the occurrence of a more or less sudden regurgitation
of the toxic matter occupying the motor nerve trunk
sheaths, the nerve terminal structures and muscles from
and along them into and amongst the contents of the
cerebro-spinal cavity, and terminating there, in the case
of metastasis to the brain, but passing out again along
the intra-spaces of the pneumogastric trunk, in the case
of metastasis to the heart.

If, therefore, this metastatic movement can haply and
happily be diverted along the peripheral sensory nerve
trunks and fibrils with their attached terminals and the
sudoriferous glands, a fatal issue may be prevented.

Thus, it will be seen that muscular rheumatism, or
rheumatism involving the motor nerves and the muscles,
can be prevented, in the first place, by being promptly
seen to and relieved or cured; and, in the second place,
by securing an excretory or forward, or a retrograde or

RHEUMATISM 221

backward, movement of the contaminated cerebro-spinal
fluid contents of the motor nerve tubes, and, concurrently,
by aiding the neutralisation and elimination of any toxic
matter which may have secured an entrance into or been
evolved in the sarcolemmar sheaths and substance of the
affected muscles.

Bearing the indications naturally suggested by these
views in mind, diaphoretics, properly so-called, aided by
the use of every external and internal measure, general
and local, which the individual case may require, in order
to initiate, sustain, and prolong the process of excretion
necessary until the materies morbi of the disease is dis-
lodged, must be promptly, continuously, and, of course,
rationally and guardedly used; the after-treatment being
regulated, necessarily, by the condition of general health
and local disablement in which the process has left the
patient. )

These observations refer to acute rheumatism, or rheu-
matic fever, only ; let us, therefore, continue on the same
lines to attempt to elucidate the subject of sub-acute or
articular rheumatism. This latter affection is frequently
a sequel of the former, as well as an apparently indepen-
dent affection, but when produced by the subsidence of
an acute attack, it may be regarded as a continuation of
the toxic invasion of the textures continuous with the
involved muscles; i.e. by the infiltration of the tendons
attached to or continuous with the affected muscles, or
rather the agglomerated sheaths of the muscles, with their
attachments to the bones, periosteum, and ligaments sur-
rounding the joints, and the cartilages covering the ends
or extremities of the bones and their contained synovial
fluids.

All this results from the histological continuity and
contiguity of the parts enumerated, and may often be
traced in regular sequence. ‘The appropriate treatment in
individual cases may, therefore, now be directed on some-
what more clear and definite lines than has too often been
the case in times gone by, or when mere empiricism was
only possible.

The chronic form of the disease may also, we think,
have its pathology to some extent cleared up by a patient

222 PHYSIC

continuation of the same line of enquiry, and its treatment
correspondingly improved and made more scientific.

Since the above observations were made on the subject
of rheumatism generally, and in its various phases and
methods of manifestation, we have to a little further extent
pursued our enquiries regarding the occurrence of meta-
stasis to the heart, or cardiac rheumatism.

The occurrence of cardiac complication during or after
the currency of an attack of acute rheumatism becomes
much clearer to us in its etiology and pathology by the
application of these views to its consideration.

Thus cardiac rheumatism, with resultant peri-carditis and
endo-carditis, is to be regarded as due to a metastasis of
the toxic matter of the disease from the more distant,
deep, or peripheral parts of the body and spinal cavity
along the trunks of the pneumogastric nerve or nerves to
the fibres distributed to the heart, and thence into and
throughout its muscular substance ; where, driven by the
sustained working and action of that never-ceasing and
continually moving mechanism, it is projected into its
very innermost parts, consisting of its series of muscular
eminences and valves and lining endo-cardial, as well as
enclosing peri-cardial, membranes, by direct communica-
tion from the one to the other ani from first to last.

Chronic rheumatic arthritis, moreover, may be said to
result, in some cases, if not in many or all, from the
percolation or infiltration of toxic material, from the
muscles through the tendons, periosteum, hotest and
cartilages, and thence through ‘the synovial lining ae the
joints themselves into their central cavities and contained
fluids.

In cases of this description, of the more acute order,
the rate of pathological change may be both rapid in rate
and destructive in the extent of its incidence, or slow and
more ankylostotic or exostotic, when more or less osseous
material is deposited during exacerbations of the disease
in the periosteal texture or the superficial layers of the
bony textures involved.

A case of the latter description might be cited in illus-
tration—as it was closely observed and noted by its subject
from inception to cessation—of the characteristic symp-

—

anh

RHEUMATISM 223

toms, and as affording a complete picture of a condition
which is only occasionally procurable by the medical man ;
as already said, its subject followed its progress with the
greatest interest and intelligence, and supplied the follow-
ing details of the case: A. A., a gentleman past middle
life and previously healthy, was some time ago, during a
very hot summer, in the habit of sitting with his window
open and enjoying the fresh air, which blew in a current
between the window and the fireplace, and struck his head,
neck, and back on their right antero-lateral aspect. This
was continued during the hot months, and produced no
injurious effects until near their close, when he began to
experience pain in the neck, extending to the point of the
shoulder, of the exposed or air-struck area, and to perceive
a gradual extension of it from the trapezius down the
deltoid muscle. to its insertion, where the periosteum of
the humerus became acutely painful, both to pressure and
on movement of the muscle; here it remained for some
time, the area of periosteal pain extending laterally and
downwards until the biceps became involved at its origin,
and afterwards at its insertion in the forearm, when shortly
afterwards there began to be felt a thickening of the distal
phalanx of the thumb, both on its palmar and dorsal
aspects, with pain on pressure and use. This thickening
continued to increase in hardness, and gradually to assume
the character and “‘ feel” of an exostosis at the points of
insertion of the distal ends of the flexor and extensor
tendons respectively. No other parts were involved to
even a slight extent, except for a vague general aching
when the arm was “‘lain upon,” and the acuteness of the
train of muscular pains began to diminish as soon as the
phalangeal pain and thickening began to be decidedly
manifest. No disturbance, constitutional or otherwise,
took place, and the case pursued a slow and even course,
leaving a thickening of the distal phalanx of the thumb
at the points mentioned, with at times a slight aching
down the area originally involved. Now this seems the
record of an ordinary slight case of rheumatic-gout, or
rheumatoid arthritis, and so it was; but it is meant to
convey the truth that the attack arose from a prolonged
partial exposure of the origins of one or two of the

224 PHYSIC

cervical branches of the brachial plexus at their points of
origin in the neck, and that the superficial or cutaneous
excretion at those points of the cerebro-spinal lymph was
transferred from the superficial afferent or sensory to the
deep efferent or motor roots of the involved nerves to be
finally disposed of ; and, thereafter, instead of being
excreted through the skin, as in the other parts of the
spinal nervature, it was reflected along the corresponding
motor nerves—these being the nearest lines of least resist-
ance—thence entering and traversing the muscles named,
with their periosteal attachments, in the order mentioned,
and ultimately being deposited as exostoses in the periosteal
layers of tissue covering the distal phalanx at the points
of attachment of the affected thumb muscle tendons.

Here, we contend, is a manifestation of a disease, from
inception to close, along certain definite histological lines,
carried by obvious and definite agencies, and leaving
definite after-effects in a consistent and intelligible manner,
like any concrete pathological entity.

It is, moreover, an illustration of the manner in which
earthy or ossific material is conveyed by neuro-muscular
agency along continuous circulatory ways from the purely
central nervine to the skeletal structures of the body, and
a collateral proof of the truth of the contention that frac-
tures do not properly unite when the systemic nerves are
severed.

Had there been here no ‘“‘concentrated and continued
exposure” of the limited surface of the neck between the
coat collar and the hair of the head, as above described,
there would have been no case to record. We may add
that there occur in like manner such pathological sequences
as the synchronous, consecutive and mixed, but etiologi-
cally connected, bacterial and other diseases, due to
cerebro-spinal sepsis and neuro-muscular morbid pheno-
mena—myopathy, for instance, cold abscesses, multiple
exostosis, and acute and chronic osteo-arthritis, with
spontaneous disarticulations, become evolved in clinical
experience in complete and definite order, one merging
in the other as parts of a single morbid entity, as well as
all the constantly occurring associated groups of pneumo-
gastrically determined and distributed diseases, acute

eee

a

RHEUMATISM 225

rheumatism, chorea, cardiac, diplococcal, pneumococcal,
and other invasion, with, it may be, pulmonary, gastric,
and other abdominal complications, besides a large number
of frequently associated and anomalously related morbid
symptoms and diseased conditions.

The case of A. A. referred to, again came under our ob-
servation in a little more than fifteen months from being
last seen, and complained as follows: About six weeks
ago, on the occurrence of a few days of rather warmer
weather than had for some time prevailed, I slightly
lightened my clothing, and shortly began to experience
in my lower limbs, but more especially in my right from
the knee downwards, a feeling of vague rheumatic pain
and a loss of tactile sense over the anterior aspects of the
lower half of the leg and the upper aspect of the foot,
with some loss of muscular control of three first toes.
Elsewhere there were no such phenomena, and the general
health was good. The condition, therefore, was akin to
his former attack, and was determined locally by the
existence of the same predisposition and the local incidence
of exciting causes sufficient to precipitate a renewal of
the morbid phenomena as above narrated. It was essenti-
ally one of limited incidence, and consisted of neural
circulatory stasis and consequent blockage of the motor
and sensory neural channels, with paralysis of the efferent
and afferent nervature to the extent of the incidence of
the local causation.

The condition did not seriously cripple its subject, and
continues gradually to disappear from both nervatures as
the phenomena of neural circulation and the materio-
dynamic needs of the muscles and skin were met by
properly adjusted nutrition and metabolism.

Il s

EXTRACT XXXIX.
ON URTICARIA.

Urticaria, or nettle rash, is an affection with which both
the laity and the profession are so very familiar that it has
perhaps thus escaped the scientific attention to which its
intrinsic nature otherwise entitles it.

In intrinsic nature it is a neurosis, or, strictly speaking,
a peripheral cerebro-spinal lymph disturbance, in which
that lymph, from local accumulation in certain nerve
terminal arborisations, it may be, associated with toxis,
distends those terminal textures and modifies their innerva-
tion, sometimes locally and sometimes generally, but always
in accordance with nerve terminal distribution raising the
super-imposed cuticle, and producing a sensation of
itching, tingling, and sensory distress often altogether
disproportionate to the visible and tangible local changes.

It generally ensues from dietetic errors, and delivers its
attacks without previous warnings, these manifesting
themselves, ‘‘like bolts from the blue,” in pale or more
or less tinted patches or areas conforming to afferent nerve
terminal distribution.

The rapidity with which these cutaneous invasions
frequently ensue, after the exciting cause has been at work,
renders it probable that that exciting cause is of a subtle
toxic character, as rapid in the production of its effects as,
for instance, prussic acid and kindred. toxic agents, and
operating along chemico-physiological lines determined by
the prevailing affinities between the toxic agent on the
one hand and the physiological tissue elements on the
other. Thus in urticaria arising from partaking of such

—————

ON URTICARIA 227

articles as certain shell-fish, green fruit, or oatmeal, a very
short interval frequently suffices to produce the character-
istic rash and to set up the familiar local itching and
sensory disturbance, so much so, that ordinary bacterial
and physical methods seem far too slow to effect the
morbid changes. We are, therefore, driven by necessity
to contrive an explanation which will at once meet this
difficulty and be more or less scientifically satisfactory.

The toxin, or materies morbi, contained in the articles
mentioned, whatever it be, must almost at once effect an
entrance into the blood stream, therefrom to be deposited
in the cerebro-spinal fluid, or possibly communicated to
certain neurons, and thereafter transferred by neural
circulation to the implicated peripheral nerve terminals,
where its presence 1s soon attended by stasis and accumula-
tion of the local neural lymph, with consequent elevation
of the overlying cuticle, and, it may be, more or less
lasting oedema, and possibly also associated capillary haemal
changes.

On the exhaustion of the pathogenic influence of the
toxin, the effects of its attack, local and general, gradually
subside, frequently almost as rapidly as they were de-
veloped, leaving, it may be, a more or less desquamating
cuticle over the affected areas, and, it may be, a more or
less perverted innervation of the implicated terminal
nervature.

Whether at the bottom of such local nervine patho-
logical phenomena there is temporary occlusion of the
neural excretory apparatus in the areas affected it 1s 1mpos-
sible yet to say, but reasoning from analogy, there seems
at any rate reason for supposing that, besides an increased
arrival of local cerebro-spinal lymph, there is increased
difficulty of excretion of that lymph, with the inevitable
local elevation of the affected areas, ephemeral or more
lasting.

The more intense and violent varieties of the affection
are characterised by the elevated areas assuming a more or
less papular and vesicular development, along with, it may
be, implication of the locally associated hamal vasculature,
consisting of a more or less pronounced erythema, which
sometimes so completely overshadows the original nervine

228 PHYSIC

phenomena of the attack as to be the only apparent patho-
logical condition calling for consideration and treatment.

All this implies that we have in urticaria to deal with an
exanthematous disease, the incubation of which is so rapid
as sometimes to be reckoned by hours, or even minutes,
efflorescence or eruption by a like period, and the establish-
ment of the status quo ante by the same brief method and
manner of pathological development and sequence. More-
ever, the behaviour of the more intense and violent
varieties of the disease but accentuate this differential
diagnosis, and bring it into line with that of the pro-
nounced exanthemata in manner of origin, culmination,
and decline, and proclaim the great fact that the central
nervous system is the fons et origo of the great proportion
of eruptive diseases. Given facilities for the introduction
of an exanthematous virus into the cerebro-spinal cavity,
including the cerebro-spinal fluid and the nervine struc-
tures proper, the cultural conditions there found by that
virus are so intrinsically conducive to the spread and
pathogenic influence of it as to ensure its easy pathological
progress, whether it be chemical, physical, or bacterial, in
nature and properties; from which it follows that we are
likely to discover that, with every increase of facilities
and powers of differential diagnosis, the number of
diseases having a nervine origin is ever increasing, and
that the sphere of nervine influence within the area of
pathogenesis is constantly broadening and extending, and
affording, at the same time, a clearer view of the thera-
peutic paths to follow in our everyday ameliorative and
curative work.

Thus, the vis medicatrix nature proclaims or indicates
in her whole behaviour that we must constantly aim at
clearing both the central and peripheral nervine elements
of the pathogenic influences at work in the evolution of
exanthematous disease, and in assisting to neutralise the
untoward effects of their morbid work.

EXTRACT XL.

INFLUENZA.

A continuation in the domain of ‘the practice of medicine”
and clinical experience of the views already formulated
on the cerebro-spinal circulation, etc.

Tue term influenza is of Italian origin, and refers to
the epidemic aspect of the disease recognised by that name,
hinting at a belief in astrological influences as the origin
of this most truly typical epidemic, and now, in this
country, endemic, disease. ‘The French la grippe is ex-
pressive of the manner and nature of its attack.

Neither term expresses anything as to the real nature
of the ailment, both are delightfully indefinite, but pass
current with the public, and, for that part, with the medical
profession itself, as great realities. During the hurry and
bustle of the progress of an epidemic, and even during
the long sequence of years.in which it has been endemic
of late, no expressive name or title has been suggested
for it.

In the light of what has been said in these pages
previously, influenza may be described as a disease owing
its existence to the influence and operation of a subtle
poison, microbic or otherwise—we may now conclude that
it is microbic—acting, primarily, on the nervous system,
both central and peripheral, and, secondarily, on the
various ‘“‘systems,” organs, and structures of the body
generally.

It must be understood as almost entirely effecting its
entrance into the bodies of its victims aérially from a con-

230 PHYSIC

taminated atmosphere, through the exposed surfaces of
their bodies, or from the walls of the air passages, including

the nasal, oral, pharyngeal, laryngeal, tracheal, and pul-

monary. }

- The entrance of the materies morbi having been effected,
and the period of incubation—which is usually compara-
tively short—having been passed, the series of phenomena
characterising the disease occur in rapid succession, and
terminate, in the mildest cases, in a few hours or days, and
in the more severe cases in as many weeks or months, or
it may be fatally, or in more or less permanent disablement.

The phenomena or symptoms of the disease primarily
centre in the nervous system, being, it may be said, at
once, or soon, followed by rapid loss of strength without
any possible corresponding loss of body weight, and hence
are, and must be, the outcome of a more or less profound
disturbance of the machinery of the production, conserva-
tion, and distribution of nerve force or energy through
contact of that materies morbi—microbes and toxins—
with the central nerve elements.

Taking for granted that this disease is truly zymotic,
it would appear that its rise, progress, and decline syn-
chronise with the stages of existence of its specific microbe
or bacillus, and that, in mild uncomplicated cases, spon-
taneous recovery is effected without the need of medical
intervention, it follows that the line of conduct to be
pursued, when dealing with such cases, must be founded
on a broad as well as minute study of its ‘‘ natural history.”
And here we might interpolate a few observations on the
subject of zymotic diseases generally, or on what we might
call zymosis as now taught.

We remark, firstly, that these diseases are characterised
by very differing periods of incubation, very different
manners of attack, as well as very different degrees and
rates of progress, due. to the particular ‘‘ system,” or part
of the body, implicated. ‘The disease under consideration,
influenza, is, as has already been observed, very short in
its period of incubation, the materies morbi acting almost
at once on the nervous system. Typhoid fever, acquired,
it may be, through the lungs, alimentary canal, or cutane-
ous surface, incubates slowly, apparently in the systemic

-"

INFLUENZA 231

blood circulation, primarily, and then, secondarily, attacks
certain specific parts. Smallpox and the exanthematous
fevers generally are more or less slow in their respective
periods and manners of incubation, and may be said to
accomplish that process within the blood streams and the
adjacent cerebro-spinal lymph, afterwards manifesting
themselves in their own peculiar and specific ways, and on
particular parts, according to the laws of what may be
called “‘natural selection.” While it may be said that
cholera confines itself to the invasion of a more limited
part of the human organism, where it germinates, lives,
and is eliminated within a much more limited area than
is claimed by almost all the members of the great families
of the exanthematous and zymotic diseases.

On dealing clinically with this disease, influenza, and
observing the progress the cases of it may have made and
the stage they have arrived at when aid has been called,
and questioning closely on the sequence of symptoms, we
have been struck with a few outstanding, almost constantly
recurring, phenomena, such as the Jocal ‘‘ feeling of relief ”
to the head experienced on the occurrence of free nasal
and ophthalmic discharge, and the general relief experi-
enced on the establishment of copious discharge from the
skin; frontal and general headache, gravedo, and nose-
ache disappearing, or being modified, on the establishment
of the former, the general “‘aches and pains” evincing
a corresponding improvement in the latter. The explana-
tion of these events would seem to be that a local outlet
is afforded to.a superabundant and contaminated cerebro-
spinal fluid in the first cases, and that a general relief is
attained in like manner by diaphoresis in the other.

The speedy accomplishment of these events is, there-
fore, of the greatest importance in order to “cut short”
the attacks or cases, and to prevent the possibility of the
occurrence of the graver sequela of the disease, and this
must be aimed at by the promotion of these local and
general discharges from the ‘breeding places” of the
disease, in order that the parasitic and pathological intru-
sion and confusion may be converted into purity and
order.

Along with lachrymation and running at the nose, as

232 PHYSIC:

‘“safety valves” may be classed herpetic eruptions on and
around the eyes, nose, and mouth, as well as the skin
surrounding these parts; while, along with general dia-
phoresis, may be classed eruptions of the same character,
which make their appearance on different parts of the
general cutaneous surface, as affording additional points
of exit to the toxic materials—the latter eruptions may
occur regularly or symmetrically, unilaterally or generally,
over wide areas.

What, therefore, it seems to us essential to recognise is,
that each of these herpetic points, papules, vesicles, or
bullez, represents a discharging “‘nerve terminal,” and
must be looked upon as a highly beneficent excretory
agency under the circumstances.

In this connection it might be pertinently asked whether,
in many cases of cutaneous disease, the pathological pro-
cesses may not be initiated in a like beneficent manner by
a natural or physiological discharge? the cause of which
should be carefully sought for, and the apparent natural
intention aided and assisted in order to procure the
co-operation of the vis medicatrix nature.

It may further be noticed that the situation of the
prevailing general ‘“‘pains and aches” of influenza is
generally to be found in the track of the great nerve
trunks, and at points where it might be supposed that
‘“nervine lymph stasis” and pressure from cerebro-spinal
fluid are most liable to occur. Thus frontal and occipital
headache, circular or coronal headache, and headache con-
fined to the upper regions of the skull, predominate, while
face-aches centre in and radiate from the root of the nose,
or where the principal frontal exit is provided from the
cerebro-spinal cavity. Likewise the area of exit of the
brachial plexus from the spinal canal is a favourite locality
for the manifestation of the characteristic pains, the dorsal
and the lumbar regions follow in proportion until the
climax is reached in the sacral, and even coccygeal termina-
tion of the cord, where the pains often encircle the pelvis
and pass into the lower limbs.

The same may be said of the great visceral nerve trunks
—the pneumogastric, for instance—entering and dis-

tributed throughout the body, the sympathetic, through

a = % ie 8 hee ee © | ae

INFLUENZA 25

its many connections with the cerebro-spinal system,
becoming involved.

Thus, the sequence of pathological phenomena may be
traced, and their varying intensities accounted for, as well
as the complications and sequel of this disease explained.

As referred to before, the materies morbi, having
obtained an entrance into the nervous system either
through its blood supply or directly from the Schneiderian
membrane of the nostrils or mucosa of the air passages,
finds a medium suitable for its growth and propagation
in the cerebro-spinal fluid, within the cerebro-spinal cavity,
and surrounding the cells and fibrils of the brain and
spinal cord, as well as within the neurilemmar sheaths,
encircling the ramifications of the nerve structures through-
out the body.

It will in this way become apparent that an explanation
can be afforded of the rapidity with which the strength
of the patient disappears, even ere the body-weight has
had time to materially diminish; the explanation being
that the production and distribution of nerve energy or
force has been stopped or interfered with in proportion to
the amount and virulence of the poison imbibed and
produced.

The rapid loss of strength, independently of the loss
of body-weight, is in strong contrast to the loss of strength
which takes place, say, in typhoid fever, where it is asso-
ciated with and in proportion to the loss of body-weight,
and is due to the disintegration and loss of tissue, and the
over-evolution of caloric and continued high temperature.

On the subject of the prevailing sequele of influenza,

we may remark that they begin and follow on very much
the same lines as those along which the disease has con-
ducted its attack, viz. on the brain and nervous system
and connected muscles first, and on the visceral and other
more outlying organs and structures second.

We would, therefore, remark that those sequele, which
are directly traceable to changes wrought by the disease
within and on the nervous system, may be accounted for,
as has already been pointed out, by the operation of the
toxic and mechanical influences of the specific materies
morbi of the disease on the various structures of that

234 PHYSIC

organism alone, or almost alone, and the consequent dis-
turbances, suppressive and perversive, of its functional
powers.

The other sequele, represented by pneumonia and
pulmonary congestion, with the consequences flowing from
them, or the secondary morbid processes, flowing directly
or indirectly from the invasion of the nervous system,
and not as primary or coincident diseases, may be traced
to the passage along the pneumogastric nerve trunks of
the germs or bacilli of the disease, and to the subsequent
attack of the lung structures, first in connection with the
nerve terminals, and thereafter by the implication of the
pulmonary parenchyma.

The latter untoward secondary occurrences may thus be
regarded as typical examples of the failure of nature, or
of nature and art combined, to clear the system of the
presence of the rapidly multiplying disease germs ere they
have had time to overflow into and invade the extra-
nervine structures of the body generally.

While remarking on the subject of the sequele of

influenza, we have also had occasion already to mention ~

that herpetic eruptions are common on various parts of the
body as symptoms or consequences of the disease, more
especially round the mouth, nose, and eyes, as well as on
distant parts, such as the genito-urinary and anal regions,
and that the cause of the preferences in site seemed to
be the anatomical nearness of the points of exit of the
cerebro-spinal fluid, viz. the nasal and coccygeal excretory
organisms.

In other words, the pent-up cerebro-spinal fluid, it may
be, under more than ordinary pressure, finds its way along
the channels of least resistance leading from the particular
part or parts of the nervous system or nerve structures

involved, besides invading the more open and yielding:

contiguous channels and inter-spaces.

We forbear, for the present, from entering into the very
important matter of the therapeutics of the disease, but
feel constrained to add a few lines regarding the results
of late research bearing on the subject of its genesis.

For instance, that Pfeiffer has discovered and isolated
the microbe or bacillus of influenza, that it is the smallest

INFLUENZA 235

such organism—according to some accounts—known to
science ; and that, consequently, it has only been possible
to detect it by the very highest microscopic power, that it
has an affinity for such substances as the cerebro-spinal
fluid, and, as we infer, has been actually found within that
fluid when drawn from the cerebro-spinal cavity. If these
things be so, and we have so far no reason to doubt the
truth of them, then we say we are warranted in advancing
the statement of opinion that there is no longer any diffi-
culty in recognising the possibility and probability, yea,
the certainty, of the direct invasion of the cerebro-spinal
cavity through the channels and air passages described in
the preceding pages, that the continuity of these channels,
with their fluid contents, affords just such a means of
access to this hitherto reputed to be “‘shut sac” that the
spores of the smallest living organism known to science
find it an “‘easy way,” and that, therefore, the morbid
entity known as influenza is revealed from inception to
close in a way which is seldom possible in the complicated
fields of pathological research and bacteriological problems.
We might here add that the lower animals, who are
liable to attacks of influenza, evince very much the same
symptomatic and pathological phenomena as those de-
scribed, and that the horse in particular has shown a
peculiar liability to attack; “pink eye” in them being
often the epizootic prelude to an epidemic spread of the
disease. In reference to this peculiar liability of the horse
to influenza, or pink eye, we would suggest that the
materies morbi, being air-borne, attaches itself with the
utmost facility to the large moist surfaces of the con-
junctival membranes of the eyes, from which they are
removed by the palpebral surfaces and lachrymal fluid into
the nasal ducts, and thence into the nasal passages, where
they are at liberty to enter and develop along the olfactory
peri-neural lymph spaces into the cerebro-spinal cavity,
when the local give place to, or are followed by, the
constitutional manifestations of the disease.

The influenza bacillus is essentially an air-borne and
atmospherically delivered zymotic organism or morbid
agent, and requires for its rapid spread the provision of
free space open to air currents, where it can play at large

236 PHYSIC

on susceptible subjects, animal and human, without “‘let
or hindrance,” in their unprotected condition of complete
unsuspicion and unpreparedness for attack. Hence the
west ends, the open places, and the great buildings and

institutions at once become victimised, while the slums

and narrow streets, alleys, and entries escape the winds
respectively sweeping through and over them, with the
effect that influenzal incidence seems a new epidemic
departure until its character has been to some extent
revealed by hygienic analysis and comparison with related
natural history methods and manners of propagation.

EXTRACT XLI.

HY DROPHOBIA.

A sHort consideration of the subject of that dreaded and
dreadful disease, hydrophobia, seems to us likely to yield
valuable results when conducted by the light that can be
shed by the foregoing views.

Let us, therefore, first remark that the dog, with its
kindred species the wolf, seems especially prone, in conse-_
quence of its anatomical peculiarities—at least so far as
its olfactory organs are concerned—to take, and give, that
disease. hus, accepting, of course, the truth of what
has been already referred to, that from the mouth of the
animal a direct passage or passages run through the
anterior palatine or incisor canals, and thence, in unbroken
continuity, along the cavities of the “organs of Jacobson”
to the base of the skull. In the lining membrane of these
organs a portion of the olfactory nerves of either side,
along which the virus of the disease finds a passage, is
distributed, and, consequently, a direct route is open into
the interior of the cerebro-spinal cavity, independently of
the communication maintained by the main body of the
olfactory nerves and tracts, where, after incubating for a
longer or shorter period, the materies morbi gathers
strength and virulence enough to produce the pathog-
nomonic symptoms and pathological changes characterising
the matured disease.

The cerebro-spinal fluid having become surcharged, a
retrogressive movement of it is commenced along the
channels by which the original infection was imbibed, as
well as all other effluent channels, and then the affected

238 PHYSIC

animal is in a condition to spread the disease, either by
direct inoculation through its teeth and saliva, or indi-
rectly, sometimes, in our opinion, by poisoning the food
and water used by other animals to which the affected
animal has gained access. |

The slowness of the infection, or the prolonged period
of incubation, in so many cases, may be explained by the
indirectness of the route travelled by: the poison when
inoculated into distant parts of the body, and where,
necessarily, it is somewhat a matter of accident whether
it reaches the central nervous system along the nerve ele-_
ments, or by the more circuitous route of the general
lymphatic and blood circulations.

EX TRACE Xi.
ECZEMA.

Eczema, constitutional and acquired, local and general,
may be regarded as largely due to general nerve influence
or to the effects of local irritation on certain peripheral
nerve terminals in skin or other exposed surfaces produced
by their contact with certain substances, such as sugar in
the cases of grocers and confectioners.

In the former, the constitutional or innate variety, the
external manifestation of the disease or rash, may be
_ regarded as due to the expulsion of the materies morbi
and to the irritant influence it exercises at. the peripheral
or excretory extremities of the implicated nerves with
their related sudoriferous outlets, and the consequent
inflammation excited with its attendant serous exudation
and vesiculation: while in the latter, the local or acquired,
it may be regarded as due to irritation arising from the
contact and, it may be, the absorption of the offending ©
saccharine or other substance.

The latest clinical illustration of this disease occurring
in our experience may be cited as a case of the consti-
tutional variety, which, in virtue of an accidentally ex-
perienced process of counter-irritation, was precipitated
or determined, as it were, and diverted into local channels.

The subject of this attack, a domestic, aged about fifty
years, and never particularly robust, being subject to
rheumatism and recurring attacks of acute dyspepsia, felt
herself ‘‘on the eve” of one of these, which was ushered
in, on this occasion, by a period of vague general dis-
comfort and local itchings, tinglings, and pains extending

240 PHYSIC

piecemeal over the whole cutaneous surface, with a feeling
as if the hands were being inflated or “‘blown up” in
“balloon fashion,” and as if the skin of the arms were
being expanded ; very little rise of temperature, quicken-
ing of pulse, or other notable general symptoms, were
observed then or during her subsequent progress towards
convalescence.

The feelings here enumerated emanated from within,
and were initiated there, but afterwards became generally
experienced without, or externally, for a brief period, and
then were focussed in the fingers and hands to the wrists,
where, after a few hours of work spent amongst materials
containing a large proportion of turpentine and other irri-
tants, the terminal result was that punctuated inflamma-
tions arose over the exposed and implicated parts, with
vesiculation of the cuticle, and cedema of the whole hands.
The general, as contrasted with the local, effects of this
process of accidental counter-irritation were not less re-
markable, in that the entire skin, with the exception of
that over the counter-irritated or affected parts, the hands,
became absolutely free from the itching referred to as
soon as the fucussing was precipitated, and did not show
afterwards the slightest disposition to or manifestation of
rash or disease.

Eczema may also be caused or precipitated during
periods of predisposition by simple local irritation, due,
for instance, to the friction of articles of attire, such as
collars and cuffs, whose edges have become broken and
serrated, and to the local pressure, for instance, of such
articles of everyday use as spectacles; the effects of these
irritants becoming visible and sensible at the seats of
friction and pressure, respectively, and if not hindered by
the removal of these irritants, progressing or spreading,
it may be, to eczematous dermatitis of considerable pro-
portions, or laying, it may be, the foundation of a general
attack. The irritant influences here mentioned being,
primarily, only local, and superficial in their action, if
withdrawn in time, immediately give place to a healthy
condition of the irritated part or parts in proportion to
the absence of predisposition, and provided the parts
affected have only been the epidermis and outer layer of

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ECZEMA 241

the dermis, with the nerve terminals therein distributed,
and, it may be, the outer capillary vessels, blood and
lymph ; and provided, also, that no solution of continuity
of these has taken place, nor other morbid results been
induced. Should, however, any rupture or solution of
continuity of nerve or vascular textures have occurred,
and healing by first intention not have taken place, then
a neuro-vascular irritative pathological process is the result,
which will persist and extend in proportion to the strength
and continuance of the original irritation and the intensity
of the existent predisposition.

The diseased process thus initiated may, at this stage,
be described as neuritis—if we are entitled to the use of
the term—involving the nerve terminals and fibrils, dis-
tributed to the parts affected, with their peri-neural sheaths
and the vascular and other textures immediately surround-
ing them, the neuritis being accompanied by more or less
thickening of the dermis, due to exudation (neuro-
dermatic) from, it may be, the capillaries, as well as from
the nerve terminals implicated, i.e. from the peri-neural

or neurilemmar sheaths, with the medullary and axis

cylinder or nerve terminal sheaths proper, the first of
which enclose inter-spaces containing cerebro-spinal fluid,
and the latter the more solid, medullary, and axis cylinder
substances respectively, the rupture of one, or both, of
which sheaths, and the exudation of their contents, afford
the thickening material. Should the fluid portion of the
extravasated or exuded material predominate, vesiculation,
followed by surface leakage, may ensue.

The first stage in the development of these untoward
pathological changes or results requires the pre-existence
of what may be called a hyper-zsthetic condition of the
peripheral or cutaneous nerve expansions, along with and
due to, it may be, an unusually acrid condition of the
peri-neural lymph or fluid, as well as the existence of the
necessary mechanical or other irritation.

As an example of a constitutional and local predisposi-
tion to the occurrence of eczema or neuro-dermatitis, we
might mention the gouty disposition or habit of body
wherein the operation of slight exciting causes usher in
or precipitate a local manifestation of gouty symptoms or

II Q

242 PHYSIC

processes, cutaneous and others, or a well-defined attack
of gout of the more prevalent or typical variety. Here
the operation of exciting causes sufficient to initiate a
gouty manifestation of morbid processes would not suthce
to disturb the equilibrium of health in the now pre-
disposed, and would, consequently, pass entirely unnoticed.

An illustration of the gouty variety of eczema, or
neuro-dermatitis, is afforded in the following case which
has lately come under our notice, and which we have very
closely watched and more fully reported and commented
upon than its intrinsic merits perhaps required.

A. A., aged 61 years, previously active and healthy
and free from disease, constitutional or acquired, began,
a few weeks previous to applying for advice, to manifest
an unusual irritability of the skin, resulting in slight
erythematous reddenings of it at points where friction
was experienced, such as the dorsal aspects of the thumbs
and forefingers of both hands at their carpal ends mainly,
or just where the shirt cuffs extended to, and the lateral
and upper parts of the nose where pressed by spectacles ;
these were the only spots on the whole surface of the skin

to manifest the erythematous appearance referred to, else-

where the skin was perfectly healthy, and the condition of
the general health of the body unimpaired. On the
removal of the exciting causes of these local manifesta-
tions improvement began to take place, and continues,
but has not as yet (after one month of treatment)
resulted in complete recovery of the former condition of
the skin, nor in the disappearance of disagreeable local
sensations, hyper-zsthetic, and par-esthetic, as well as
an-zsthetic.

The condition originally set up by the irritants men-
tioned, and which still to some extent persists, is one,
primarily, of peri-neuritis and neuro-dermatitis, involving,
in clearly defined small surface areas, the peripheral cutane-
ous nerve terminals, with their neurilemmar coverings,
and, secondarily, of hyperemic and inflammatory vascular
local changes dependent on the primary nervine disturb-
ances. The clearly defined small surface areas are situated
over the papillary elevations of the dermis, are smaller
or larger according to the development of these individu-

wv ——

a

ECZEMA 243

ally, and are usually grouped around one particular papilla,
which seems to be the primary seat of the initial neural
disturbance, each papilla so affected becoming, as the
neighbouring vascular structures become, secondarily en-
gaged or implicated, gradually surrounded by a halo of
hyperemic or congested cutis, and surmounted by a
miniature scaly cap of rapidly shedding horny epidermic
scales from what appears to be a hypertrophic development
or keratine, or, in this case, neuro-keratine from the nature
of the structures involved. The local discomfort has not,
on the whole, been severe, and has been mainly due to
disturbances of the nerve elements, and manifested in
degrees of itching in intensity from the slightest to the
very severe—there has been virtually no pain—a peculi-
arity of this feeling of itching is, that it is only felt
proceeding from the seat of the eruptive patches, which
vary in size from a pin’s head to a sixpenny piece, to
the distal ends of the thumbs and fingers affected, i.e. the
sensation of itching passes from the proximal, as repre-
sented by the nerve structures of the implicated skin, to
the distal distribution of the implicated nerve fibre ter-
minals on the bodies and points of the fingers and thumbs
before it can be consciously appreciated, or, in other words,
the molecular disturbances, initiated in the affected nerves,
pass onwards or forwards to their peripheral terminal
extensions preparatory to their conscious appreciation by
a reversal of the currents of the molecular disturbance.
The sense of itching, however, can be correctly localised
or located when the eyes are closed, but when the local
areas of disturbed sensation are rubbed or scratched, the
molecular disturbance ensuing, continues to extend ex-
clusively in a peripheral direction along the tracks of
distribution of the affected nerve fibres to their terminal
arborisations, their proximal parts being entirely un-
affected. All these phenomena have been, and are still,
confined within the layers of the skin, the affected parts
being easily and conspicuously movable over the under-
lying cellular and deeper seated structures, the hyperemic
reddening, discolouration, and pigmentation being little
affected by pressure or position ; a noteworthy observation
made in this case, relating to the distribution of the areas

244 PHYSIC

of morbid cuticular disturbance, was that the dorsal, as
distinguished from the palmar aspect of the affected carpi
and digits, was alone affected, that the lines of demarcation
between the two aspects were sharply defined, and that
above the wrist joints the inner, as distinguished from
the outer, surfaces or aspects of the forearms were affected,
so far as any infinitesimal sympathy, structural or func-
tional, was concerned.

As an explanation of these seeming local preferences of
the disease, besides its unmistakable distribution on
strictly nerve “‘trunk and fibre lines,” we would suggest
that the anatomical and histological characters of the
affected and unaffected areas, respectively, constitute it one
of natural selection, founded on the progress of the
materies morbi along the lines of least resistance, these
being afforded in and determined by the more soft and
yielding cutaneous textures covering the affected, as com-
pared with the more resistant and denser unaffected parts,
where, naturally, the facility or otherwise of the nervine
circulation is modified by the nature of its environment.

Pigmentation, to some extent, marks the sites of the
disappearing eruptive patches, and seems to be due to the
slow absorption of neurolised hemoglobin, and, it may be,
the limited presence of arsenic, due to its therapeutic intro-
duction during the course of the treatment latterly pur-
sued. The nasal development of the eruption, which was
followed by disturbed innervation of the frontal parts of
the scalp with a few small patches, or rather points, of
keratosis, disappeared in less than two months, leaving
the affected parts of the skin quite normal both in colour
and texture. About this period the wrists and hands,
which had also greatly improved, began to show, especially
on the dorsal aspect of the left wrist extending to the back
of the same hand, a blush of cutaneous hyperemia, with a
slight sense of itching, in patches more or less correspond-
ing in position with those of the primary attack, and which
looked like a slight recrudescence of the disease, and seemed
to point to the presence of lurking remains of the eczema-
tous materies morbi, and to an effort of the vis medicatrix
nature to “‘clear the system.” |

Immediately after this slight recrudescence, an acute

ECZEMA 245

return of the eczematous nerve disturbance, in the form
of intense itching over the areas formerly affected, was
experienced, along with a thickening. of the cutis, and at
sone spot over the metacarpal bone of the right thumb at
its proximal end, a small amount of a clear translucent fluid
was exuded in three separate minute droplets. At this
point, the capillary circulation of the skin had undergone
no alteration, in the way of congestion or reddening, so
that the extravasated fluid could not have come from these
vessels—whence then could, and did, it come? From
one or other of the two sources remaining it, therefore,
must have come, i.e. either from the lymphatic channels,
or from the inter-neurilemmar spaces of the cutaneous
nerves, and from the former of these it was most unlikely
to come, inasmuch as these vessels—lymphatic—pursue a
course in the same direction as the blood vessels, and,
therefore, have to discharge their contents at their
proximal, or trunk, extremities, where stasis and regurgita-
tion are obviated by the onward flow of the blood streams,
and by the provision within themselves of a complete
series of valvular textures, which effectually bar the back-
ward flow of their contained lymph, along the lumina of
their tubes, passages, and spaces; moreover, at the distal,
or peripheral, extremities of the lymphatic vessels and
spaces no great amount of fluid can accumulate, and, there-
fore, no appreciable intra-vascular pressure can exist, hence,
we must regard exudation from this quarter as impossible.
From the latter source, the inter-neurilemmar spaces of the
involved nervature of the part, it must have come, there-
fore, and come through the overcharging of these spaces
by the lymph, or fluid, occupying them, which lymph, or
fluid, being derived from, and continuous with, the
cerebro-spinal lymph or fluid, and, consequently, emanating
from the spinal cavity, had been driven, it may be, by
super-normal pressure, through its neurilemmar barriers,
on to the cutaneous outer surface, bringing with it, we
may conclude, the materies morbi of the disease, from the
recesses of that cavity in which it has been hatched and
matured by morbid processes at work amid its liquid and
solid contents.

Eczema of this variety and, we may take it, of most

246 PHYSIC

other varieties, except those of purely external origin,
must, therefore, be a disease, primarily, of the nervous
system, first invading the cerebro-spinal cavity and its
contents, and secondarily, the systemic—-peripheral and,
cutaneous—nerve coverings, endings, and inter-spaces.
The sequence of the pathological events characterising the
onset and progress of the disease, the nature of the struc-
tures selected by it, as the theatre for the display of its
morbid processes, the correspondence of the extravasated
fluid, in consistence and appearance, with cerebro-spinal
fluid, or lymph, plus, it may be, an admixture of neuro-
keratinous material, due to rupture and disintegration of
the containing textures, surrounding the terminal arbori-
sations of the cutaneous nerve fibrils, all lend themselves
to prove that we have to deal with a disease of the nervous
system.

In this connection, the occurrence of what are denomi-
nated keratosis and hyperkeratosis, may be said to be due
to the pathologically free discharge into the peri-nervine
textures of cerebro-spinal fluid, loaded with neuro-kera-
tine, and, it may be, the medullary and axis cylinder
substances, filtered through the disorganised remains of
the neuro-keratine sheaths surrounding the final divisions
of the terminal fibrils, with the subsequent consolidation,
and thickening, of these peri-neural textures, while the
‘‘ weeping,” so conspicuous in certain cases, may be said
to be due to the abnormally free discharge of the more
unmixed, and liquid, cerebro-spinal lymph.

For three months longer the case under discussion con-
tinued to manifest the formation of spots and patches of
hyperkeratosis, at places over the surface areas primarily
affected, easily detected by touch, and mostly apparent to
the sight, along with irregular stretches of an-zsthesia,
par-zsthesia, or even kak-esthesia—(used to indicate an
absolutely ‘‘ bad” feeling)—in the distal distributions of —
the implicated nerve fibres. In association with these
latter sensory phenomena, a limited motor paralysis of
certain of the extensor muscles of the left forearm took
place, leading to the production of fairly well-defined
‘drop wrist,” and the serious curtailment of the range of
movements required in everyday work. The explanation

ECZEMA 247

of this latter occurrence seeming to be that it was due to
invasion, by the same materies morbi, of a contiguous
set of motor-fibre channels, at a certain point in the distri-
bution of the implicated nerve trunk, where the continuity
of the common inter-neurilemmar spaces, and their con-
tained fluid, was maintained along the common sheath,
enclosing both the affected sensory and motor fibres, thus
proving that here a common cause has been productive of
two forms of morbid nervine processes, leading: to results
quite different in character, in accordance with the anatomi-
cal nature and functions of the parts involved, the result
in the one case being an eruption (cutaneous), and in the
other a paralysis (muscular).

The muscular paralysis, above mentioned, continued for
a few weeks, after which it slowly disappeared, apparently
with the absorption, neutralisation, or elimination of the
materies morbi, the cutaneous phenomena also slowly
disappearing meanwhile.

The simultaneous occurrence of two such diverse
morbid processes, as the results of the action of one virus,
or materies morbi, opens a somewhat novel, but wide,
field of investigation in the etiology and pathology, as well
as the therapeutics of disease, and promises important aid
in the work of grouping and classification of the morbid
entities with which medical science has to deal.

In concluding our remarks on this case, which terminated
in complete recovery, we would claim that undoubtedly
the source of the local disturbance, and disease, was to be
found within the cerebro-spinal cavity, amid the fluid with
which it is pervaded, and that a chemical, if not bacterial, —
sepsis of that fluid took place, eventuating in its overflow,
into a limited number of the inter-neurilemmar spaces,
leading out of, and continuous with, that cavity, and the
subsequent invasion of the textures in which they hap-
pened to terminate, and to which they were distributed.
An eczema and a paralysis are thus parts of the same
disease, or, more exactly, they constitute parts of one
disease, of which they are symptoms, the full and true
nature of which disease is still to be discovered. That the
gouty constitution underlay it we have already indicated,
but what that really is, and how much it means, we are yet

248 PHYSIC

far from knowing, and, hence, we accentuate the necessity
of obtaining clearer views and notions of the ‘essential
conditions” underlying this, as well as all diseased states
bearing the title gouty and rheumatic, they being terms
which cover a large area of the field of diseased conditions,
and which require more care in their use than they have
hitherto obtained.

The later stages and progress of the disease were char-
acterised by slight but diminishing recurrences, when
disturbances of sensation were felt, followed by the appear-
ance, on small detached areas, of slight hypereemia, with
subsequent thickening of the overlying epidermis, and the
development of a “brown paper” feel to the finger.
This latter phenomenon, as already described, being due
to the rupture of the neural coverings of the involved
peripheral nerve terminals, or arborisations, and the sub-
sequent invasion of the epidermic cell strata by the
escaping neurilemmar lymph and nerve plasm, from the
white, or medullary, and the axis cylinder substances, along
with their ruptured and disintegrating neuro-keratine
sheaths, or containing membranes, and thus constituting
a limited neuro-dermal keratosis.

EXTRACT XLII. .
ACROMEGALY.

It may be now conceded that the pathological conditions
representing the disease denominated acromegaly begin or
coincide with the development of minute and gross histo-
logical changes in the pituitary gland, or hypophysis, and
that, in fact, disease of that organ constitutes its starting
point: that being taken for granted, we may now enquire
how disease of the pituitary gland produces, throughout
the entire body structures, such unique changes and symp-
toms as are observed in acromegaly. It seems a “‘ far cry”
to assign such changes as lengthening, thickening, consoli-
dation, and thinning, or attenuation, of the bones, wasting
of the muscles and hypertrophy of the skin, for example,
to the existence of disease in the hypophysis, but yet we
think we can, with the aid of the views we hold as to the
function, or functions, of that organ, trace, to an extent
hitherto impossible, the operation of physiological and
pathological factors in the process, which will entitle us
to describe it as one of cause and effect. Thus, regarding,
as we do, the pituitary body as a true gland, and assigning
to it the function mainly of dealing with, and excreting,
the more solid, as well as fluid, nervine and neuroglial
débris, which finds its way into the third ventricle of the
brain, in such a way as to clear it of these waste products,
which it does by a process of disintegration, liquefaction,
and excretion into the surrounding cavernous sinus of
the cephalic venous circulation, and also by the more direct
routes of the central and lateral cranio-pharyngeal
foramina, which are specially observable in embryonic or

250 PHYSIC

foetal life—into the pharyngeal cavity, through the related
and continuous uvular and tonsillar structures.

The lymph, or more fluid material, circulating within
the third ventricular cavity, may, to some extent, find its
way along the other passages and cavities leading from, or
communicating with, it, viz. through the-foramen of
Munro and the aqueduct of Silvius, and, in the case of
obstruction to these, through the pineal gland, into the
sub-arachnoid and the sub-dural spaces, while the quasi-
solid, or less fluid, residual material, from which the term
pituitary is derived, remaining after the draining off of the
supernatant lymph, finds its way into the glandular inter-
stices, and passages, of the anterior portion of the hypo-
physis, from its posterior, or infundibular, portion, and
thence passes by the cranio-pharyngeal foramina, through
the uvular, and tonsillar, spongio-porous textures, into the
pharynx and cesophagus. A portion of this latter, or
pituitary material, also seems to percolate from the. tonsils
into the matrix of the hinder, or posterior, portion of the —
tongue—(the truth of which is observable by all consumers
of the commercial article known by that name)—where it
effects its escape, by the papillz there so prominently dis-
tributed ; hence, when these latter become occluded, as we
may suppose they do, in certain pathological conditions, we
find that the forward or anterior parts of that organ become
invaded by the retained matter, when the phenomena of
‘“furred tongue,” with its long familiar tell-tale features,
and far-fetched stories, begin to develop in consequence ;
in which latter occurrence we see the operation of what may
be regarded as the law of ‘“‘compensation,” the anterior
excretory agencies of the tongue taking up and performing
the work of their posterior neighbours. A considerable,
if not measurable, quantity of such material must, there-
fore, be tipped, or discharged, into the pituitary gland,
calling for a never-ceasing activity of its structures and ~
associated agencies, and necessitating the continued main-
tenance of a fluidity of effluent, so to speak, capable of
securing complete patency of the oro-pharyngeal points of
exit. Should this excretory process in any degree fail, or
for any length of time lag, danger will arise from the
accumulation of undealt with material, both to the integrity

ACROMEGALY 251

of the gland organism, and to the system at large, which,
if not relieved or removed, must necessarily end in the
production of disease. This, to our mind, or in our
Opinion, is just what does occur in the disease called
acromegaly, and the sequence of the accruing events may
be described as follows: a stasis, more or less complete,
occurs in the gland, beginning either in itself, on the one
hand, or in the infundibulum, or the other points of exit,
on the other, and which, if it persists, leads to a permanent
damming-back of the pituitary materials, and to their over-
flow into the various channels leading from the ventricle.
This overflow is followed by the invasion of the body
generally, but some parts in particular, by the pituitary
matter, along the lines of least resistance, or along the
lymph paths leading from, in the first place, the intra-
spaces of the brain and cord, and thence, from the sub-
arachnoid and sub-dural spaces, along the neurilemmar
inter-spaces of the nerves, sensory and motor, and, con-
sequently, into the tissue of the skin, the sheaths of the
muscles, and their individual fibres, to which they are
respectively distributed. Through its communicating
fibres, the invading material also reaches the sympathetic
system of nerves, and so also the parenchyma of every
organ and viscus, to which that system is attached, it also
reaches the diploé, and tables of the skull bones, through the
Pacchionian bodies of the arachnoid, moreover, some com-
pensatory escape must take place from the other “‘ points
of exit,” such as the olfactory apparatus and apertures, and
the coccygeal gland and related structures. The cerebro-
spinal lymph, which, in its normal physiological condition
of fluidity, enters and penetrates all the passages and spaces
above mentioned with ease, and without difficulty, on be-
coming contaminated, and loaded, or thickened, with the
undealt with residuum of the pituitary material, or neuro-
glial and nerve mud, resulting from the incapacity of the
pituitary gland structures, and associated anatomical parts,
to perform their normal physiological functions, breaks up
en route, leaving its more solid impedimenta, in the form
of more or less amorphous deposits, amid the interstices
of certain of the structures, which, from affinity for its
elements, or histological difficulties in the way of their

252 PHYSIC

transmission, or circulation, become more or less organised
substances in, and around, the invaded textures and
organs; hence, an explanation of the apparent enigma,
of the association of disease of the pituitary body with the
enlargement of bones, and a pachydermatous condition of
skin, is thus afforded on definite anatomical and _histo-
logical lines; an explanation, moreover, which should be
fruitful in suggesting the lines along which clinical research
may be most profitably conducted, and relief or cure
secured, for a hitherto almost hopeless disease.

Thus, the overflowing, now pathological, cerebro-spinal
fluid, circulating along the afferent or peripheral nerves,
deposits in and amongst the cutaneous textural elements
whatever portion of its more solid constituents as refuses
to pass through the sweat glands, sudoriferous and
sebaceous, with the inevitable result of thickening or
hypertrophy of the skin. Thus, likewise, does the con-
taminated cerebro-spinal fluid, on reaching the periosteum
of the bones to which the various muscles of the body
and limbs are attached, and to which the motor or efferent
nerves are distributed, deposit its more solid constituents
on the surface and within the texture of these bones, with
the results of thickening and lengthening of the shafts
of the limb bones and obliteration of the cancellous inter-
spaces of such osseous structures as the spinous processes
of the vertebre, along with the gross enlargement of the
points and surfaces of attachment of the various muscles.
Thus, also, do the Pacchionian bodies account for invasion
of the diploé of the bones of the cranium, the obliteration
of their cancellous structure, and the universal or local
thickening of the whole calvarium, except what has been
produced externally where the various muscles are attached
through the motor nerves supplying these muscles. Be-
sides these somewhat general hyperostotic effects of the
disease on the skeleton, sequestered bony deposits are
found attached or lying close to certain bones, or developed
on or within the muscle sheaths and in connection with
their tendonous continuations. A curious departure from
the general hypertrophic progress characterising the disease
is observed in the thinning of the bony walls of the
pneumatic or air-spaces so plentifully developed along and

ACROMEGALY 253

under the base of the skull and in part of the facial
skeleton, the explanation of which seems to be that no
infiltration of their texture is permitted on account of
their anatomical seclusion from the sensory and motor
nervature, or exclusion from the area of distribution of
the hypertrophic material, and of the natural attenuation
due to enlargement of these spaces on account of broaden-
ing and deepening of the osseous structures of the face ;
moreover, absorption, due to lateral and downward pres-
sure of the pituitary growth, more especially overtakes:
the body of the sphenoid bone, reducing it, in many cases,
to a thin “‘ vestige of itself.” Further, and in like manner,
it may be said that the wasting and consequent asthenia
of the muscles of the limbs, as well as of the muscular
tissue of the heart and involuntary muscular tissues
generally, are due to the toxic, devitalising, and disinte-
grating influence exercised by the noxious cerebro-spinal
ymph exuded into their substance by the motor systemic
nerves. Likewise, the retrograde or degenerative optic
phenomena developed in the course of this disease are due
_ to the forward mechanical pressure of the enlarging gland
as it ploughs its malign way, rending and obliterating the
adjoining commissural nerve fibres of the optic chiasma
until their terminal special sense continuations wither and
die, shutting out and extinguishing the light of day from
its unfortunate subject for ever. The general cerebral and
mental changes observed in the progress of the disease
are also due, to a great extent, to the incidence of
mechanical pressure and the accumulation of effete matter,
and continue to extend with the widening boundaries of
the enlarging gland. From beginning to end, therefore,
an inevitable, although generally protracted, process of
centrifugal destruction and degenerative change char-
acterise the course of this disease, which at last overwhelms
and finally destroys piecemeal every vital organism and
function. In considering this subject a little more in
detail it has forced itself upon us that, in early embryonic
life, the surplus cerebro-spinal fluid and pituitary material
were disposed of by drainage through certain channels
left or laid down during early developmental processes
dating from before the time when the pharyngeal and hypo-

254 PHYSIC

physeal cavities became contiguous, if not histologically
continuous or dovetailed into one another, and which, on
their common encapsulation, was succeeded by a permanent
system of drainage directly into the pharyngeal cavity
through the ante-natal or early central and post-natal lateral
sphenoidal foramina, uvula, and tonsils; thus, in the
embryo, physical contiguity if not continuity of texture,
intra-spatial continuity of cavities and oneness of function,
lay the foundation of an intimate after-life physical and
functional relationship—a relationship which, to our mind,
will be found to explain many of those ever-recurring
sequences of pathological events or groups of morbid
processes, which constitute such a large item in the daily
work of observation and the more ordinary experience
of every practitioner of the healing art. And so such
expressions as a “‘ simple cold,” an “‘ ordinary sore throat,”
and other kindred popular ailments of the region in
question, will take their place amongst the definite scientific
titles and morbid entities known to modern medicine.
Concerning the functional réle of the pituitary body, we
become more and more convinced of the truth of our
contention that the earlier anatomists were right in their
conclusion regarding it, namely, that in structure it is a
true gland. Being a true gland, therefore, we further
contend that it both secretes and excretes. In the per-
formance of the latter function, it excretes, as above
mentioned, into the chain of hollow inter-spaces, and
_ through them into the cavity of the pharynx, thus securing
a continuous series of passages for the direct conveyance
of the ventricular sweepings of cerebral débris from the
third ventricular cavity into the usually patent and freely
washed throat and cesophageal passage, the saliva suspend-
ing or dissolving and voluntary or involuntary deglutition
conveying it into the stomach; any interference, conse-
_ quently, with the performance of this function is soon and
duly felt. In connection with this subject of the disposal
of the excretion of the pituitary gland, we would remark
that a common tipping-ground, so to speak, is provided
for the surplus or residual secretions of the mouth, nasal
passages, with their communicating air-spaces, the Eus-

tachian tubes, and the parts in question—the upper surface —

i me

—-

ACROMEGALY 255

of the epiglottis being the tipping-ground—and that
whenever these varied materials have been properly dis-

z posed thereon, the required act, voluntary or involuntary,

of tipping into the oesophagus is at once effected, thus
obviating the immanent danger of allowing their descent
into the pulmonary cavities.

EXTRACT AEA,

ON THE CAUSATION AND EVOLUTION OF SOME CASES
OF GOITRE, WITH OBSERVATIONS ON CRETINISM,
MYXCDEMA, ETC.

Wuen discussing the methods of disposal of the pituitary
secretion or excretion by the tonsillo-glossal excretory
mechanism in a former study, we became possessed of the
idea that in certain conditions of post-natal and adult
existence favourable or conducive to the survival or
renewal of the patency of pre-natal gland ducts, we had
in view a possible cause of the origin of some diseases
affecting ductless glands of which the thyroid may be
regarded as a typical example. This gland, during its
embryonic and fcetal stages of existence, undergoes many
evolutionary and developmental changes in the arrange-
ments of its parts preparatory to their permanent assocta-
tion as component lobes or divisions of the same glandular
organ, its two lateral lobes undergoing a separate or
unilateral development, and ultimately uniting with and
merging into each other through the central lobe or
isthmus, which is the terminal inferior extremity of the
duct known as the glosso-thyroid or thyro-glossal, whose
superior extremity begins at or opens through or by the
foramen cecum on the posterior aspect of the upper surface
of the tongue, and “‘hereby hangs a tale.” Anatomically
speaking, no duct can open by or through a foramen
cecum, and hence we must believe that the thyro-glossal
duct is no exception to the rule. Therefore, the thyro-
glossal duct gave passage in its pre-natal or foetal con-

SOME CASES OF GOITRE 257

dition to material either going to or returning from the
thyroid isthmus, and latterly, when the evolution of the
entire thyroid gland had been effected, the entire gland.
That being so, what more reasonable and likely could we
suggest than that an unusual post-natal patency of the
thyro-glossal duct, either as a survival from pre-natal times
or the product of causes conducive to the revival of its
dormant, pristine, ante-natal patency and conductin

powers, allowed of, or lead to, its original functional réle
being re-taken up.

These possibilities, and the fact that cystic tumours
and local balloonings of its lumen take place post-natally
from time to time, render the further possibility, nay proba-
bility, of the occurrence of the invasion of the central
inter-spaces of the gland—a most likely and, in fact, an
actual occurrence. ‘The natural, and perhaps sometimes
exaggerated, endothelial secretion and resultant material
débris might, in the event of the renewed patency of the
duct, be sufficient to produce ballooning of the gland, but,
if not, we have not far to seek for the requisite material
for its accomplishment if we but turn to that pituitary
_ dumping-ground situated “‘all round” the upper extremity
of the Jumen of the duct, where it originates in the before-
mentioned foramen cecum, into which or where the
V-shaped sulcus or gutter terminates or dips. This
abundant supply has only to be tapped in order that an
unfailing stream of the required ballooning material should
inundate the yielding textures of the thyroid gland, and
produce the disease known as goitre; therefore, we may |
take it, cum grano salis, that this may frequently be the
“state of things,” and, hence, that we must look “‘for a
way out of the situation” by a careful survey of these
local conditions, which may haply yield practical indications
for the direction of both the art and science to be involved.

A renewal of the activities of the duct, an attenuated
condition of its re-developed walls, and the presence around
these walls of a plastic but circulatable material, which
only waits to feel the “‘line of least resistance,” constitute
the essential conditions on which the causation and evolu-
tion of this disease in such cases at least are likely to
depend, and offer a rational solution of a very enigmatous,

II R

258 PHYSIC

curious, and geographically interesting pathological con-
dition.

Along with goitre proper, we may classify a recently
described morbid condition, viz. lingual goitre, and claim
it as an example of ballooning of the upper extremity
of the thyro-glossal duct, and a conversion of the lumen
of the duct into a localised tumour, composed.of the same
material as constitutes the matrix of the proper goitrous
tumour, a truly remarkable verification of the pathological
inferences here drawn from the views we entertain regard-
ing the pituitary excretory mechanism.

Throughout the sequence of physiologico-pathological —
events, of which this may be regarded as marking the
point of differentiation or connection, if we may call it so,
we still or continually see at work the moving principle
of circulation, albeit a supernumerary stage here in the long
series of physiological circulatory acts or events, initiated
or begun in the primary act of taking food, and ended,
in this instance, in the primary pathological circulatory
act of exudation into the central cavity or intra-spaces of
the thyroid gland, the concluding stages of which patho-
logico-physiological sequence of events have yet to be
traced.

Moreover, the colloid. material, so often discovered
within the enlarged or goitrous thyroid gland, bears a
considerable resemblance to what we might expect to find
from its being the residual part of the material discharged
into the gland from the tongue through the re-opened
thyro-glossal duct after its imprisonment within the
dumping-ground, and consequent inspissation from. the
separation of its more fluid parts from the more solid.

The passive circulatory réle of the pituitary material
resulting from the disposal of brain waste, which is dis-
charged from the gland of that name, is thus a very large
one, for have we not seen and traced it from its production
in the cerebrum, through the basi-sphenoid foramina, along
the spongy tissues of the uvula and tonsils into the
pharynx, and by structural continuity into the body of
the tongue, and thence through its papillary openings on
to the surface of that organ into the cavity of the mouth,
besides, under certain circumstances of patency, along the

SOME CASES OF GOITRE 259

lumen of the thyro-glossal duct into the cavity of the
thyroid gland? A truly wonderful series of connected
vascular disposals, a stoppage of or interference with
which, as here, may have far-reaching consequences,
physiological, pathological, and clinical, if true!

The very frequent occurrence of enlargement of the
cervical glands seems also to be possibly related to the
local wandering of pituitary material beyond its usual exit
mechanism and vasculature, and its lymphatic absorption
and passage into the nearest lymphatic glands, which here
are the cervical ; moreover, the enlargement of the glands
usually begins with the most superior, which corresponds
with anatomical and histological necessities, and progresses
downwards from gland to gland, the matter accumulating,
and undergoing caseation, before its relief by necrosis
of super-imposed textures, and breaking down of the
accumulated mass. Besides the anatomical conditions
being satisfied, the characteristics of the gland ballooning
material conform to those of an inspissated pituitary
excretion, and warrant us in claiming for its etiology, in
such cases, a real existence of cause and effect in their

development and sequence—the performance by the glands
of an unwonted physiological function leading to the
development of a pathological condition.

Besides rendering possible the occurrence of such disease
as goitre, the occasional occurrence of patency of the thyro-
glossal duct also lends possibility, nay, probability, to the
conclusion that the physiological disposal of cerebral
residual matter is part of the function of the thyroid
gland, and, if so, that we have here afforded a clue to the
explanation of many very obscure symptoms and diseased
conditions, whose only connection with each other is that
they are in some way related to pathological conditions
of that gland, and themselves lead to or flow out of that
relationship. Thus, cretinism is associated with absence
or atrophy of the thyroid gland, and, consequent, local
and general wandering of brain waste, with implied
hindrance of physiological or normal developmental
changes, and the appearance of other related characteristic
and specific developmental aberrations. Myxadema, like-
wise, asserts itself in association with non-effective thyroid

260 PHYSIC"

disposal of brain waste, and gives rise to symptoms due
to systemic invasion and local and general pseudo-organic
disposal of non-hygienic or effete plasma accruing from
the absence of the proper gland disposal by certain struc-
tures, such as the cutaneous and sub-cutaneous tissues of
the face and supra-clavicular regions, whose position, with
relation to the outflow of this material and the nature of
their anatomical structure, make them suitable dumping-
grounds and storage areas in such emergencies.

A family relationship, in fact, on account of the position
and function of the thyroid gland in the work of pituitary
excretion, thus may be said to exist between such affections
as cretinism, myxcedema, and dwarfism, on the one hand,
and acromegaly and gigantism, on the other, which makes
more intelligible many of the likenesses and unlikenesses
that characterise this group of diseases, whose etiology is
so intimately associated with the negative and positive -
aspects respectively of pituitary excretion and retention.

EXTRACT XLV.

ON COCCYDYNIA OR COCCYGODYNIA AND HAMOR-
RHOIDS, IN RELATION TO THE FILUM TERMINALE
OF THE CORD, AND THE COCCYGEAL GLAND,

Tue former of these morbid conditions seems to us to be
so intimately related to that gland as to be dependent for
its causation on a condition or conditions of its structure
and function, and, consequently, that we must look to it
(the gland) to indicate and determine the line of treatment
to be pursued in its abatement or removal. The situation
of the affection is entirely determined by that of the gland,
and would seem to be due to glandular conditions prim-
arily, and secondarily to the implication of its proper
nervature and blood-vessel arrangements. Being, accord-
ing to our contention, a bladder or cystic structure
developed in or surviving from the metamorphic and
differentiating embryonic elements of the neurenteric
canal wall, for the drainage and collection of the residual |
thecal cerebro-spinal lymph finding its way through the
porous or patent lumen of the filum terminale or residual
canal texture, it is liable to all the vicissitudes of a cystic
organ, as, for instance, retention, suppression, or mal-
composition of its contents, and, therefore, to the incidence
of a wide range of morbid conditions, determined by its
structural and functional relationships to the cerebro-spinal
and alimentary canals respectively, as well as to those
arising from its own intrinsic and immediate condition and
surroundings. Hemorrhoids may also directly and in-
directly be largely influenced by conditions affecting the
excretory mechanism of the coccygeal gland, their etiology

262 PHYSIC

and course being alike affected by the existence or non-
existence of the coccygeal excretion.

It would not be too much to say that the prevailing
habits of modern civilisation, in so far as they are seden-
tary, largely pre- dispose to, and to a great extent excite,
both these classes of diseases, inasmuch as the continued
local pressure of the sitting position results in more or
less closing the excretory mechanism or vasculature of the
gland, with the effects that coccygodynia from retention,
and hemorrhoidal engorgement of the peri-anal structures
from transudation through the walls of that vasculature,
sooner or later begin to be experienced to a greater or
lesser extent, according to the particular occupation or
‘walk in life.” Per contra, we observe that the savage,
and those who are much engaged on their feet in their
daily occupation, as well as those who can live with a
minimum of exertion, but adopt, in their frequent periods
of rest, the habit of resting on their “hunkers,” suffer
much less from these ailments. We observe, further, that
the tailed animal, and our nearest neighbours in the animal
scale, do not seem to suffer much, if at all, from these
diseases, and why? because these animals are possessed of
a different method, and perhaps increased facilities, for
eliminating their residual cerebro-spinal fluid along their
caudal appendages, and through peri-caudal eliminatory
mechanisms or sudoriferous glands. The horizontal posi-
tion, moreover, assumed by most of the animals in
question, must also do away to a great extent with the
necessity for such an arrangement as exists in man because
of their entirely different relationship to the incidence of
etavitation and biological hydrostatics, if we may be
permitted the use of the phrase.

What man gains in dignity through his erect bearing
he therefore, to some extent, pays for, or forfeits, by the
addition to his category of diseases of these sothe whan
distinctively, if subsidiary, human ailments.

Another, and a very troublesome ailment of the region
in question, is fistula in ano, which may, likewise, be
claimed as flowing out of and evolved from its peculiar
anatomical position and surroundings; thus the perineal
abscess from which it usually results is for the most part,

ON COCCYDYNIA AND HA;MORRHOIDS 263

in fact we may say entirely, situated in the posterior and
lateral aspects of the anal termination of the rectum, and
why? because the excretory outlets of the coccygeal gland,
according to our view of the matter, are largely latero-
posterior, and pass through the textures of the usually
fistulous parts, and, therefore, are subject to all the morbid
influences, pre-disposing and exciting, which are operative
in bringing about disease in this region, such, for example,
as may arise from stasis of exuding lymph in or occlusion
of one or more coccygeal gland outlets, and consequent
inflammation and suppuration, with local abscess, tissue
destruction, and recovery, with a more or less permanent
sinus, peri-anal or endo-anal, or both. Moreover, the
occurrence of suppuration and necrosis of the tissues
involved in the evolution of perineal abscess may be said
to be naturally or anatomically prone thus to leave a cavity
with communicating sinus or sinuses which lend them-
selves to the passive collection of coccygeal gland excretion,
to its greater or lesser retention, and to its continuous or
intermittent discharge through the fistulous opening or
openings, a condition of things which may easily become
permanent, and be, as it were, a supernumerary cyst or
bladder, and the quasi-functional exit or exits of the
coccygeal organism in perpetuity.

In connection with the inferior or posterior termination
of the cerebro-spinal cavity, many other local departures
from the normal anatomical condition might be referred
to, and many consequent local troubles might be enumer-
ated, as related to these, in the way of cause and effect ; _
but let it suffice to say that all these anatomical, physio-
logical, and pathological occurrences are due, primarily,
to the metamorphic character of the structures involved,
and are the residual products of the great developmental
differentiation to which the neurenteric canal is subjected
in embryonic times; around this condition of meta-
morphism of structure and function, we are persuaded
that a great many peculiar and otherwise anomalous patho-
logical occurrences might be grouped with advantage to
nosology, as well as therapeutics and surgical procedure,
in many other localities besides the one under discussion.

Since writing the above, we have had an opportunity

264 PHYSIC

of diagnosing a case bearing directly on the truth of our
views regarding the functional réle of the coccygeal gland,
and associated anatomical ductiform outlets, as well as
on the meaning and significance of the morbid entity
coccygodynia.—M. G., a gentleman of active business
habits, and at the time he consulted us in the middle of
worry, had allowed his bowels, which were usually inclined
to be costive, to become unusually so, owing to the various
distractions with which he was at the time surrounded,
and had thought to make things right again by having
recourse to some aperient. This, however, he had not
done, when the following occurrence dismayed and alarmed
him into seeking advice, and he narrated as follows :—
‘This morning I dreamt that I was visiting some
mountain scenery, where there were other people besides
myself engaged in the same pleasant manner, moving
about to the best points for gaining views of the surround-
ing hills and dales, when a desire came upon me to gain
a quiet retreat in which I might ‘relieve nature.” In
doing so, it seemed to me that I had chosen a place where
I could be overlooked, and I immediately prepared to
obtain another where such danger did not exist. I then
awoke, and realised that it was true that I needed actually
to follow out what I had so realistically dreamt. In
doing so, and when in the act of micturating, I became
aware of a trickling sound, as well as a feeling of a very
embarrassing nature, due to the escape from the rectum
of a fluid. Of what nature that fluid was became a
question of pressing importance, as my character for
personal cleanliness and the possible existence of personal
danger, seemed to me to be in the balance, and I proceeded
at once to strike a light and obtain ocular demonstration
on the subject. I had thought it might be blood, or that
it might turn out that my bowels, which at the time, as
has been already observed, were costive, might have
become relaxed, and hence my trouble; but neither the
one nor the other fear proved true, and I was at my wits’
end for an explanation of the occurrence and a means of
satisfying myself that there was really nothing seriously
wrong with me, hence my visit to you.” On questioning
him as to his feelings at the time of the occurrence, we

ON COCCYDYNIA AND HEMORRHOIDS 265

elicited that there had been absolutely no diarrhoea nor
exaggerated peristalsis of the bowel, and that the fluid
discharged was pale, in fact quite colourless, when examined
on the carpet of his bedroom.and in the basin of the
W.C., where the greater quantity of it was discharged,
with the slight exception of a few very minute flakes and
shot-like particles of fecal matter which had evidently
been detached from the anal extremity of the rectum,
which was otherwise empty, the solid fecal matter not
having as yet descended into it; there was thus no fecal
matter. The bowels still continued confined, and there
was no feeling of discomfort or as if they were going to
be moved, and there were no piles or solution of continuity
of the mucous membrane. Whence then could this serous
or watery discharge—which would measure from one to
two ounces—have come, and what did it indicate? That
the fluid could have reached the anal extremity of the
bowel without admixture with alvine or fecal matter it
was impossible to conceive, and that the fecal matter
which was discharged represented only what was present
in the otherwise empty recto-anal extremity of the bowel
was equally apparent, rendered it necessary to seek a
solution of the problem in another direction. That the
serous or lymphoid fluid in question came from the blood
circulation it was also impossible to conceive, inasmuch as
no hemorrhage took place, and no solution of the con-
tinuity of the lining mucosa of the bowel could be found,
nor could local congestion or hyperemia be discovered ;
hence we were and are driven by elimination of all possible.
likely causes or sources of the discharge to admit that it
must have come from the inferior or posterior eliminatory
apparatus of the cerebro-spinal lymph cavity, and that, in
this case, it represented, it may be, the exaggerated physio-
logical performance of a constantly operative and impera-
tively necessary excretory function. The actual cause of
the accumulation of the cerebro-spinal fluid had been the
sustained and effective contraction of the anal sphincter,
which, on being overcome by sympathy with the kindred
vesical operation then in process, allowed the accumulated
excretion of the coccygeal gland to escape as already
narrated.

266 PHYSIC

We, therefore, claim that the truth of our already
expressed opinions regarding the provision of an excretory
outlet for superabundant cerebro-spinal fluid and its
utilisation for purposes of post-rectal lubrication and the
maintenance of local plasticity is, if not absolutely proved,
so strongly supported as to warrant us in claiming for it
the assent of anatomists, histologists, physiologists, and
clinicians, as a principle which must always be considered
in the solution of problems which concern the region in
question, scientific and practical alike.

Another remarkable case, and, in our opinion, bearing
out the truth of these remarks, is recorded in the British
Medical Journal of date May 23rd, 1903, page 1209,
which, therefore, we shall take the liberty of quoting :—
‘“A congenital coccygeal tumour about the size of a foetal
head, attached by a broad pedicle to an eight months’
foetus. The tumour presented, and was mistaken for a
large uterine fibroid. The tumour was situated between
the coccyx and the rectum, subjacent to the levator ani
muscles. The spinal canal was continuous with the interior
of the tumours capsule by an opening that admitted a
No.8 Urethral bougie—(the italics are ours]. The tumour
was solid and arranged in large lobules, which were held
together by a loose frame-work of fibrous tissue. On
microscopical examination it was found to consist of a
fine round-celled groundwork, with masses of cartilage
irregularly scattered about, and numerous tubules lined by
a single layer of cubical epithelium. The tubules varied
considerably in size, showed well-marked convolutions,
and occasionally intra-cystic growths. The tumour pos-
sessed a well-marked capsule, which was loosely attached
to all its surroundings, except the tip of the coccyx. It
might safely be called a congenital adenoma, which in all
probability arose from the embryonic neurenteric canal,
rather than from the coccygeal gland.”

According to his presently available “lights,” we con-
sider Mr. Hewitson amply justified in his opinion of the
case as related, and we congratulate him on the terse but
clear manner in which its salient features are recorded.
We are, therefore, sorry to have to disagree with his
opinion, and at the same time glad to have the opportunity

——————

ON COCCYDYNIA AND HASMORRHOIDS 267

of claiming the case as an illustration of the embryonic
and foetal arrest and perversion of the metamorphic
changes in progress in the differentiation and division of
the neurenteric canal.

In our opinion the tumour is not a new growth, or an
adenoma arising from the embryonic neurenteric canal,
but a simple enlargement or hypertrophy of the coccygeal
gland itself and its capsule, due, in all probability, to
imperfect or absent eliminatory facilities for, and the
consequent accumulation of cerebro-spinal fluid and other
débris in the enclosing /umen of the neurenteric canal and
the developing coccygeal gland; this opinion being borne
out by the macroscopic, as well as microscopic, character
of the tumour and its contents, its normal, although hyper-
trophied, encapsulation, and its still very patent connection
with the intra-meningeal cavity. We, therefore, claim
this case as another proof of the truth of the views we
have advanced in this hitherto very obscure and little
noticed subject, and would add that, had this child sur-
vived, the local conditions were such as to justify a
favourable prognosis. On ‘“‘all fours” with this case is a
case of pendulous tumour hanging from the buttocks, or
a so-called tailed child, described and illustrated by Mr.
J. B. Sutton on page 52 of his work on Evolution and
Disease.

EXTRACT XLYI.

ON THE EVACUATION OR DISCHARGE OF COLLOIDAL
MATERIAL THROUGH NARROW EXCRETORY CHAN-
NELS, AS CONTRASTED WITH THAT OF MORE FLUID
OR SEROUS MATERIALS.

GENERALLY speaking, the physical consistency of the
residual material due to bodily waste, being serous or
sub-serous, is evacuated through narrow channels secured
by muscular sphincters or structures acting ina sphincteroid
manner with the greatest success and comfort; if, how-
ever, the consistency of the fluid be above that of serum,
the narrow channels and the previously successful elimin-
atory machinery become clogged, and the usually increasing
colloidal condition gives rise in two directions to a patho-
genic state of affairs which may, and does, frequently lead
to the production of definite states of disease. These two
directions lead respectively to, on the one hand, ballooning
of channels by the accumulating non-eliminated colloidal
material, and, it may be, the formation of “cystic” or
‘“new” growth partaking of the character of the original
colloid and the nature of the histological elements of the
excretory mechanism involved, and, on the other, to
shrinking and ultimate obliteration of the inter-spatial
lumina of the channelled textural elements, and hardening
or sclerosis, with atrophy and disappearance of the struc-
tures involved. The recto-anal textures illustrate both
these varieties of pathological development, and afford
examples in the two directions mentioned of the working
out of pathological problems by pathogenic factors, deter-
mined by the property of physical consistency of circulating

DISCHARGE OF COLLOIDAL MATERIAL 269

fluid and character of circulatory media—the pathological
result, in the one case, being a condition of pseudo-
hypertrophy or hemorrhoids, and in the other, pseudo-
atrophy or fissure of the anus.

In the normal condition of the ‘‘complexus” of circu-
lations in the recto-anal textural economy, the circulatory
machineries dovetail and harmonise in their working in
such a perfect way that not the slightest discomfort is
experienced, but, if the slightest departure from that
normal condition obtains a “‘ footing,” then a long list of
possible pathological conditions begins to unfold itself,
the various factors in which become determined, primarily,
by the relative degrees in which three or, it may be, four
definite circulations of the parts affected become involved,
viz. the alvine, the cerebro-spinal lymph, sometimes, it
may be, the systemic lymph and the blood circulation
proper; and, secondarily, the manner in which their
mutual disturbances work out the final pathological results.
We may take it, under the circumstances here enumerated,
that the condition of colloid, as applied to the consistency
of excretion, can only pertain to the cerebro-spinal lymph,
and can, therefore, only effect the production of a patho-
logical condition through its action on the principle of
circulation, and the consequent stasis of the excretory flow
from increasing consistency of that lymph, and the engorge-
ment of the cerebro-spinal lymph excretory vasculature.
Under ordinary or normal circumstances the excretion of
the cerebro-spinal lymph from the coccygeal gland and
excretionary vasculature is effected by the combined
influence of proper gland contracture, the subsidiary local
or external muscular compression of the gland, and the
involved mechanical emptying of its excretory vasculature
in its course through the peri-anal structures by the
queezing or compression exercised by the intra-mural
bowel structures on the passing fecal materials through
ordinary peristalsis, and the associated action of the
abdominal musculature ; but, when an unusual viscosity
or hyper-colloidal condition of that fluid ensues from any
cause so as to impede its excretion, the result is a stasis,
with ballooning of the excretory vasculature, in the distal
bowel border immediately beyond the sphere of irifluence

‘

270 PHYSIC

of the available circulatory factors—an incipient hzmor-
rhoidal condition, local or general, the super-addition of
other circulatory difficulties, the ultimate general involve-
ment of the entire circulatory machineries of the parts
involved, and finally fully evolved pathological conse-
quences, circulatory and textural. Prophylaxis must,
therefore, be constantly kept in view, and such occurrences
or emergencies prevented by the maintenance of free out-
lets to all excretory products by unhampered circulation
and excretory disposal.

Mucus is a secretion or excretion much in evidence
throughout the alimentary and respiratory tracts and
genito-urinary organs, and is formed in or by cells alter-
nating often with others supplied with ciliary processes or
flagella, which give the requisite direction and impulse
to the mucous material for lubricating and environing the
delicate mucosa and sub-mucosa; inspissation and over-
consistence of it sometimes, however, making a patho-
logical condition, and leading, it may be, to a specific form
of disease of the areas affected, with secondary consequences
of a far-reaching and often dangerous character, but seldom
primarily in connection with the hemorrhoidal condition.
Pituitary matter, as it is excreted from the brain or gravi-
tates along the channels of entrance and exit of the great
blood vessels and nerve trunks as they pass through the
base of the skull, as has already been described in con-
nection with some cases of gof#tre and some other affections,
is another substance which lends itself to colloidal inspissa-
tion and, it may be, caseation in such affections as
enlargement of the tonsils and of the cervical and other
associated glands, thoracic and mediastinal, and, it may be,
to some extent in the often allied pulmonary tuberculosis,
miliary and general. In this relationship with the causa-
tion of these diseases, we would again call attention to
the importance of a free exit being maintained for the
evacuation of all cerebral and spinal débris, and cerebro-
spinal effete products, as they have, when admixed with
systemic lymph, a most hampering and deleterious effect
on the systemic circulatory and excretory vasculatures,
eventuating often in mechanical ballooning of glands and
vessels, active inflammatory conditions, and subsequent

DISCHARGE OF COLLOIDAL MATERIAL 271

destruction of the involved parts and their over and under-
lying structures, with necessary permanent interference
with the economy of circulation and excretion of effete
products, general or systemic, and cerebro-spinal.

EXTRACT XLVII.
ON GLYCOSURIA AND DIABETES.

Tuat a relationship exists between these two conditions
there seems to be no reason to doubt, but that they are
one and the same in nature and character we are not pre-
pared to acknowledge. Glycosuria is frequently, if not
always, to be regarded as a physiological condition of
hyper-katabolism of the sub-cutaneous and general fatty
tissues of the body under certain conditions of faulty
systemic hygiene, and abnormally rapid molecular disinte-
gration of these tissues, whereby their fatty elements are
reduced to a glycerinoid or glycero-saccharine composition
and consistency enabling them to pass through the kid-
neys; and diabetes may begin in this condition and be
a continuation and exaggeration of it, while pathologically
developing into a continuous hyper-katabolism of these
and of other structural elements, as well as a direct or
pre-metabolised conversion of various articles of diet into
the condition of sugar, followed by a continuous and
pathological activity of the renal glands.

Glycosuria, thus, in its earlier stages may represent only
a physiologically exaggerated condition of a normal tissue
change, which in the end slows down to its normal rate,
leaving the condition of bodily health unimpaired and the

bodily textures and organs unaffected, save perhaps in a-

more or less permanent lessening of their adipose, sur-
rounding, and inter-penetrating elements, which seems to
be the material outcome of the unusual katabolic activity
and glycero-saccharine change in these latter usually
passive structures. It, nevertheless, seems to mark an
epoch in the history of its subject’s health and metabolism

Gu

ON GLYCOSURIA AND DIABETES 273

from which to date the commencement of involutionary
change, and the necessity for altering the course of life
in relation to physical exertion, mental effort, and the
continuance of the worries of life, with all that represent
pathogenic factors in the economy of tissue change and
metabolism.

In like manner diabetes may represent only an aggra-
vated and more or less permanent establishment of the
condition here described as glycosuria, or it may represent
a condition of an acutely pathological character in which
the phenomena of tissue change and katabolism follow
each other in such rapid succession that body weight is
reduced at such a rapid rate that normal metabolism,
however abundantly ministered to by raw material, becomes

uite unable to keep pace with physiological requirements,
and life flickers out amid scenes of involutionary tissue
change, and chemical resolution of alimentary material,
into saccharine excretion of the most alarming intensity
and of the most wholesale character and proportions, in
which treatment proves as futile as the play of a single
fire-engine in a great conflagration. In this condition of
pathological things, alimentary materials do not reach the
tissues, being snatched up, as it were, by a pre-metabolic
resolvant chemico-pathological activity, which sweeps them
almost in toto through the kidneys, leaving the tissues to
pine away and perish from inanition, deprived of their
nutritive pabulum and wasted by pathological katabolism.
At this stage of development of the disease the affected
organism has become or is now a huge chemico-patho-
logical laboratory, in which are simultaneously being
performed the synthetic and analytic processes of saccharine
or glycerinoid production to meet the morbid ends of
some as yet unknown subtle disease factor or factors, the
satisfaction of which usually culminates in materio-dynamic
exhaustion and death.

We may, thus, compare diabetes to cancer, in that it
converts the physiological tissues, and the raw elements
of nutrition, with their inherent dynamic powers and
energies, into the elements of its own specific pathological
individuality and morbid being—with the universal
result, the destruction of their subject—passing them out

Il S

274 PHYSIC

of the body, through the kidneys, while cancer usually
retains them within the body.
The physiologico-chemical processes undergone by the

tissue elements, and the elements of the ingesta, represent,

respectively, a retrogressive and a prematurely construc-
tive vital activity, the former consisting of the premature
or immediately post-metabolic resolution of tissue sub-
stance into fatty degenerative products and saccharine or
glycerinoid elements, the latter consisting of the pre-
metabolic resolution of the alimentary materials into
saccharine or glycerinoid elements, in accordance, appar-
ently, with the principle seen determining the production
of glycerine from fatty matter as an artificial process, but
modified by the play of vital energy, in its various stages,
on the physiological and pathological results.

It may, therefore, be said to illustrate the failure of
vital energy to maintain the histological and molecular
cohesion of developed structure, and the inability of vital
energy to obtain the development and organisation of
tissue pabulum, each failure representing two aspects of
a common vital failure to maintain and produce vital
tissue cohesion and organic health.

The great result of this dual failure is profound general
abnegation of function, and absolute materio-dynamic
collapse, toge her with auto-toxis, due to the presence of
devitalised and non-vitalised materials throughout the
fluids and solids of the whole organism which have failed
to find an exit through the overwrought kidneys, and
which, therefore, have been brought into universal contact
with the living and acting tissues, poisoning their nutritive
supplies, and mechanically interfering with their freedom
of action, individual and communal, until their very
vitality has become asphyxiated and overwhelmed by sheer
negation of its essential conditions.

When looking for indications as to treatment of these

conditions, it, therefore, behoves us to remember that the
presence of sugar in the urine is due both to ephemeral
and persistent conditions, and that the one is amenable to
treatment, while the other usually finally baffles all treat-
ment, and that our prognosis should be, in consequence,
of the most cautious order.

EXTRACT XLVIII.

A MODE OF EMPTYING ABSCESSES, SEROUS CAVITIES,
INCLUDING THE CEREBRO-SPINAL, ETC., AND THE
OBVIATING OF PITTING IN SMALLPOX.

Tue following observations apply to an instrument origin-
ally invented for the purpose of evacuating smallpox
vesicles with a view to prevent pitting, but which may
be adapted to the evacuation of any collection of fluid
in any part of the body, and were a contribution to the
International Medical Congress held in Rome in March

and April, 1894.

Surgical aid in the prevention of pitting in smallpox (instru-
ment shown), and on the use of the same instrument in
the treatment of abscesses and the collection of fluid
materials generally within the body.

“Mr. President and gentlemen,—The subject of my
remarks is mainly that of preventing the unsightly occur-
rence of pitting by smallpox, and, incidentally, that of
the treatment of abscesses. Of course pitting results
from the destruction of more or less of the dermal tissues,
and is due to the formation of pus in the interior of the
smallpox vesicles, and the disintegration of the surface
layers of the dermis in immediate contact with the area
of suppuration.

If this process can be prevented, therefore, by checking
or altogether avoiding pyogenesis with its destructive
dermal changes and consequent hollowing of the surface,
the occurrence of pitting should cease.

To accomplish this it has for some time struck me that

Il S2

276 PITrsre

the evacuation of the vesicles while the lymph is in its
transparent condition, or before it has had time to become
purulent, and the sterilisation of the interior of the
vesicles by the introduction of an antiseptic, or what we
may call bacillicide, might be effective. .

This I have sought to do by combining in one instru-
ment an aspirator and injector, the barrels of which unite
in a single doubly tubular needle designed for insertion
into the vesicles.

The needle having been introduced, the vesicle is
emptied as far as possible, and, to a certain extent, refilled
with the antiseptic.

The choice of this antiseptic is a matter of some
difficulty, and is still to a certain extent in the experi-
mental stage. It may be laid down, however, as an
axiom, that the principles guiding the choice should be
efficiency as a germicide, with innocuousness to the subject
of treatment.

The instrument has already been subjected to the test
of clinical experience in the treatment of smallpox, but
to too limited an extent to enable me to lay down anything
like final directions.

It seems to me further, that the principle of simul-
taneous or continuous evacuation and sterilisation (as
embodied in the instrument) is capable of widely extended
use in the treatment of abscesses, superficial and deep,
and in emptying accumulations, morbid and otherwise, of
liquid materials almost anywhere within the body.

The pistons of the instrument, it ought to be men-
tioned, may be operated by either screw or traction
movement according to the size of the cavity to be
evacuated and the nature of the contents.

One of the great advantages claimed for the instrument
is, that only one insertion is necessary to effect both
evacuation and sterilisation.

—_-

wo

EXTRACT XLIX.

THE CELL UNIT AS THE CENTRAL TEXTURAL ELEMENT
IN ORGANIC PATHOGENESIS.

In assigning a structural limit to the commencing process
of local organic pathogenesis, and tracing disease to its
absolute beginning as a local entity, it would seem to
accord with truth were we to assume the individual cell,
or group of cells, as the locale in which its first morbid
element or elements appeared, and from which the patho-
genetic process spread from cell to cells, from texture to
textures, and from organ to organs.

Thus the.cell, wherever situated, is liable to invasion
by chemical, physical, and bacterial influences, and so
becomes the vehicle of conveying that influence or these
influences to the cell or cells with which it is related
through its attached and inter-communicating processes,
or by structural or histological continuity, and which,
being the lines of least resistance, constitute the easiest

and direct means of spread of the disease, that spread

being determined by and effected through, in the first
place, the normal or physiological media. The cell may
thus be reduced to an inert or pathogenic condition by
the chemical or physical action on its contained proto-
plasm, of solidifying or liquefying substance or force,
or become the nidus in which and from which dead matter
is exuded or bacterial organisms are incubated and spread,
should the hygienic agencies of the vis medicatrix nature
be unable to cope with the circumstances so created. _

While claiming the cell as the foundation pathogenic
organic unit, it must be conceded that the lymph or fluid

278 PHYSIC : ba

surrounding and inter-penetrating the cell may be the
medium of carrying to that pathogenic organic unit the
materies morbi or the dynamic influence determining the
process of pathogenesis, and of distributing the viri and
toxins to surrounding cells and structures, and so be really —
the first, but not truly organised, material to become
affected.

of

EXTRACT L.

ON CIRCULATORY STASIS AS A PATHOGENIC FACTOR.

Aut the circulations within the human body are liable to
the phenomenon of stasis, and hence are liable to initiate
mechanically many forms of disease, and to lay a founda-
tion for the genesis of many more, according to the locale
and extent of its incidence and character, and the nature
of the super-added pathogenic influences. Thus gastro-
intestinal circulatory stasis may mechanically give rise to
fatal obstructions, or less lethal consequences, in accord-
ance with the nature of its cause, or may be followed by
consequences of an easily remedied character or which
yield to the influence of the unaided vis medicatrix
nature ; hemo-lymphatic stasis may originate oedema of
all intensities between the most ephemeral and persistent,
such as simple sub-cutaneous passive accumulation
and elephantiasis; neuro-lymphatic stasis may originate
adenoids and hydrocephalus, blood circulatory stasis may
cause simple congestion or gangrene, stasis of the circu-
lation of particular organs or textures may be followed
by all degrees of local implication, in accordance with the
structural elements affected, while stasis of the metabolic
or nutritive circulation may induce an innumerable multi-
tude of affections in proportion to the extent, intensity,
and persistence of its incidence.

Indeed, circulatory stasis, however induced, and where-
ever existent, as a pathogenic influence exercises a wider
range of morbid effect than any other causa morbi
with which we are acquainted, and requires to be en-
quired after, in a far-spreading range of organic and even

280 PHYSIC

so-called functional disease. From the preparation of the
alimentary materials for the process of nutrition until
their excretion from the body at all points of their circu-
lation, but more especially at the “linking up” of the
various circulatory acts, stasis is liable to take place, and
to be followed by, it may be, a merely ephemeral dis-
turbance, or a most lasting and destructive pathological
entity. The appreciation, therefore, of every stage of
the great process of circulation throughout the human
body becomes a matter of the first necessity in all diag-
nostic and therapeutic work.

When circulatory stasis has done its mechanical work,
and established a larger or a smaller area of arrested
circulatory movement, it has then established a basis for
the operation of further morbid etiological influences in
the form, it may be, of still merely mechanical agency,
or of the super-added physical, chemical, and bacterial
morbid elements, which are ever ready to seize a chance
to follow up a pathogenic opportunity, and to assist the
process of involution “‘in season and out of season” in
the young, the adolescent, and the aged alike; but, from
this point of view, involution is as natural as evolution.
At the linkages of the various circulations, great and
small, wherever a change of lumen of vasculature or inter-
spaces takes place, the predisposing causes of circulatory
stasis exist in greatest proportion, and when disease pre-
sents itself for consideration at its very earliest stages, the
truth of this can be observed with much greater ease and
certainty than can be the case when pathological changes
have ensued, which destroy the traces of the original
incidence of the process of disease and the sequence of
its various stages.

Who would at first sight suppose, for instance, that in
the evolution of the formidable disease, elephantiasis, we
had only to reckon with a simple erysipelas and inflam-
mation of lymphatic vessels, which, being repeated, it
may be, time after time, have left the whole lymphatics”
of a limb or limbs absolutely occluded and impervious to
the passage of lymph, rendering the affected limb or limbs
the receptacles of uncirculatable or derelict lymph and
the accumulators of metabolic waste until the limits of

ON CIRCULATORY STASIS 281

encircling cutaneous expansion have been reached or art
has stepped in to avert final consequences? Who, more-
over, would suppose, on the spur of the moment, that a
fully developed hydrocephalus had originated in a simple
closure of the central cerebro-spinal lymph exits, and a
consequent damming back and accumulation of that fluid,
with its far-reaching results on the processes of local
ossification, and formative extension of the external
cephalic structures?

And what more evident than the cause of the atrophic
effects of arrested blood circulation on the process of
nutrition of the tissues to which the affected vessels and
arrested circulation lead?

In every instance of circulatory stasis it will be found
that relationship to the heart and blood vessels determines
to a large extent the manner of incidence of the arrestment
phenomena, thus the proximal and the distal sides of that
relationship, while they are attended with different dynamic
procedures, yet combine to produce one unbroken system
of circulation, beginning at the oral orifice of the body
and terminating at its various eliminatory exits; on its
proximal side the circulation being effected by a vis a
fronte, and on its distal side by a vis a tergo, each of
which is alike the product, directly and indirectly, of
cardio-vascular contraction, aided by the other general
circulatory agencies operative in organic fluid movements.

As we have elsewhere contended, the central and indis-
pensable element in this circulation, both in its initiation
and maintenance, is the creation of auriculo-ventricular
vacua, which result, on the distal side of the heart, in
sending currents of blood away from it and along the
arterial vessels, and on the proximal side in bringing
currents of blood into it and along the venous vessels,
both of which currents, while sustained by muscular
agency, superinduce throughout the whole range of the
subsidiary and uniting circulations forward movement of
the various fluids within these circulations, nutritive and
effete alike, to the end that one continuous forward circu-
lation of the entire fluid contents of the body should be
maintained without stasis or regurgitation. The alternate
contractions and relaxations of the heart in rhythmic

282 PHYSIC

sequence determine the circulation of the blood absolutely,
and, at the same time, materio-dynamically inspire, so
to speak, the machinery of all the other circulations, simple
and complex, subservient to the necessities of the organic
life of the body. Any failure of the heart’s action is,
therefore, attended with general slowing of rate and
lowering of tone of the whole circulatory system, and an
increased tendency to stasis at its linking up junctures,
capillary areas, and terminal metabolic or interstitial dis-
tribution.

Besides these forms of circulatory stasis, which are
mostly illustrative of obstruction within the area inner-
vated by the sympathetic nervature, and concern the
circulation of the blood and the hemal lymph principally,
are a great variety of stases within the systemic nervous
system itself, and the structures innervated by that system.
Thus, besides hydrocephalus, stasis of, or obstruction to,
the outflow or exit of neural or cerebro-spinal lymph, is
attended by adenoids in the nasal passages and polypus
amongst others, from obstructed olfactory excretion
acromegaly, from obstructed pituitary outflow, pendulous
tumour of buttocks or false tail, from obstructed coccygeal
exit and various superficial tumours of the skin, from ob-
structed discharges of sweat and other material, including,
in our opinion, retention of the sub-arachnoid fluid in
cases of wens of the scalp.

This is a large array of obstructive ailments, but it
may be said, with all truth, that it constitutes but a very
small proportion of the total diseases traceable to stasis
of circulation. |

EXTRACT LI.
ON MAL DE MER OR SEA SICKNESS.

Tuts is an affliction, we can scarcely call it an affection,
with which the human family and some of their lower
neighbours have been familiar since its members “‘ went
down to the sea in ships” or trusted themselves to less
substantial means of support on the undulating surface
of river, lake, or sea.

Its causation is but too apparent, and its incidence what
would seem somewhat capricious, thus, one or a few only
may succumb to it out of a large party, while one or a
few only may escape out of a large party, when the
exciting causes have been but: slightly modified or
intensified.

It is essentially of nervine origin, and due to the
difference in the specific gravity of the various component
parts or organs of the human body whereby their various
rates of upward and downward movements are irregularly
effected in every succeeding rise and fall of the craft,
engendering mechanical jarring and concussion, and finally
affecting the neuro-muscular economy to such an extent
that general materio-dynamic demoralisation ensues, with
the familiar consequences.

To illustrate this theory of its causation, we may fill
a hat, or other hollow receptacle, with a dozen substances
of different weights and differing sizes and densities, and
throw them up out of the receptacle with some force, and
it will be seen that they do not all reach the same height
or traverse space at the same rate of speed, and that in
descending their rates of movement are in thé inverse

284 | PHYSIC

order. In like manner every upward and downward
movement of the body affects its structures, organs, and
viscera, although enclosed in a common envelope, in a
similar manner, with the effect that disturbance of the
physico-physiological equilibrium takes place, and pro-
duces disturbance, more or less profound, of the whole
sympathetico-systemic nervous system, and, indirectly, of
the whole related parts, with consequent sicknaee

Every remedy for the condition has been used, prophy-
lactic and remedial, with but very questionable effect,
and we still, as our forefathers did, look forward to the
discovery of some in fallible means through which we may
be saved from that dreaded and more or less unavoidable
penalty of visiting Neptune “‘at home,” and it may well
be that every fresh remedy may fail, as usual, until we
can succeed in devising a means whereby the incidence
of the exciting causes can be altogether obviated or
rendered abortive by the maintenance of the physico-
physiological equilibrium amid the unstable elements of
““wind and water.”

GLASGOW : PRINTED AT THE UNIVERSITY PRESS BY ROBERT MACLEHOSE AND CO. LTD.

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