UNIVERSITY OF CALIFORNIA 
 AT LOS ANGELES 
 
 GIFT OF CAPT. AND MRS. 
 PAUL MCBRIDE PERIGORD
 
 
 

 
 DISSOLUTION AND EVOLUTION 
 
 AND THE 
 
 SCIENCE OF MEDICINE.
 
 PRINTED BY 
 
 SPOTTISWOODE AXD CO., NEW-STREET SQUARE 
 LONDON
 
 DISSOLUTION AND EVOLUTION 
 
 AND THE 
 
 SCIENCE OF MEDICINE : 
 
 AN ATTEMPT TO CO-OEDINATE THE NECESSARY FACTS OF 
 
 PATHOLOGY AND TO ESTABLISH THE FIRST 
 
 PRINCIPLES OF TREATMENT. 
 
 J. 
 
 C. PITFIELD MITCHELL, 
 
 MEMBER OF THE ROYAL OOLI.RRE OP RUKGEOXS, KNOLAND ; 
 AUTHOR OF 'THR TREATMENT OF WOUNDS AS BASED OX EVOLUTIONARY LAWS.' 
 
 LONDON : 
 LONGMANS, GREEN, AND CO. 
 
 AND NEW YORK : 15 EAST 1C 11 ' STREET. 
 
 1888. 
 
 144607
 
 Entered according to Act of Congress, in the year 1888, 
 
 by C. Pitfleld Mitchell, 
 in the Office of the Librarian of Congress, at Washington.
 
 5" I 
 
 A 
 
 PBEFACE 
 
 BY the following pages it is proposed to disseminate 
 some new applications of Mr. Herbert Spencer's 
 leading generalisations. The sustaining elements of 
 the Synthetic Philosophy are the doctrines of evo- 
 lution and dissolution. The design is to inquire 
 whether these may not be made fertilising principles 
 for large collections of the data of pathology, and 
 thus the means of practice for the physician and 
 surgeon. 
 
 ^j The raw material of medical science grows with 
 
 <a an acceleration of rate that gives acuteness to the 
 need of great central truths about which facts may 
 be organised. I venture to think that the doctrines 
 of dissolution and evolution supply, in useful measure, 
 this large and pressing want ; and, contrary to all 
 appearances, that they bear, in their present applica- 
 tion, upon every aspect of the work of the practitioner. 
 In substantiation thereof this volume is offered, but 
 here the prospect must be unfolded. 
 
 A multitude of facts will be seen to acquire a
 
 VI 1'ltEFACE. 
 
 remarkable concinnity, unity, and order. The unifi- 
 cation of truths so voluminous and diverse as those 
 constituting pathology is undoubtedly of educational 
 value. To make all diseases, from a whitlow to 
 mania, one in principle by cause and effect is an 
 aid to practical thought. It vastly augments the 
 carrying capacity of the mind. I am convinced that 
 one of the chief hindrances to our advancement to 
 an organised system of rational procedure in the 
 treatment of disease is the want of a perception of 
 the uniformities that exist amid the diversities of 
 morbid phenomena. The proclivity, handed down 
 to us from pre- scientific times, to regard each disease 
 as individual, is discernible almost everywhere in the 
 scientific medicine of to-day. With primitive man, 
 diseases were personified entities ; with ourselves, they 
 are pathological entities. It is surely as desirable 
 for the practical physician as for the philosopher to 
 perceive the continuity and inseparableness of natural 
 processes and their most essential general differences 
 and likenesses. General truths that will break down 
 the factitious divisions which convention has raised 
 are exceedingly helpful instruments in the progress 
 of science and art. I believe that the principles of 
 dissolution and evolution are such general truths. 
 
 But it is among the services of great generalisa- 
 tions to exert a purifying influence upon all that 
 comes within the range of their generalising power. 
 If true, they are at variance with what is untrue, and
 
 PREFACE. Vli 
 
 will lead to the correction of erroneous observation 
 and erroneous inference. An influence of this kind 
 may be seen in the co-ordination of the data of 
 pathology by means of Mr. Spencer's resplendent 
 discoveries. To mention first some of the minor 
 effects of this influence. There is the idea, suggested 
 by the formula of dissolution, of inflammation as a 
 process of disintegration throughout the series of its 
 essential component phenomena. In truthfulness, 
 comprehensiveness, and simplicity, the conception 
 approaches perfection, and immediately clarifies all 
 previous notions of the pathology of inflammation. 
 
 There are the so-called interstitial inflamma- 
 tions known as ' fibroses,' 'cirrhoses,' and 'scleroses.' 
 Dissolution and evolution at once hint that the in- 
 crease of connective tissue in these morbid changes 
 is the result of a process the opposite of inflamma- 
 tory, the result of a reparative process the connec- 
 tive-tissue growth is a scar. When the changes are 
 further examined by the light of this suggestion, and 
 by further light from the general principles, it is 
 found that every consideration consists with the 
 view. That it will ultimately become the prevailing 
 view I have not the least doubt, and its acceptance 
 at the present juncture would modify momentously 
 our ways of looking at the chief organic pathological 
 processes. 
 
 I will not particularise the new aspects in which 
 the principles present the phenomena of regressive
 
 VIM PKEFACE. 
 
 metamorpliosis, of tumour-formation, of the organic 
 diseases, of functional diseases, and of insanity ; but 
 will observe that each of these aspects should assist in 
 shaping the actions of the practitioner. Only among 
 leading physicians is it appreciated that a knowledge 
 of the intimate changes of diseases, and oar manner 
 of viewing them, are more than practice. They are 
 its very mainsprings, and, still more, have the govern- 
 ance or direction of it ; not only do they supply the 
 motive power, but they make practice good or bad. 
 Let us suppose that the case for which advice is 
 sought is one of croup, where laryngeal obstruction 
 threatens to induce death. One skilled in practice 
 but imperfectly acquainted with the recondite and 
 interdependent chemical and physical tissue-changes 
 which are the essence of the disease, will advise and 
 perform tracheotomy, or intubation of the larynx ; 
 or pin himself to medication, poultices, and steam 
 inhalations. But such a one will be heedless of the 
 remote causes of the asphyxia. The urine may be 
 examined and albumen discovered, but beyond 
 adding to the gravity of the case, the albuminuria 
 will not have much significance ; it will not serve as a 
 clue to the antecedents of the laryngeal obstruction. 
 These are not known, they will not be thought of, 
 and no steps will be taken to deal with them either 
 by removing the conditions upon which they depend, 
 or by furthering the natural processes of functional 
 adjustment. The case will probably terminate fatally
 
 PREFACE. IX 
 
 by extension of the disease to the bronchi, by septi- 
 cuemia, or nephritis. Hence, in a medical journal of 
 to-day we read that of fifty cases of croup treated 
 by the new method, 'intubation of the larynx,' death 
 resulted in thirty-eight. In the cases of the twelve 
 patients that survived, it is not certain that intu- 
 bation was the only factor concerned in the re- 
 coveries. 1 
 
 There are results of pre-eminent importance issu- 
 ing from the application of dissolution and evolution 
 to pathology. I refer to the proposition that diseases 
 are the outcome of interactions between the organism 
 and its environment. This is not an unfamiliar pro- 
 position. Ziegler says : 'A true disease is not a conse- 
 quence of the indwelling and inherited properties of 
 the cell. The efficient causes of a disease are always 
 external. In the observations we made on the amoeba, 
 it was heat or cold, an altered surrounding medium, 
 or the galvanic current, which brought about disease 
 and death. All these noxious influences are derived 
 from without ; and what we have here remarked in a 
 single instance experience shows us to be universal. 
 Autonomous as the cell may seem, it is yet unable, 
 without external impulsion, to heighten its functions 
 above the physiological standard, or, on the other 
 hand, to check or to suppress them. We can, there- 
 fore, give a still more exact definition of the notion 
 
 1 I shall not be understood to inveigh against tracheotomy, intuba- 
 tion of the larynx, or inhalations as measures of expediency.
 
 X I'KKFACE. 
 
 of disease. By the term disease we are to understand 
 a deviation of some of the vital manifestations from 
 the normal, the deviation being conditioned by external 
 influences.' l Now this conception, perspicuous enough 
 when it applies to the vital manifestations of the 
 simplest organisms, loses all clearness and is without 
 effect upon practical procedure when we come to the 
 diseases of man. But, seeing that the induction is 
 all-important both in the prevention and cure of 
 disease, it needs to be established and brought into 
 the boldest relief by instance upon instance endlessly 
 varied. It is needed to show, if possible, that every 
 disease is the outcome of environmental actions, and 
 that every symptom also expresses a relation of the 
 organism to external conditions. As dissolution is 
 here applied to pathology, it is proved, nearly as far 
 as it is at present possible to prove, that the deepest 
 causes of all diseases lie outside the organism. To 
 us, the most sterling merit of the formula of dissolu- 
 tion is that it holds the mind in constant communion 
 with the external factors in pathogenesis. 
 
 To the question, Are diseases inherited ? as im- 
 portant as any in practical medicine, the doctrines of 
 dissolution and evolution will be found to reflect an 
 answer as unexpected as it is, I think, satisfactory. 
 In the final chapter it is shown to be a necessary 
 conclusion from many considerations that non- con- 
 genital diseases are rarely subject to heredity in the 
 
 1 A Text-book of Patlwlogical Anatomy and Pathogenesis.
 
 PREFACE. XI 
 
 way currently believed. Out of this conclusion 
 potent for incalculable good if true and out of a 
 conception I have presented of the processes of or- 
 ganic equilibration (organic equilibration is the vis 
 medicatrix natures) there emerge fundamental canons 
 of rational medical practice, and a medical practice 
 dynamic in present possibilities and of dazzling 
 promise. 
 
 Thus the remoteness of the subject-matter of this 
 work from the daily concerns of the practitioner is 
 only apparent. 
 
 It may possibly be thought that the attempt to 
 make a synthesis of all orders of the facts of patho- 
 logy is rather supererogatory ; that a less exhaustive 
 treatment would perhaps have been sufficient. The 
 monotony of a single theme long drawn out is cer- 
 tainly very fatiguing ; but I think the partial or 
 general exemplification of principles embracing so 
 wide a diversity of fact and idea would not avail to 
 obtain an extensive recognition for the principles. 
 Unlimited reiteration is necessary that their truth and 
 power may penetrate many minds ; and is necessary 
 also for the acquirement of an easy use of them 
 among new orders of phenomena. Who, for example, 
 ignorant of histological morbid anatomy, but know- 
 ing something of gross anatomy, would assent to the 
 mere statement that the consolidated lung of pneu- 
 monia is a partially disintegrated lung ; that cancer
 
 Xll PREFACE. 
 
 results from a process of disintegration in the tissues ; 
 or that tuberculosis of the hip-joint is related to the 
 action of external forces ? Yet these statements are 
 true beyond all doubt. It is with clear design that I 
 have carried out the illustrations in plenteous detail. 
 
 I am conscious that the argument is in very 
 many places most incomplete and defectively pre- 
 sented. The phraseology is often far from being 
 what I wish, and it has caused me much regret that 
 many interesting points have had to be dealt with in 
 a very superficial manner. But the extent of the 
 ground to be covered, and my own deficiencies, have 
 rendered it difficult to produce a more satisfactory 
 work. 
 
 I would that the task I have undertaken had 
 fallen into hands more competent than my own to do 
 justice to Mr. Spencer and others whose work I have 
 availed myself of. As must be obvious to anyone 
 familiar with Mr. Spencer's writings, my essay is to 
 the Synthetic Philosophy as an absolutely dependent 
 outgrowth ; and if it has other than commonplace 
 merits, the credit in large measure properly belongs 
 to Mr. Spencer. The reader may, however, feel as- 
 sured that upon the work of Mr. Spencer, as well as 
 upon the work of others, I have exercised such truth- 
 testing capacity as I possess. 
 
 The task has occupied me while embarked in 
 private practice. I have therefore been afforded
 
 PREFACE. Xlll 
 
 opportunity to apply the supreme proof of medical 
 doctrine, opinion, and statement : that of their con- 
 gruity or incongruity with personal experience in the 
 observation and treatment of disease. It is needful 
 to say that the interpretations herein given of the 
 Synthetic Philosophy are my own, and that the re- 
 sponsibility attached thereto rests solely upon me. 
 
 With comparatively few exceptions, only the 
 material of recently-published text-books has been 
 dealt with, the statements of fact resting mainly on 
 the authority of their general acceptance by the pro- 
 fession. Consequently the text is free from the 
 incubus of many references. 
 
 For the sake of completeness, I have included a 
 few illustrations from nervous and mental diseases ; 
 but with unwillingness to trespass upon the field 
 occupied by Dr. Hughlings Jackson, M. Ribot, Dr. 
 Henry Maudsley, Dr. James Ross, and Dr. Charles 
 Mercier. 
 
 While residing latterly in New York I have been 
 so fortunate as to enlist the able offices of Dr. Her- 
 mann M. l^iggs, of the Carnegie Laboratory. He 
 has assisted me in satisfying myself upon many 
 points of morbid anatomy, and has supplied me with 
 much valuable suggestion. For these services my 
 thanks are heartily tendered to him. 
 
 The following are the text-books from which I 
 have drawn most freely : Dr. T. II. Green's ' Intro-
 
 XIV 1 'UK FACE. 
 
 duction to Pathology and Morbid Anatomy ' ; Dr. 
 Joseph Coats's ' Manual of Pathology ' ; Zicglcr's 
 'Text- book of Pathological Anatomy and Patho- 
 genesis,' translated by Dr. Donald MacAlister ; Dr. 
 Klein's ' Elements of Histology ' ; and ' Insanity and 
 Allied Neuroses,' by Dr. George H. Savage. I have 
 found Dr. Quain's ' Dictionary of Medicine ' inex- 
 pressibly serviceable. The ' Text-book of the Prin- 
 ciples of Physics.' by Mr. Alfred Daniell, M.A., 
 and the ' Outlines of Psychology,' by Mr. James 
 Sully, M.A., have been very helpful. I am much 
 beholden to Mr. Bland Sutton, F.R.C.S., for the 
 chapters on Teratomata and Cystornata in his re- 
 cent work, ' An Introduction to General Pathology.' 
 Figures 1 and 5 I owe to Dr. Coats's ' Patlio- 
 
 o 
 
 logy,' and figures 2, 3, and 4, to the text-book of 
 Dr. Green. 
 
 If the views offered upon the nature and origin 
 of tumours have the value I suppose, then it should 
 be said that their development has been greatly 
 furthered by the writings of Mr. J. F. Payne, M.B., 
 F.R.C.P., and the utterances of the distinguished 
 participants in the memorable ' Discussion on Cancer.' 
 
 These, and the acknowledgments in the body 
 of the work, are a very inadequate requital of my 
 obligations to contemporary writers. It is possible 
 to give only a fragmentary history of the mental 
 savings of several years. 
 
 LONDON : March 1888.
 
 CONTENTS. 
 
 I'AOK 
 
 INTRODUCTORY 1 
 
 PART 1. 
 GENERAL DISEASE. 
 
 CHAPTER 
 
 I. INFLAMMATION AND SUPPURATION AS DISSOLUTIONAL 
 
 CHANGES . 5 
 
 1. Preliminary . . . . . . . 6 
 
 2. The Disintegration of Matter . ... 7 
 
 3. The Absorption of Motion 12 
 
 4. The Change from a Definite (special), Coherent 
 (organised) Heterogeneity (multifwmity) (com- 
 plexity) to an Indefinite (general), Incoherent 
 (unorganised) Homogeneity (unifomaty) (sim- 
 plicity) .... .... 23 
 
 II. RESOLUTION AND REPAIR AS EVOLUTIONAL CHANGES . 28 
 1. The Integration of Matter and Dissipation of 
 
 Motion 28 
 
 2. The Change from an Indefinite, Incoherent 
 Homogeneity to a Definite, Coherent Hetero- 
 geneity . . ... 31 
 III. THE RETROGRADE METAMORPHOSES AS DISSOLUTIONAL 
 
 CHANGES 34 
 
 1. Coagulation of the Blood ..... 34 
 2. Thrombosis and Embolism . . . 40 
 3. Gangrene, Coagulation-Necrosis, and Allied Meta- 
 morphoses 45 
 
 4. Atrophy and the remaining Retrograde Meta- 
 morphoses . . . . . . 49 
 
 5. Wallerian Degeneration of Nerve and Acute 
 
 Neurotic Atrophy of Muscle . . . .53
 
 XVI CONTENTS. 
 
 illUTKR I'AOK 
 
 IV. THE CHANGES INDUCED BY VEGETABLE AND ANIMAL 
 
 PARASITES AS EXEMPLIFYING DISSOLUTION. . . 57 
 
 V. NEOPLASMS AS EXEMPLIFYING DISSOLUTION AND EVOLUTION GO 
 
 1. The Infective Tumours 60 
 
 2. The Simple and Compound Tissue Tumours (ex- 
 cluding Cystomata and Tcratomata) . 63 
 3. The Cystomata, Teratomata, and Malformations . 100 
 
 PART II. 
 SPECIAL DISEASE. 
 
 I. SPECIAL DISEASES AS EXEMPLIFYING DISSOLUTION AND 
 
 EVOLUTION 121 
 
 1. Preliminary : Interstitial and Parenchymatous 
 
 Inflammation 121 
 
 2. Acute and Chronic Bright's Disease . . . . 126 
 
 3. Cirrhosis of the Liver 145 
 
 4. Inflammation of the Lungs 151 
 
 II. SPECIAL DISEASES AS EXEMPLIFYING DISSOLUTION AND 
 
 EVOLUTION CONTINUED 162 
 
 1. Locomotor Ataxia and other Disorders of the 
 
 Nervous System 162 
 
 2. The Fevers 176 
 
 3. Diabetes and Allied Affections 188 
 
 4. Diseases of the Mind ...... 195 
 
 PART III. 
 IMPLICATIONS. 
 
 I. THE RESULTS AND CONTINGENT PRINCIPLES . . . 213 
 
 1. Summary . . ' . . . 213 
 
 2. Heredity and Disease 222 
 
 3. Organic Equilibration ...... 231 
 
 4. Practical Deductions and Conclusion . . . 239
 
 DISSOLUTION AND EVOLUTION 
 
 I 
 
 AND THE 
 
 SCIENCE OF MEDICINE. 
 
 INTRODUCTORY. 
 
 HERBERT SPENCER lias brought many to the convic- 
 tion that his view of the processes of nature as divi- 
 sible into evolutional and dissolutional processes is 
 essentially veracious. If the formulas which he has 
 given to us, setting forth the salient features of these 
 processes, are placed in apposition with any group of 
 natural changes coming within the purview of obser- 
 vation, there is discovered an invariable correspon- 
 dence between the formulas and the facts they purport 
 to represent. It does appear from examination that 
 all the changes going on within and without us have 
 the characters of the one or the other order of muta- 
 tions, and that the generalisations, in their most 
 abstract form, really stand for universal verities. 
 Therefore it may be possible to translate the facts of 
 any science in terms of these all-embracing princi- 
 ples. In our endeavour to do this with the data of 
 pathology the mode of exposition will be to take the
 
 2 INTRODUCTORY. 
 
 formulated statements of the principles and compare 
 with them the facts they are expected to unify. First, 
 the essential truths of general pathology, as those 
 of inflammation, suppuration, repair, and resolution, 
 will be considered in respect of their conformability 
 to the formulas. Next, the retrograde metamorphoses 
 and neoplasms will be looked at from the same points 
 of view, later chapters including a rough inspection 
 of the general pathological changes as they are pre- 
 sented in special diseases. Finally, the results will be 
 considered from practical aspects. 
 
 This manner of presentation seems to possess 
 superiority in simplicity and directness, and in per- 
 mitting a comprehensive survey of the field. The 
 difficulties are of some magnitude in the way of 
 making intelligible application of doctrines as elabo- 
 rate in organisation as the doctrines of evolution and 
 dissolution ; and any other method of presentation 
 would, perhaps, have involved an undesirable discur- 
 siveness of exposition. 
 
 Some acquaintance with ' First Principles ' will 
 be required for the easy understanding of all that 
 follows ; but I am in hope that the simple arrange- 
 ment adopted will make the work acceptable to 
 medical readers unfamiliar with the Synthetic Philo- 
 sophy.
 
 PART I. 
 GENEBAL DISEASE 
 
 B 2
 
 CHAPTER I. 
 
 INFLAMMATION AND SUPPURATION AS DISSOLUTIONAL 
 
 CHANGES. 
 
 1. PRELIMINARY. 
 
 Definition I. ' Dissolution is a disintegration of 
 matter and concomitant absorption of motion ; during 
 which the matter passes from a definite, coherent 
 heterogeneity to an indefinite, incoherent homoge- 
 neity ; and during which the retained motion under- 
 goes a parallel transformation.' 
 
 The process of dissolution is antithetical to the 
 process of evolution ; and the reader will find the 
 inductive basis of this formula expounded per contra 
 in abundant detail in ' First Principles,' chapters 
 xiii., xvii. ; cf. also chapters xii. and xxiii. 
 
 As in the investigation of the phenomena called 
 physical, changes in the living organism are made 
 known to us as alterations in the form of the matter 
 of an aggregate, and as alterations in the form of its 
 energy. In the language peculiar to the science of 
 biology these changes are spoken of as morphological 
 and physiological. Inasmuch, however, that matter 
 may be a species of energy, and its distinction as 
 substance forced by the nature of our experiences, 
 the dual division of phenomena into material and 
 non-material may possibly be only temporary. A
 
 6 GENERAL DISEASE. 
 
 higher plane of contemplation would combine the two 
 as one form of experience. But scientific knowledge 
 and conceptions have not yet reached a stage of 
 development permitting this; hence the cognisance 
 taken in the formula of changes of matter and 
 changes of energy, or motion, to use the term in the 
 formula. 
 
 For, since the varieties of energy, at least the 
 varieties of kinetic energy, are conceivably modes of 
 motion, it appears allowable to give co-extension and 
 connature to kinetic energy and motion ; therefore, 
 these terms will generally be used interchangeably. 
 ' Scientific scrutiny, so far as it has penetrated, finds 
 motion throughout external nature motions every- 
 where, motions underlying every phenomenon, how- 
 ever different from motions some of them may seem 
 to common apprehension ; and no scientific investi- 
 gation has as yet detected anything but motion.' 1 
 
 The changes of matter in the organism are chiefly 
 and most definitely perceived as histological trans- 
 formations ; the changes of motion as molar and 
 functional transformations. Molar action is the visi- 
 ble movement of bodies, as of particles and cells- 
 cells undergo transpositions, and their protoplasm 
 is capable of intrinsic movement. What we dis- 
 tinguish as functional action is the equivalent of 
 motion, since, whatever the form of the function, we 
 may think of it as proceeding from the motion of 
 molecules, whether such function is manifested as 
 perceptible motion, heat, chemical change, or the 
 operations of the mind and nervous system. 
 
 1 J. Johnstone Stoney, F.R.S., in Nature, xxxi. 529.
 
 INFLAMMATION AND SUPPURATION. 
 
 2. THE DISINTEGRATION OF MATTER. 
 
 We shall not expect the law .of dissolution, for- 
 mulated as above, to obtain striking exemplification in 
 the phenomena presented by inflammation of liminal 
 intensity. Inflammation being, as we now know, 
 merely a perversion of normal functions and struc- 
 tures, the transition from normality to abnormality 
 must necessarily be gradational. And this how- 
 ever swiftly the transition is effected. Thus, there 
 is a stage or degree of inflammation which closely 
 approximates to health, and one which widely de- 
 viates from it; and where the deviation is extreme 
 we may look for the plainest marks of dissolution. 
 Yet even in incipient inflammation faint though 
 certain marks can, I think, be descried. 
 
 At the outset the reader may be reminded that 
 the formulas do not stand for state or being, but for 
 changes of state, and are therefore to be understood 
 always in relative senses, that is, in connection with 
 antecedent being. The transformation in evolution, 
 for example, is not to absolute but to relative 
 definiteness, coherence, and heterogeneity. Hence, 
 in seeing whether the anatomical and physiological 
 changes characteristic of inflammation are compre- 
 hended by the principle of dissolution, reference 
 must be made to the state we call normal, and it 
 must be conceived from our present point of view. 
 
 What is the normal arrangement of matter and 
 motion in a compound structure such as inflamma- 
 tion in the human subject commonly involves ? The
 
 GENERAL DISEASE. 
 
 cellular and non-cellular units of every tissue-system 
 have an integrated arrangement due to the interrela- 
 tions of their component forces. In simple vascular 
 connective tissue, which may be conveniently selected 
 for consideration, the blood-vessels, lymph-vessels, 
 nerves, and connective tissue cells are all bound 
 together, and are interdependent both structurally 
 and functionally. Not only are the stationary ele- 
 ments united in close aggregation, but the moving 
 elements are constrained to take definite directions. 
 The fluids have their courses prescribed by the ves- 
 sels, and the blood-corpuscles traverse distinct paths. 
 For the most part, as when the circulation is active, 
 the corpuscles are disposed centrally in blood-vessels 
 while the blood-plasma flows at the periphery. 
 
 The blood-cells and plasma having in certain 
 directions definitely limited space relations like the 
 fixed components of the tissue, if these space relations 
 are so disturbed that corpuscles and plasma overstep 
 their normal confines, they become less integrated, or 
 relatively disintegrated. 
 
 We may say thatjt structure is being disintegrated 
 when, from a common centre, the motions of its units 
 are increasing ; and is being integrated when its units 
 are approaching a common centre. 
 
 Inflammation is first evidenced, when its pheno- 
 mena are observed by means of the microscope, by 
 changes complying with this definition ; there is a 
 dispersion of corpuscles and plasma. These consti- 
 tuents of simple connective tissue corne to occupy 
 more space ; they begin to lose their aggregated 
 form, moving away from one another.
 
 INFLAMMATION AND SUPPURATION. .9 
 
 In the adjoined figure (Fig. 1) are seen on the 
 left hand the normal configuration of blood com- 
 pacted by the vessels, and on the right, over the area 
 of inflammation, corpuscles scattered in all direc- 
 tions. In health the leucocytes, for the greater part 
 assembled with the coloured discs as the core of the 
 
 FIG. 1. Inflamed human omentnm. The phenomena of inflammation are seen in the veins 
 and capillaries, the condition being normal at the artery (c) where 6 represents endo- 
 thelium covering the trabecula (a). In the vein (rf) there are many white corpuscles 
 along the wall. Some of these are emigrating (e) ; f, desquamated endothelium ; g, 
 extravasated red corpuscles. (ZIEGLEB). 
 
 vascular column, at the setting in of inflammation 
 pass to the circumference and issue through the 
 walls of the capillaries and veins. And there is the 
 extravasation of red cells known as diapedesis. Now 
 the truest and simplest conception of such disparting 
 of units is that the collective mass of blood and 
 vessels is undergoing disintegration.
 
 10 GENERAL DISEASE. 
 
 Arterial dilatation is a primary effect of inflam- 
 matory action. Whatever the particular physio- 
 logical explanation of this phenomenon, it is the 
 beginning of disunion among the structural units 
 of the arteries. The endothelial plates of the capil- 
 laries lose their closeness of cohesion, so that stomata 
 are produced, and the trabecular endothelia desqua- 
 mate further disaggregations. 
 
 A more obvious disintegration is the exudation of 
 plasma. The plasma, or certain constituents of it, is 
 freed from its normal structural associations and 
 escapes, going to form the well-known inflammatory 
 products serum and fibrine. Cellular proliferation 
 undoubtedly forms a part of degeneration and other 
 morbid processes ; and if we think it part of the 
 process of inflammation, then it must be counted 
 among the disintegrations. It is essentially a proto- 
 plasmic dissolution (see chap. v.). In the genesis of 
 cells, either the parent whole is reduced to a number 
 of parts, which is complete disruption, or particles 
 of protoplasm are detached, as nuclei or gemmae, 
 and this is partial disruption. Further, as the new 
 cells are born they do not, while the inflammation 
 is in progress, approach or integrate towards com- 
 mon centres, but are diffused, wandering from place 
 to place. 
 
 This is inflammation of moderate degree. But if 
 we pass from incipient to advanced forms of the pro- 
 cess there may be discriminated increasing degrees of 
 disintegration. Through the wall of a burrowing 
 abscess, proceeding from the healthy to the destroyed 
 tissues, there are found the following changes. In
 
 INFLAMMATION AND SUPPURATION. 11 
 
 the zone of least perceptible change there is an ex- 
 udation of serum and a few leucocytes ; then the 
 exudate becomes more coagulable more of the blood 
 is separated from the vessels, and red cells in large 
 number are extruded ; next, thrombosis of vessels and 
 stasis, with consequent softening of vessels and tissue 
 cells, may be observed ; and at the centre complete 
 molar disintegration, or necrosis. 
 
 Thus, the most conspicuous changes, seen micro- 
 scopically, in inflammation of a simple tissue have 
 in common this character, namely, that constituent 
 parts are dislocated or loosened from their centres of 
 attachment or attraction and become less integrated, 
 or relatively disintegrated. It is reasonable, therefore, 
 to see in the phenomena of inflammation a corre- 
 spondence with the first proposition of the principle 
 of dissolution. 
 
 Inflammation is said to be sometimes initiated by 
 a contraction of vessels. As this is most probably an 
 effect of reflex action, and not essential to the pro- 
 cess of inflammation, it hardly makes the foregoing 
 correspondence less complete. Nor does the massing 
 or concentration of cells in inflammatory stasis. Here 
 the elements of the blood may cohere simply on 
 account of the mechanical conditions, and the abso- 
 lute or relative subsidence of circulation-forces. The 
 injury done to the vascular endothelium is said to in- 
 crease the adhesiveness of the leucocytes. 
 
 The inflammatory changes just noticed are usually 
 transitory. Hereafter we shall have to examine in 
 connection with disintegration the permanent altera- 
 tions of structure which are secondary to inflamma-
 
 12 GENERAL DISEASE. 
 
 tion, and classed among the retrograde metamor- 
 phoses. Where inflammation terminates in suppura- 
 tion, sloughing, gangrene, ulceration, haemorrhage, 
 and the discharge of exudations, the disintegration 
 is very obvious. Integral parts are then destroyed, 
 and may be separated completely from the body. 
 
 3. THE ABSORPTION OF MOTION. 
 
 By the absorption of motion in dissolution we are 
 
 to understand the imbibition of any of the varieties 
 
 of kinetic energy thermal, chemical, mechanical, or 
 
 other ( 1). And this absorption of energy is not 
 
 only a concomitant of the disintegration of matter, 
 
 but is also the cause of the disintegration. The in- 
 
 fduction is, that particles of matter come to occupy 
 
 more space from receiving additional motion from the 
 
 ' environment. 
 
 In the present and succeeding illustrations the 
 term of the formula of dissolution we are now con- 
 sidering should recognise, in the most general way, 
 the cause or causes of pathological changes. 
 
 First, let us look at the common examples of 
 dissolution or disintegration as associated with the 
 reception of an excess of energy from without. 
 
 Where inorganic bodies are broken up into their 
 constituent elements by distinguishable causes, the 
 changes are known to be wrought by the action ot 
 surrounding forces. When heat is the force at work, 
 it may, either slowly and imperceptibly, or quickly 
 and perceptibly, reduce solid bodies to their elemen- 
 tary parts.
 
 INFLAMMATION AND SUPPURATION. 13 
 
 Where the molecules of gases, liquids, and solids 
 are diffused through or dissolved by different media, 
 the energy required for diffusion is obtained from ex- 
 ternal sources. Water evaporates speedily or tardily, 
 other conditions being the same, in proportion to the 
 amount of heat-energy imparted to it ; and the rapid 
 melting of sugar, say in a warm infusion of tea, 
 represents work done both by liquid and thermal 
 motion in overcoming the cohesions of the molecules 
 of the immersed solid. 
 
 1 Masses of sediment accumulated into strata, after- 
 wards compressed by many thousands of feet of 
 superincumbent strata, and reduced in course of time 
 to a solid state, may remain for millions of years 
 unchanged ; but in subsequent millions of years 
 they are inevitably exposed to disintegrating actions,' 
 such as the actions of the waves, rain, frost, and 
 snow. 
 
 Organic matter retains or loses its figure, in num- 
 berless familiar cases, according as it receives much 
 or little kinetic energy in the shape of liquid, thermal, 
 and other environmental motion. As all know, dry- 
 ing or freezing organic substances is preservative of 
 them; and heat, and moisture, and micro-organisms 
 are destructive. 
 
 How directly related to the incidence of some 
 external force may be the disintegration of living 
 aggregates, the following illustration shows, and it 
 shows also the nature of the relation. 
 
 If the hand is placed for a few moments in water 
 having a temperature of 100* F., we notice among 
 the effects an increase in the limb's bulk or volume ;
 
 14 GENERAL DISEASE. 
 
 whereas if the hand is placed in water of 40 F. its 
 volume is lessened. Regarding these effects from a 
 physical standpoint, and disregarding the physiolo- 
 gical mechanisms by which they are brought about, 
 and by which in certain cases they may be neutralised, 
 we see in them a conformity to the rule that bodies 
 expand when heated and contract when cooled. In 
 explanation we may apply the theory valid in the 
 case of inorganic bodies, that the augmented mole- 
 cular activities of the tissues are such as to increase 
 the intermolecular spaces, and therefore the total 
 space occupancy of the limb. Now let the hand sus- 
 tain contact with water of sufficiently high tempera- 
 ture to cause inflammation and subsequent death of 
 tissue. In this event, the enlargement of the ampli- 
 tude of molecular oscillations is such, in the first in- 
 stance, as to induce that scattering of cells and fluids 
 which, we have seen, is characteristic of inflamma- 
 tion ; and in the suppurative stage, the amplitude 
 of molecular oscillation is such as to have for its 
 resultant a molar segregation. The destroyed parts 
 are actually dislocated, and finally dissevered and 
 cast off from the body either en masse , as slough, or 
 in particulate form, as pus. 
 
 Regarding this dissociation of a portion of the 
 body from our special point of view, it is discerned 
 that the impacts of the thermal vibrations have been 
 adequate to destroy not only the qualities distin- 
 guished as vital, but what is essential to this vitality 
 the union subsisting between the parts and the 
 corporate organism. The physical fact of disunion 
 may be perceived in its nakedness, by paralleling the
 
 INFLAMMATION AND SUPPURATION. 15 
 
 case of heat applied to an inorganic body until its 
 component particles burst asunder. 
 
 Mr. Spencer's arguments tend to show that the 
 redistributions of energy in any system are the 
 manifestations of forces everywhere in opposition as 
 attractions and repulsions. That is to say, evolution 
 or dissolution is the differential result of a play of 
 energies, resolvable into the ultimate forms in which 
 force is made known to us attraction and repulsion. 
 Therefore we may perhaps say of the foregoing case 
 that the forces by which parts were held together 
 have been more than counterbalanced by the repul- 
 sive tendencies of the thermal movements of the 
 molecules. 
 
 In conclusion, it should be noted that the taking 
 up of energy is not peculiar to dissolving aggregates. 
 All bodies, whether integrating or disintegrating, 
 receive molar or molecular motion from surrounding 
 things and give off motion to them. This reciprocal 
 transference of energy in the case of heat finds its 
 expression in the theory of exchanges. Living 
 creatures during the evolutional stages of their exist- 
 ence absorb stores of potential force in the form of 
 food, and of actual force in the form of light and heat. 
 The truth really enunciated by the principle of 
 dissolution is not simply that dissolving aggregates 
 absorb motion, that this absorption is a necessary 
 concomitant of the disintegration of matter, but 
 that the motion absorbed is the cause of the dissolu- 
 tion. 
 
 For, as just mentioned, evolution or dissolution is 
 the resultant of contrary actions ; now it testifies to
 
 16 GENERAL DISEASE. 
 
 the ascendency of conditions favourable to a concentra- 
 tion of parts and a dissipation of kinetic energy, and 
 now to the ascendency of reverse conditions those 
 favourable to diffusion of parts and an absorption of 
 energy. In the words of Mr. Spencer, ' neither of 
 these two antagonistic processes ever goes on abso- 
 lutely unqualified by the other ... a change towards 
 either is a differential result of the conflict between 
 them. An evolving aggregate, while on the average 
 losing motion and integrating, is always in one way 
 or other receiving some motion, and to that extent 
 disintegrating.' 1 The resultant changes are not dis- 
 solutional until the energy received preponderates 
 over the energy dissipated. 
 
 Prepared by these reflections, we may proceed to 
 inquire whether inflammation and suppuration are 
 attended by the conveyance of a superaddition of 
 external energy. 
 
 When the conditions of the cases are known, in- 
 flammation may then be causatively referred to one 
 or more of the outer influences to which the organism 
 is exposed. If the inflammatory process is excited 
 by mechanical injury, by chemical agents, by burn- 
 ing and scalding, or by parasites, the transference of 
 energy to the organism is direct and manifest. It is 
 less direct and less manifest where tissues are inflamed 
 from contact with poisonous matters distributed to 
 them by the blood ; for instance, in gout and the 
 later lesions of syphilis. Yet here the phlogogenic 
 agents come originally from without ; in syphilis the 
 virus is derived from another organism, and gout is 
 
 1 First Principles, 177.
 
 INFLAMMATION AND SUPPURATION. 17 
 
 unquestionably dependent on dietetic and other habits, 
 that is, upon environing actions (see chap. vii. 3). 
 
 In many other cases the causes of particular in- 
 flammations cannot be traced even remotely to the 
 organism's conditions. What shall we say of these ? 
 When we come to consider the involved and well- 
 nigh inscrutable but ever interdependent patho- 
 logical sequences met with in special diseases, good 
 reasons will appear for believing that where inflam- 
 mations cannot be finally followed out to the opera- 
 tion of external conditions the cases are imperfectly 
 understood ; and that, with great probability, were 
 our knowledge of such cases complete, a reception of 
 energy from without would prove to be the primary 
 cause of all inflammations. It is impracticable to 
 bring forth here the a posteriori evidence of this, so 
 complicated and multitudinous are the facts. There- 
 fore, the reader is referred to succeeding chapters. 
 We may j ust notice that each progressive step in our 
 knowledge of the causes of inflammation brings us 
 nearer to the recognition of some external factor or 
 group of factors. Mention may be made of formerly - 
 so-called idiopathic pleurisy and peritonitis. Some 
 of these forms of inflammation are now known to be 
 associated in causative sequence with morbid states 
 certainly referrible to external actions. The pleurisy 
 secondary to Bright's disease caused by intemper- 
 ance is an example, and we have another in the 
 peritonitis secondary to metritis arising from septic 
 infection. 
 
 Experimentally produced inflammation demon- 
 strates unequivocally the correspondence to the 
 
 c
 
 18 GENERAL DISEASE. 
 
 formula we are seeking. When inflammation is 
 excited by incising the web of a frog's foot, we see 
 that the mechanical power which severs the tissues is 
 not only the cause, but is also quantitatively related 
 to the degree of inflammation. Other things being 
 equal, the deeper the injury inflicted, or the larger 
 the quantity of disturbing motion imparted to the 
 elements of the tissue, the more intense the morbid 
 process. 
 
 In considering (2) how the matter of a part is 
 disintegrated in inflammation, we saw that this dis- 
 integration is first indicated by a diffusedness of the 
 organic particles. Hence, in the case now instanced, 
 we must recognise in the centrifugal movements of 
 cells and fluids in the web of the frog the persistence 
 of that mechanical energy noted as the source of the 
 disturbances. Similarly, where there is a different 
 etiology, as when nitric acid or heat is the phlogogenic 
 agent, the chemical or thermal energies are conserved 
 in part, we may assume, in the visible perverted 
 motions which result. Or perhaps a more faithful 
 representation of the actuality is the following. In 
 inflammation the first effect of the causative agent is 
 to produce a partial disintegration of the vascular 
 structure ; as would be the case with an inorganic 
 aggregate, the incident forces shake the units slightly 
 apart. The extravasation of serum and leucocytes, 
 and diapedesis, are the consequences of this change 
 in the vessels. 
 
 In the causes of suppuration, the relation under 
 consideration is daily demonstrated, and most clearly 
 in the causes of suppuration in wounds. When
 
 INFLAMMATION AND SUPPURATION. 19 
 
 caustic silver is applied to granulations, these struc- 
 tures will almost visibly melt into pus. Drainage- 
 tubes, sutures, and ligatures very frequently give 
 rise to tracts of suppurating .tissue. There is also 
 ' antiseptic suppuration,' from irritation of the anti- 
 septic agent, sometimes witnessed in aseptic wounds 
 treated with carbolic acid or perchloride of mercury. 
 And putrefactive and other micro-organisms known 
 to have external origin are among the well-esta- 
 blished causes of suppuration ; indeed, they are pro- 
 claimed by some observers to be the only cause. 
 
 Pus formation as witnessed in abscesses, either 
 primary or metastatic, is, in many cases, known to 
 be directly or indirectly related to some external 
 influence. Instances are furnished by pyaemic ab- 
 scesses, and by phthisical vomicae. 
 
 Thus, as far as the facts extend, they do affirm 
 that inflammation and suppuration are attended by 
 an absorption of environmental energy. 
 
 It may make conception of the process of inflam- 
 mation clearer if we consider here the motion disap- 
 pearing when functions are annihilated. The imper- 
 ceptible molecular activities of living matter, which 
 have then* summations in visible functional action 
 the contraction of muscles, the circulation of fluids, 
 secretion and excretion cease at death ; and there 
 is an analogous cessation of function in parts that 
 are inflamed, as is well known. What becomes of 
 this functional motion ? It is not easily understood 
 as furthering the inflammatory process. The answer 
 appears to be contained in our conception of the 
 
 c 2
 
 20 GENERAL DISEASE. 
 
 attributes of organic function. What exactly should 
 we mean by function, as we perceive it in the vital 
 actions of simple tissue, in the contraction of muscle, 
 or in the digestion of food ? A common quality of 
 these and all organic functions, whether simple or 
 compound, is that of co-ordinate action ; the consti- 
 tutional energies of tissues and organs are combined 
 for some distinct end. But in being co-ordinate, 
 the energies bear to one another a determinate not 
 necessarily equal proportion in time, space, and 
 magnitude, and it is this determinateness of the propor- 
 tions which makes the actions ivhat we call co-ordinate. 
 First, to exemplify the time ratios. The exchanges 
 of matter and motion going on in any simple tissue 
 are first summed up as the primitive processes of 
 assimilation and disassimilation. These follow one 
 another in times more or less definitely proportioned. 
 If, following dissociation, the re-association or absorp- 
 tion of new material is unduly postponed, the func- 
 tions of assimilation and disassimilation are without 
 co-ordination, or come altogether to an end. Again, 
 the blood-vessels bring food-material, and carry away 
 the products of its decomposition ; therefore, the ac- 
 tions of the blood-distributing system, and associated 
 nervous functions of this system, must be definitely 
 timed to the processes of assimilation and disassimi- 
 lation. And behind these resultant and recognisable 
 forms of organic energy, we may infer among the 
 factors the existence of precise ratios that are unre- 
 cognisable ratios among the molecular forces. 
 
 That the energies of this simple tissue must act 
 through constant spaces is implied by the uniformity
 
 INFLAMMATION AND SUPPURATION. 21 
 
 of its structural conformation. In witness thereof 
 the space relations of blood-vessels and the outlying 
 cells to be fed by them are invariable. 
 
 The determinate character of the force -magni- 
 tudes finds illustration in the provisions for regulat- 
 ing blood -propulsion and cell- alimentation. If the 
 strengths of these are not in certain proportions, 
 if the blood-pressure is too high or too low, if 
 aliment is unduly deficient or unduly excessive, the 
 combined energies of the tissue will not be co-ordi- 
 nate but inco-ordinate. 
 
 When we say that the function of muscle is to 
 contract and do work we mean that its purpose 
 (function) is subserved by contraction for some 
 specified object. If this object is the adjustment of 
 the calibre of vessels, the muscle-cells and fibrils 
 must contract at certain proportionate times, through 
 certain proportionate spaces, and with certain pro- 
 portionate strengths ; otherwise the object of con- 
 traction is not attained, or is attained imperfectly, 
 inco-ordinately. And so with the simultaneous and 
 successive actions making up the functions of diges- 
 tion, or other organised group of forces : these also 
 must be in determinate ratios. 1 
 
 Organic function, then, being the expression of 
 energies co-ordinate in time, space, and magnitude, 
 an effect of any inflammation-producing agent will 
 be to make them inco-ordinate ; the ratios among 
 them will become indefinite, or less definite ; and 
 the specific function will be annulled temporarily, or 
 
 1 I am indebted to Dr. Charles Mercier for the suggestion of th 
 views. See his essay on Inco-ordination, Brain, vol. vi. p. 78.
 
 22 GENERAL DISEASE. 
 
 permanently. The agents causing inflammations do 
 not, however, unless necrosis is the sequel, destroy all 
 organic co-ordination, but only that which we distin- 
 guish as the special work of the cellular community. 
 The alteration from a combination of forces in defi- 
 nite proportions to one in indefinite proportions is a 
 relative one, the change being from higher co-ordina- 
 tions to lower ones. While a cirrhosed kidney has 
 almost lost that coherent arrangement of its energies 
 which ends in the excretion of urea, there may still 
 be going on in its substance lower grades of cohe- 
 rent action, as the excretion of water, the processes 
 of cell-respiration and reproduction. Similarly with 
 the elements of muscle that have been degraded by 
 suppuration, or the elements of nerve in Wallerian 
 degeneration. 
 
 If this view of the matter is acceptable, it will 
 explain that disappearance of specialised functional 
 motion which is an accompaniment of inflammation 
 and death. Yet it should not be forgotten that, when 
 any force giving origin to the inflammatory process 
 has worked its effects, a re-doing of the part reso- 
 lution or repair sets in if the conditions are favour- 
 able, and energy is probably then drafted off from 
 neighbouring parts for the purposes of 'this new 
 development. Hence there will be local deductions 
 from the force otherwise available for normal work. 
 
 If we may not conclude from the foregoing that 
 inflammation and suppuration are marked by a dis- 
 integration of matter and absorption of motion, a 
 closely approaching coincidence with this clause of 
 the formula of dissolution must be conceded
 
 INFLAMMATION AND SUPPURATION. 23 
 
 4. THE CHANGE FROM A DEFINITE (special], COHE- 
 RENT (organised) HETEROGENEITY (multiformity) 
 (complexity) TO AN INDEFINITE (general), INCO- 
 HERENT (unorganised) HOMOGENEITY (uniformity) 
 (simplicity). 
 
 Besides the equivalents here introduced within 
 parentheses, while exhibiting the illustrations in the 
 present and following chapters, the terms of this 
 clause of the formula will receive ample definition. 
 
 When adverting just now to the inco-ordination 
 of function attendant upon inflammation, there was 
 partly anticipated the present task, which is to in- 
 quire whether functions and structures become rela- 
 tively indefinite, incoherent, and homogeneous. 
 
 We may take some form of local inflammation 
 and suppuration say an acute abscess, or the sup- 
 purative degeneration of granulations where the 
 result is a destruction of tissue. In the process of 
 suppuration the solid elements of the tissue may 
 presumably contribute to the formation of the pus or 
 be liquefied and absorbed by pus derived from the 
 serum and leucocytes of the blood. But in all cases 
 of suppurative destruction of portions of the body 
 the rearrangements of matter and motion are identical 
 in general character. 
 
 Forcing itself first upon attention is the change 
 from heterogeneity to homogeneity. However multi- 
 form, morphologically and physiologically considered, 
 was the tissue destroyed, the resulting product pus 
 is little more than an assemblage of homogeneous
 
 24 GENERAL DISEASE. 
 
 cells bathed in a pabulum of serum. And, looking 
 further, we find that tissue- elements which were 
 coherently associated and specialised have become 
 less coherently associated and unspecialised both as 
 to anatomical disposition and service or function. 
 Let the example be a metastatic abscess of the 
 kidney ; then the glomeruli, tubules, secreting cells, 
 vessels, and nerves, all combined into a definite 
 structure, and doing definite work in the economy, 
 have been deposed for simple cells having neither 
 determinate arrangement nor functional utility, and 
 only such combination as is afforded by a common 
 nutrient fluid. 
 
 If the suppuration is not joined with marked 
 destruction of the tissues, as where pus is discharged 
 from mucous and serous surfaces, the elements of the 
 purulent matter are degenerated blood-constituents 
 and superficial cells of epithelium ; and in this case 
 the transformations do not answer so strikingly to 
 the requirements of the formula. Morphologically, 
 pus-cells bear a close likeness to white corpuscles ; 
 yet there are some structural and other dissimilarities. 
 They do not exhibit amoeboid movements, their 
 nuclei are divided, and they are incapable of absorb- 
 ing, like the leucocytes of granulations, such, dead 
 tissue as a sequestrum of bone. These attributes are 
 understood to signify degenerative changes. Re- 
 garded from another aspect, pus leucocytes do not 
 play in the economy the special role of blood 
 leucocytes, and they are in no sense subordinate to 
 or united in coherent working with the other com- 
 ponents of tissues, So that suppuration, both when
 
 INFLAMMATION AND SUPPURATION. 25 
 
 resulting in loss of solid tissue and simply in loss of 
 elements of the blood, is in accord with dissolution, 
 being a change to relative indefiniteness, incoherence, 
 and homogeneity of functions and structures. 
 
 Is this clause of the formula descriptive of in- 
 flammation ending in resolution? The functions and 
 structures of parts are decided as specialisation is 
 advanced. In the simple tissue depicted in fig. 1, 
 the more highly specialised organs, the blood-vessels, 
 are seen in the inflamed portions to have lost some- 
 thing of their normal definiteness ; there is a slight 
 obscuration of parts in that the contrast between 
 the vessels and the extravascular tissue is less pro- 
 nounced. 
 
 Functionally considered, the blood-vessels have 
 not their normal distinctness, inasmuch as their con- 
 tents are distributed indifferently, here and there, by 
 extravasation through the vessel-walls, and not to 
 the normal seats of tissue-respiration and alimen- 
 tation. 
 
 The diminished structural coherence and conse- 
 quent inco-ordination of function scarcely require 
 delineation. With the escape of serum and leuco- 
 cytes, and with the stasis of blood, the pre-existing 
 orderly arrangements give place to confusion. 
 
 Apparently, functional and structural heteroge- 
 neity is increased rather than lessened by the new 
 arrangement. Greater heterogeneity, however, im- 
 plies a specialisation of parts, is consequent, indeed, on 
 specialisation ; and what we really see in inflamma- 
 tion is an increase in the number of the more simple 
 and less specialised units, the white corpuscles ; and,-
 
 2(> GENERAL DISEASE. 
 
 were the inflammation to terminate destructively, 
 these bodies, aggregated as pus, would be the only 
 remaining representatives of the previously differ- 
 entiated structures. And the previous diversity of 
 function would give place to uniformity simple assi- 
 milation, disassimilation, and multiplication among 
 the leucocytes. Inflammation, then, as well as suppu- 
 ration, harmonises with the final terms of the formula. 
 
 This chapter may be appropriately concluded 
 with a short reference to local anaemia, active and 
 passive hyperamia, and haemorrhage, as dissolutional 
 changes. 
 
 Only in extreme forms, and in the structural 
 transformations following long- continued anaemia 
 and hypereamia, do we find all the characters the 
 formula denotes. As states of the vessels, both 
 deficiency and excess of blood may occur within the 
 boundaries of normality. The pallor of the face in 
 fright or the turgescence of the hands after exposure 
 to cold cannot be regarded as pathological. But, 
 natural limits being exceeded, it is worth while to 
 note one or two correspondences with the formula 
 signs of disintegration as an effect of absorbed 
 energy. 
 
 A vessel that has been long deprived of blood, as 
 by ligatures, loses the power to retain serum, leuco- 
 cytes, and red cells ; when the circulation is restored 
 they pass through the interstices of the vessel-walls. 
 The previous anaemia has induced that degree of 
 vascular disintegration we observed in inflammation. 
 Nutrition having been stopped, the plastids (units of
 
 ANEMIA AND HYPER JEMIA. 27 
 
 structure) are unable to withstand the incident 
 motions chemical and mechanical strains and the 
 slight disruption ensuing makes possible the ex- 
 travasations. 
 
 The phenomena and conditions of hyperaemia are 
 quite comparable. Relatively diminished arterial 
 resistance, variously caused, is uniformly the mor- 
 phological condition upon which arterial hyperaemia 
 depends. This is equal to saying that the less inte- 
 grated state of the vascular tissue permits the over- 
 filling with blood and the transudation of serum 
 sometimes associated with active hyperaemia. 
 
 Mechanical or venous congestion is always a 
 consequence of motion conveyed in the shape of 
 increased blood-pressure in the veins ; and the result- 
 ing disintegration is borne witness to by transudation 
 of serum, diapedesis, and haemorrhage. Some of the 
 enduring changes, as fibroid induration, thrombosis, 
 and necrosis, resulting from prolonged passive hyper- 
 aemia, will be considered in later chapters. 
 
 Haemorrhage, either as diapedesis or from the 
 coarse rupture of vessels, is obviously a disintegra- 
 tion of the body. Diapedesis is due to communicated 
 motion, as we have just seen, and in haemorrhage 
 from traumatic injury energy is manifestly absorbed. 
 Of haemorrhage associated with deteriorated blood, 
 as in leukaemia, scurvy, or small-pox, or haemorrhage 
 from ulceration and atheroma, the first causes are 
 numerous, often obscure and entangled, and the 
 reader must be referred to the examples to be met 
 with in the section occupied with special diseases.
 
 28 GENERAL DISEASE. 
 
 CHAPTER II. 
 
 RESOLUTION AND REPAIR AS EVOLUTIONAL 
 CHANGES. 
 
 Definition II. ' Evolution is an integration of matter 
 and concomitant dissipation of motion ; during which 
 the matter passes from an indefinite, incoherent 
 homogeneity, to a definite, coherent heterogeneity ; 
 and during which the retained motion undergoes a 
 parallel transformation.' 
 
 1. THE INTEGRATION OF MATTER AND 
 DISSIPATION OF MOTION. 
 
 Single living particles, or their assemblages as 
 tissues, organs, and compound individuals, present 
 us with a conservative system of forces. Employ- 
 ing the terminology of physical science, if, in these 
 assemblages, the configuration of matter and motion 
 is deformed within certain limits the system is under 
 stress, and the status quo will be restored when the 
 deforming action ceases. If the distortion is that 
 known as inflammation, it may be of greater or less 
 degree, to which the subsequent restitution of figure 
 will be related. Should the inflammation be, in the 
 main, limited to a deflection of the courses normally
 
 RESOLUTION AND KEPAIR. 29 
 
 taken by the fluids and moving cells, and have as its 
 visible product simply an exudation of serum or 
 fibrine and hcemocytes into the meshes of the tissue ; 
 then the organic aggregate will behave in a way 
 comparable to an inorganic aggregate strained within 
 the limits of its elasticity ; the previous configuration 
 will be restored with all measurable completeness. 
 The cells and fluids will resume their habitual courses, 
 and the exudations will become absorbed. This is 
 resolution after inflammation. 
 
 Should the phlogistic process be of severer form, 
 and have for its product a cellular necrosis, or other 
 destruction of tissue, then the organic structure will 
 behave in a way comparable to an inorganic structure 
 strained beyond the limits of its elasticity ; there will 
 have been wrought a ' permanent set.' That equi- 
 librium may be restored, there must be a redevelop- 
 ment of particles. This is repair after inflammation, 
 involving the birth of new tissue-elements and the 
 organisation of them into structure. 
 
 It was seen in the preceding chapter that inflam- 
 mation, as observed microscopically, consists of 
 changes corresponding to those formulated as disso- 
 lution. The correspondence was seen to be most 
 distinct when inflammation ended in complete dis- 
 integration, sloughing, suppuration, and ulceration. 
 Hence, resolution being the sequence of a partial 
 inflammatory dissolution, it will, we may expect, 
 less perspicuously agree with the formula of evolution 
 than will repair, which is the sequence of complete 
 dissolution. Yet that resolution and evolution are 
 the same in principle seems sufficiently clear.
 
 30 GENERAL DISEASE. 
 
 Taking, again, the inflammation of simple tissue, 
 the fact must be borne in mind that we are dealing 
 with a system normally in moving equilibrium. The 
 units of living tissue have their own proper visible 
 motions, and these should be kept apart from the 
 motions which are proper to the process of resolution. 
 We find, for example, that in inflammation blood - 
 cells are concentrated within the vessels, and as 
 resolution begins they gradually move off owing to 
 the restoration of the normal blood-current. In this 
 respect units are separated, not brought together. 
 
 It being understood that always prior to the 
 setting in of resolution the cause of the inflamma- 
 tion has ceased, then in inflammation of simple tissue 
 the fixed cells lie bathed in a leucocyte-containing 
 exudate. Now when resolution takes place, this 
 exudate and contained cells are taken up either by 
 local cell-imbibition or by lymphatics and veins. 
 There is thus a reaggregation within cells or ves- 
 sels, and this constitutes integration (chap. i. 2). 
 With the contraction of arteries and the closing of 
 capillary stomata there is a further consolidation of 
 substance. 
 
 But is there in the process of renewal we are 
 considering a concomitant dissipation of motion ? 
 Exuded serum, or plasma, and corpuscles, are matter 
 diffused through the walls of vessels, and in becoming 
 diffused the particles must have acquired relative 
 motion. Diffusion is a separation of parts, and parts 
 cannot become separated without their motions in 
 respect of one another being increased. Therefore 
 the motion taken up in the inflammatory diffusion of
 
 RESOLUTION AND REPAIR. 31 
 
 haemocy tes and plasma must be rendered again when 
 these elements concentrate or are integrated by ab- 
 sorption, as in resolution. And being thus rendered 
 again, it is dissipated or lost in the meaning of the 
 formula, though of course, as already pointed out, 
 motion is gained by the restoration of circulation. 
 So that resolution shows us a reversion of the 
 antecedent partial dissolution, in that matter is inte- 
 grated and motion dissipated. 
 
 2. THE CHANGE FROM AN INDEFINITE, INCOHERENT 
 HOMOGENEITY TO A DEFINITE, COHERENT HETE- 
 ROGENEITY. 
 
 In comparing the process of resolution with the 
 remaining terms of the definition of evolution, it is 
 perhaps enough to say that since inflammation has 
 been shown to be betokened by a loss of denniteness, 
 coherence, and heterogeneity of function and structure, 
 recovery from inflammation resolution must be a 
 gain of these qualities. With the resorption of an 
 exudate say into pulmonary alveoli the normal 
 exchanges of matter and motion are re-established. 
 Functions and structures return to- the standard of 
 speciality, co-ordination, and variety from which they 
 had regressively diverged. 
 
 In considering whether the phenomena of repair 
 fulfil the requirements of the formula, we may choose, 
 as suitable in its simplicity, and as a type of reparative 
 action, the repair of wounds by the growth of granu- 
 lations. 
 
 Confining attention to the positively ascertained
 
 32 GENERAL DISEASE. 
 
 phenomena of this mode of healing, there is first to be 
 noted the deposition of leucocytes and plasma upon 
 the wounded surface. Whether these leucocytes have 
 origin in the fixed cells of connective tissue, or are 
 emigrant white blood-corpuscles, need not now con- 
 cern us. We are assured of the fact of their genera- 
 tion at the seat of an antecedent inflammation, and 
 that by their increase in mass and structural differ- 
 entiation they become connective tissue. 
 
 In the early stage of development these cells have 
 amoeboid characters, undergoing changes of shape and 
 movements of translation which the feebleness of 
 their mutual attachments permits. With each stage 
 of development there is a progressive consolidation 
 of the cells and vascular components of the young 
 tissue, and a cessation of the changes of cell-form, and 
 the movements from one place to another. In the 
 final stage the resulting tissue is compact, and the 
 non-vascular elements of it are fixed : the units have 
 lost their visible motions. 
 
 This graduation of primitive plasma and forma- 
 tive cells into mature connective tissue is thus a con- 
 tinuous integration of matter and concomitant dissi- 
 pation of motion. 
 
 That increased definiteness, coherence, and hetero- 
 geneity of matter and motion are coincident with the 
 foregoing changes appears to be demonstrable. The 
 development of connective tissue from granulation 
 tissue commences in relatively homogeneous plasma 
 and simple cells, having little organisation and unde- 
 cided functions. Later the cells become spindle-shaped, 
 their substance differentiates into fibres, blood and
 
 RESOLUTION AND REPAIR. 33 
 
 lymph channels are marked out as vessels, and all 
 become firmly joined together, forming a definite and 
 coherent structure, having definite and coherent 
 purposes. 
 
 The phenomena of resolution and repair as wit- 
 nessed in systemic diseases will obtain further notice 
 subsequently. Here it may be observed that what 
 has just been said respecting the reproduction of 
 common reparative tissue connective tissue is true, 
 mutatis mutandis, of structures of higher speciality ; 
 of the regeneration of bone, cartilage, muscle, or 
 epithelium.
 
 34 GENERAL DISEASE. 
 
 CHAPTER III. 
 
 THE RETROGRADE METAMORPHOSES AS DISSOLUTIONAL 
 
 CHANGES. 
 
 1. COAGULATION or THE BLOOD. 
 
 COAGULATION of the blood, being the essential pheno- 
 menon of many kinds of retrograde metamorphosis, 
 naturally comes first in the order of the present illus- 
 trations. But there is immediately encountered a fact 
 which apparently negatives any expectation that co- 
 agulation changes are generalised by the principle of 
 dissolution (chap. i. def. 1). Instead of material dis- 
 integration the foremost characteristic of dissolution, 
 the death of blood is distinctly a material integration, 
 the leading characteristic of evolution (chap. ii. def. 
 2). Obviously, in the formation of solid fibrine from 
 fluid blood there is not a diffusion but a concentra- 
 tion of parts. How is this to be reconciled with 
 any presumption that coagulation is a dissolutional 
 process ? 
 
 Here we are re-introduced to a truth without 
 which the phenomena of disease will be but loosely 
 translated by the formulas of dissolution and evo- 
 lution. There has already been occasion to note 
 (chap. i. 3) that evolution or dissolution expresses 
 the difference between forces tending to dispersion of
 
 THE RETROGRADE METAMORPHOSES. 35 
 
 the members of a system and forces tending to their 
 condensation, and that in no aggregate does either of 
 the processes go on singly. Whichever the change 
 observed, it is a differential result. Thus, while a 
 body in the totality of its changes may be evolving, 
 portions of it are dissolving ; and, conversely, while 
 the entirety of the changes may be dissolutional some 
 of the details will be evolutional. ' Everywhere, and 
 to the last . . . the change at any moment going on 
 forms a part of one or the other of the two pro- 
 cesses.' . . . ' The chances are infinity to one against 
 these opposite changes balancing one another ; and 
 if they do not balance one another, the aggregate as 
 a whole is integrating or disintegrating.' l 
 
 Illustrations by case and example will give clear 
 meaning to these statements. In the normal living 
 organism the two orders of mutation are ever in pro- 
 cess throughout the system, are mutally complemen- 
 tary, and jointly contributory to the total evolutional 
 result. This is shown in assimilation and disassimi- 
 lation, processes of evolution and dissolution ; in in- 
 terstitial waste and repair ; in accretion and excre- 
 tion. The secretions of the mammary and other 
 glands are good examples of normal dissolutions. 
 
 In decomposition after death not only is there a 
 reduction of organic substance to simple constituents 
 carbonic acid, water, and ammonia, &c. but many 
 chemical redintegrations are effected, as in the forma- 
 tion of the organic alkaloids, the ptomaines. 
 
 The chemical changes of inorganic systems supply 
 innumerable examples. If manganese monoxide and 
 
 1 First Principles, p. 285. 
 
 D 2
 
 36 GENERAL DISEASE. 
 
 hydrochloric acid are mixed together under appro- 
 priate conditions, the resulting redistribution is a dis- 
 sociation of chlorine gas, and an association of oxygen 
 with hydrogen to form water, and of chlorine with man- 
 ganese to form manganous chloride (Mn0 2 + 4HC1 = 
 MnCl 2 + 2H 2 + C1 2 ). Here the change in the whole 
 is analytical, minor syntheses accompanying. 
 
 Everywhere in the domain of pathology dissolu- 
 tion and evolution are presented to us in this aspect. 
 When detailing the histological changes in inflam- 
 mation it was seen that, at large, the process is a dis- 
 solution of particles, but attended by incidental unions 
 of particles. Sometimes arteries contract, and, blood 
 stagnating, there ensue local integrations of haemo- 
 cytes. Thus with the general disaggregation there 
 are associated particular aggregations. Throughout 
 the present and succeeding chapters this point will 
 demand frequent recognition. We shall meet with 
 examples in dealing with the neoplasms ; the organic 
 diseases, as nephritis and pneumonia ; the functional 
 diseases ; and diseases of the mind. And it is the 
 key to understanding our present subject coagula- 
 tion as a process of dissolution. It will be seen that 
 the integration of matter to form fibrine, in the clot- 
 ting of blood, is explicable as due to a play of par- 
 ticular chemical attractions. According to prevailing 
 views, these attractions are between fibrinogen dis- 
 solved in the blood-plasma and fibrino-plastin and 
 fibrine-ferment contained in the white corpuscles. In 
 deciding whether the phenomena of blood-coagulation 
 satisfy the formula of dissolution by including a 
 disaggregation of matter, the blood must be regarded
 
 THE RETROGRADE METAMORPHOSES. 37 
 
 as a system or group of combined elements, and 
 then there is found to be really a physical disunion 
 of substance. The white corpuscles and, as some 
 assert, the blood-plaques, are in part destroyed, their 
 destruction appearing to be a necessary condition of 
 fibrine formation ; and the unformed element, the 
 plasma, is broken up into simpler bodies the liquor 
 sanguinis and fibrinogen ; the secondary integration 
 of fibrinogen and fibrino-plastin being quite in har- 
 mony with the general doctrine of dissolution. 
 
 But do the conditions of coagulation show its 
 relation to an accession of environing energy ? 
 
 Blood clots slowly if the circumstances permit 
 the reception of little motion, and, on the other 
 hand, clotting takes place quickly if much, motion is 
 received. Attesting this, blood kept in contact with 
 living tissue is inapt to coagulate. ' If an artery be 
 ligatured in two places and cut out while full of 
 blood it may be hung up and the blood will remain 
 fluid for some days.' Clearly the blood is here un- 
 favourably situated for receiving any form of molar 
 or molecular energy with which it is not equipoised 
 or that is competent to overthrow the balance of its 
 contained forces. The blood and tissue together 
 form an equilibrated system. 
 
 When blood is exposed to the chemical, thermal, 
 mechanical, or other energies present, say, in the 
 atmosphere, with which it is not organically balanced, 
 coagulation is facile. Contact with the air, whipping 
 the blood, the introduction of needles into vessels, or 
 the destruction of vascular endothelium all suffice to
 
 38 GENERAL DISEASE. 
 
 induce clotting. In these ways there are imparted 
 to the blood motions that cannot be harmonised with 
 its own intrinsic motions, and its substance is rent 
 both physically and chemically. But in these ways 
 energy is absorbed in the meaning of the principle of 
 dissolution. 
 
 Digression for a moment may be permitted to 
 Bay that the agency of bodies of diverse chemical and 
 physical properties as excitants of coagulation is 
 similar to, if not identical with, ' contact action.' 
 It is well known that solids have the capacity for 
 condensing gases in contact with their surfaces, but 
 the researches of M. Konovaloff intimate a capacity 
 of solids for dissociating gases. ' Platinum enjoys 
 this property to a high degree, but also many other 
 solid bodies, glass among them, the intensity of its 
 contact action obviously depending upon several cir- 
 cumstances ; its chemical composition, the structure 
 of its surface and its temperature, as also upon the 
 density of the gas it is brought in contact with.' 1 
 
 H. Ernst Freund, in ' Wiener medicinische Jahr- 
 bucher,' 1886, Heft 1, has shown that blood will not 
 coagulate when drawn into a vessel the inside of 
 which is coated with vaseline ; nor will fibrine se- 
 parate when the blood is stirred with glass rods if 
 these are smeared with oil. j^ nd soaked fish-bladders 
 and parchment- tubes are similarly anti-coagulative. 
 These facts, which I have taken from ' Nature,' No. 
 852, vol. xxxiii., are readily assimilated with pre- 
 ceding considerations. Coagulation of the blood is 
 not prevented only by ' vital influences,' as we were 
 
 1 Nature, vol. xxxiii. p. 350.
 
 THE RETROGRADE METAMORPHOSES. 39 
 
 wont to believe, but is determined by the quantity 
 and the quality of the molar and molecular energies 
 presented from without. 
 
 In seeking to learn if dissolution is further sub- 
 scribed to in the qualitative changes of function and 
 structure which transpire when blood dies, there is to 
 be marked first that loss of speciality which results 
 from the rending of corpuscles and plasma. Moving 
 for specific ends from one part of the body to another, 
 the living corpuscles and plasma lose, it must be con- 
 ceded, in definiteness of motion as they become dead 
 fibrine. This must be granted also of the inter- 
 molecular motions through which exist the vitality 
 and functions of cells and plasma. 
 
 Loss of definiteness of matter, though appreciable, 
 coagulation being a change from speciality to gene- 
 rality, is conspicuous at a later stage of blood disso- 
 lution ; that is, when it is decomposed and resolved 
 into imperceptible gases. 
 
 Blood in dying also loses in the coherence and 
 heterogeneity of its matter and motion. While living 
 it is an organised system, each part being subservient 
 to the whole and the .whole to the parts ; and shows 
 much heterogeneity of function and structure, espe- 
 cially in its formed elements, the white and red cells, 
 blood-plaques, microcytes, &c. But coagulated or 
 dead blood is quite without such co-ordination of 
 forces as would be called function, and its varied 
 histology gives place to uniformity on the destruc- 
 tion of its cellular components.
 
 40 GENERAL DISEASE. 
 
 2. THROMBOSIS AND EMBOLISM. 
 
 Thrombosis is a particular case of blood- coagula- 
 tion, and exhibits as the latter does the essentials of 
 the dissolutional process. The following description 
 of artificially-produced thrombosis indicates the nature 
 and conditions of the phenomenon : 
 
 1 The mesentery of a frog is exposed and subject 
 to microscopic examination. A vessel of some size, 
 an artery or vein, is chosen, and its wall in some way 
 injured, as by twitching it slightly with forceps, or 
 by placing a small crystal of common salt near it. 
 Very soon white blood- corpuscles begin to adhere at 
 the injured part. As the blood passes over it succes- 
 sive layers of white corpuscles adhere, and a growing 
 clump of them is formed. Along with the white 
 corpuscles a stray red one may be insinuated, or there 
 may be several red ones. The clump so formed, be 
 it wholly white or partly mixed with red corpuscles, 
 may be carried off, in which case a new one begins to 
 form, but the clump may remain fixed and be con- 
 tinuously enlarged by successive depositions of cor- 
 puscles from the circulating blood. In course of time 
 a change occurs in the appearance of the clump, the 
 white corpuscles lose their individual outline to a 
 great extent, and the clump gathers itself together 
 into a grey granular mass, in which neither by acetic 
 acid nor by staining are the majority of the white 
 corpuscles to be discovered. It has, indeed, very much 
 the characters of fibrine which has been obtained by 
 whipping the blood outside the body. The clump of
 
 THE RETROGRADE METAMORPHOSES. 41 
 
 white corpuscles, in fact, by the disintegration of the 
 corpuscles and the attraction of the fibrinogen from 
 the blood plasma, has converted itself into a fibrinous 
 coagulum/ 
 
 Thrombosis as here typically portrayed is accom- 
 panied, we may safely say, by a disintegration of 
 matter. In an assemblage of leucocytes or blood - 
 plaques (the latter are thought by some observers to 
 be the chief agents in the construction of a thrombus), 
 the protoplasm of the individual cells coheres in 
 spheroidal forms. When thrombosis results, this 
 protoplasm is subjected to radical rearrangement, 
 moving from the former centres of aggregation so 
 that the spheres are obliterated (chap. i. 2). 
 
 The known causes of this morbid change prove 
 in many cases, and imply in others, an absorption of 
 energy from the outer surroundings. It is most 
 plainly shown in thrombosis induced experimentally, 
 as when foreign bodies are introduced into veins. 
 But less so when apparently set up solely by the 
 stagnation of blood in vessels, in the apices of the 
 ventricles, in the auricles, or about the columnar 
 carneas. Here thrombi are probably due indirectly 
 to stagnation and directly to the structural and 
 functional alteration to which stagnation gives rise 
 in the endothelium. 
 
 When thrombi grow by the accretion of layer 
 upon layer of corpuscles, as in aneurismal coagulation, 
 and as in the extension of thrombi from the uterine 
 to the iliac veins, the surface of the coagulum plays 
 the part of a foreign body in transferring a molecular 
 motion to the circulating corpuscles sufficient to
 
 GENERAL DISEASE. 
 
 overthrow the balance of their inherent forces and 
 effect their continuous deposition. 
 
 Where thrombi form at the mouths of wounded 
 vessels, upon valves that have suffered inflammation, 
 as in endocarditis and phlebitis, upon tumours pro- 
 truding into vessels, or upon the walls of atheroma- 
 tous arteries, the conditions sustain the inference that 
 a passage of molecular energy from the immediate 
 investment of the blood is the cause of the coagula- 
 tion. In these cases, as in cases of inflammation, the 
 remote origin of the changes in surround ing struc- 
 tures, upon which thrombi so commonly depend, is 
 not in all instances certainly known. Nevertheless, in 
 numerous instances, the starting-point in the series 
 of causes is indubitably among the forces externally 
 incident. If in endocarditis the qualitative change 
 in the living membrane of the heart is the immediate 
 forerunner of thrombosis, the inflammation of the 
 endocardium we find related to some impurity of the 
 blood, and the cause or causes of this impurity may 
 generally be traced to some form of external energy. 
 This is the case with endocarditis from rheumatism, 
 measles, and scarlet fever. 
 
 The remote antecedents of thrombosis sequential 
 to aneurism, phlebitis, and atheroma, may, in part, 
 be traced to the conditions of the individual life. 
 Efficient causes of aneurism are found in atheromatous 
 disease and increased arterial pressure. The frequency 
 of aneurism among those whose occupation entails 
 great stress being put upon the heart and vessels, 
 shows us that the absorption of energy in undue 
 functional exercise is an important factor. Soldiers,
 
 THE RETROGRADE METAMORPHOSES. 43 
 
 ironworkers, and others who perform severe manual 
 labour, are the chief sufferers from aneurism. And 
 atheroma itself may possibly be related to the same 
 causes. Its common seats are those points in the 
 arterial system where friction of the blood is most 
 felt, as at the arch of the aorta, at the bifurcations 
 of arteries, in the pulmonary artery when the right 
 ventricle is hypertrophied. There are also unknown 
 factors in the production of atheroma. 
 
 Of phlebitis, its associations with the specific 
 fevers, pyaemia, and gout, may be alluded to as indi- 
 cating its connection with external incident forces. 
 
 The remaining qualities of the dissolutional pro- 
 cess can be inferred of thrombosis, since it is but a 
 variety of blood -coagulation in which the change 
 from a definite, coherent heterogeneity to an indefi- 
 nite, incoherent homogeneity, was perceived, indeed, 
 to obtain. 
 
 The softening, putrefaction, and desiccation to 
 which thrombotic coagula are liable exemplify disso- 
 lution carried a step further ; and so does the so- 
 called organisation of thrombi. In the process of 
 becoming organised the substance of a thrombus is 
 not an active participant ; it is dead matter and can- 
 not give origin to a new formation. Its role is a 
 passive one ; the fibrinous substance is disintegrated 
 and resorbed by the wandering cells from neighbour- 
 ing structures. These cells uniting to form, with 
 young vessels from the rasa va.sorum, a granulated 
 tissue, a cicatricial mass having the characters of con- 
 nective tissue is developed. 
 
 Particles detached from the substance of a throin-
 
 44 GENERAL DISEASE, 
 
 bus may be carried into different divisions of the 
 arterial system and, becoming arrested in arteries or 
 capillaries, give rise to embolism. This involves trans- 
 formations recognisable as dissolutions. Emboli 
 have also, of course, other sources of origin, as neo- 
 plasms, vegetations, fat, pigment, &c. They may 
 bring about inflammation and irritation of vessels, and 
 in the brain the phenomena of apoplexy ; but these 
 results we shall pass over, being here interested only 
 in the infarctions which embolism occasions. 
 
 Infarction is a common consequence of the plug- 
 ging of end-arteries, and may be either ha3morrhagic, 
 in which case the wedge-shaped piece of tissue 
 possesses the general lineaments and attributes of a 
 blood-clot ; or the infarction may be necrotic, in 
 which case the metamorphosis is a species of coagu- 
 lation-necrosis ; a solid homogeneous mass is sub- 
 stituted for the normal structure. In both of these 
 effects of an embolus the individualities of the tissue 
 elements are sooner or later completely effaced by the 
 redistribution of matter ; the mass exhibiting no 
 marks of organisation. 
 
 The conditions under which necrotic infarction 
 occurs have suggested that stoppage of nutritive 
 supply is the proximate cause of the death of the 
 tissue. Can local or systemic death from starvation 
 be harmonised with the doctrine of dissolution, which 
 requires an absorption in excess of outside forces ? 
 Dissolution from innutrition implies a deficiency of 
 ingested energy, since food is the source of organ- 
 ismal power. 
 
 The answer is, that, failing due nourishment, the
 
 THE RETROGRADE METAMORPHOSES. 45 
 
 organism, or any of its units, becomes prey to its 
 circumstances. It is no longer able to resist, from its 
 store of ingrained power, the disintegrating actions 
 that beset it ; the wear and strains of its own sub- 
 stance, mechanical pressures, the chemical and ther- 
 mal actions that encompass it. So that while 
 withdrawal of food-material is in itself a subtrac- 
 tion from and not an addition to the total energy 
 obtained from without, it makes possible such an 
 absorption as suffices to cause disintegration and 
 dissolution. 
 
 One of the immediate resulting phenomena of 
 embolism of an artery is diapedesis. As an ele- 
 ment of the dissolutional process diapedesis has re- 
 ceived notice in the chapter on Inflammation. The 
 intimate changes in necrotic infarction will be given 
 in the next section. 
 
 3. GANGRENE, COAGULATION-NECROSIS, AND ALLIED 
 METAMORPHOSES. 
 
 In gangrene of external parts the predominating 
 transformations are those of putrefactive decomposi- 
 tion, which transformations strikingly coincide with 
 the terms of the formula. When dead tissues are 
 freely exposed to the actions of the outer forces there 
 is a copious consumption of kinetic energy, and a 
 proportionately quick disintegration of substance. 
 By invisible motion in the shape of heat, and by the 
 chemical action of the atmosphere, including its living 
 constituents putrefactive bacteria and other micro- 
 organisms the tissues may ultimately be reduced to
 
 46 GENERAL DISEASE. 
 
 their simplest indefinite inorganic elements. The 
 proportional relation just mentioned between the 
 quantity of absorbed motion and the rapidity of 
 dissolution is seen in that dryness of the air and 
 lowness of temperature (a deficit of liquid, chemi- 
 cal, and thermal motion) ; the absence of bacteria, 
 and protection from oxidation, retard the process of 
 dissolution. 
 
 When necrosed tissues are internal and not ex- 
 posed to the influences of forces without, the changes 
 differ from those of ordinary decomposition. Then 
 the metamorphosis is known as coagulation-necrosis, 
 and is comparable to blood-coagulation ; the solidi- 
 fied tissue corresponding to the fibrine. As the death 
 of white corpuscles is essential to blood-clotting, so is 
 the death of tissue-cells to coagulation-necrosis. The 
 living cells contain, as the leucocytes do, fibrino- 
 plastin and ferment, and the lymphatic fluid which 
 bathes them, fibrinogen. If the cells die, and there 
 is liberation of their fibrinoplastin and ferment, the 
 tissue may coagulate. 
 
 Upon the structure of the tissue the effect is 
 similar to the effect of coagulation upon the blood. 
 At first the morphology may be distinguishable ; 
 later the nuclei of the cells disappear, then the cells 
 themselves are obscured, and at last the tissue be- 
 comes a nearly structureless or sometimes fibrillate 
 substance without differentiation of parts and without 
 organisation. 
 
 As just remarked in the preceding section, necrotic 
 infarction is an example of coagulation-necrosis. It 
 occurs also as hyaline or Zenker's degeneration of
 
 THE RETROGRADE METAMORPHOSES. 47 
 
 muscle, where * to the naked eye a portion of the 
 muscle is seen to be pale and glassy-like, resembling 
 the flesh of uncooked fish.' Muscle which under- 
 goes this transformation loses its transverse striae, its 
 fibres become friable, and readily break crosswise. 
 
 Diphtheritic exudation is another example. The 
 false membrane in diphtheria is partly an inflamma- 
 tory exudation and partly the coagulated peripheric 
 layers of mucous membrane. Coagulation-necrosis 
 has been observed in paralysed muscles, and rigor 
 mortis is probably a similar coagulation of the 
 sarcocele. 
 
 Tube-casts of the kidney are sometimes the coa- 
 gulated epithelium of tubules. Caseous necrosis is 
 a kindred change. ' The necrosed tissue presents 
 the same obscuration of the nucleus as is found in 
 coagulation-necrosis, but in addition all details of 
 structure are completely obscured by the general 
 opaque granular appearance presented by the caseous 
 material.' 
 
 Further examples of this variety of retrograde 
 metamorphosis are found in the changes of desiccation 
 and mummification, in softening or colliquefaction, 
 and in sloughing. 
 
 In each of the foregoing examples the change is 
 more or less disruptive and destructive of the elements 
 of the tissues. From the displacement of their par- 
 ticles of matter from the former foci of distribution 
 a fine or coarse disintegration results. 
 
 Our knowledge of the causes of these degenera- 
 tions is wanting in completeness, but those causes 
 ascertained imply an absorption of external energy.
 
 48 GENERAL DISEASE. 
 
 The acute fevers, as typhoid and scarlet fever, give 
 rise to hyaline degeneration of muscle. Here, besides 
 febrile heat-energy, there are the chemical energies of 
 the specific poison tending to shake the molecules and 
 particles of the living matter asunder. In all like- 
 lihood, with the progress of knowledge the origin of 
 these fevers as related to external conditions will 
 become determinately established, this being quite 
 the drift of gathering facts. The case of diphtheritic 
 necrosis lends itself to the same vaticination. 
 
 Tube-casts, whatever their composition, are very 
 probably the result of the injurious action, upon the 
 glandular cells, of chemically perverted or degraded 
 blood and urine, whether arising from disease of the 
 kidney cortex or from the quality of the blood 
 depurated by the renal gland. And changes in the 
 quality of the blood and urine are already, in very 
 many disorders, attributable to forces acting on the 
 organism from its environment (chap. vi. 2). 
 
 Caseous necrosis may be causally connected im- 
 mediately or mediately with syphilitic poison ; with 
 the conditions giving rise to tuberculosis, prominent 
 among them being the tubercle bacillus. 
 
 Desiccation and mummification are invariably 
 associated originally with the incidence of some force 
 or set of forces that has killed the tissues outright ; 
 and the details of the metamorphosis are decided by 
 the relations of the dead tissue to its environment. 
 
 Colliquefaction, especially of central tissue, is 
 often a consequence of embolism, and that form of 
 softening known as sloughing is a commonly observed 
 consequence of destructive agents. The slough
 
 THE RETROGRADE METAMORPHOSES. 49 
 
 following the application of the actual cautery, the 
 electric current, or caustic potash, will be at once 
 recalled. 
 
 And in addition to the disintegration of matter 
 and absorption of motion which these degenerations 
 more or less clearly display, the morphological and 
 physiological changes are quite overtly a transition 
 from relative heterogeneity, definiteness, and coherence 
 to relative homogeneity, indefiniteness, and incohe- 
 rence. In all, the distinctiveness of the tissues and 
 their elements is lessened, order gives place to dis- 
 order, and sameness is substituted for difference. 
 
 4. ATROPHY AND THE REMAINING RETROGRADE 
 METAMORPHOSES. 
 
 A disintegration of matter is not discernible in 
 the process of simple and numerical atrophy ; it is, 
 however, implied in the results. The dwindling of a 
 testicle from the pressure of a hydrocele, or of muscle 
 from paralysis, requires us to think that since gross 
 substance has passed into the imperceptible form the 
 particles composing it have been dispersed. The dis- 
 integration is generally a molecular one, and there- 
 fore invisible. But sensible disintegration occurs in 
 atrophy in the multiplication of nuclei (chap. v. 
 2). This is witnessed both with the atrophy of 
 adipose tissue and of muscle. And the integrated fat 
 of adipose tissue undergoes separation into distinct 
 droplets. 
 
 All atrophic changes, general or local, are the 
 effects of conditions fundamentally the same. In
 
 50 GENERAL DISEASE. 
 
 every case waste is in excess of repair ; that is, the 
 absorption of motion preponderates over its dissi- 
 pation (chap. i. 3, p. 16). 
 
 The waste may be excessive in relation to the in- 
 gested nutriment. Emaciation following stricture of 
 the oesophagus serves as an example of this. Or, 
 the food supply being normal, the tissue changes are 
 greater than normal ; this is observed in the wasting 
 from undue functional activity, as when the testes 
 atrophy from overuse ; and in hemorrhages, pro- 
 longed suppuration, and exhausting diseases. 
 
 In senile atrophy the power to assimilate nutri- 
 ment falls short of wear and tear, and this favours 
 the absorption of disintegrating energy. Diminished 
 functional action, in like manner, leads to atrophy by 
 reducing the demand of the tissues for aliment, and 
 by consequence lessening their resistance to what- 
 ever forces are incident upon them. Atrophy from 
 mechanical pressure shows a more direct relation to 
 the absorption of energy. In most cases of atrophy 
 the causes are not single and simple but multiple 
 and complexly interconnected ; yet it seems probable 
 that the conditions of any particular case will be 
 found on investigation to be those required by the 
 principle of dissolution. 
 
 For the remaining correspondences to the formula 
 we may take extreme examples of atrophy. Then 
 we find either in tissues or organs a reduction to the 
 extreme of indefiniteness, incoherence, and homo- 
 geneity. Functions and structures utterly disap- 
 pear, and with them all organisation and differentia- 
 tion. The atrophy of bone and pulmonary vesicular
 
 THE RETROGRADE METAMORPHOSES. 51 
 
 emphysema, as instances of partial atrophy, may be 
 profitably compared with the formula. 
 
 Fatty infiltration is oftener a physiological than a 
 pathological change, and therefore may be passed over 
 for the changes of fatty metamorphosis. In the latter 
 the substance of tissue- cells is actually converted into 
 fat ; the fat is not directly derived, as in fatty in- 
 filtration, from the oleaginous and other constituents 
 of food. 
 
 First the cell-body, and later the nucleus, are 
 replaced by granules of fat. In the final stage, with 
 the disappearance of the cell- wall, all that remains 
 is a disintegrating congeries of fatty particles cor- 
 puscles of Gluge. Thus the previous specialised 
 organised unlikeness of structures and functions is 
 represented by simple uniform unorganised fat. 
 
 The traits of dissolution are especially well seen 
 in cerebral softening, in which fatty degeneration 
 plays a leading part. ' The white substance of the 
 fibres first coagulates, then breaks up into masses of 
 various sizes (myeline), and these usually undergo 
 more or less fatty metamorphosis. The cells of the 
 neuroglia, the small blood-vessels, and, when the 
 grey matter is implicated, the large nerve-cells, are 
 also involved in the change. The tissue is thus 
 converted into broken-down fibres, granular matter, 
 and molecular fat.' But the process and results are 
 essentially the same in all structures in muscles, in 
 vessels, and the tissues of viscera. 
 
 A satisfactory demonstration of absorptions of 
 
 E 2
 
 52 GENERAL DISEASE. 
 
 energy as the causes of fatty metamorphosis appears 
 to be impossible as these causes are at present under- 
 stood. When resulting from phosphorus and alcohol 
 poisoning, or from high temperatures, the absorption 
 is evident. It cannot positively be said to occur 
 when fatty metamorphosis proceeds from deficient 
 nutritive and blood supply, as it does so frequently. 
 The chemical changes involved in the transformation 
 of protoplasm into fat are unknown, though im- 
 perfect oxidation is a recognised condition. Un- 
 doubtedly the albuminous constituents of the cells 
 split up into the more simple substance, and the 
 decomposition, we must suppose, is effected by 
 incident energies. 
 
 Mucoid, colloid, and amyloid degeneration respec- 
 tively accord in part with the formula. The meta- 
 morphosis is of the albuminous elements of the 
 tissues ; these are turned into dead homogeneous 
 material of less complex chemical composition 
 mucin, colloid and amyloid matter. 
 
 When the mutations are advanced, all distinction 
 of parts may vanish, functions are abolished, and no 
 signs may remain of the former varied, concerted, and 
 determinate structural units. As witji the degenera- 
 tions previously considered, the present changes are 
 probably chemical decompositions involving the re- 
 moval of matter from around its former atomic or 
 molecular centres of arrangement. 
 
 Nothing is known as to the etiology of mucoid 
 and colloid decay, and the conditions of lardaceous 
 or amyloid disease are not well understood. The 
 frequent association of the latter with syphilis and
 
 THE RETROGRADE METAMORPHOSES. 53 
 
 long-continued suppuration point to the indirect in- 
 fluence of external forces. 
 
 Calcareous and pigmentary degenerations are not 
 pronounced as pathological changes, and so do not 
 exemplify dissolution very distinctly. The deposition 
 of calcareous particles and pigment in the substance 
 of cells does, however, lead to partial obliteration of 
 histological elements, and to inco-ordinations of 
 function. 
 
 In the tissue transmutations of pyrexia, ' cloudy 
 swelling,' or granular degeneration, as it is called, 
 the same obscuration of the forms and contents of 
 cells is observed. The nature of the change and its 
 association with acute disease signify its dependence 
 upon the action of disintegrating energies. 
 
 5. WALLERIAN DEGENERATION OF NERVE AND 
 ACUTE NEUROTIC ATROPHY OF MUSCLE. 
 
 These pathological states are taken together be- 
 cause they have much in common in respect of the 
 microscopic structural changes. 
 
 It is desired to show their remarkable exempli- 
 fication of dissolution. 
 
 Wallerian degeneration may be induced by section 
 of a nerve ; it is also associated with injury and 
 disease of the central conducting paths of the cord. 
 If in divided nerves the distal portion is not allowed 
 to reunite with the central portion, it will suffer 
 Wallerian paralytic degeneration, with the following 
 microscopic appearances. 
 
 Note in how many ways matter is disintegrated.
 
 54 GENERAL DISEASE. 
 
 The substance of the medullary sheath the myeline 
 becomes first separated into cylindrical masses, and 
 afterwards completely broken up into globular masses 
 and granules. 
 
 And in addition to this physical disintegration 
 there is a chemical one : the myeline is decomposed, 
 fat remaining as the residue. There is also dis- 
 integration by proliferation ; the interannular nuclei 
 multiply so that three or four may be seen within the 
 space of an internode. At a late stage the axis- 
 cylinder divides, and is ultimately destroyed ; absorp- 
 tion of this element and of myeline being followed 
 by shrinking of the nerve- sheaths ; and nerve-fibres 
 are then collapsed and wasted. 
 
 A new formation of protoplasm within the neuri- 
 lemma is spoken of, and, if it actually occurs, is a 
 subordinate evolution (chap. iii. 1). Usually fat 
 granules and myeline are interspersed through the 
 normal protoplasm, and this may give a mere sem- 
 blance of protoplasmic increase. 
 
 Thus, when Wallerian degeneration is set up by 
 nerve-section the absorbed mechanical energy, which 
 disintegrates the nerve by severance of its continuity, 
 initiates a disintegration of all the specialised in- 
 dividual neural elements. And the principle of dis- 
 solution is further satisfied by the resulting disarrange- 
 ments of function and structure ; by the reduction to 
 extreme indefiniteness, for axis-cylinder and medulla 
 pass out of existence ; and by the effacement of all 
 functional and structural elaboration. 
 
 Three stages of neurotic muscular atrophy have
 
 NEUROTIC MUSCULAR ATROPHY. 55 
 
 been distinguished : simple atrophy, atrophy with 
 division of nuclei, and atrophy with cirrhosis. 
 
 Taking the stage fharked by the multiplication of 
 nuclei, which serves our purpose the best, we find 
 changes quite analogous to the changes of nerve in 
 Wallerian degeneration. The contractile substance 
 of the fibres assumes a granular degenerated appear- 
 ance, becomes fatty, and is finally absorbed. The 
 nuclei of the muscle corpuscles multiply abundantly, 
 and sometimes fill the sarcolemma, the muscle- 
 fibres in the end being wholly extinguished. 
 
 Subsequently the nuclei of the endomysium, or 
 the corpuscles of connective tissue, proliferate and 
 form new connective tissue. This, called cirrhosis of 
 muscle, is, however, a secondary regenerative process 
 quite opposite to, and not to be confounded with, the 
 process we are contemplating. 
 
 Neurotic muscular atrophy is not as definitely 
 related to the action of disintegrating forces as Wal- 
 lerian degeneration from the simple division of nerves, 
 for its conditions are often very intricate. It is fre- 
 quently the consequence of injury or disease of the 
 motor ganglion cells of the grey matter of the cord, 
 and is found joined with 'acute central myelitis, 
 spinal apoplexy, fractures and luxations of the ver- 
 tebral column, infantile spinal paralysis, and related 
 diseases.' 1 In some of these an absorption of energy 
 is determinable, but this cannot be asserted of those 
 cases where the first causes are unknown. 
 
 We see how the many contrasted elements of 
 
 1 A Treatise on the Diseases of tfie Nervous System, by James Ross, 
 M.D.,LL.D.
 
 56 GENERAL DISEASE. 
 
 iimscle-fibre-'-the sarcous elements, muscle corpuscles. 
 Hensen's and Krause's membranes are reduced to 
 the grade of uniform granules and fat ; and that all 
 order and speciality of both structure and function 
 are brought to an end.
 
 57 
 
 CHAPTER IV. 
 
 THE CHANGES INDUCED BY VEGETABLE AND ANIMAL 
 PARASITES AS EXEMPLIFYING DISSOLUTION. 
 
 PARASITES, by their presence within or upon the body, 
 excite, for the greater part, diseases of the inflam- 
 matory class ; and inflammation, as we have seen 
 (chap. i. 2, 3, 4), accords closely with the formula. 
 
 Beginning with vegetable parasites of the natural 
 order Schizomycetes, micrococci play a superordinate 
 part in septicaemia and pyaemia. In these affections 
 the disintegrating action of micro-organisms upon 
 the cells and fluids of the body has been clearly 
 established, and the general, changes of function and 
 structure are those of dissolution (cf. chapters on 
 Special Diseases). 
 
 Anthrax, or splenic fever, caused as surely by 
 micro-organisms (bacilli) as any other disease, evi- 
 dences exactly corresponding changes by haemor- 
 rhages, ecchymoses, inflammatory exudations, suppura- 
 tion, and sloughing. The efficient condition of scarlet 
 fever is believed to be the inception of a micrococcus. 
 And we see in these, as in other diseases conjectured 
 to emanate from the actions of this kind of parasite, 
 that the disintegrations, if proceeding from the as-
 
 58 GENERAL DISEASE. 
 
 signed causes, are due to the reception of external 
 motion. For, whether micro-organisms disintegrate 
 the body by the direct influence of their protoplasm 
 upon animal protoplasm, or by the chemical agency 
 of their decomposition products, disruptive energy is 
 communicated. 
 
 Bacterium termo is concerned in putrefactive de- 
 composition where protoplasm is split up into pep- 
 tones, peptones into leucin and tyrosin, and these 
 into simpler substances. In the septicaemia of mice, 
 bacilli may be seen in the act of breaking up the sub- 
 stance of white corpuscles. 
 
 The pathogenic moulds, or hypomycetes, are the 
 causes of Favus, Tinea tonsurans, Tinea circinata, and 
 Tinea sycosis, in which the disintegrations and other 
 changes of inflammation are found. In Tinea unguium 
 the nails become fragile, that is, disintegrate. 
 
 Of the Entozoa, or internal animal parasites, it will 
 be remembered that Distoma hepaticum produces 
 rot significant word in sheep ; and other Trema- 
 toda. as Distoma sinense and Distoma haBmatobium, 
 produce paralytic and haBinorrhagic dissolutions. 
 
 Would it not uselessly postpone the exposition of 
 diseases to be made in later chapters, it might here be 
 made plain that the primary phenomena of all para- 
 sitic diseases are in agreement with the principle of 
 dissolution. The essential functional and structural 
 perturbations from Tamia solium and its cysticercus, 
 from Tasnia echinococcus, Bothriocephalus latus, Tri- 
 china spiralis, and the rest, are changes to diminished 
 definiteness, coherence, and heterogeneity ; and that 
 absorbed energy is the cause of these changes is quite
 
 VEGETABLE AND ANIMAL PARASITES. 59 
 
 patent. Intercurrently, there are, as in other diseases, 
 minor evolutions. We must so consider the forma- 
 tion of the hyaline membrane found in hydatid cysts, 
 and the new development of encapsuling connective 
 tissue which the presence of certain entozoa leads to. 
 It is needless to say that the Epizoa, or external 
 animal parasites, Acarus scabei, pediculi, and the larvae 
 of insects, yield phenomena in strict parity with the 
 foregoing.
 
 60 GENERAL DISEASE. 
 
 CHAPTER V. 
 
 NEOPLASMS AS EXEMPLIFYING DISSOLUTION AND 
 EVOLUTION. 
 
 1. THE INFECTIVE TUMOURS, 
 
 INFECTIVE tumours, or granulomata, occupy, both 
 histologically and clinically, a position intermediate be- 
 tween the inflammatory new formations and the true 
 tumours. Granulomata correspond morphologically 
 to embryonic reparative tissue granulations and, 
 like the true tumours, are reproduced in distant 
 places, being infective. Their infectiveness, however, 
 rather resides in their causes in most examples 
 micro-organisms not in a power of autonomous 
 growth, such as the true neoplasms exhibit. We 
 may, therefore, take the granulomata for examination 
 before the other forms of new growth. 
 
 Since infective tumours manifest a tendency to 
 the formation of cicatricial tissue, the life-history 
 shows alternations of dissolution and evolution. 
 
 Syphilitic granuloma may be considered as typify- 
 ing this class of new growths. If we scrutinise the 
 microscopic features of a hard chancre, there is found 
 beneath the epidermis a replacement of the normal 
 tissue by a congeries of indifferent cell-forms. Now
 
 NEOPLASMS. 61 
 
 whence come these ? Are they derived from the 
 normal units of the organism ? or are they imported 
 with the virus of syphilis ? That syphilitic granu- 
 loma is capable, though with difficulty, of differentia- 
 tion into connective tissue may be trusted alone as 
 conclusively testifying to a community of nature be- 
 tween the indifferent cells of infective tumours and 
 the ordinary formative cells of the body. If the 
 cytoblasts of the new growth were specific their 
 developmental changes would be specific. 
 
 Concerning the origin of these indifferent cells, it 
 appears safe to infer that the virus of syphilis sets up 
 an inflammatory process, destructive in some cases of 
 the higher structural units. From the more stable 
 connective- tissue cells, and perhaps emigrant blood- 
 cells, there is produced a cellular mass with the 
 characters of granulation tissue. But whatever the 
 process of the metamorphosis, we are more especially 
 interested in the results. Without question the func- 
 tionally and structurally complex specialised and 
 multiform normal tissue-cells are replaced by simple 
 cells having little organisation and great uniformity 
 of parts. And with equal certainty the parts dis- 
 placed have been destroyed, and therefore their sub- 
 stance has been disintegrated, and this from an 
 absorption of energy, as the virus of syphilis. Hence 
 the transformations of matter and motion, culminat- 
 ing in syphilitic granuloma, are the transformations 
 of dissolution. 
 
 If the indifferent cells, of which granulomata are 
 chiefly and characteristically composed, pass through 
 the further changes which end in the production of
 
 62 GENERAL DISEASE. 
 
 connective tissue, the formula of evolution will, as in 
 the case of repair, generalise those changes. If the 
 transformations end, as they often do, in caseation, 
 coagulation necrosis, and ulceration, these, as was 
 seen (chap. i. and chap. iii. 3), are a continuation 
 of the process of dissolution. 
 
 The morphology of the remaining varieties of 
 infective tumour acute miliary tuberculosis and 
 tubercle, glanders and farcy, lupus, leprosy, and 
 framboesia, bovine tuberculosis and actinomycosis 
 does not differ in necessary nature from the morpho- 
 logy of syphilitic granuloma ; as in the last-named, 
 the lesions are essentially a local conversion of nor- 
 mal into granulation tissue, inclosing in addition to 
 irregular cell-forms those chemical and organic ele- 
 ments which give specificity to the new formations. 
 
 Our knowledge of the causes of these diseases, 
 incomplete as it is, is an implied recognition of 
 energy transferred from the environment to the or- 
 ganism. To the Bacillus tuberculosis is assigned the 
 leading part in the genesis of tubercle and perlsucht. 
 The nature of the agent or agents producing glanders 
 and farcy is unknown ; these diseases are, however, 
 highly contagious a fact suggesting that their causes 
 may come from without. 
 
 Lupus, leprosy, and framboesia are surmised to 
 depend each upon a peculiar virus or micro-organism ; 
 and actinomycosis is etiologically ascribed to the ray- 
 fungus, whence comes the name of the disease.
 
 NEOPLASMS. 63 
 
 2. THE SIMPLE AND COMPOUND TISSUE TUMOURS 
 (EXCLUDING CYSTOMATA AND TER ATOM ATA). 
 
 The phenomena of tumour formation will not fall 
 into like order with the morbid phenomena we have 
 already surveyed, unless the data are true. General 
 laws when applied to new classes of particulars yield 
 new products only when the particulars are purged of 
 inaccuracies. Since, therefore, our knowledge of the 
 nature and causes of tumours is admitted by all to 
 be at present extremely unsettled, it is requisite to 
 attempt an adjustment of some of the data to be now 
 dealt with. 
 
 The subject is one of transcendent interest on 
 philosophical as well as on practical grounds, and is 
 deserving of ampler treatment than we shall here be 
 able to accord it. But the object is not to offer a 
 rationale that will be on all points conclusive to the 
 physician. One having such general validity as will 
 justify the application of the principles of evolution 
 and dissolution will satisfy present purposes. To 
 present an argument that might be thought worthy 
 of the subject would be to destroy whatever sym- 
 metry this work may possess. As it is, the proposed 
 attempt to co-ordinate the facts will necessitate a 
 divagation of such dimensions that I fear the good- 
 nature of the reader will be strained. Yet some 
 indemnification will accrue if, as is anticipated, the 
 tentative conception to be unfolded ultimately proves 
 to contain the essentials of a true hypothesis. First, 
 we may consider the nature of tumours, and it will
 
 64 GENERAL DISEASE. 
 
 afford an introduction to the subject if we look for a 
 moment at the tenability of an hypothesis that has 
 obtained much advocacy the hypothesis of Em- 
 bryonic Remains. 
 
 Of late renewed attention has been directed to 
 Professor Cohnheim's suggestion that tumours are 
 produced by the formative activity of embryonic 
 rudimental cells. It is supposed that, owing to some 
 development fault, embryonic cells not required in 
 ordinary growth and differentiation are left over in 
 the tissues. Under unknown influences these em- 
 bryonic remains germinate and form neoplasms. 
 
 In speaking of the reasons pro the hypothesis, it 
 may first be said that the hypothesis has higher 
 credentials as applied to certain teratomata and other 
 congenital tumours. It will be remembered that 
 these are excluded from the present discussion. 
 
 Important evidence is not wanting to prove the 
 existence of the required germs, and there are good 
 reasons for regarding them as the source of mesoblas- 
 tic neoplasms. Undeveloped pieces of cartilage have 
 been discovered by Professor Virchow in the shafts 
 of long bones. These cartilages are believed to give 
 origin to tumours. Mr. Bland Sutton, F.R.C.S., ex- 
 amining foetal fingers, has discovered little nodules 
 of undeveloped cartilage in the phalanges, and from 
 these may arise subungual exostoses. Odontomata 
 and dentigerous cysts ' may be positively ascribed to 
 pre-existing teeth-germs which never advanced to 
 maturity.' 
 
 As indirect evidence it is argued that cysts are 
 known to originate in obsolete canals and tubules ;
 
 NEOPLASMS. 65 
 
 as in the tubules of the parovarium and the duct 
 of Gartner. Tumours are frequently found where 
 development is presumed to be complicated, and 
 therefore where errors are like to arise. The orifices 
 of the body are such places ; the mouth, the cardiac 
 and pyloric openings, the external os uteri where 
 4 Miiller's ducts opened into the urogenital sinus.' 
 At these points there are transitions in the character 
 of the epithelium. 
 
 This is, in brief, the foundation upon which 
 Cohnheim's hypothesis rests, though the argument 
 might be strengthened from collateral sources. 
 
 Against the hypothesis it has been urged that the 
 proof offered of the existence of embryonic rudi- 
 mental cells is inadequate. Excepting the cartilage 
 islands nothing is actually known of such cells. 
 
 The hypothesis is infertile in explanation, not 
 supplying us with a better understanding of the 
 general pathology of neoplasms. It is also in conflict 
 with many facts ; for instance, it is opposed to the 
 well-established dependence of many varieties of 
 tumour upon the agency of external irritants ; nor 
 would it be valid to account for one form of neoplasm 
 grafted upon another, as happens in the cancerous 
 degeneration of adenomata. 1 
 
 As an alternative hypothesis, to fill if possible the 
 want which the preceding leaves unsatisfied, it is here 
 suggested that the formation of a tumour is a ' seed- 
 ing ' of the natural plastids of the body. As repro- 
 
 1 The writings of Mr. J. F. Payne, M.B., F.R.C.P., in the British 
 Medical Journal for 1874, part i. , may be consulted for much that 
 bears upon the acceptability of this explanation of the origin of 
 tumours.
 
 G() GENERAL DISEASE. 
 
 duction for the entire individual is effected by organs 
 ovaries and testes specialised for the purpose, repro- 
 duction for the individual units is accomplished by 
 the units themselves. Since the process is by fission 
 or nuclear segmentation, it is an example of agamo- 
 genesis, or asexual genesis, the only mode of repro- 
 duction known in Protozoa ; and in all probability 
 it is a reversion to this primal type of multiplication. 
 
 In the course of evolution the transition from 
 the protozoan simple, unicellular condition, to the 
 metazoan compound, multicellular condition, was 
 marked by the assumption on the part of special 
 cells of the procreative function. Protozoan asexual 
 genesis is, however, retained by the cellular units of 
 Metazoa ; growth and repair are effected by asexual 
 cell-multiplication ; but the reproductive process is 
 not a separation : it is an accrescence. Growth and 
 repair thus differ from the simplest kind of genesis 
 in being a continuous, not discontinuous, increase of 
 cells. It is to be observed that in Protozoa growth 
 and reproduction are one ; the aboriginal form of 
 organic increase is a discontinuous multiplication. 
 Since this point is of some importance as a consti- 
 tuent of the conception now being presented, further 
 exposition is desirable. 
 
 In tracing out the evolution of structural forms 
 among the different animal and vegetal groups, Mr. 
 Spencer has argued most forcibly to show that, 
 beginning with aggregates of the first order, which 
 consist of unicellular organisms living and propa- 
 gating as discrete bodies, the superior orders arise by 
 the union and compounding of these single cells. 
 ' The transition to higher forms begins in a very
 
 NEOPLASMS. 67 
 
 unobtrusive manner. Among these aggregates of the 
 first order, an approach towards that union of which 
 aggregates of the second order are produced is 
 indicated by mere juxtaposition. Protophytes mul- 
 tiply rapidly, and their rapid multiplication some- 
 times causes crowding. When instead of floating 
 free on the water they form a thin film on a moist 
 surface, or are embedded in a common matrix of 
 mucus, the mechanical obstacles to dispersion result 
 in a kind of feeble integration vaguely shadowing 
 forth a combined group.' By increasing mass and 
 defihiteness this second order of aggregates is per- 
 fected, and by coalescence with like aggregates and 
 by physiological divisions of labour organisms of the 
 third order arise, and so on through higher degrees 
 of composition. So that, assuming the primordial 
 mode of organic growth and reproduction to be a 
 separation of the proliferating units, coherent aggre- 
 gates have been evolved by arrest of this separa- 
 tion, and specialised reproductive organs have arisen 
 with the differentiations wrought by adaptation and 
 natural selection. 
 
 The fundamental likeness of nature thus precon- 
 ceived between growth and genesis is the source of 
 the difficulties met with when attempts are made to 
 construct classifications of forms of growth (increase 
 of mass), forms of development (increase of struc- 
 ture), and forms of genesis (increase of individuals). 
 Classifying from any one of these points of view, 
 there will inevitably be included phenomena classible 
 from the other points of view. 1 
 
 1 See Principles of Biology, chap. vi. 
 
 F 2
 
 68 GENERAL DISEASE. 
 
 And a like difficulty would confront us in the 
 classifying of tumours as modes of tissue-genesis. If 
 according to the present hypothesis all primary new 
 formations are the asexual products of existing tissue, 
 the offspring are found sometimes closely assimilated 
 to the parent cells both in structure and function so 
 closely as to be almost indistinguishable, and therefore 
 without that distinctive attribute of a tumour, a more 
 or less definite individuality. 
 
 Every degree of autonomy is observable in neo- 
 plasms : from the almost completely independent 
 cells of very diffluent round- celled sarcoma to fatty 
 tumours welded with contiguous structures in such 
 manner that no line of demarcation can be drawn 
 between the tissues which are normal and those 
 which are abnormal. 
 
 If we make the continuity and discontinuity of 
 the processes a basis of distinction between growth 
 and true genesis, the following table, modified from 
 the ' Principles of Biology,' will give the relations : 
 
 ' Continuous, J ' I including agamogenesis 
 
 which is . ( njg^ojv, ^ n } f plants and animals. 
 Cellular pro- 
 liferation is 1 Discontinuous (homogenesis } gamogenesis. 
 
 which is or gamogenesis alterna- 
 
 ' (heferogenesis I ting with discontinu- 
 ) ous agamogenesis. 
 
 Continuous asexual reproduction (agamogenesis) 
 is the accretive development of the morphological 
 units of composition in compound plants and animals. 
 Each separate shoot of herbs, shrubs, and trees, con- 
 sisting of an axis, foliar appendage, and axillary bud, 
 is regarded as an individual ; and in the compound
 
 NEOPLASMS- 69 
 
 Hydrozoa, each bud in a colony of corynids is one of 
 a community. This form of reproduction it appears 
 better to distinguish as a form of growth, making the 
 difference between growth and genesis one of un- 
 interruption and interruption respectively of the 
 processes. 
 
 We may say, then, that normal growth, hyper- 
 trophy, repair, and so-called inflammatory new forma- 
 tion, to which neoplastic growth bears many resem- 
 blances, are distinguished from true genesis in that 
 they are continuous processes ; and we reach the 
 important fact that neoplastic growth is like genesis 
 in being discontinuous discontinuous in the sense 
 that the reproduced cells are independent of the re- 
 producing cells. Both functionally and structurally 
 tumours are segregated with varying degrees of definite- 
 ness from the tissues in which tJiey live, and this auto- 
 nomy is sui generis of them. 
 
 Let us now see if this supposed derivation of 
 tumours is substantiated by several classes of facts. 
 Does the embryology of tumours render any confirma- 
 tion ? If tumours begin as offshoots of normal parts ; 
 if they are, as assumed, the yield of tissue-germs or 
 seeds, then in the first period of their life-history 
 they will be germ-like in appearance. This, \ve find, 
 they are. Probably, whatever the structure of a 
 tumour whether of epiblastic, hypoblastic, or meso- 
 blastic tissue in the embryonic stage, the morpho- 
 logy is the same. 
 
 Tumours of connective-tissue type mesoblastic 
 tumours are known to consist at first of ' indifferent 
 tissue,' accumulations of small spheroids of proto-
 
 70 GENERAL DISEASE. 
 
 plasm not to be discriminated from the cells of granu- 
 lations ; they have, indeed, the characters of amvebce, 
 organisms of the natural order Protozoa. ' The first 
 stage in the process of development consists in the 
 formation of an embryonic tissue, and this embryonic 
 tissue subsequently develops into the tissue of which 
 the new growth is composed.' 
 
 That tumours of epithelial type are, when em- 
 bryonic, of like structure, is very probable, though 
 many observations upon this point are not recorded. 
 The accompanying figure (fig. 2) shows the advanc- 
 
 FlG. 2. SCIKRHUS OF THE MAMMA. 
 
 A thin section from the most external portion of the tumour, showing the 
 sma.l-celled infiltration ('indifferent tissue') of the muscular fibres and 
 adipose tissue in the neighbourhood of the gland, x 200. 
 
 ing edge of a carcinoma ; and we may, I think, believe 
 that its ' indifferent tissue ' represents an early stage 
 in the development of all epithelial tumours. The 
 almost immediately following illustration of nephritic 
 cancer greatly encourages this belief. 
 
 Starting thus from normal cells, the growth of a 
 neoplasm, its mere increase of mass, appears to result 
 partly from the multiplication of its own units, and 
 partly from the continued division of the protoplasm 
 of healthy tissue. In primary cancer of the kidney 
 this germination of the body's substance has been
 
 NEOPLASMS. 71 
 
 actually witnessed. Then * the tumour is virtually 
 a cancerous degeneration of the organ. The kidney 
 may be completely converted into a tumour which 
 sometimes attains a very large size, retaining the 
 general shape of the organ, and covered by its capsule. 
 But in some cases only a part of the kidney is in- 
 volved, and in that case while the affected part retains 
 the general shape of the organ, although enlarged, 
 the remaining piece of the kidney has quite the 
 normal appearance. To the naked eye it is as if a 
 portion of the kidney were transformed, and with the 
 microscope it can be seen, at the margin of normal 
 and pathological, that the tumour is advancing by 
 a conversion of the proper kidney tissue. The epi- 
 thelium of the tubules is multiplying so as to form the 
 cancerous epithelium, and is becoming irregular in 
 form while the cancerous stroma is being formed of the 
 connective tissue of the organ." 1 Also, ' at the marginal 
 parts of an epithelioma of the tongue, for instance, 
 it can nearly always be seen how the normal epithe- 
 lium is extending and penetrating inwards/ 
 
 And it consists with the present hypothesis that 
 not only normal but abnormal tissues are the parents 
 of new growths. If neoplasms are the asexual pro- 
 geny of the individual cells of the organism, and the 
 genetic process is a reversion to the simplest form 
 of reproduction, then pathological structures may 
 exhibit the phenomenon. Now various kinds of 
 imperfectly developed and redundant tissue are well 
 known to be the sources of neoplasms. From nrcvi, 
 warts, and moles they not infrequently arise. And 
 uterine polypi, dermoid and other tumours, may
 
 7 ''2 GENERAL DISEASE. 
 
 undergo cancerous degeneration, a tumour giving 
 origin to a tumour. 
 
 It will readily be granted that if the cells of these 
 eccentric structures are subjected, like normal cells, 
 to the conditions necessary for neoplastic activity, such 
 agamogenesis may be manifested by them. Presently 
 it will be shown that their conditions of life are pecu- 
 liarly favourable. With this view it can also be 
 understood that ' cartilage islands,' teeth-germs, and 
 functionless structures anywhere, have the potency 
 for producing tumours. 
 
 Another group of harmonising facts is comprised 
 in the histology of tumours. The morphological re- 
 lations among tumours of the connective- tissue class, 
 and among those, too, simulating the epithelial tis- 
 sues, are just what might be inferred if neoplasms 
 are local offshoots of existing parts. ' Every patho- 
 logical growth has its physiological prototype.' We 
 see the parents in the progeny. 
 
 Of tumours of mesoblastic tissue, if the germ-cells 
 reach full development we have the reproduction of 
 adult tissues fibroma, myxoma, lipoma, chondroma, 
 osteoma, odontoma, lymphoma, angioma, myoma, 
 and neuroma. If development does not advance be- 
 yond the embryonic stage there results round-celled 
 and melanotic sarcoma ; and spindle-celled, alveolar, 
 and myeloid sarcomas are slightly higher forms of the 
 preceding. Likewise, in epithelial neoplasms accord- 
 ing as the seeds develop there are encephaloid and 
 scirrhus cancers with attempts at glandular arrange- 
 ments of the elements ; or adenomata with sometimes
 
 NEOPLASMS. 73 
 
 perfect gland-structure. And so with epitheliomas, 
 cylindrical and papillary ; they repeat the parent 
 structures. If we consider the developmental changes 
 in tumours as illustrating the formula of evolution, 
 these important relations will be brought out in ex- 
 plicit detail. 
 
 Round-celled sarcoma, regarded as the most em- 
 bryonic of the connective-tissue tumours, is often in 
 point of development but little in advance of the feebly 
 integrated homogeneous protoplasmic particles of 
 which, as we have found, all neoplasms of this class 
 at first consist. ' It is an exceedingly soft tumour, 
 often half-diffluent.' Its cells are clustered with little 
 connecting substance ; nor does round-celled sarcoma 
 generally possess that compactness conferred by the 
 development of a capsule. By this as well as by the 
 superior kinds of sarcoma the formula of evolution 
 appears to be illustrated. In the process of structural 
 differentiation the small, round, discrete plastids of the 
 embryonic tumour become relatively less numerous, 
 cellular, and nucleated ; a more definite intercellular 
 substance appears ; this commences as a soft amor- 
 phous or granular matter, and later becomes fibrillate, 
 the entire structure acquiring greater concreteness. 
 
 In the gliomatous, melanotic, spindle-celled, and 
 myeloid varieties of sarcoma, the elements show 
 further advance in integration, speciality, complexity, 
 and multiformity. There is, with more or less re- 
 gularity, a progressive firmness of consistence, the 
 cells lie nearer together, and the growth is often 
 encapsulcd. And with the assumption of fusiform 
 shapes, the appearance of nucleoli, and the new
 
 71 GENERAL DISEASE. 
 
 arrangement of the cells, there may be deciphered a 
 growing resemblance to the diversiform, definite, 
 and co-ordinate tissue whence presumably they were 
 derived. 
 
 Through the myxomata and lipomata and their 
 sub-varieties, teaching the same truths, we reach 
 neoplasms copying mature forms of tissue. Biolo- 
 gically and histologically speaking, the distinction 
 between the sarcomata and fibrous, cartilaginous, and 
 osseous tumours is principally one of development, 
 however wide their clinical differences. Beginning 
 like the sarcomata in germ -protoplasm, these new 
 growths, in the nearness of their approach in struc- 
 tural characters to full-grown tissues, describe by 
 their life-changes yet more vividly the traits of evolu- 
 tion. And so of tumours of higher orders of tissue 
 the lymphomata, angiomata, myomata, and neuro- 
 mata. 
 
 Passing to neoplasms originating in epithelial 
 tissue, we find the counterpart of round -celled sarcoma 
 in encephaloid cancer ; a new growth remarkable for 
 the want of union among its elements and for the 
 simplicity of its structure. ' Encephaloid cancer is of 
 soft brain-like consistence.' ' The proportion of its 
 strorna is very small.' 
 
 Thence the transitions of growths leading on the 
 one hand to scirrhus and adenoma, and on the other 
 to epithelioma and papilloma, accord with the formula 
 of evolution. The advance in integration and the 
 concomitant dissipation of motion the advance from 
 the general to the special, from the simple to the
 
 NEOPLASMS. 75 
 
 complex, and from the uniform to the multiform is 
 very distinguishable. 
 
 In scirrhus the growth is often hard and com- 
 pact ; the cells are comparatively few, and the stroma 
 abundant. Sometimes, as in mammary cancer, there 
 are well-formed acini, the neoplasm closely repeating 
 the morphology of the parent glands. 
 
 Glandular tumours frequently resemble precisely 
 the tissue of glands. An adenoma of the mamma is 
 reported as containing acini so advanced in organisa- 
 tion as to produce milk. 
 
 Epithelioma, reproducing in different degrees the 
 peculiarities of the epithelial tissue of the regions 
 which are its common seats, exhibits by individual 
 development and the divisions of its class the same 
 degree of correspondence to the principle of evolu- 
 tion. Flat-celled epithelioma of the mouth, pharynx, 
 vagina, &c., is described in various stages of develop- 
 ment of cells and stroma ; it often grows outwards, 
 as does villous cancer, and approximates to the 
 papillomata. And cylinder-celled epithelioma, as of 
 the stomach and intestines, sometimes partakes of the 
 characters of cylinder-celled glands. 
 
 The family relationships indicated by the transi- 
 tional varieties of neoplastic growth have been given 
 perspicuous expression by Mr. Frederic S. Eve, 
 F.R.C.S. 1 ' The glandular structure of cancer is most 
 beautifully shown in cancer of the thyroid gland and 
 of the large intestine. The morbid growth in the 
 thyroid consists of gland-tubes lined with one or more 
 
 1 The British Medical Journal, Feb. 17, 188G, p. 299.
 
 76 GENERAL DISEASE. 
 
 layers of regularly arranged columnar or spheroidal 
 epithelial cells ... if the existence of transitional 
 forms can be proved between the innocent and malig- 
 nant types of the epithelial-tissue tumours, these are 
 as potent as any anatomical fact can be in the connec- 
 tive-tissue series, whether of the hard or soft parts. 
 Fibrous tumours occur in every variety, from the 
 dense compact nodules composed of parallel bundles 
 of well-formed fibrous tissue to the soft and some- 
 times semi-gelatinous growths, which, however, are 
 not malignant.' Descending from the fibre-sarcomata, 
 ' we reach the spindle-celled and finally the round- 
 celled varieties of sarcoma, in which the elemental 
 round-cell makes not the slightest effort in the direc- 
 tion of organisation, not even to the formation of a 
 spindle-cell.' The osteomata are said by Mr. Eve also 
 to present analogous intermediate forms, and the fact 
 is noted that tumours of epithelial origin may have 
 the primitive characters of round- celled sarcoma. 
 
 All these facts are at one with the supposition 
 that neoplasms result from tissue agamogenesis. It 
 quite accords, if the various tissues reproduce their 
 kinds, that there should be such individual and 
 generic differences among tumours as pathologists 
 have recorded. The continuation of internal forces 
 in the germs is expended ' in working out a structure 
 in equilibrium with the forces to which ancestral 
 organisms were exposed/ modified by existing con- 
 ditions. 
 
 It may now be inquired whether the circumstances 
 under which neoplasms are known to originate also
 
 NEOPLASMS. 77 
 
 bear witness to their being the products of a genera- 
 tive process. This will involve an investigation of 
 the causes of tumours, a subject of superlative im- 
 portance. 
 
 To appreciate the bearing and force of much that 
 will follow, the essential nature of genesis should be 
 comprehended ; it should be conceived as a process 
 of disintegration. We may take the case of tumour- 
 genesis. Tumours being hypothetically the descen- 
 dants of existing or pre-existing tissues, we have to 
 look at the transition from the normal to the abnor- 
 mal type of structure. The formed protoplasm of 
 the body gives birth, by a partition of its substance, 
 to particles capable of undergoing autonomous de- 
 velopment. Now what essentially is this parturient 
 process ? It is a disintegration of the living matter of 
 the tissues, and in so far a dissolution of it. 
 
 The process of cell-proliferation has already been 
 alluded to (chap. i. 2) as a species of disintegra- 
 tion ; but to thoroughly comprehend it as such, there 
 must be noted its analogue in those primitive organic 
 types which prefigure for us the remote ancestors of 
 the superior types. 
 
 Referring to previously cited cases of self-division 
 among the Diatomacerc, Mr. Spencer observes : l ' In 
 these cases the multiplication is so carried on that the 
 parent is lost in tha offspring the old individuality 
 disappears either in the swarms of zoospores it dis- 
 solves into, or in the two or four new individuals 
 simultaneously produced by fission.' And ' among the 
 Protozoa as among the Protophyta, there occurs that 
 
 1 Principles of Biology, vol. ii. p. 427, E. 1867.
 
 78 GENERAL DISEASE. 
 
 process by which the individuality of the parent is 
 wholly lost in producing offspring, the breaking up 
 of the parental mass into a number of germs. An 
 example is supplied by the lowest class, the Gre- 
 garina3. This creature, which is nothing more than 
 a minute spheroidal nucleated mass of protoplasm 
 having a structureless outer layer denser than the 
 rest, but being without a mouth or other organ, re- 
 solves itself into a multitude of still more minute 
 masses, which w r hen set free by bursting of the enve- 
 lope shortly become amcebaforin, and, severally as- 
 suming the structure of the parent, go through the 
 panic course.' Also, of creatures multiplying sexually 
 by the formation of sporangia and by conjugation, 
 we read that l as the entire contents of the parent- 
 cells unite to form the sporangium the individualities 
 are lost in the germs of a new generation. In these 
 minute simple types sexual propagation just as com- 
 pletely sacrifices the life of the parent or parents as 
 does that form of asexual propagation in which the 
 endochrome resolves itself into zoospores.' 
 
 In these aboriginal modes of reproduction in 
 which the dissolution of the mass is complete, and in 
 those higher modes throughout the animal and vege- 
 table kingdoms where only portions of the parturient 
 mass are sacrificed, the common relation of likeness 
 is the disintegration of the parent body. In the pri- 
 mordial types, complete disintegration ; in the derived 
 types, partial disintegration. Disintegration is, as we 
 know, a mark of dissolution. 
 
 And now we may inquire as to the causes of this 
 disintegration. Under what conditions are tumours
 
 NEOPLASMS. 79 
 
 generated ? There have been submitted cogent 
 reasons for supposing that tumour-formation is a 
 form of genesis. It may be expected, then, to show 
 some conformity to the laws of normal genesis. We 
 shall again find it useful to state in advance the 
 general conclusions that have been reached. 
 
 The conditions of genesis at large, and the known 
 circumstances under which tumours arise, lend a high 
 degree of certainty to the inference that tumour-germs 
 are set free by the tissues in the process of dying. 
 The histogenic dissolution or disintegration by pro- 
 liferation, which has just been considered as belong- 
 ing to tumour genesis, is the expression of a nearly 
 exhausted tissue- vitality. The phenomenon may be 
 put in the same category as the multiplication of 
 nuclei accompanying the death of cells from de- 
 generative changes, e.g. the atrophy of muscle, the 
 degenerations of nerve or of the cells of glands. And 
 it is paralleled by certain productive phenomena of 
 the inferior types in the organic world. It will pre- 
 sently be seen that various kinds of exhausting in- 
 fluences acting under particular conditions are the 
 causes of tumours. We may first look at some of 
 the conditions of normal genesis, and afterwards at 
 the conditions of tumour genesis. 
 
 In plants there appears to be a relation between 
 reproduction and relative innutrition. As this rela- 
 tion, if real, may prove to have important significa- 
 tions, we may quote at some length the observations 
 upon it made by Mr. Spencer. 1 
 
 ' The relation between fructification and innutri- 
 
 1 Principles of Biology, vol. i. chap. vii.
 
 80 GENERAL DISEASE. 
 
 tion among plants was long ago asserted by a 
 German biologist by Wolff, I am told. When 
 some years ago I met with the assertion I was not 
 acquainted with the evidence on which it rested. 
 Since that time, however, I have, when occasion 
 favoured, examined into the facts for myself. The 
 result has been a conviction, strengthened by every 
 further inquiry, that such a relation exists. Uni- 
 axial plants begin to produce their lateral following 
 axes only after the main axis has developed the 
 great mass of its leaves and is showing its diminished 
 nutrition by smaller leaves or stunted internodes. In 
 multiaxial plants, two, three, or more generations of 
 leaf-bearing axes or sexless individuals are produced 
 before any seed-bearing individuals show themselves. 
 When, after the first stage of rapid growth and 
 agamogenetic multiplication, some gamogenetic indi- 
 viduals arise, they do so where the nutrition is least ; 
 not on the main axis or on the secondary axes, but 
 on the axes that are most removed from the channels 
 which supply nutriment. Again, a flowering axis is 
 commonly less bulky than the others: either much 
 shorter, or, if long, much thinner. And further, it is 
 an axis of which the terminal internodes are un- 
 developed. The foliar organs, which instead of be- 
 coming leaves become sepals and petals and stamens, 
 follow each other in close succession, instead of being 
 separated by portions of still-growing axis. Another 
 group of evidences meets us when we observe the varia- 
 tions of fruit-bearing that accompany any variations of 
 nutrition in the plant regarded as a whole. Besides 
 finding, as above, that gamogenesis commences only
 
 NEOPLASMS. 81 
 
 when the luxuriance of early growth has been some- 
 what checked by the extension of the remoter parts 
 of the plant to some distance from the roots, we find 
 that gamogenesis is induced at an earlier stage than 
 usual by checking the nutrition. Trees are made to 
 fruit while still quite small by cutting their roots, 
 or by putting them in pots ; and luxuriant branches 
 which have had the flow of sap into them diminished 
 by what gardeners call ' ringing,' begin to produce 
 flower- shoots instead of leaf- shoots. Moreover, it is 
 to be remarked that trees which, by flowering early 
 in the year, seem to show a direct relation between 
 gamogenesis and increasing nutrition, really do the 
 reverse ; for in such trees the flowering buds are 
 formed in the autumn that structure which deter- 
 mines these buds into sexual individuals is given 
 when the nutrition is declining. Conversely^ very high 
 nutrition in plants prevents or arrests gamogenesis.' 
 
 These facts, with others of the same import, are 
 brought forward by Mr. Spencer as evidence that 
 high nutrition is one of the conditions of agamo- 
 genesis and low nutrition of gamogenesis. Here w r e 
 appropriate them simply to show that discontinuous 
 reproduction is conditioned in some cases by rela- 
 tively low nutrition. 
 
 In further support of this we also read l of plants 
 the cryptogamia that ' fissiparously-multiplying 
 cells in some cases fly asunder, while in other cases 
 they unite into threads or lamime or masses ; and 
 fronds originating proliferously from other fronds, 
 sometimes when mature disconnect themselves from 
 
 1 Principles of Biology, p. 48.
 
 82 GENERAL DISEASE. 
 
 their parents and sometimes continue attached to 
 them. Whether they do or do not part is clearly 
 determined by their nutrition. . . . That disunion 
 is really a consequence of relative innutrition, and 
 union a consequence of relative nutrition, is clear a 
 posteriori. On the one hand, the separation of the new 
 individuals, whether in germs or as developed aggre- 
 gates, is a decaying away of the connecting tissue ; 
 and this implies that the connecting tissue has ceased 
 to perform its function as a channel of nutriment.' 
 
 I have myself recently observed an interesting 
 corroboration cf this. Bacilli cultivated upon hard- 
 boiled egg a very rich soil may acquire gigantic 
 proportions. Bacillus anthracis thus propagated I 
 have seen of extraordinary thickness, and many times 
 longer than those grown in gelatine. 
 
 Reproduction by spores in micro-organisms is 
 also seemingly related to a deficiency of nutritive pabu- 
 lum. In the culture of bacilli it is found that when 
 the gelatine or other culture-medium is becoming 
 exhausted the bacilli are resolved into spores. With 
 test-tube cultures, spore formation takes place from 
 above downwards as the food is used up ; on the 
 surface of the gelatine where the nutriment has been 
 consumed spores are abundant, but in the deeper 
 parts multiplication is proceeding by simple division 
 of the bacillary rods. This phenomenon of spore- 
 formation, it should be stated, is viewed by Dr. 
 Klein, F.R.S., as the effect of oxygen at the surface of 
 the gelatine. Here is called to mind the observations 
 of Dr. Downes and Mr. T. P. Blunt, M.A., on the 
 effect of light and oxygen upon the protoplasm of
 
 NEOPLASMS. 83 
 
 bacteria. From the results . of their experiments, 
 which I take from Mr. Spencer's ' Factors of Organic 
 Evolution,' these observers conclude that light and 
 oxygen may combine for the destruction of the 
 protoplasm of bacteria, as they do for the destruction 
 of inorganic matter. May it not be that spores are 
 made up of partly oxidised protoplasm, and that by 
 this reduction to a semi-inorganic constitution there 
 is conferred that resistance to heat and other forces 
 which so excites our wonder in microbic spores? 
 These germs would then, perhaps, represent by their 
 molecular structure one of the evolutionary stages 
 marking the passage from the not-living inorganic 
 matter to individualised protoplasm. 
 
 But to continue the argument. Some features of 
 the segmentation of the ovum appear to me to have 
 a kindred meaning ; division of the germ-mass is de- 
 cided, other things being equal, by the distribution 
 of the food-yolk the nutritive aliment of the pro- 
 toplasm of the germ. That this is so is not uni- 
 versally assented to;- but it has the high sanction 
 of Professor Balfour, from whose work, ' A Treatise 
 on Comparative Embryology,' the following facts 
 are extracted : ' Most of the eggs, which have a per- 
 fectly regular segmentation, are of a very insignificant 
 size and rarely contain much food-yolk : hi the vast 
 majority of eggs there is present, however, a con- 
 siderable bulk of food material, usually in the form of 
 highly refracting yolk spherules. These yolk spherules 
 lie embedded in the protoplasm of the ovum, but are 
 in most instances not distributed uniformly, being 
 less closely packed and smaller at one pole of the
 
 84 GENERAL DISEASE. 
 
 ovum than elsewhere. Where the spherules are 
 fewest the active protoplasm is necessarily most 
 concentrated ; and we can lay down as a general law 
 that the velocity of segmentation in any part of the 
 ovum is, roughly speaking, proportional to the con- 
 centration of the protoplasm there ; and that the size 
 of the segments is inversely proportional to the con- 
 centration of the protoplasm. Thus the segments 
 produced from that part of an egg where the yolk 
 spherules are most bulky and where, therefore, the 
 protoplasm is least concentrated, are larger than the 
 remaining segments, and their formation proceeds 
 more slowly.' This effect of the food-yolk upon the 
 division of the protoplasm is shown by what is 
 called unequal segmentation. Here the disposition of 
 the viteline substance is unsymmetrical, the larger 
 spherules being at the lower and the smaller at the 
 upper pole. After the primary furrows have been 
 formed, the segmentation proceeds in suchwise that 
 in the later stages there are 128 segments in the 
 upper half of the ovum and 32 in the lower. This 
 action of the food-yolk is extensively manifested, and 
 on the ground of it a special terminology is applied. 
 Ova which segment uniformly are termed ' alecithal,' 
 ' as implying that they are without food-yolk, or 
 what food-yolk there is is distributed uniformly. 
 Telolecithal ova are ova in which the food-yolk is 
 not distributed uniformly, but is concentrated at one 
 pole of the ovum. When only a moderate quantity 
 of food-yolk is present, the pole at which it is con- 
 centrated merely segments more slowly than the op- 
 posite pole ; but when food -yolk is present in very
 
 NEOPLASMS. 85 
 
 large quantity, the part of the ovum in which it is 
 located is incapable of segmentation and forms a 
 special appendage known as the yolk -sack.' In 
 centro-lecithal ova the food-material is centrally dis- 
 posed ; the segmentation involves only the circum- 
 ferential zones and advances centripetally until the 
 food -yolk is reached, leaving a central undivided 
 portion. 1 
 
 It must be remembered that the segmentation 
 changes of an ovum are not to be identified with the 
 subsequent embryonic changes, the differentiation of 
 the epiblast and hypoblast, but with the primordial 
 mode of growth in Protozoa, which is a discontinuous 
 multiplication of cells (p. 66). Balfour observes : 
 ' Although the various types of segmentation which 
 have been described present very different aspects, 
 they must, nevertheless, be looked on as manifesta- 
 tions of the same inherited tendency to division, 
 which differ only according to the conditions under 
 which the tendency displays itself. This tendency is 
 probably to be regarded as the einbryological repeti- 
 tion of that phase in the evolution of the Metazoa 
 which constitutes the transition from the Protozoon 
 to the Metazoon condition.' 
 
 In what way food-yolk influences segmentation 
 Professor Balfour does not vouchsafe explanation. 
 Obviously, as he suggests, where food-yolk is present 
 almost to the exclusion of protoplasm these segmen- 
 tations will not occur, the quantity of protoplasm 
 being too small. He believes that cell-division is 
 the result of molecular changes affecting the cohesion 
 
 1 Op. cit. vol. i. p. 91 ; vide fig. 48 (2).
 
 86 GENERAL DISEASE. 
 
 of the protoplasm ' alternations of cohesion are 
 produced by a series of molecular changes the ex- 
 ternal indications of which are to be found hi the 
 visible alterations of the body of the cell and of the 
 nucleus prior to division.' I think the facts quoted 
 favour the conjecture that food -yolk so influences the 
 play of molecular forces in the protoplasm of an 
 ovum as to give relative cohesion to its particles, and 
 that this influence is nutritive. But, whatever the 
 true interpretation, there is clearly, from the pre- 
 viously given examples, a causal connection between 
 genesis and relatively low nutrition. 
 
 Genesis is also related to high nutrition. That 
 animals and plants are fertile or infertile according 
 as they are respectively well or ill nourished, is almost 
 a commonplace truth. Therefore it must be that 
 the just observed connection of reproduction in the 
 lower forms of life with deficiency of nourishment 
 is a relation to relative innutrition. In the case of 
 plants, fructification takes place at those terminal 
 points where nutritive changes are least active ; but 
 unless the general nutrition reaches a certain level 
 reproduction will not set hi at all. When once 
 inaugurated, it will, too, be furthered by abundant 
 nourishment. ' Were it otherwise, the manuring of 
 fields that are to bear seed-crops would be not simply 
 useless but injurious. Were it otherwise, dunging 
 the roots of a fruit-tree would in all cases be im- 
 politic ; instead of being impolitic only when the 
 growth of sexless axes is still luxuriant. Were it 
 otherwise, a tree which has borne a heavy crop
 
 NEOPLASMS. 87 
 
 should, by the consequent depletion, be led to bear a 
 still heavier crop next year ; whereas it is apt to be 
 wholly or partially barren next year has to recover 
 a state of tolerably high nutrition before its sexual 
 genesis again becomes large.' Among animals also 
 this is evident ; a good supply of nourishment facili- 
 tates reproduction, and the casting off of new indi- 
 viduals is generally a casting off of a surplus of 
 something over and above what is required for in- 
 dividuation. 1 
 
 There remains to be mentioned the antagonism 
 between genesis and growth, development, and ex- 
 penditure. By the laws of reproduction, whatever 
 energy is used up for growth of mass, for advance of 
 structure, and for functional work, is so much de- 
 ducted from the energy available for reproductive 
 processes. It has been established by induction, and 
 is required by deduction, that there exists an inverse 
 relation, variously complicated, between genesis and 
 growth, development, and expenditure. For the 
 elaborate arguments by which these laws have been 
 founded the reader is referred to the ' Principles of 
 Biology,' vol. ii., part vi. 
 
 And now we have to learn whether the condi- 
 tions of tumour-genesis are coincident with these 
 conditions of normal genesis. Are the relations just 
 considered reproduced in essential features in the phe- 
 nomena presented by neoplasms ? In the first place, 
 does the production of morbid growths evince any 
 relation to local nutrition ? The answer is in the 
 
 1 Vido Principles of Biology, vol. ii. chap. ix.
 
 88 GENERAL DISEASE. 
 
 affirmative ; but the relation is traversed by other 
 relations in such manner that only in a general way 
 is the truth recognisable. 
 
 The obstruction to be overcome by the blood- 
 propelling forces increases at a high rate with each in- 
 crement of distance from the central organ (the heart) 
 of the nutriment-distributing system. Hence the 
 heart, and organs clustered round the great arterial 
 trunks, will, if other things are equal, be more favour- 
 ably situated for obtaining nourishment than will 
 distant parts. Now as we proceed from the trunk 
 to the periphery of the vascular tree there is found 
 a general increase in the liability of organs and 
 tissues to new growths. (We must leave out of con- 
 sideration all secondary tumours, for their distribu- 
 tion is usually determined by the distributing systems, 
 the blood and lymph- vascular systems.) Tumours 
 of the heart itself are ' exceedingly rare,' and prac- 
 tically this organ is exempt from any liability to 
 primary new formations a singularly impressive fact. 
 Tumours of the lungs, central organs, are almost 
 invariably secondary. ' Cancer of the lung is a 
 disease of which I have no knowledge.' 1 Primary 
 cancer in them is not described. 
 
 In the very vascular liver, tumours are oftener 
 seen than in the lungs ; but, omitting cavernous 
 angioma, primary growths are comparatively seldom 
 found in the hepatic substance. And they are very 
 infrequently observed in the spleen, but as we pass 
 to the pancreas and kidney they become more 
 common. 
 
 ' Dr. Wilks, F.R.S.
 
 NEOPLASMS. 89 
 
 Receding in the same direction still further from 
 the centre of the vascular system, we reach the blad- 
 der, in which papilloma and cancer occur with fre- 
 quency. 
 
 Of the organs of generation in the male the 
 testicle is very sparingly nourished. The spermatic 
 arteries are long and slender vessels, and arise from 
 the abdominal aorta almost as high as the point of 
 origin of the renal arteries. Correlatively with this, 
 and not fortuitously, we may think, these glands 
 are peculiarly disposed to generate morbid growths. 
 Sarcomas and cancers are the usual forms, and less 
 commonly enchondromas, fibromas, myomas, &c. 
 
 Turning to the organs of generation in the female, 
 the ovaries, analogous to the testes, and similarly 
 circumstanced in respect of their blood-supply, are 
 similarly ready to undergo neoplastic degeneration. 
 In the uterus, myomas are so common that, it is 
 said, one woman in every ten is afflicted ; and some- 
 times the new centres of development are so numerous 
 that * there may be as many as fifty attached to the 
 same uterus.' The frequency of cancerous disease in 
 this organ is notorious. 
 
 Passing upwards from the heart, leaving for the 
 present the entire alimentary tract, we have remarked 
 the rarity of tumours of the lung, which organs are 
 in immediate contiguity with the heart. Now the 
 bronchus and trachea enjoy a similar immunity, but 
 the distantly situated larynx gives origin to many 
 kinds of morbid growth, including papilloma, fibro- 
 ma, mucous polypi, sarcoma, and epithelioma. The 
 favourite seats, too, are the projecting vocal cords
 
 90 GENERAL DISEASE. 
 
 and epiglottis. The brain is a fertile soil for new 
 growths. 
 
 This general proneness to tumour-genesis be- 
 trayed by tissues according as they are near to or 
 far removed from the centre of the nutrient system 
 appears in another way. 
 
 We may roughly regard the blood-vessels of the 
 entire organism, and of its organic or visceral parts, 
 as having central and peripheral dispositions. Thus, 
 for the whole body there are the great central 
 arterial trunks ; the general external periphery, the 
 skin ; and the general internal (involuted) periphery, 
 the lining tissues of the alimentary canal. For the 
 separate organs there are usually a fundus, body, or 
 base as of the uterus, stomach, and mamma and 
 extremities and surfaces. Now these terminal parts, 
 whether surfaces or points, are generally at the ends 
 of the vascular branches ; and it is remarkable that 
 here neoplasms, with few exceptions, take origin. 
 
 Looking at the case of the first of these divisions, 
 how marked is the proclivity of the skin and alimen- 
 tary canal to generate tumours, and how compara- 
 tively seldom are they generated by the interperipheric 
 tissues ! 
 
 Then, of the viscera individually, the gastric and 
 duodenal tissues furnish a very large number of 
 cancers. In this the stomach is excluded from the 
 rule that organs near the heart show exemption. 
 The usual starting-point, however, of the cancerous 
 growths is the submucous tissue of the pyloric and 
 cesophageal orifices, though they are commonly ob- 
 served clinically along the lesser curvature. Can-
 
 NEOPLASMS. 91 
 
 cers do not often grow from the fundus, nor other 
 tumours from the peritoneal surfaces where the stems 
 of the vessels are. 
 
 Apparently a similar relation to vascular supply 
 is traceable with tumours of the intestine. In the 
 caecum, sigmoid flexure, and rectum, cancers are 
 observed with a gradually increasing frequency as 
 the terminus of the gut is approached. But in the 
 centrally-situated ileum and jejunum they are scarcely 
 ever found. 
 
 And if we examine the case of the uterus, or of the 
 mammary gland, similar facts are pressed upon us. 
 It is chiefly at the peripheries of the visceral systems 
 of vessels, at the orifices and upon the internal surface 
 of the uterus and near the external surface and at the 
 nipple of the mamma, that neoplasms first appear. 
 
 These illustrations might be multiplied consider- 
 ably by noting the common situations of tumours of 
 the mouth, nose, ears, eyes, brain, and penis. From 
 the gums spring various forms of cystic tumour ; 
 and from the edges of the lips and tip of the tongue, 
 epithelioma. In the brain the peripheric hemispheres 
 are the favourite sites for glioma. Cancers spring 
 generally from the dura mater and pia mater sar- 
 comata, from the ' free surfaces of the interstitial 
 spaces.' Epithelioma of the penis begins usually in 
 the glans penis. Further, in the bones, speaking 
 generally, osteo-sarcoma arises at the extremities of 
 long bones, and from the external and internal peri- 
 pheries, the medulla and periosteum. 
 
 Very striking is the fact that sarcoma has a pre- 
 dilection for those parts of the bones where growth
 
 92 GENERAL DISEASE. 
 
 last ceases, i.e., at the ends opposite to the line of 
 direction of the nutrient arteries. The lower epi- 
 physis of the femur is the last to join the shaft, and 
 the nutrient arteries are oppositely directed towards 
 the upper epiphysis. Of seventeen central tumours 
 of the femur, ten were situated at the lower epiphysis. 
 The upper epiphysis of the tibia and humerus join 
 the shafts at twenty-five and twenty years respec- 
 tively, when growth in the rest of the bone is com- 
 plete ; and the nutrient arteries are directed down- 
 wards in both bones. Of thirteen tumours of the 
 tibia, ' eleven started in the upper epiphysis ; and of 
 eight affecting the humerus, all but one were in the 
 upper epiphysis.' The fingers and toes are extremely 
 liable to enchondromata, and upon the ends of divided 
 nerves it is common to find small fibro-neuromata. 
 
 Although the relation is confused by conditions 
 we have purposely refrained from taking into account, 
 but which will presently be dwelt upon, it is undeni- 
 able that there is an increasing propensity to generate 
 tumours in tissues according as they are remote from 
 the source of nutritive supply. And this may be 
 regarded as analogous to the connection with relative 
 innutrition which is observed in the seeding of plants. 
 
 Tumour-formation is also, doubtless, related to 
 high nutrition and excess of food. There are not at 
 present any facts to show what this relation is, but I 
 strongly suspect, on several grounds, that it is one of 
 very great practical importance. 
 
 Can there be discerned of tumour-genesis the 
 antagonism to growth, development, and expenditure
 
 NEOPLASMS. 93 
 
 established for normal genesis ? It does appear to 
 be feebly shown. 
 
 First to be perceived is- the broad fact, having 
 many exceptions, that the tumour- developing period 
 of life is the reproductive period. It is not during 
 the time of most active growth and development, but 
 in the interval between puberty and senility, that 
 tumours are of most common occurrence. Adeno- 
 mata are ' almost invariably observed between 
 puberty and the age of thirty years.' Cystic ade- 
 noma is ' most common between seventeen and forty,' 
 and myo- fibromata of the uterus have never been 
 seen before puberty. Of sixty-three cases of cen- 
 tral tumours of bones, only two occurred before the 
 age of sixteen. Of fifty-six cases of sub-periosteal 
 tumours, four-fifths occurred between the ages of 
 sixteen and forty. Again, cancer of the breast and 
 uterus are most common between the ages of forty 
 and fifty years, the period immediately preceding 
 senility of these organs. ' These diseases are very 
 rare before thirty.' Cancer of the tongue, mouth, and 
 oesophagus is most frequently observed between the 
 ages of fifty and seventy. 
 
 That other coincidences with the laws of genesis 
 are not observable is perhaps to be expected. If the 
 phenomenon of neoplasm-formation is a reversion 
 to Protozoan reproduction the conditions will only 
 partially resemble the specialised conditions of Me- 
 tazoan reproduction. But from the considerations 
 that have been advanced it will, I think, be safe to 
 conclude that the genesis of tumours ix a phenomenon 
 of the same order as reproduction in general.
 
 94 GENERAL DISEASE. 
 
 Yet this will not suffice for a satisfactory appli- 
 cation of the principle of dissolution. It will be 
 necessary to pass under notice, with all convenient 
 brevity, the remaining factors in the production of 
 neoplasms. 
 
 The reader who has followed the preceding para- 
 graphs will have mentally passed the criticism that 
 the usual sites of new growths, besides being at the 
 vascular peripheries, are also points where tissue irri- 
 tation is particularly concentrated ; and that such 
 irritation is probably a considerable factor in the 
 generation of tumours. Unquestionably this is so. 
 Irritation must be recognised among the important 
 co-operating conditions. Chemical and mechanical 
 irritants are positively known to be causes of neo- 
 plasms. Chimney-sweeper's and coal-miner's cancer 
 and the scrotal epithelioma of persons exposed to the 
 vapours of naphthaline are those specially referred to. 
 And among these may be included forms of papilloma 
 condylomata, venereal and other verrucas result- 
 ing from the irritation of unhealthy secretions. 
 
 It is not improbable that kindred causes are at 
 work in the production of gastric cancer. Usually 
 the overt declaration of this disease is preceded by a 
 long period in which dyspepsia is suffered, when the 
 prominent pyloric and cesophageal orifices will be 
 acted upon by the hurtful products of imperfect 
 digestion. And in the caecum and rectum, if fasces 
 are unhealthy their frequent stagnation at these situa- 
 tions will occasion irritation of the intestinal mucous 
 membrane. 
 
 Leucorrhoeal and morbid menstrual discharges
 
 NEOPLASMS. 95 
 
 are possibly adjuvant causes of uterine cancer ; and 
 epithelioma of the lips and tongue is known to be 
 determined by the action of tobacco or the irrita- 
 tion of clay pipes smoker's cancer. Here may be 
 pertinently mentioned the lines of cancerous nodules 
 noticed in the tracks of sutures after operations for 
 the removal of carcinoma. 
 
 It would not require prolonged search to find 
 further evidence of causes of this nature ; but we 
 must pass to another class of actions known to be 
 concerned in the bringing forth of tumours. 
 
 In the cases of so-called ' traumatic malignancy' 
 a definite relation has been made out to the infliction 
 of mechanical injury. Sarcoma following the frac- 
 ture of bones is not seldom met with. There is next 
 that comprehensive class of cases which recognises 
 inflammation as one of the antecedent conditions, of 
 new growths. Eczema of the nipple as the precursor of 
 duct cancer, to which attention has been called by Sir 
 James Paget, is one among many possible examples. 
 
 Cases evidencing another kind of instrumentality 
 are those showing the relation of tumour-genesis to 
 imperfections of development or structural inferiority 
 of tissue. Reparative or cicatricial tissue often 
 undergoes neoplastic degeneration. Tumours have 
 many times been observed to emanate from the ear- 
 ring cicatrices of the aural lobes, and with special 
 frequency from the cicatrices of burns. ' It is not 
 uncommon to see a cancerous growth in the base of 
 a healed ulcer.' Possibly traumatic neoplasms grow 
 from the newly-formed tissue of repair. 
 
 Then, as already adverted to, tumours themselves
 
 96 GENERAL DISEASE. 
 
 germinate : polypus of the uterus will become 
 cancerous, that is, will cast off cells of less develop- 
 mental power than the parent growth. Uterine 
 myomas and mammary adenomas originate respec- 
 tively secondary fibromas and cancers. An identical 
 phenomenon is the production of tumours by nsevi, 
 warts, and moles. 
 
 The relics of once functional structures are dis- 
 posed to neoplastic activity. In the next section it 
 will be seen that -they are the common seats of cys- 
 tomata. The pineal gland, now regarded as the 
 ' vestige ' of an ancestral median eye, sometimes be- 
 comes hyperplasic, forming a considerable tumour ; 
 and hyperplasia of the peripheral Pacchionian bodies 
 is recorded. From the walls of cysts formed in 
 obsolete canals neoplasms may grow. 
 
 These are the various conditions under which new 
 growths are known to arise. What is the uniformity 
 amidst their diversity ? What is there in the func- 
 tionless state, in relative innutrition, in the continued 
 action of irritants, that is common as conditioning 
 the genesis of tumours ? With the understanding 
 that what follows is not presented as a completely 
 reasoned theory, but as a rough though in the main 
 true synthesis, to round off the conception our pur- 
 poses have demanded, there may be framed a pro- 
 visional statement of the causation of tumours which 
 will be comprehensive of all these and other factors. 
 
 The data brought forward sustain the conclusion 
 that the genesis of neoplasms is another example of 
 histogenic dissolution. The phenomenon must be 
 classed with the multiplication of nuclei in Wallerian
 
 NEOPLASMS. 97 
 
 degeneration and atrophy of muscle, with inflamma- 
 tory cell-proliferation, with certain of the reproduc- 
 tive changes seen in tuberculous and other infective 
 tumours, and in parenchyrnatous degenerations, like 
 multiple neuritis and nephritis. And in all these 
 cases the reproductive process is a reversion to that 
 simplest form of genesis found in the Protozoan 
 ancestors of the Metazoa. where cells are resolved 
 into a fresh generation, or give off by division por- 
 tions of their protoplasm for the making of new indi- 
 viduals. An invariable feature of this simple genesis 
 is the drawing to a close of developmental or vital changes. 
 The decline of cell-life, we have learnt, is brought 
 about in many ways. With plants and micro-organ- 
 isms relatively low nutrition will determine the 
 division into germs ; at those points on the axis of 
 plants where germs are produced the sap reaches with 
 difficulty, and at those points, consequently, the pro- 
 cesses of life first diminish. In the case of the simpler 
 micro-organisms, genesis, we may rightly suppose, is 
 still more under the empire of directly-acting agents, 
 and less subservient to inherited tendencies than in 
 plants. Hence, just prior to the death of the pro- 
 toplasm from failing nutriment separation into new 
 centres may be wrought chiefly by the environment. 
 Inflammatory proliferation is initiated by the 
 devitalising influence of phlogogenic agents ; the 
 muscle nuclei sometimes found surrounding Trichina 
 spiralis lodged in the contractile substance are the 
 product of an inherited proclivity incited into action 
 by the disruptive actions of the parasite. In like 
 manner, the increased nuclei of Wallerian degeneration 
 
 ii
 
 98 GENERAL DISEASE. 
 
 and atrophy of muscle are liberated in the process of 
 dying, which process the causes of these degenerations 
 set up in the nerve or muscle. Similarly, whatever 
 the cause of multiple neuritis, or nephritis, in which 
 diseases centres are set free as nuclei, one of the 
 effects of this cause is to stop those changes which 
 constitute the lives of cells, and as the life is ending 
 there is a dissolution into germs. 
 
 The conditions of tumour- genesis, though peculiar, 
 do not differ essentially. It has been pointed out that 
 peripheric parts, parts furthest removed from the 
 heart or from the vascular centre of the particular 
 organ, are liable greatly beyond others to give origin 
 to tumours. Now just at such places the tissues may 
 be expected first to ripen ; besides the feebleness of 
 nutritive changes where blood-supply is relatively 
 deficient, surfaces and extremities are most exposed 
 to surrounding forces capable of bringing on local 
 tissue senility. It is observed that long-continued and 
 exhausting influences are effective instigators of neo- 
 plasms ; instances are the cases of warts induced by 
 working with the hands in foreign matter, and cases 
 of cancer from the irritation of soot and coal-dust. 
 
 The skin and the mucous membrane of the ali- 
 mentary canal, the most common seats of neoplasms, 
 are at the extremities of the vascular branches, but 
 furthermore are in direct and constant converse with 
 the energies of the outer world. Thus the life-con- 
 ditions of those units of the body the readiest to pro- 
 create tumours are conditions highly favourable for 
 the premature exhaustion of the energies cognised as 
 vital. The molecular motion through which proto-
 
 NEOPLASMS. 99 
 
 plasm undergoes the adjustments to incident forces 
 constituting evolution must soonest run out where the 
 draughts upon it are greatest, and where the store 
 of motion is from the beginning relatively small, and 
 augmented by nutritive substances with relative 
 difficulty. 
 
 Why is reparative tissue inclined to histogenic 
 dissolution ? We may answer with the assumption 
 that its capacity for passing through the changes of 
 continued life will be less than that of the tissues from 
 which it was derived, and, playing a more passive 
 part, as cicatricial tissue usually does, it is correspond- 
 ingly less vascular. Cicatricial tissue is tissue of 
 relatively low vitality. This is true also of germinat- 
 ing tumours ; and in moles, ' vestiges,' and embryonic 
 remnants no demand is made by function for active 
 nutrition ; hence, slight forces impinging, and in 
 obedience to a disposition inherited from remotest 
 ancestors, they disintegrate by proliferation. 
 
 But a condition necessary and peculiar to neoplastic 
 growth remains to be noticed. When generative disso- 
 lution takes place hi ordinary inflammation and de- 
 generation, the germs do not, in general, subsequently 
 appear as tumours. Why is this ? They perish by 
 further disintegration or are absorbed by the sur- 
 rounding tissues. In the growth of tumours there 
 must be recognised a struggle for existence as going 
 on between the old tissues and their young, and the 
 survival of the latter constitutes neoplastic power. 
 It is easily perceived that the circumstances favour- 
 able for tumour-genesis are circumstances inimical 
 to tissue-resistance. At the vascular peripheries, and 
 
 ii >
 
 100 GENERAL DISEASE. 
 
 in functionless and regenerated parts, decline of tissue- 
 life is promoted by the conditions we have noted ; but 
 this very senescence permits the new growth to .gain the 
 mastery. The tissues germinate, the forces of life 
 being nearly spent ; but the new generation of cells is 
 endowed by what process we know not- with the 
 prepotency of all germs ; and the latter survive in 
 the competition for nourishment. It is usually other- 
 wise in the tissue-germinations of inflammation and 
 degeneration. Here the young cells may be released 
 at any point, in the substance of the heart or on the 
 outer covering of the body ; but the genetic process is 
 set up in tissues whose stores of vitality are not 
 depleted, apart from the influence upon them of the 
 forces causing inflammation. The action of the 
 phlogogenic or other force is limited to the area of its 
 distribution, and the potentialities for continued life in 
 the contiguous tissues may be normal. 
 
 If the cells proliferated in inflammation eventually 
 become tumours, the combination of requisitions for 
 tumour-growth have been accidentally fulfilled. 
 
 But whether the young cells outlive the old ones 
 will probably be governed by still other, conditions : 
 the power of multiplication in the germs, and the 
 systemic health of the person that bears them. In 
 proportion as the seeds have imperfect developmental 
 powers they multiply rapidly, and may survive by 
 reason of their numerical strength. And lowly- 
 organised tumour-cells are usually discrete, readily 
 gaining access to the lymphatic and blood-vessels, 
 through which they reach the general system. Clini- 
 cally, this is spoken of as malignancy in tumours.
 
 NEOPLASMS. 101 
 
 That the general health of the host has much to 
 do with the survival of the parasite is a reasonable 
 inference. Tumours being insubordinate in the 
 general working of the body, and united with it 
 only by the common nutrient system, if the ' tide of 
 life ' is low the organism will retire the more easily 
 before the invasions of the parasite. This will be 
 found assimilable with many clinical facts, as those 
 which show that depressing nervous and other in- 
 fluences make patients an easy prey to cancerous 
 disease, and that improved hygienic surroundings 
 will cause a new formation like lupus to disappear. 
 I have now in mind an instance of this, reported, I 
 believe, by Mr. Jonathan Hutchinson, F.R.S. And 
 thus is afforded a means of explaining, the casual 
 spontaneous disappearance or diminution of cancers. 
 Cancer ' may dry up and be in fact cured, which is 
 sometimes seen in the breast, and occasionally in 
 the internal organs.' Reproduction by fission is a 
 supersession of special functions by a more general 
 function. Loss of the higher co-ordinations of cell- 
 protoplasm revokes the subordination of the lower. 
 Simple procreation in cells is normally kept in check 
 by the more specialised activities ; hence, whatever 
 maintains the integrity of the latter will tend to the 
 subjection of the former. 
 
 Benignancy is usually the correlative of superior 
 development in tumours. Here the power in the 
 germs to attain the higher orders of structure pre- 
 sumably arises from a less degree of that agedness of 
 tissue which, by the hypothesis, favours the genesis 
 of tumours. And it agrees that in these cases the
 
 102 GENERAL DISEASE. 
 
 mother-tissues oppose the growth of the germs by 
 the organisation of a capsule. Also in harmony is 
 the fact that tumours of higher tissue-type appear 
 earlier in the life of the individual than do the em- 
 bryonic cancers. Embryonic sarcomas are, however, 
 often seen in early life. 
 
 We have spoken of reversion to the simplest 
 form of reproduction as the manifestation of an in- 
 herited trait called out by the inception of disinte- 
 grating motion. Can there be divined any reasons for 
 such inherited predisposition ? All attributes trans- 
 mitted by descent were at some period of evolutional 
 history acquired by the interactions of organism and 
 environment, not even excepting the inherited ' spon- 
 taneous ' variations which form the ' purchase ' of 
 natural selection. What, then, in most general terms, 
 were those interactions which initiated or resulted in 
 multiplication by cell -division ? Only very specula- 
 tive opinion can at present be fashioned upon a ques- 
 tion so abstruse ; yet there is a convergence of testi- 
 mony giving reasonableness to the following view. 
 
 Every protoplasmic body, like every aggregate of 
 such bodies, dissipates in the course of life its store of 
 ' vital ' (molecular) motion, and in doing so loses that 
 plasticity of molecular structure which permits ad- 
 justments to surrounding circumstances. It follows, 
 therefore, that while it becomes in one sense more 
 rigid, it becomes more liable to have its particles 
 separated in coarse disintegration by whatever forces 
 fall upon it. If, then, during the evolution of 
 ancestral Protozoa the molecular disruptions just
 
 NEOPLASMS. 1 03 
 
 preceding death which is always succeeded by 
 coarse disintegration took the shape of generative 
 dissolution, this would be perpetuated by heredity. 
 Highly conserving the continuation of the species, 
 the tendency to dissolve into germs before life ceased 
 altogether would be appropriated by natural selection, 
 and become deeply stamped in the constitution of the 
 units of compound organisms. Hence, with the re- 
 currence in a general way of the conditions of its 
 evolution, it is natural that there should be such re- 
 currences of the phenomenon as pathology widely 
 illustrates. The evolution of the higher types of 
 the reproductive process seen in the multicellular 
 organisms, its distinction as a function of specialised 
 organs and ministered to by high nutrition, would 
 follow according to well-known principles. 
 
 Thus, I think, is made less incomprehensible the 
 apparent nonconformity to rules of morbid action 
 displayed by tumours. The uncertainty of their 
 appearance in a given case is explicable when it is 
 seen that a concurrence of circumstances is required. 
 There must be a conspiration of both local and 
 systemic conditions, using the last term in the 
 broadest sense. The presence of one cause of neo- 
 plasms will not suffice in the absence of another or 
 of others. 
 
 It ensues from all that has been said that a 
 primary tumour is both a local and systemic disease, 
 but that local conditions largely predominate as 
 determining factors. 
 
 There are groups of miscellaneous facts not yet 
 noticed to be placed side by side with the hypo-
 
 104 GENERAL DISEASE. 
 
 thesis. It is inexpedient to enter upon their con- 
 sideration in this work, though the questions they 
 suggest may possess much immediate economic im- 
 portance. We must content ourselves with the mere 
 mention of some of them : The special causes of 
 uterine myoma what connection has this variety 
 of neoplasm with functional exercise of the sexual 
 organs ? The conditions of neoplasms in infancy 
 and youth. The relation of neoplastic degeneration 
 to over-feeding and superfluous body -energy ; to the 
 ingestion of particular kinds of food. The facts of 
 secondary growths (metastasis) are they at one or 
 at issue with the conception put forth ? &c. 
 
 And now, after all this preparation, can it be said, 
 that dissolution and evolution find further fulfil- 
 ments in the phenomena of tumour-genesis ? The 
 evidence of tissue-disintegration has been adduced. 
 
 O x 
 
 Is the principle of dissolution complied with in 
 that an absorption of energy causes this disintegra- 
 tion ? The evidence on this head has also been pre- 
 sented. It is clear that traumatic injury, mechanical 
 and chemical irritants, the intercourse with external 
 powers which exhausts the means of tissue-life, testify- 
 to inordinate inceptions of motion as the true causes 
 of the tissue disintegration. 
 
 And, unmistakably, the rearrangements of matter 
 and motion involved are those of dissolution. In 
 the beginning all tumours, we may not unwarrant- 
 ably believe, are congregations of lowly organised pro- 
 toplasmic particles indifferent cells. If, then, we 
 compare this relatively simple, general, and uniform
 
 NEOPLASMS. 105 
 
 structure, having like functions, with the relatively 
 complex, specialised, and heterogeneous parent-tissue, 
 there truly comes into view the exemplification of 
 dissolution we have sought. 
 
 The later transformations through which the 
 germs pass in the process of development, conform, 
 we have found, to evolution, and it remains to refer 
 to the retrogressive changes. Those met with in 
 tumours are of the same kind as the degenerations of 
 normal tissues, and as such they have already been 
 considered. Therefore, all that is required here is their 
 enumeration. They are calcification, caseation, and 
 softening ; colloid, mucoid, and fatty degeneration. 
 Tumours are also liable to haemorrhage, ulceration, 
 suppuration, and decomposition. 
 
 The morbid affection set going in the organism 
 by the expansion of a new growth within its sub- 
 stance mav be an inflammation or irritation followed 
 
 / 
 
 by the development of cicatricial tissue in surround- 
 ing parts ; it may be an extension of the neoplastic 
 change to normal tissues from the influence of the 
 tumour-cells ; or it may be a reproduction of the 
 growth in distant places due to the dissemination of 
 these cells by lymphatic, blood -vascular, and other 
 channels. From what has gone before it will be seen 
 at once that all these changes are comprehended by 
 the principles of evolution and dissolution. 
 
 Neoplasms interfere with the functions of organs. 
 A tumour in the spinal cord will give rise to disorders 
 of motion and sensation ; in the stomach, to disorders 
 of digestion ; in the bladder, to disorders of vesical 
 function. And there is the cancerous cachexia, the
 
 100 GENERAL DISEASE. 
 
 components of which are systemic and recondite al- 
 ti rations in the physiological processes of the body. 
 As seen from the point of view of the principle of 
 dissolution, this class of disturbances consequential to 
 the diseases under consideration may be more con- 
 veniently instanced in succeeding chapters, especially 
 since the pathology of cancerous cachexia is too 
 indefinitely understood to admit of separate treat- 
 ment. 
 
 3. THE CYSTOMATA, TERATOMATA, AND 
 M ALFORMATIONS. 
 
 The very many modes of origin of cystomas, and 
 our ignorance in manifold cases of the conditions of 
 their formation, quite preclude such references to the 
 formulas as we might rest content with. Glancing 
 first at retention cysts, those due to the confine- 
 ment of normal secretions within pre-existing cavities, 
 doubt arises whether this disease can truly be called 
 a dissolution. Sebaceous cysts wens, for example 
 are not obviously accompanied by disintegrations of 
 matter ; rather is matter integrated. This is strikingly 
 the case of the curious horns growing from sebaceous 
 tumours. It seems possible to effect a reconciliation 
 with the formula of dissolution only by regarding the 
 contents of the cavities as the accumulated products 
 of normal processes of dissolution. The epithelial 
 scales, fatty matter and cholesterine of sebaceous cysts, 
 are excrementitious elements collecting from closure 
 of the excretory ducts ; and the horns just alluded 
 to are nothing more than exfoliated epidermal cells 
 dried and hardened by exposure to the air.
 
 NEOPLASMS. 107 
 
 It coincides with dissolution that the disease is 
 sometimes caused by inflammation and excessive 
 activity of the sebaceous glands. Unhealthy matters 
 finding outlets through these channels provoke 
 hyper secretion and inflammatory closure of the 
 cutaneous openings. Congenital piliferous cysts, 
 which resemble sebaceous tumours but are congenital 
 and have fully developed hairs growing from them, 
 rather belong to the order of neoplasms. 
 
 Cysts arising from the retained secretions of 
 mucous glands, as the glands of Bartholin and 
 Cowper, and also galactoceles, probably originate in 
 the same way as sebaceous tumours. Ranulae, from 
 occlusion of the ducts of salivary glands, are often- 
 times connected with the iinpaction of a calculus, and 
 with the irritation of bits of vegetable fibre and fruit- 
 seeds derived from articles of food. New growths, 
 calculi, and parasites are among the causes of pan- 
 creatic ranulaa, biliary cysts, and hydronephrosis. 
 
 The cystic kidney of chronic nephritis, where 
 there is ectasia and dilatation of urinary tubules, 
 must be referred, remotely, to the causes of the 
 latter disease. 1 Congenital cystic kidneys are now 
 thought by some observers to depend upon the 
 degeneration of persistent fatal structures, e.g., the 
 Wolffian body, and not upon the congenital absence 
 of the pelves of the kidneys. 
 
 Dilatation of the vermiform appendix, leading to 
 a cystic tumour of this structure, commonly results 
 from closure by foreign bodies or inflammation at the 
 
 1 See Part II. chap. v. 2.
 
 108 GENERAL DISEASE. 
 
 opening into the csecum. The causation of cysts of 
 the vitelline duct and urachus is very obscure. 
 
 In this form of cystic disease, then, the indications 
 of dissolution are exceedingly weak ; only here and 
 there can we detect an initial disintegration of matter 
 and concomitant absorption of motion. Perhaps by 
 an examination of each example in all possible 
 detail a less incomplete correspondence might be 
 effected. But, by the formation of these tumours, we 
 may legitimately say that the organism sustains a 
 loss in the federation, expressness, and variety of its 
 functions and structures. 
 
 Exudation cysts call forth similar comments. In 
 tli^se there is excessive secretion in cavities not 
 provided with an excretory duct. The slighter forms 
 of certain examples (burste and ganglia) are not 
 diseases, but adaptations of structures to simple 
 increase of function. The enlargement of bursa? and 
 ganglia is the result of increased action of tendons 
 and muscles. When the actions are excessive, and 
 other conditions are favourable, inflammatory disso- 
 lution may ensue, which in numerous familiar ex- 
 amples is the clear effect of communicated motion. 
 Ganglia of the extensor tendons of the hands in 
 pianists, the swelled bursa patella of housemaids, and 
 miner's elbow are cases in point. 
 
 Most cystomata connected with the brain, spinal 
 cord, and their membranes are cases of malformations 
 by arrest, and will presently be mentioned with these 
 affections. Naming them here, they are anencephalia, 
 meningocele, encephalocele, syringo-myelus, and the 
 varieties of spina bifida.
 
 NEOPLASMS. 109 
 
 Many of the cysts in structural relation with the 
 organs of reproduction rehearse the truth we had 
 occasion to note in the chapter on new growths, 
 namely, that ' obsolescent remnants ' are eminently dis- 
 posed to neoplastic degeneration. Relics of the meso- 
 nephros, or Wolffian body an ancestral excretory 
 organ persist in the hilum of the human ovary ; the' 
 tubules of the mesonephros within the folds of the 
 broad ligament are known as the parovariurn. It is 
 a credible presumption that these relics are the 
 sources of what are spoken of as ovarian papillary 
 and parovarian cysts, and, in the male, as encysted 
 hydrocele. 
 
 The duct of the mesonephros Gartner's duct 
 opening into the vagina, is almost certainly concerned 
 in cystic formations. Mr. Bland Sutton has brought 
 forward an impressive array of facts to show that 
 numerous cystic growths of the ovarian parenchyma 
 start in the arrested normal decay of ovarian follicles. 
 There is hardly any doubt that one of the conditions 
 of the genesis of true tumours obtains with these 
 cystic new formations in diseased parts. And it 
 seems as likely, from the observations and reasoning 
 of Dr. W. 0. Priestley, F.R.C.P., LL.D., 1 upon the 
 genesis of cystic chorion the so-called hydated mole 
 that cysts of this class are true tumours ; that they 
 originate from asexual reproduction of normal cells ; 
 and that, some of the new generation undergoing 
 retrogressive changes which bring them to the fluid 
 
 1 The Lumleian Lectures on the Pathology of Intra-Uterine Death. 
 British Medical Journal, No. 1371.
 
 110 GENERAL DISEASE. 
 
 state, the product is the pro-cellular albuminous or 
 gelatinous substance which these cysts contain. 
 
 Very little that is positive can be said concerning 
 the causation of cysts of the broad ligament not con- 
 nected with the parovarium. Cystomata of the Fallo- 
 pian tube, known as hydro- and pyo-salpinx, and 
 hydroceles of the spermatic cord and tunica vaginalis, 
 may be more satisfactorily brought under the formula 
 of dissolution, causally linked as they are with in- 
 flammations often ascribable to external conditions. 
 
 Cysts formed by hernial protrusions of intestinal, 
 pharyngeal, and other membranes, by the softening 
 of new growths, by extravasations of blood and 
 serum, and by parasites, clearly begin in the majority 
 of cases as disintegrations of matter caused by the 
 absorption of energy, and are accompanied by the 
 qualitative changes of function and structure belong- 
 ing to dissolution. 
 
 The congenital cervical hygromata call to mind 
 the air-chambers beneath the deep cervical fascia in 
 some apes ; but this does not help us to an assi- 
 milation of these obscure cases with the principle of 
 dissolution. Certain of the hygromata are classed 
 among the Teratomata, to which we may now pass. 
 
 Teratomata are congenital tumours peculiar in 
 the multiformity of their constituent tissues. ' Some 
 of them contain rudimentary skeletal elements, such 
 as those of the spine, pelvis, &c.; as well as rudi- 
 ments of various organs, like the brain, intestine, 
 different glands, kidneys, and muscles. Others con- 
 tain tissue-formations of various kinds, such as mus- 
 cular tissue, cartilage, skin, bony substance, gland-
 
 NEOPLASMS. Ill 
 
 tissue, cysts, &c. ; but no definitely formed masses 
 which can be regarded as representing any special 
 organ or member/ 
 
 If we might accept the conclusion of Mr. Sutton, 1 
 that teratomata arise where the three germinal layers, 
 epiblast, hypoblast, and mesoblast are in contact, then 
 these new growths could be classed with the true 
 tumours. They might be regarded as resulting from 
 germination of epiblastic, hypoblastic, and mesoblastic 
 tissues, which would explain their multifarious struc- 
 ture. But beyond a relationship to ancestral vestiges 
 there are no data bearing upon the actual factors 
 concerned in their genesis. Mr. Sutton's investiga- 
 tions tend to show that teratomata connected with 
 the sacrum, pituitary fossa, pharynx, ovaries, and 
 testes, and the lingual teratomata, all take origin in 
 desuete and embryonic structures, as the post-anal 
 gut, Wolffian bodies, lingual canal, &c. It would 
 sustain in a remarkable manner the argument of the 
 preceding section if tissues incapable of further de- 
 velopment should thus so widely assume the simple, 
 general, archaic function of agamic reproduction. 
 But since hi teratomata the actual determinants of 
 the reproductive process are unknown, it is impos- 
 sible to harmonise the phenomena with that term of 
 the formula of dissolution which comprehends causes. 
 In a remarkable paper ' Teratomata : an /Etiological 
 Study ' published in the ' Journal of Comparative 
 Medicine and Surgery ' for October 1887, Mr. Sutton 
 brings forth evidence, to me convincing, that many 
 congenital dermoids are related to general conditions 
 
 1 An Introduction to General I'utlwloyy.
 
 112 GENERAL DISEASE. 
 
 of embryonic development. He points out that his 
 conclusions strongly uphold Professor Cohnheim's 
 hypothesis of embryonic remains, as the hypothesis 
 covers this class of tumours. It appears to me that 
 they are not against the theory I have sketched in 
 the preceding section. Therefore, in order to add 
 a word of comment, I take the liberty of inserting 
 Mr. Button's introduction to his consideration of 
 sequestration cysts : 
 
 ' In order to comprehend in its full significance 
 the cetiology of this interesting group, we must con- 
 sider briefly the main features connected with the 
 formation of the body- walls. In a transverse section 
 of the body of a mammalian embryo at an early 
 period of gestation, we find that it consists of two 
 bilateral portions united by an isthmus. This isthmus 
 contains the notochord, flanked on each side by the 
 mesoblastic somites. Its lateral parts present a 
 smaller dorsal moiety, which may be considered as 
 upgrowths from the larger ventral portions. The 
 dorsal upgrowths tend gradually to fuse across the 
 median line to complete the spinal cord and the 
 skin covering it. ... Ventrally each half subdivides 
 the inner layer ; the splanchnopleure eventually co- 
 alesces with its fellow to form the walls of the gut ; 
 the outer, which is continuous at first with the 
 amnion, also fuses with its fellow to form the body- 
 walls ; hence it is termed the somatopleure. Coales- 
 cence may fail to occur at any spot along this ex- 
 tensive line, or even throughout the whole length of 
 it. If it fails at certain spots we may get such con- 
 ditions as ectopia cordis and eventration".
 
 NEOPLASMS. 113 
 
 'Dorsally this line of coalescence extends from 
 the occipital protuberance to the coccyx, then passes 
 beneath the notochord, and extends ventrally, involv- 
 ing the perineum, scrotum in the male, abdominal and 
 thoracic walls, neck, symphysis pubis, and finally 
 becomes arrested at the septum nasi. The line of 
 coalescence also extends from the septum nasi 
 through the mid-line of the palate to the uvula. It 
 also involves the tongue ; the original cleft in this 
 situation extends from the mental symphysis to the 
 hyoid bone. In any part of this line epiblastic in- 
 volutions occur, which may manifest themselves as 
 dermoids.' 
 
 Dermoids appearing in this tract Mr. Sutton 
 arranges in three groups : the dorsal, ventral, and 
 cranial ; and he refers to the fact that the tumours 
 rarely spring from the trunk or central divisions. 
 From the scrotum, sometimes from the penis, and 
 from the neck, palate, and cranium, dermoids com- 
 monly grow ; but not on the line of coalescence from 
 the coccyx to the occiput behind, and from, the penis 
 to the neck in front. Now it may be, as Mr. Sutton 
 strongly inclines to think, that these teratomata 
 ' originate in detached masses of embryonic tissues.' 
 The line of coalescence is caused by the infoldings of 
 the embryonic tissues ; and along this formative tract 
 the structures are liable, as we know, to imperfections 
 of development. It is therefore conceivable that where 
 growth and development are defective redundant cells 
 may be included and become the germs of tumours. 
 Is it not, however, equally conceivable, and as pro- 
 bable, that from the influence of injurious forces
 
 114 GENERAL DISEASE. 
 
 acting during embryonic life the tissues upon the 
 formative tract revert to agamogenesis, as we have 
 supposed adult tissues do in the case of non-con- 
 genital tumours ? The tissues upon the line of coa- 
 lescence are analogous to the growing extremities 
 of the fruit-bearing axis of a plant, and to the peri- 
 pheric parts from which cancer and other neoplasms 
 so frequently originate. If this explication, which 
 comprehends rather than runs counter to the one 
 favoured by Mr. Sutton, is valid, it accounts in a 
 manner for the relative frequency of dermoids at the 
 extremities of the line, the scrotum, head, palate, and 
 neck. Here, perhaps, would first be felt any failure in 
 the capacity of the embryo for continuous growth, and 
 centres of discontinuous growth might arise. The 
 very different and mixed constituents of dermoids 
 would be determined by the stage of embryonic de- 
 velopment at which the division into tumour germs 
 happened. 
 
 If with some authors we regard teratomata as 
 forms of acardiac monsters (acardiaci amorphi), then 
 some, force which cleaves the developing embryo is 
 the aboriginal cause (see following paragraphs). 
 
 It will be seen that if cystomata and teratomata 
 arise initially from local disintegrations and give rise 
 by their remote effects to secondary changes of this 
 nature, the growths and development of the compo- 
 nent tissues, including fibrous capsules, are inter- 
 current evolutions. 
 
 There is to be included under the present heading
 
 MALFORMATIONS. 1 1 5 
 
 a brief closing allusion to the phenomena of malfor- 
 mations. 
 
 For the most part in the diseases thus far referred 
 to we have looked for primary causes to the external 
 forces which act upon the organism during extra- 
 uterine life. In the diseases now to be contemplated 
 we look for the first disturbers of function and struc- 
 ture to the external forces acting during intra-uterine 
 life ; and notwithstanding the remoteness of the 
 aetiological factors from direct observation, we are not 
 debarred from an attempt to gather the facts together 
 under the principle of dissolution. 
 
 Malformations may be referred to external inter- 
 ferences with normal growth and development in utero. 
 These interferences may occur at any stage in the 
 ovum, in the embryo, or in the foetus ; and if in 
 ancestors, then the defect may be transmitted by in- 
 heritance, as seen in the cases of supernumerary 
 fingers. Or the causes of the defect may be repeated 
 in the uterine lives of successive or alternate genera- 
 tions with a feigning of the action of heredity. 
 
 Cases of malformation by arrest (monstra per 
 defection) are ascribed to actions which stop or pervert 
 the maturative changes of a normal embryo. Among 
 them are classed ' defective development or disease 
 of the membranes and placenta (uterine or foetal), 
 adhesion of the amnion to the foetus, abnormally 
 small quantity of liquor amnii, -tumours of the uterus, 
 concussions of the uterus with separation of the 
 membranes, haemorrhages in the membranes or in 
 their neighbourhood, &c. As concerns the foetus 
 itself, its development may be disturbed by inflam- 
 
 i 2
 
 116 GENERAL DISEASE. 
 
 matory affections which it acquires by transmission 
 from the mother (smallpox, scarlatina, endocarditis), 
 or by inherited disease, such as syphilis. In the 
 earlier stages of development abnormal twists and 
 flexures of the embryo may be enough to cause very 
 serious hindrances to growth.' l In whichever of 
 these ways deformity is induced, there is no impro- 
 priety in saying that absorbed motion is the cause. 
 Be the case of malformation by arrest acrania or 
 anencephalia, where the vault of the skull or the 
 brain is wanting, the causes conjectured are undue 
 pressure by the head-fold of the amnion or acute 
 cranial flexure of the embryo, and in such manner 
 force is incepted as mechanical motion. And 
 Dareste supposes that synophthalmia, where the 
 orbital cavities coalesce and parts of the brain are 
 absent, may be attributed to imperfect development 
 of the head-fold of the amnion. This presumably 
 permits pressure upon the anterior cerebral vesicles. 
 ' In some cases the cause of cleft palate has been 
 found to be a morbid adhesion of the amnion to the 
 face.' Many other forms of malformation receive no 
 specific explanation of their causation ; among these 
 are hernia cerebri and spina bifida, cleft-face and 
 bronchial fistula, clefts of the abdominal and 
 thoracic walls. Defects in the development of the 
 limbs (amelus, peromelus, &c.) are commonly ac- 
 counted for by supposing ' constriction, and even 
 amputation, by folds or bands of the foetal membranes 
 or by loops of the umbilical cord.' 
 
 1 A Text-book of Pathological Anatomy and Pathogenesis, by Ernst 
 Ziegler. Translated by Donald Macalister, M. A. , M. D. , F. R. C. P.
 
 MALFORMATIONS. 117 
 
 The causes assigned, then, of malformations by 
 arrest are such as connote an absorption of motion 
 and disintegration of matter ; and the effects are 
 obviously in most cases a reduction of functions and 
 structures in definiteness, coherence, and heterogeneity. 
 
 Double monsters (monstra duplicia} and malfor- 
 mations by multiplication of parts are assumed to 
 proceed from complete or partial cleavage of the 
 embryo and its parts. If the cleavage is entire and 
 occurs at a very early stage of embryonic life, e.g., in 
 the germinal area, there result thoracopagi, xiphopagi, 
 &c. ; and should the development of the segments be 
 unequal, there may ensue forms of parasitic twin 
 foetus papyraceus, acardiacus,thoracopagus parasiticus, 
 inclusio foetalis, &c. Partial cleavage of the rudi- 
 mental embryo may lead to varieties of duplicitas an- 
 terior and duplicitas posterior. Homologous triplets 
 are initiated by threefold cleavage ; and cleavage 
 affecting the rudiments of individual structures 
 occasions multiplication of the limbs, mammary 
 glands, &c. 
 
 This theory of the aetiology of double and triple 
 monsters is not opposed to the principle of dissolu- 
 tion. There is implied by such cleavage of the em- 
 bryonic elements the incidence of a separative or 
 disintegrative force either in the individual, or, where 
 the deformity is inherited, in ancestors. The func- 
 tional and structural changes induced in the organism 
 correspond but vaguely with the remaining clause of 
 the formula. It is said that double monsters and 
 other malformations have been produced experiment-
 
 118 GENERAL DISEASE. 
 
 ally, as by varnishing hen's eggs before incubation. 
 But the active agents in the production of monsters 
 in the ordinary way are wholly unknown. 
 
 Of cases of congenital hypertrophy, where mem- 
 bers of the body are unduly large, it appears at 
 present impossible to make a satisfactory synthesis.
 
 PART II. 
 SPECIAL DISEASE
 
 121 
 
 CHAPTER I. 
 
 SPECIAL DISEASES AS EXEMPLIFYING DISSOLUTION 
 AND EVOLUTION. 
 
 1. PRELIMINARY : INTERSTITIAL AND PARENCHY- 
 MATOUS INFLAMMATION. 
 
 Corollary I. Incident forces being equally distri- 
 buted among the elements of an organic system, the 
 dissolution of functions and structures follows the 
 opposite order of their evolution ; the higher and 
 accessory are less stable than the lower and funda- 
 mental. 
 
 The structural plan of the organs is that of an 
 active proper substance or parenchyma fixed in a 
 passive supporting substance or interstitial tissue. 
 When the process of inflammation terminates in 
 growth of the supporting framework, it is the custom 
 to speak of this as chronic inflammation. Frequently 
 it is called interstitial inflammation, as distinguished 
 from inflammation of the parenchyma. Manifestations 
 of the phenomenon are widely extended in pathology. 
 An increase of connective substance is the constant 
 and conspicuous change in fibroid induration of the 
 heart, fibrosis of the lungs, cirrhosis of the liver and 
 kidney, sclerosis of the spinal cord, and many other
 
 122 SPECIAL DISEASE. 
 
 pathological states. Commonly, if not always, there 
 is an associated degeneration or disappearance of 
 parenchymatous elements. The adjoined figure, re- 
 presenting the effects of chronic myocarditis, shows 
 the muscular bundles wasted and degenerated, and 
 their places occupied by fibroid tissue. Similarly, 
 
 chronic inflammation of 
 the liver, kidney, or 
 other organ is found to 
 be accompanied by de- 
 cay and atrophy of the 
 parenchyma, or proper 
 substance of the viscus, 
 and by a new growth 
 
 FJG. 3.-FIBR01D INDURATION OF THE HEART. o f interstitial Substance. 
 
 A section from the left ventricle. The fibroid 
 
 tissue surrounds the individual muscular NfYW tllP Tisjllfll and TP- 
 
 fibres, which are undergoing fatty dege- a OW m6 
 
 ceived theory states that 
 
 the overgrowth of interstitial material is a direct 
 effect of its inflammation, and destruction of the 
 parenchyma is an indirect effect, following the inroad 
 upon it and contraction of the new connective tissue. 
 The connective tissue supports the nutrient vessels, 
 and by its shrinking shuts off the blood- supply of the 
 parenchyma and causes its decay. 
 
 There appear to be just grounds for dissenting 
 from this interpretation. All observation leads us to 
 affirm that inflammation is in its very nature depres- 
 sant and destructive, and not constructive. When 
 we noticed inflammation as illustrative of dissolution 
 we saw that the process is essentially in its primary 
 aspects a disintegration (chap. i. 2). How, then, can 
 the growth (integration) of connective tissue be an in-
 
 PRELIMINARY. 123 
 
 flammatory process ? I think it is preferable to view 
 these cases of connective-tissue formation joined with 
 atrophy and decay of parenchyma, as instances of 
 overgrowth from removal of the normal resistances 
 to growth. In a structure that has reached a state of 
 equilibrium in respect of its tendencies to increase in 
 mass, there is among the components a balanced 
 opposition to disproportionate increase of any one or 
 any group of them. Facts will presently appear 
 which show that, in a great preponderance of cases, 
 in chronic inflammation the elements first affected 
 are the most differentiated and specialised elements 
 those constituting the parenchyma. The damage or 
 destruction of these is not caused by the encroachment 
 and condensation of the connective tissue, but by the 
 original disease-producing agent, whatever that may 
 happen to have been, and the formative action of the inter- 
 stitial tissue is in response to the lessened resistance to its 
 growth which follows injury to the parenchyma. When 
 we come to consider the causes of chronic hepatitis and 
 nephritis cirrhosis of the liver and kidney we shall 
 find that the noxse are distributed to the proper work- 
 ing substance of the organ, not to the interstitial 
 substance. Looked at in this way, cirrhosis, fibrosis, 
 and sclerosis are tied by common nature to repair by 
 scar tissue, which is essentially a new production of 
 connective tissue, along lines where the opposition to 
 growth has been diminished by a destruction of parts. 
 In the following chapters this conception will be 
 invoked to aid in making clearer the pathology of 
 both chronic and acute inflammation of special or- 
 gans. Acute inflammation, as familiarly understood, is
 
 124 SPECIAL DISEASE. 
 
 nearly co-extensive with parenchymatous inflamma- 
 tion ; the damage to parenchymatous elements is the 
 leading feature, and the growth of connective tissue 
 insignificant or absent. Here we shall suppose that 
 acute and chronic disease are related to the intensity, 
 duration, and distribution of the incident forces. 
 Acute disease being usually the correlative of severe, 
 and often sudden, action of irritants, the parenchyma 
 is generally damaged or destroyed without sequent 
 formative changes in the connective tissue. But 
 chronic disease being the correlative of relatively 
 slight and gradual actions, the parenchyma is more 
 slowly affected and time is allowed for interstitial 
 growth. 
 
 If we make requisition also of the supplemen- 
 tary doctrine to dissolution (cor. i.), it will be seen 
 that when the morbific forces, in both acute and 
 chronic disease, fall equally upon all the elements of 
 an organ or tissue, the later evolved functional and 
 structural attributes are less resistant than those 
 antecedently evolved. The specialised parenchyma 
 is injured or obliterated before the general basis 
 substance, and the elements of the parenchyma suffer 
 more or less according as they are more or less 
 specialised. The chief reason of this relative insta- 
 bility of the least organised and most specialised 
 elements is that these are the active workers in the 
 body physiological, and are in consequence, largely 
 by means of the blood, brought into closest contact 
 with injurious agents. They are also situated at the 
 expanding distant parts of the nutrient system of 
 the organ. Already we have met with a noteworthy
 
 PRELIMINARY. 125 
 
 example of this general truth in the facts of true 
 tumour-formation. We saw in the last chapter that 
 the fundamental organs are scarcely known as the 
 seats of primary new growths, but that accessory or- 
 gans and structures are highly susceptible to tumours. 
 The heart and lungs enjoy singular freedom ; but the 
 sexual organs, the mammary glands, the vocal cords, 
 the epiglottis, the tonsils, and the pyloric valve are 
 among those parts which suffer frequently. 
 
 The two principles of interpretation now enun- 
 ciated will be found, I think, to greatly transform 
 our conceptions of the diseases whose consideration 
 we are to enter upon in the succeeding chapters. 
 Not only shall we find unlooked-for harmonies in the 
 results of morbid actions, but a much greater sim- 
 plicity in the processes than is generally suspected ; 
 and this last is of immediate practical moment. 
 
 We shall now select from the principal noso- 
 logical divisions further illustrations of dissolution 
 and evolution. Some of the general morbid changes 
 considered in the foregoing chapters will in the fol- 
 lowing chapters be met with again, though under 
 different aspects. And, as with general disease so 
 with the diseases of organs, the changes regarded in 
 their entirety will be seen to be analytical or disso- 
 lutional, minor syntheses or evolutions always being 
 accompaniments. 
 
 It is conceived to be important to sustain by in- 
 duction from accumulated facts the proposition that 
 dissolution proceeds from the absorption of external 
 energy that diseases are the outcome of environing
 
 12G SPECIAL DISEASE. 
 
 conditions ; hence this will be given precedence over 
 other features of dissolution. Where the phenomena 
 of familiar affections can be exhibited in new and 
 interesting relations by regarding them from the dis- 
 soludonal point of view, such affections will have 
 claims upon our attention. If we followed the esta- 
 blished order of nosological tables we should begin 
 with general diseases those that affect the entire 
 system, as the infectious diseases. But expediency 
 must be allowed to overrule the demands of usage or 
 logic ; and in the next section we shall look at some 
 disorders of the urinary system. 
 
 2. ACUTE AND CHRONIC BRIGHT'S DISEASE. 
 
 T/ie Structural Changes. Nephritis, whether of the 
 acute, waxy, or cirrhotic variety, presents us with 
 lesions that are clearly changes towards a less definite, 
 coherent, and heterogeneous structure (chap. i. 4). 
 Of the acute form we read that in the first stage ' the 
 convoluted tubules often present a swollen opaque 
 appearance, and occasionally contain blood. On micro- 
 scopic examination the congestion of the vessels be- 
 comes very apparent, and the tubules are found to 
 be dark and opaque ; their lumen is frequently oc- 
 cluded. The individual epithelial cells are granular 
 and in a state of cloudy swelling.' In the second or 
 stage of fatty transformation ' the convoluted tubules 
 are in many parts occupied by sebum-like material, 
 and sometimes the straight tubes present the same 
 appearance.' Microscopically, some of the tubules 
 ' present under low powers a black appearance due
 
 BRIGHT'S DISEASE. 127 
 
 to fatty degeneration of the contents of the tubules.' 
 Many of them 'are completely blocked up by this 
 material ; and sometimes, in making the section, there 
 is such an amount of oil set free, that it permeates 
 the whole structure of the organ and is liable to pro- 
 duce the impression that the fatty degeneration is 
 universal.' In that form of acute nephritis marked 
 by a special implication of the glomeruli there is an 
 infiltration of leucocytes, and sometimes haemorrhage 
 in the Malpighian tufts. 
 
 By these changes the secreting structure, the 
 tubules, their lining epithelium, and the Malpighian 
 bodies lose in distinctness of parts (definiteness), 
 and in the exactness of the proportions of their con- 
 stituents (coherence). But by these changes they 
 are clearly made more multiform, not more uniform, 
 which is inconsistent with the formula of dissolution. 
 This again instances that disordered heterogeneity 
 which is often observed as one of the phenomena 
 of dissolution. But the morbid matters introduced 
 among the tissues have not, it will be noticed, the 
 heterogeneity of elaboration and specialisation de- 
 scribed by the formula of evolution. 
 
 In the organ as a whole there are like changes. 
 The differentiated substance of cells is converted into 
 albuminoid and fatty material, and the intertextural 
 spaces and the protoplasm of matrix-cells are per- 
 meated by these degraded products and blood and 
 serum. 
 
 In the third or atrophic stage the same order of 
 metamorphosis results from the disappearance of tubules 
 and glandular cells of epithelium.
 
 128 SPECIAL DISEASE. 
 
 The tissue-changes in the waxy and cirrhotic 
 varieties of Bright's disease exhibit correspondences 
 to the fatty transformation and atrophic stages of 
 acute nephritis. But the amyloid degeneration of 
 waxy kidney commences, not in tubules, but in the 
 Malpighian tufts and arteriae rectse ; degeneration of 
 the tubules is secondary to the vascular changes. The 
 third stage of the amyloid form is one of atrophy. 
 
 Following. Dr. George Johnson, F.R.S., 1 we learn 
 that in cirrhotic or contracted kidney ' the epithe- 
 lium is opaque and granular, in a state of cloudy 
 swelling ; the tubes are crowded and opaque with 
 degenerated and disintegrated epithelium ; some tubes 
 are deprived of their epithelium, some contracted, 
 others dilated in various degrees, some lined by trans- 
 parent uninucleated cells, others filled with organised 
 fi brine, rarely with blood or with oil ; the basement 
 membrane and the Malpighian capsules are thickened.' 
 Malpighian bodies are completely destroyed in ad- 
 vanced cases, and represented by glistening spheres 
 of connective tissue. To the naked eye the organ is 
 contracted and its cortical substance diminished. 
 
 Quite evidently the essential lesion is a destruc- 
 tion of the cortical or secreting portion of the organs, 
 and its reduction to relatively general, simple, and 
 uniform fibrous tissue. 
 
 The Functional Changes. Correlated with the re- 
 arrangements of structure are certain rearrangements 
 of function, both in the kidneys and in organs that 
 have physiological relations with them. To notice 
 first the quality of the work done by the renal 
 
 1 Lectures on Briqhfs Disease,
 
 BRIGHT'S DISEASE. 129 
 
 glands. This is made obvious in the urine. Within 
 the range of healthy physiological action, there are 
 present in the urine more or less precise proportionate 
 quantities of water, nitrogenous matters, acids, salts, 
 pigments, &c. In normal urine, too, there are such 
 mutual relations among its constituents that the 
 excretion when voided is a consistent body, being 
 chemically stable under ordinary conditions, and, 
 excepting a little mucus, holding its many ingre- 
 dients in solution. 
 
 Can we say that the secretion of the kidneys met 
 with in Bright's disease shows divergences from the 
 normal corresponding in character with the associated 
 structural divergences ? The specialised substance 
 urea, the highest product of tissue metabolism, is 
 more or less diminished in percentage quantity in 
 acute and cirrhotic nephritis, and probably in the 
 later stages of the amyloid disease, where the secret- 
 ing cells are only secondarily involved. Then there 
 are present, with varying frequency in different cases, 
 the substances albumens, globulins, peptones, extrac- 
 tives, urates, oxalates, &c., which nre intermediate be- 
 tween urea and the food-materials proteids, fats, and 
 starches from which urea is derived. Of these un- 
 specialised intermediate bodies found in the urine in 
 Bright' s disease, serum-albumen is the most notable. 
 
 O ' 
 
 Next there are casts of the uriniferous tubes, cells 
 from the kidney and urinary passages, and commonly 
 blood in the acute disease. And the urine of ne- 
 phritis is relatively unstable, being often decomposed 
 and malodorous at the time of evacuation. Lastly, 
 there is the relative irregularity in quantity and 
 
 K
 
 130 SPECIAL DISEASE;. 
 
 quality of the urine at different periods and under 
 different conditions of the organism. Now the excre- 
 tion is abundant, and at another time scanty ; at one 
 hour of the day there may be much albumen, at 
 another none ; and similarly with the casts and 
 other abnormalities. Although acquiring a more 
 heterogeneous composition, urine so changed is 
 changed towards indefiniteness and incoherence, and 
 this stands for like changes in the renal functions. 
 
 Passing to the functional disturbances of parts in 
 physiological union with the kidneys, we may note 
 the inconstancy with which the bladder discharges its 
 contents. In health, vesical action is timed with 
 considerable exactitude to certain organism al con- 
 ditions, as rest, work, and alimentation. But in 
 Blight's disease these relations are abrogated. Urina- 
 tion is uncertain, sometimes very infrequent, or for a 
 time in abeyance, in the acute disease ; while in 
 chronic nephritis micturition is apparently simply 
 related to the presence in the bladder of an irritant 
 urine ; those nice adjustments of the function to 
 social requirements and personal habits enjoyed in 
 health are thoroughly spoiled. The actions of the 
 bladder, in short, are less definite and co-ordinate. 
 
 The effusion of dropsical fluid into interstitial 
 spaces and serous sacs, which is met with most fre- 
 quently in tubal or acute nephritis, may be considered 
 to obscure in some degree the distinct and orderly 
 heterogeneity of structures and functions ; though 
 there may be considerable water-logging of organs 
 without obtrusive physiological perturbations. 
 
 Of other symptoms and complications of nephri-
 
 BRIGHT'S DISEASE. 131 
 
 tis that lend themselves to interpretation as disso- 
 lutional changes, anasmia is one. Here the blood 
 is despecialised and simplified by an increase of its 
 water and a decrease of its albumen and blood-cor- 
 puscles, especially of the highly differentiated red 
 corpuscles. 
 
 Gastric and intestinal catarrh, seen in all the 
 forms of nephritis, show us a diminished speciality, 
 complexity, and variety of functional performance. 
 There is digestive capacity for only the simplest and 
 most homogeneous of alimentary substances a con- 
 dition implying simplicity in the chemical and physical 
 processes of digestion ; and the gastric pains and dis- 
 comforts are the subjective concomitants of discords 
 among these processes. Normally, food, and the in- 
 digestible residue of food, pass in the definite direc- 
 tion from mouth to anus, and evacuations from the 
 lower bowel take place at regular times ; but in 
 vomiting, diarrhoea, and constipation, so often asso- 
 ciated with nephritis, we see a subversion of this 
 definiteness of functional action. 
 
 Albuminuric retinitis, being histologically a fatty 
 degeneration and haemorrhage in the retinal elements, 
 fully complies with the terms of the formula of disso- 
 lution. And by amblyopia, whether it depends upon 
 uraemia or retinitis, the functional attributes of the 
 organism certainly become less special, coherent, and 
 multiform. And as well by other nervous disorders 
 of Bright's disease for example, loss of hearing, loss 
 of speech, or imperfections of speech, paresis, dyspnoea, 
 &c. Coma and convulsions, with their constituent 
 and accessory phenomena, loss of consciousness, dis- 
 
 K 2
 
 132 SI'KCIAL DISEASE. 
 
 ordered movements of limbs, Chcyne- Stokes respira- 
 tion, &c., might easily be shown, were it required, 
 to possess the characters of dissolution. It will not 
 escape recognition that the pathognomonic high arte- 
 rial tension conceals or erases the specific qualities of 
 the pulse the pulse ' wave,' peripheral outflow, and 
 normal dicrotism. 
 
 Some of the inflammatory complications of ne- 
 phritis, as pericarditis, bronchitis, pneumonia, and 
 cirrhosis of the liver, will be noticed at length in 
 later chapters. 
 
 But these are agreements only with the ultimate 
 clause of the formula. Is there in Bright's disease a 
 disintegration of matter and concomitant absorption 
 of motion ? 
 
 To begin with the first proposition, the disinte- 
 gration of matter. This appears to describe the 
 intrinsic nature of the transformations. Early in the 
 course of the acute disorder, the stage of inflammation, 
 there are found extravasations of blood and exuda- 
 tions into the interstitial spaces and tubules. That 
 these involve disintegration was seen when we dealt 
 with the phenomena of inflammation (chap. i. 2). 
 Tubules are crowded with cells of epithelium and 
 fibrine, much of which becomes completely separated 
 from the viscus, in the shape of casts. There is often 
 a free proliferation of the nuclei of the epithelial cells 
 a phenomenon already expounded as virtually a break- 
 ing up of cell-substance. The urine usually contains 
 blood, albumen, casts, leucocytes, and cells of epi- 
 thelium ; and these are portions of matter disunited
 
 HEIGHT'S DISEASE. 133 
 
 from the body ; they are the products of disiii- 
 tegrative actions. That disintegration continues 
 through the fatty and atrophic stages is evidenced 
 by the presence of cells and fat and casts in the 
 urine. 
 
 In the lardaceous or amyloid kidney both molar 
 and molecular disintegrations of the substance of 
 the organ are unquestionably the intimate changes. 
 Describing a typical example, Dr. George Johnson 
 says : ' Most of the tubes were enlarged, and their 
 epithelium was opaque from "cloudy swelling." 
 ... In some, the cells were in a state of fatty 
 degeneration ; and some tubes contained fibrinous 
 
 O ' 
 
 coagula.' In other cases it is remarked that * occa- 
 sionally the tubular structure is rendered indis- 
 tinct by an unorganised intertubular effusion. The 
 Malpighian capillaries are thickened, opaque, glisten- 
 ing, and waxlike.' In the later stages the urine is 
 often densely albuminous, and deposits casts and 
 epithelial debris disintegrated matter. 
 
 To be assured that the primary histologicai 
 changes of cirrhotic nephritis are disruptive, the 
 reader needs but reperuse what is said of this disease 
 on a preceding page. 
 
 Turning to secondary and remote disintegrations 
 of parts and functions correlated with the kidneys, 
 the urine of nephritis is observed to be a less in- 
 tegrated and consistent fluid, insomuch that its 
 
 O ' 
 
 constituents are often chemically dissociated, as 
 proved by its premature decomposition. It has 
 often an offensive odour when voided. Albuminnria 
 implies a separation of the blood-serum, as also
 
 134 SPECIAL DISEASE. 
 
 does the effusion of dropsical fluid. (See the defini- 
 tion of Disintegration, chap. i. 2.) 
 
 Epistaxis, haematemesis, and other forms of 
 haemorrhage, are more obviously disintegrations ; 
 and catarrh occurring in Bright' s disease, as gastric, 
 intestinal, vesical, and bronchial catarrh, presents the 
 disintegrations that inhere to the inflammatory 
 process exudation and cellular proliferation and 
 exfoliation. And so do, in greater degree, the 
 inflammatory complications pericarditis, bronchitis, 
 retinitis, &c. 
 
 That the nervous phenomena of nephritis have 
 for their physical bases a molecular or molar 
 disintegration can hardly be doubted. Pain is the 
 subjective side of physical disruptions ; l and patho- 
 logical anatomy testifies in numberless cases that 
 paralysis and paresis are related in causation to 
 destroying lesions in nerve-substance. It is probable 
 that coma and convulsions in Bright's disease are 
 due to chemical dissociations wrought by unde- 
 purated blood as it circulates in the higher cerebral 
 centres, or by obstructed capillary circulation. 
 
 Disintegration of a kind differing from that just 
 considered may finally be called to mind. The func- 
 tion of cleansing the blood of certain waste materials 
 poured into it everywhere in the system is centred or 
 integrated in the renal glands. Instead of each living 
 ceP, or assemblage of cells, having its own arrange- 
 ments for excreting effete nitrogenous matters an 
 actual condition in the lowest organisms the dis- 
 
 1 See Mr. Grant Allen's Physiological ^Esthetics. Henry S. King 
 and Co. London, 1877.
 
 BRIGHT'S DISEASE. 135 
 
 tributing system the vessels and their contents 
 compounds the entire community of cells, and so 
 brings every part into functional union with organs 
 specialised for the business of excretion. In some of 
 the Protozoa, organisms without divisions of labour, 
 there are found spaces in the protoplasm that are 
 probably concerned in the excretion of water and 
 other residual substances. The individual creatures 
 in a sponge probably discharge their nitrogenous 
 excreta into the water-canals which traverse the 
 colony. In Platyhelminthes and Trematoda the 
 renal function is distinctly organised, but is still 
 diffused. We read of the excretory system of the 
 latter, ' the finest ducts are distributed through all 
 parts of the organism, and they pass into collecting 
 vessels, which, by the formation of anastomoses, give 
 rise to a most complicated plexus ; from these arise 
 the efferent ducts, which gradually unite into collect- 
 ing vessels. 1 Now in Bright's disease we find a sort 
 of return to this primitive diffused form of the func- 
 tion in that other distantly connected organs probably 
 assume vicariously the work of the impaired kidneys. 
 The diarrhoea of chronic nephritis is generally attri- 
 buted to intestinal efforts to discharge urinary sub- 
 stances. The serviceableness of purgatives in the 
 treatment of Bright's disease bears out this view. A 
 like meaning is attached to gastric catarrh and 
 vomiting. And the presumption is a reasonable one 
 that dropsical transudation is a still more general 
 action, by which water and other components of the 
 urine are stored up or cast out upon the intertextural 
 spaces. In like manner, nasal and bronchial catarrh
 
 13G SPECIAL DISEASE. 
 
 are probably depurating processes, and the inflamma- 
 tion of serous membranes may arise from the deter- 
 mination of unexcreted matters to surfaces where 
 local conditions and constitutional peculiarities make 
 excretion relatively easy. Thus the kidneys fail to 
 do for the economy their appointed work, and the 
 function becomes divided among the various co- 
 operating parts of the system, and so becomes less 
 integrated. 
 
 And now to learn whether this complicated series 
 of disintegrations is accompanied by concomitant 
 absorptions of motion. This calls out the question, 
 What are the causes of Bright's disease ? and our 
 knowledge of these takes us at once to environmental 
 influences. 
 
 All the various known conditions of the acute 
 disorder include a poisoned state of the blood as the 
 leading factor. In scarlatinal nephritis it is a neces- 
 sary conclusion from the facts that excretion by the 
 kidneys of vitiated blood induces the demolition of 
 glandular substance. Doubtless enfeeblement of tis- 
 sues, however occasioned, is often conjoined ; but the 
 substantial cause is the unhealthy matter in the blood 
 seeking elimination by the kidneys. 
 
 Exposure to cold is said to stand next to scarlet- 
 fever in point of frequency as a cause. Depression of 
 the cutaneous temperature throws additional work 
 upon the renal glands ; but this can scarcely in itself 
 be adequate to produce inflammation of them, and 
 almost certainly co-existing depravity of the blood is 
 the more efficient factor. 
 
 Blood rendered impure by imperfections of the
 
 BUIGHT'S DISEASE. 137 
 
 digestive processes, connected with excess or defect of 
 alimentary material, is a very common cause. 1 Then 
 there is the acute nephritis of diphtheria, measles, 
 acute rheumatism, erysipelas, pyaemia, malaria, 
 typhoid and typhus fever ; and of the parturient state, 
 in which the blood to be cleansed is unduly charged 
 with excremental matter derived from the foetus or 
 absorbed from the uterus. And clearer instances are 
 obtained in poisoning by carbolic acid, cantharides, 
 and turpentine. These causes of acute Bright' s 
 disease show in every example that the disintegration 
 of matter in the kidneys is the consequence of energy 
 absorbed from the environment, however complex 
 and extended the chemical and physical events inter- 
 mediate between the incidence of the external force 
 and the production of the special internal lesion. 
 
 We do not yet know all the causes of chronic 
 nephritis, but those now recognised are co-natural 
 with the causes of acute nephritis. The large white 
 kidney sequential to the desquamative nephritis of 
 scarlet-fever or other zymotic disease, with great 
 likelihood follows from the inability of the glands, 
 weakened and disorganised by previous inflammation, 
 to do the work entailed by the organism's resump- 
 tion of normal dietetic and other habits. According 
 to Dr. George Johnson, large white kidney may be 
 related to excessive eating and drinking. He has 
 known it as the sequel of tropical malarious fever, and 
 of ague, which are blood diseases beyond question. 
 
 The aetiology of lardaceous kidney is obscurely 
 related to constitutional syphilis, protracted suppura- 
 1 Cf. Dr. George Johnson, Op. cit. p. 40.
 
 138 SPECIAL DISEASE. 
 
 tion, and other states of the system that may be 
 referred to outer actions of one kind or another. 
 
 Common causes of cirrhosis of the kidneys are 
 alcoholic intemperance and intemperance in the con- 
 sumption of food. It is probable that excessive 
 eating is as frequently the cause of hepatic and renal 
 disease as excessive drinking' l an opinion my own 
 experience obliges me to endorse. Less frequently, 
 gout, diabetes, and lead-poisoning produce the cir- 
 rhotic disease. Gout and diabetes, as we may possibly 
 see subsequently, are causally connected with the 
 alimentary environment ; and the nephritis co-existing 
 with these diseases is generally regarded as dependent 
 directly upon the elimination in the one case of uric 
 acid and allied substances, and in the other of sugar. 
 
 I think the available data regarding the aetiology 
 of nephritis support the conclusion that with the dis- 
 integration of the structural elements of the kidney 
 there is a concomitant reception of energy from 
 without. 
 
 Of the secondary changes in other organs and 
 tissues, the intimate and immediate cause of the dis- 
 integration can be safely assumed in only a few 
 instances. The inflammations of serous and other 
 membranes may be supposed to be directly connected 
 with absorptions of chemical energy from the blood. 
 Ho3morrhages in Bright's disease result from increased 
 intravascular pressure and degeneration of vascular 
 tissue, and these are effects of abnormal states of the 
 blood, as, in all probability, are many of the nervous 
 
 1 Urinary and Renal Disorders, by Lionel S. Beale, M.D., F.R.S.
 
 BRIGHT'S DISEASE. 139 
 
 phenomena of Bright' s disease. Apoplexy and para- 
 lysis are secondary to cerebral haemorrhage. 
 
 The Evolutional Changes. Acute nephritis ter- 
 minates in complete recovery in a large number of 
 cases. With the removal from the body of the causes 
 of its disturbances the dissolutional processes are 
 succeeded by those of resolution and repair (chap. ii.). 
 Our knowledge of the rearrangements of matter and 
 motion leading to recovery is almost wholly inferen- 
 tial. Irritant substances are probably slowly elimi- 
 nated by the excretory channels, or are temporarily 
 disposed of with the fluid of effusions in the inter- 
 stitial spaces, these adaptive changes being often 
 furthered by the art of the physician. 
 
 There are no direct observations to prove that 
 the destroyed portions of the kidney are regenerated, 
 but we may rest upon the inference that such is the 
 case. Since the kidneys ultimately resume their 
 normal work, the matter cells and serum which 
 was exuded through vessel- walls into the connective- 
 tissue spaces and tubules must be either cast out of 
 the body, which would complete the disintegrative 
 process, or it must be resorbed, which resorption we 
 saw to be an integration of matter and dissipation of 
 motion. Renewal of the epithelial elements of the 
 glands is also an evolutional process. 
 
 One of the earliest signs of returning health in 
 acute desquarnative nephritis is the disappearance of 
 dropsical effusions. Here, again, the effused matter 
 reaggregates (integrates) within the vessels, restoring 
 (dissipating) that motion which was imparted to it
 
 140 SPECIAL DISEASE. 
 
 at its effusion. And to replace the losses by disinte- 
 gration there is ingested fresh integrable matter in 
 the shape of food. Seeing that recovery means the 
 organism's return to a normal state, functions and 
 structures regain their lost speciality, organisation, 
 and multiformity. 
 
 Chronic nephritis is held to be incurable ; conse- 
 quently we cannot speak of resolutional operations. 
 But there are well-recognised reparative and adaptive 
 changes. As cardiac hypertrophy and arterio-capillary 
 fibrosis are conjoined in causation, they may be re- 
 ferred to together. A careful appraisement of all the 
 facts that bear upon the difficult question as to the 
 conditions out of which they arise almost convinces 
 me that enlargement of the left ventricle and thicken- 
 ing of coats of the systemic arteries are joint effects 
 of a single cause. This is an alteration in the quality 
 of the blood. It usually depends, I think, on slight 
 failure of excretory power in the kidneys long aiite- 
 ceding distinct signs of Bright's disease; or it has 
 a different origin. But on account of it the blood 
 passes with difficulty through the finest conduits of 
 the arteries, and thus there is imposed an unnatural 
 resistance to the onward flow of arterial blood. To 
 meet the obstruction, the coats of the arteries and 
 the left ventricle become hypertrophied, and this 
 induces high arterial tension. These we must include 
 among the minor evolutions in the general dissolution 
 of Bright's disease (chap. iii. 1). 
 
 Others are seen in the new growths of connective 
 tissue in the kidneys themselves. In acute nephritis, 
 when somewhat prolonged, as well as in the chronic
 
 BRIGHT S DISEASE. 
 
 disease, there is an accession of fibroid material. The 
 walls of the small arteries, the capillaries, the Mal- 
 pighian tufts, Bowman's capsule, and the basis sub- 
 
 Fio. 4. TUBAL NEPHRITIS. 
 
 Duration of disease, six months. Kidneys large ; capsu'es, non- 
 adhercnt ; surface, smooth ; tissue, soft. Showing, in addition 
 to the intratubular change, the cellular infiltration of the 
 iiitratubular connective tissue, x 200. 
 
 FlO. 5. ISTKIWTITIAL XF.riiniTIB. St'LKFlOSIS OF OLOMKnULUS. 
 
 a, thickened capsule ; &, condensed vessels of tuft; c, dwarfed tubules 
 remaining ; /, abundant round cells In interstitial tissue, x 350. 
 
 stance of the tubules, are seen to have grown. The 
 annexed drawings (figs. 4 and 5) are, in part,
 
 1-12 SPECIAL DISEASE. 
 
 demonstrations. According to the view we have 
 submitted (chap. i. 1, pt. ii.), this increase in the 
 connective tissue is explained as an effect of loss of 
 parenchyma, and not of inflammation from irritant 
 blood acting directly upon the interstitial substance. 
 It was seen a moment ago that the destination of the 
 irritant blood is the proper excreting substance. We 
 must, then, number it among the evolutional changes 
 of Bright's disease. Observation of the figures and 
 specimens, guided by the view proposed, will satisfy 
 the reader that this added substance has the sym- 
 metrical and orderly characters of a reparative struc- 
 ture, that it advances always in the direction of 
 diminishing resistance to growth caused by removal 
 or death of the parenchyma, and that it is never 
 unaccompanied by disease of the parenchyma. Senile 
 renal atrophy, the later periods of acute nephritis, the 
 later stages of amyloid disease, and chronic cirrhosis, 
 one and all bear testimony. Why this parenchyma- 
 tous change is never absent we shall now be able to 
 understand more completely. 
 
 The Lesions as related to the Developmental Rank 
 of the Tissue- Elements. Is the order in which the 
 histological parts are implicated in the dissolutional 
 process unisonous with the tenet that the most 
 specialised parts are the least stable ? (chap. i. cor. 1, 
 pt. ii.). Mark first the broad fact that in all forms 
 of haematogenous nephritis the pathological changes 
 begin in those elements deputed to do the special work 
 of the organ. Though contrary to the usual explica- 
 tion of the changes, in renal cirrhosis the disease 
 begins in the secerning portion of the glands the
 
 BRIGHT'S DISEASE. 143 
 
 cortex. This is the opinion of Dr. George Johnson 1 
 an opinion borne out, I think, by every example. 
 (See figures and text on preceding page.) 
 
 Mark next that the separate elements of the 
 secerning portion are involved according to their 
 degree of speciality. With the epithelial structures 
 it is first the epithelial cells, then the tubules, and 
 the more specialised convoluted tubules before the 
 straight tubules, that are affected. With the vascular 
 structures, it is the very specialised expansions of the 
 nephritic vessels, the Malpighian tufts, and smallest 
 capillaries that prove most unstable. This gives the 
 distinguishing morphological features to glomerulo- 
 nephritis and amyloid kidney ; but acute tubal 
 nephritis and granular kidney do not supply less 
 perfect exemplifications. 
 
 Interpreted in this way, the several kinds of 
 hrematogenous nephritis, in which the incident de- 
 structive force is somewhat equally distributed, arise 
 in chief part from differences in the intensity, duration, 
 and nature of the irritation caused by the depraved 
 blood. In each kind it is the most differentiated 
 portion of the gland that undergoes dissolution. If 
 the irritation is severe and transitory, we may have 
 the phenomena of acute nephritis, with damage to 
 specific elements and a subsequent restoration of 
 functions and structures ; if the irritation is of mode- 
 rate intensity and long- con tinned, there is a gradual 
 effacernent of the specific elements, and a reproduction 
 of connective tissue to replace them. In such way 
 arises the atrophic kidney after acute nephritis, after 
 
 1 Lectures on Bright'* Disease.
 
 144 SPECIAL DISEASE. 
 
 amyloid nephritis, and after chronic desquamative 
 nephritis. The higher and accessory structures and 
 functions pass away, but the lower and fundamental 
 continue to live. And thus the views that paren- 
 chymatous disease is primary, and not secondary, to 
 interstitial growth, and that the highest elements 
 have the least stability, are views sustained by the 
 facts, and are mutually sustaining. 
 
 We must not linger over other affections of the 
 kidneys and urinary system, useful as it might be to 
 apply the principles to them. It may be incidentally 
 pointed out that calculus disease presents pheno- 
 mena paralleling the phenomena of blood-coagulation 
 (chap. iii. 1). The aggregation of the matter of 
 a calculus is an evolution intercurrent with a larger 
 dissolution. Perfectly healthy human urine holds its 
 varied constituents in a state of solution, and the pre- 
 cipitation of these within the body may be regarded 
 as a decomposition of the urine, the formation of a 
 calculus being a redecomposition. In the common 
 cases of stone this unbalancing of the chemical com- 
 position of the water can generally be shown to 
 proceed from physiological disturbances that possess 
 the generic characters of dissolution. And there are 
 facts at hand arguing the causal connection of these 
 disturbances with the inception of surrounding 
 energies. But many links in the chain of causations 
 remain to be discovered.
 
 CIRRHOSIS OF THE LIVER. 145 
 
 3. CIRRHOSIS OF THE LIVER. 
 
 The Stnicturnl Changes. Chronic interstitial 
 hepatitis serves most conveniently as a test of the 
 principles we are employing. The changes of mor- 
 phology and physiology are well-defined ; the disease 
 is a familiar one, and its ordinary cause is simple, and 
 known with certainty. 
 
 To see that the general transformations of struc- 
 ture are in keeping with dissolution, we may first 
 recall the normal histology of the gland. Briefly, 
 hepatic tissue consists of an assemblage of specialised 
 epithelial cells separated more or less distinctly into 
 lobules or acini by connective substance. This inter- 
 secting connective substance forms a kind of trellis 
 for the support of branches of the hepatic artery, 
 hepatic duct, portal vein, lymphatics, and nerves. 
 
 Looking at the results of well-marked common 
 multilobular indurative hepatitis, we perceive the 
 following alterations. The hepatic cells with their 
 albuminous cement and the intercellular vessels are 
 destroyed in great numbers ; whole lobules are 
 blotted out, and others remain as mere collections of 
 fat. One of the intervening changes appears to be 
 the conversion of hepatic cells into oily matter. 
 Coincidently there is an overgrowth of connective 
 substance. In addition, bile-ducts and portal veins 
 are narrowed and obstructed or annihilated. 
 
 Throughout the tracts of interstitial tissue, and 
 often at the margins of the lobules, lie numbers of 
 inflammatory corpuscles, and drops of oil are inter- 
 spersed among the glandular epithelia. And the 
 
 L
 
 1 1(5 SPECIAL DISEASE. 
 
 nuclei of the latter are obscured owing to their de- 
 
 generation. 
 
 Thus, the architectural features become less recog- 
 nisable, less definite ; the gland becomes disorganised, 
 and the substitution of connective tissue for hepatic 
 cells, bile-ducts, and vessels clearly constitutes a 
 change to relative simplicity and generality. 
 
 The Functional Change*. The physiological 
 counterparts of these lesions are found among the 
 symptoms of cirrhosis. Of course many of the 
 symptoms are caused by the direct influence upon 
 the stomach and other organs of the forces that pro- 
 duce hepatitis. Including any of the chief disturb- 
 ances of function, these are seen to bear the stamp of 
 dissolution. The multitudinous, orderly connected, 
 and decided functions of the stomach are either sus- 
 pended or performed very indeterminately. The 
 contractions of the stomach, in health definite in time 
 and direction as related to the taking in of food, are 
 so perverted that food returns through the mouth, or 
 the contractions take place as in * morning sickness,' 
 independently of the normal excitants to contraction. 
 
 Diarrhoea evidences the same order of changes in 
 the intestinal functions ; and ascites and redema show 
 how the infinitely nice and varied circulatory actions 
 going on in the normal liver are greatly disordered 
 or have ceased altogether. Jaundice tells of identical 
 mutations in one of the gland's special functions. 
 But these correspondences with dissolution, which 
 might be readily extended, are less interesting than 
 the disintegrations of matter and concomitant absorp- 
 tions of motion.
 
 CIRRHOSIS OF THE LIVER. 147 
 
 Disintegration of matter is seen in the degene- 
 ration and fatty metamorphosis of liver- cells and 
 intralobular vessels, and in the subsequent atrophy 
 of them. Secondary disintegrations are founl in the 
 effusions of dropsical fluid, in diarrhoea, htematemesis, 
 and other accompaniments of cirrhosis. And along 
 the entire series of disintegrations the concomitant 
 absorptions of energy can be followed out. 
 
 Supposing the cause of the interstitial hepatitis 
 to be the common one, an intemperate consumption 
 of alcohol, then, beginning with this chemical energy 
 we infer that it is first absorbed by the veins of the 
 stomach. As it enters next the substance of the liver 
 by the channels of the portal system it is conducted 
 along the connective tissue to the hepatic lobules. 
 As we have chosen to decipher cirrhotic changes 
 (chap. i. 1 and 2, pt. ii.), the alcohol setting 
 up chemical dissociations destroys the proper liver 
 substance, and the interstitial tissue grows out to fill 
 its place. Thence backward upon the portal and 
 abdominal veins, as the portal capillaries and ducts 
 become defunct, motion in the form of intravascular 
 mechanical pressure gives rise to the effusions of 
 ascites, or diarrhoea, or haematemesis. Or bile is 
 forced into the blood, producing jaundice. And so on 
 with the remaining disintegrations : they are all, in- 
 cluding those attendant upon inflammation (chap. i. 
 3), caused by the incidence of energy referrible more 
 or less remotely to the energy ingested as alcohol. 
 
 The, Evolutional Change*. There are few well- 
 authenticated cases of recovery from unmistakable 
 cirrhosis. It is conceivable, and indeed to be 
 
 L 2
 
 148 SPECIAL DISEASE. 
 
 expected, that in the early stages, as the action of the 
 cause ceases, and other conditions become favourable, 
 resolution, or even the reproduction of true liver-tissue, 
 might occur. 
 
 A redevelopment of bile-ducts is spoken of by 
 French observers ; but others suppose the ducts to be 
 dilatations of pre-existing bile capillaries. Adaptive 
 developmental changes are found in new venous com- 
 munications between the portal and general systems. 
 The vein of Sappey, connecting a branch of the 
 portal and the epigastric and internal mammary veins, 
 is an example. And there is said to be occasionally 
 a temporary compensatory growth of hepatic arteries 
 to meet the cutting off of portal blood by the destruc- 
 tion of portal capillaries. 
 
 Lastly, the new formation of interstitial connec- 
 tive tissue may be again cited as a reparative process. 
 We see that in hepatitis as in nephritis the noxa 
 is carried to and most freely dispersed among the 
 glandular cells, not to the ramifications of the capsule 
 of Glisson, whose blood-supply is from the hepatic 
 arteries. The proper substance is the destination of 
 the portal blood as far as the liver is concerned with 
 it. And in many cases the anatomical changes make 
 it demonstrable that the disease begins in the paren- 
 chyma. Specimens of cirrhosis are met with show- 
 ing parenchymatous degeneration without interstitial 
 growth. There are, on the other hand, some forms of 
 hepatic disease that apparently militate against this 
 rendering of the changes. The atrophy of glandular 
 cells in simple and pigmentary atrophy is not attended 
 with marked increase of interstitial substance. Here, 
 however, as in certain cases of cirrhosis, it is highly
 
 CIRRHOSIS OF THE LIVER. 149 
 
 probable that nutrition is too low to admit of con- 
 nective-tissue growth. Simple hepatic atrophy un- 
 attended with augmentation of interstitial substance 
 is one of the consequences of starvation. 
 
 If so-called ' hypertrophic cirrhosis ' presents as 
 stated l an interstitial hyperplasia, without equivalent 
 atrophy of lobules, this would conflict more seriously. 
 But not improbably the hepatic enlargement is due 
 to inflammatory exudation and hypersemia, and this 
 variety may really be an early stage of ordinary 
 cirrhosis. 
 
 The Lesions as related to the Developmental Rank 
 of the Tissue- Elements. Like Bright's disease, ordi- 
 nary indurative hepatitis is haematogenous, and there- 
 fore the tissue-elements are under nearly equal strains 
 from the action of the destroying force. Can we say 
 that the highest structures are the least stable ? We 
 must first think of the liver as accessory to the in- 
 testine. Its embryological history teaches that the 
 gland arises as a differentiation of the enteron ; in 
 vertebrata budding out from the duodenum upon the 
 abdominal cavity. Thus it is an appendage to the 
 alimentary canal, and this may in part explain its 
 relative susceptibility, as compared with the stomach, 
 to the disintegrating influences of alcohol. When 
 cirrhosis is caused by intemperance the stomach must 
 sustain the stress of the irritant ; yet gastric fibrosis 
 does not appear to have been observed as often asso- 
 ciated with hepatic fibrosis (cirrhosis). That the 
 liver rather than the stomach is destroyed must be 
 determined by several circumstances ; but it seems 
 likely that one of these is the greater stability of the 
 
 1 Ziegler's Text-book of Fnthology.
 
 150 SPECIAL DISEASE. 
 
 more fundamental gastric tissues. Whether the loss 
 of acini is occasioned, according to the explanation in 
 vogue, by atrophy secondary to growth of connective 
 tissue, or, as I prefer to think, by the direct action 
 of alcohol, the fact remains that the specialised por- 
 tions of the gland are alone destroyed. Note the 
 order of their destruction. The changes begin at 
 the peripheries of the lobules. Judging from cases 
 in the early stage, the nuclei of the epithelial cells 
 disappear sooner than the protoplasm. The cells lose 
 their distinctive polygonal shapes and become simple 
 spheres ; then the protoplasm loses its specialised 
 chemical qualities, as evidenced by the action upon it of 
 staining-agents. Bile-ducts and vessels are more per- 
 sistent, but in the end common connective tissue and 
 simple fat are almost the only surviving elements. 
 
 If we remember the symptoms and morbid anatomy 
 of biliary cirrhosis, simple hepatic atrophy, acute yellow 
 atrophy, passive hyperaemia of the liver, and other 
 diseases of this organ, no doubt will be felt as to the 
 possibility of making an equally satisfactory synthesis 
 of the facts. It will receive attention that in acute 
 yellow atrophy from phosphorus-poisoning, the de- 
 stroyed elements are the glandular cells, though the 
 poison may greatly injure the connective substance, 
 which is unable to withstand its intense action. The 
 energy is absorbed by radicals of the portal veins. In 
 passive hyperasmia of the liver (nutmeg liver) there 
 is again partial extinction of the proper liver sub- 
 stance, the energy pressure of venous blood being 
 transmitted by way of the hepatic veins.
 
 INFLAMMATION OF THE LUNGS. 151 
 
 4. INFLAMMATION OF THE LUNGS. 
 
 Under this heading may be noticed the most 
 important affections of the lungs. These are 
 croupous, catarrhal, and interstitial pneumonia, and 
 phthisis. 
 
 The St)~uctural Changes. Important as are the 
 clinical, and certain as are the pathological, differences 
 in these forms of pulmonary inflammation, they can- 
 not radically be separated from one another. The 
 dissimilarities in the textural changes are dissimi- 
 larities in details merely. 
 
 In the case of each the minute specialities of 
 structure in the tissue of the lung are decreased, COP- 
 fused, and rendered less distinguishable. And these 
 transformations are effected in quite corresponding 
 ways. We may notice first the morbid anatomy of 
 croupous pneumonia. This begins as inflammation ; 
 the vessels of the parenchyma dilate, and serum and 
 cells pass out of them (chap. i. 2). This consti- 
 tutes the stage of engorgement. In the next stage, 
 that of red-hepatisation, the extravasated matter has 
 filled the pulmonary alveoli, still further cancelling 
 the structural differentiations. Additions to the cel- 
 lular elements of the exudate and its degeneration 
 and disintegration mark the stage of grey hepatisa- 
 tion. If the process terminates in abscess or gan- 
 grene, the changes of dissolution are then very pro- 
 nounced. 
 
 Broncho- or catarrhal pneumonia is also an in- 
 flammation of the parenchyma with inflammation of
 
 152 SPECIAL DISEASE. 
 
 the bronchi superadded ; and it differs histologically 
 from croupous pneumonia only in the qualities of the 
 exudate and in the concomitance of collapse and 
 emphysema. 
 
 ' Interstitial or chronic pneumonia is charac- 
 terised by a gradual increase in the connective tissue 
 of the lung, which leads to an induration of the 
 pulmonary texture, and to progressive obliteration of 
 the pulmonary cavities.' As in interstitial nephritis 
 and hepatitis, by this destruction of pulmonary paren- 
 chyma and growth of fibroid material the lungs are 
 disorganised and reduced to relative uniformity and 
 generality. 
 
 Phthisis derives its distinctive characters from a 
 particular combination of the foregoing changes. It 
 is an inflammation of the parenchyma with accumu- 
 lation -of fibrine, leucocytes, and epithelial cells in 
 the alveoli ; there is conjoined a thickening and 
 infiltration of the walls of the alveoli and terminal 
 bronchioles, and a growth of the interlobular con- 
 nective tissue. These changes, broadly considered, 
 are a criterion of dissolution ; and so in a greater 
 degree are the changes of coagulation-necrosis, 
 softening, ulceration, and excavation, which belong 
 especially to phthisis. The consolidation of tissue 
 associated with inflammations of the lungs, when 
 simply the consequence of effusion into the alveolar 
 spaces, is not strictly an evolutional change or inte- 
 gration of matter ; as just shown, the tissue is 
 really disintegrated. But the coagulation of the 
 effused substances, their occasional organisation, and 
 the concretion of interstitial matter, are secondary
 
 INFLAMMATION OF THE LUNGS. 153 
 
 evolutions intercalated with the primary dissolu- 
 tion. 
 
 The Functional Changes. Reserving for later con- 
 sideration those dynamic phenomena which inflam- 
 mation of the lungs shares with the fevers, it will be 
 sufficient to note of the functional correspondences to 
 dissolution that with dyspnoea, irregular and hurried 
 breathing, and cough, the respirations of health lose 
 their determinate and orderly qualities. And the 
 pulse-respiration ratio being disturbed, the respiratory 
 rhythms cease to be less consentaneous with the car- 
 diac rhythms. These perversions of organic rhythms 
 correspond with perversions of function in the pul- 
 monary tissue correlated with the observed structural 
 perversions. 
 
 It is evident, both from the lungs as seen micro- 
 scopically, and from the clinical phenomena, that 
 these diseases are essentially a disintegration of the 
 body. Cells and serum are separated from the blood, 
 and the alveolar epithelium desquamates. There are 
 the disintegrations of the fevered state ; and in croup - 
 ous and catarrhal pneumonia rusty and bronchitic 
 sputa. Phthisis is an obvious ' wasting away ' ; the 
 waste matter being thrown off abundantly as sputum, 
 as haemorrhages from the lungs, as diarrhceal dis- 
 charges, as sweats, &c. 
 
 But is it possible to connect these disintegrations 
 with absorptions of energy as their causes ? If we 
 could accept the assumption that micro-organisms 
 the pnmmococcus and bacillus tuberculosis are the 
 intrinsic factors this would be possible and easy.
 
 154 SPECIAL DISEASE. 
 
 But, the assumption being held as not consonant with 
 the varied clinical and pathological facts, can a dif- 
 ferent aetiology be suggested ? 
 
 In the special diseases discussed in the immedi- 
 ately preceding sections the data clearly prove that 
 the parenchyma of the kidneys and liver is destroyed 
 by matters received from the blood. Bright's dis- 
 ease and cirrhosis of the liver are said to be haema- 
 togenous. Now in the case of the kidneys we see 
 that there are two chief paths by which noxse are 
 conducted to the renal substance. One of these is 
 along the renal arteries, and the other is by extension 
 of morbid processes from contiguous parts, as when 
 the renal disease is metastatic or caused by the mi- 
 grations of micro-organisms. In the case of the 
 liver, if we exclude obstructions to the outflow of 
 bile, the ways by which noxse arrive are three 
 namely, by the portal vessels, by the hepatic arteries, 
 and by metastasis. But with the lungs the routes 
 are four. Irritants may come with the air breathed, 
 by way of the pulmonary arteries, by way of the 
 bronchial arteries, and by continuity of tissue. That 
 the irritants producing ordinary pneumonia and 
 phthisis do not take the two last-mentioned courses, 
 may be concluded without misgivings. There remain, 
 then, the air and the blood conveyed by the pulmo- 
 nary artery. Inhaled impurities are beyond all doubt 
 the causes of many lung affections. The mention 
 of stonemason's cirrhosis, of grinder's rot, and of 
 miner's lung will recall many more kindred examples. 
 Or the inhaled impurities may be gaseous or organic. 
 Breathing nitrous fumes will cause extreme irritation
 
 INFLAMMATION OF THE LUNGS. 155 
 
 of the lungs ; and purulent and other secretions of the 
 mucous membranes of the air-passages are often in- 
 spired, producing infective inflammation and collapse 
 of the pulmonary parenchyma. It is almost certain 
 that insufflated bronchial secretion containing tuber- 
 cle bacilli has a vicious influence in the late stages of 
 phthisis. The relations of the lesions to the branches 
 of the bronchi are indicative of this. Broncho- 
 pneumonia may be caused by inflammatory products 
 being drawn into the air- vesicles. And the micro- 
 coccus pneumonice and bacillus tuberculosis may reach 
 the pulmonary tissue with the respired air. But 
 these contributory and extraordinary sources of pneu- 
 monia and phthisis have not been accepted by physi- 
 cians and pathologists as sufficing for the daily 
 occurring forms of these diseases. The fact that 
 tubercle bacilli are inhaled in the hospitals for con- 
 sumptives by persons who do not contract phthisis 
 shows that the micro-organism alone is inefficient. 
 And states of the atmosphere, as east- winds, are not 
 active with all persons in assisting to produce pneu- 
 monia. Efficient or co-efficient causes must, then, 
 have some other source. What, probably, is this ? 
 I think the blood distributed to the pulmonary paren- 
 chyma by the pulmonary arteries. It has not been 
 dwelt upon by writers that the blood coursing through 
 the alveolar and bronchiolar ramifications of the 
 pulmonary artery bears to the parenchyma of the 
 lungs relations analogous to those which the blood of 
 the renal arteries and the blood of the portal veins 
 bear to the parenchymas of the kidney and liver. 
 The lungs may be said to exist for the blood of the
 
 156 SPECIAL DISEASE. 
 
 pulmonary arteries as the kidneys and liver exist 
 for the blood of the renal arteries and portal vein. 
 Should we not, then, look to the pulmonary arterial 
 blood as the source of the chief disturbances of func- 
 tion and structure in the pulmonary parenchyma ? 
 The proper substance of the lungs is exposed on 
 the side of the pulmonary arterial blood to inci- 
 dent forces far surpassing in magnitude and variety 
 the forces incident from other sides. And this truth 
 is accentuated by the consideration that the lungs 
 have almost immediate relation with every ounce of 
 digested food. After elaboration by the processes of 
 digestion alimentary matter is then passed through 
 the portal vessels to the parenchyma of the liver, and 
 through the lacteals to the receptaculum chyli. It 
 is very probable that the bulk of the food-material 
 enters the portal circulation ; but the point to be em- 
 phasised is, that after leaving the liver and recepta- 
 culum nutrient substances are at once carried to the 
 lungs. Before being subjected to further chemical 
 and physical changes they are brought into the 
 closest converse with the pulmonary parenchyma 
 through the blood of the pulmonary artery. The 
 parenchyma of the lungs, indeed, is scarcely more 
 than a plexus of pulmonary capillaries. How pro- 
 foundly and constantly, then, must the proper tissue 
 of the lungs be ordered by the amounts and kinds of 
 the food ingested ! As profoundly and constantly, 
 probably, as the life of the proper tissues of the liver 
 and kidney. 
 
 For these and other indirect reasons, and directly 
 from my own observations in the treatment of pul-
 
 INFLAMMATION OF THE LUNGS. 157 
 
 monary affections, it appears to me that ordinary 
 pneumonias and phthisis are most intimately con- 
 nected in causation with the quantity and quality of 
 the pulmonary arterial blood as related with the 
 quantity and quality of the air respired. But of 
 these two sets of related and reciprocal factors, I 
 think the former is at least of equal practical impor- 
 tance with the latter. Giving as concrete an expres- 
 sion of the view as will be proper in the absence of a 
 full exposition, it may be said that both pneumonia 
 and phthisis are initially dependent on the action of 
 pulmonary arterial blood made irritant by the inges- 
 tion of superabundant, improper, or impure food ; 
 closely associated conditions being a relatively feeble 
 respiration of irritant air. 
 
 It is certain, however, that if the principal factors 
 are thus circumscribed there are in every actual case 
 many accessory determining and predisposing fac- 
 tors of much moment, and that out of their inter- 
 relations arise the differences among cases and the 
 special features of each disease. The infectiveness of 
 phthisis, its clinical history, certain features of its 
 pulmonary lesions, as their lobulated character and 
 apical distribution, imply a distinct unlikeness of 
 causative conditions to those obtaining in pneumonia. 
 But, as here suggested, an important likeness underlies 
 this unlikeness. At what stage of phthisis the spe- 
 cific organism becomes active, whether it is usually 
 received by the food or by the air, it is at present 
 impossible to say. 
 
 Would it not introduce a too lengthy digression, 
 it could be shown that the aetiology of pneumonia
 
 158 SPECIAL DISEASE. 
 
 and phthisis so conceived may be the means of 
 rendering more intelligible several classes of facts. 
 It is a matter of common observation that phthisis 
 frequently begins as a disease of the digestive organs, 
 and is accompanied throughout its course by deep 
 disturbances in the functions of these organs. The 
 dietetic and other habits of those suffering from 
 phthisis, and the commencement of the disease at the 
 apices of the lungs, would acquire a better meaning. 
 And so would the clinical phenomena and earliest 
 histories of cases of pneumonia, the signs of plethora 
 and indigestion, and the precursory nasal and bron- 
 chial catarrh. And the pneumon : as secondary to 
 blood-poisoning and other conditions could by this 
 aetiology be assigned a natural place. 
 
 Granting for the nonce that this is a general pre- 
 sentation of the truth, the blood of the pulmonary 
 artery acts as a phlogogenic agent, and irritants being 
 present in the air or in the secretions of the respira- 
 tory tract, the absorbed energy sets up the various 
 disintegrations. The alveolar membrane is denuded 
 of its epithelial cells ; serum and leucocytes pass out 
 of the vessels into the alveolar and trabecular spaces, 
 and, the process becoming chronic the causes per-, 
 sisting there results such destruction of bronchioles 
 and alveoli as is observed in fibrosis and phthisis. 
 And so with the less common forms of pulmonary 
 inflammation, pneumonia by metastasis, pleurogenous 
 pneumonia, and pneumonia caused by the inspiration 
 of mechanical and other irritants ; the disintegra- 
 tions of matter can be traced to concomitant absorp- 
 tions of energy.
 
 INFLAMMATION OF THE LUNGS. 159 
 
 The Evolutional Changes. Resolution is the 
 usual ending of both croupous and catarrhal pneu- 
 monia ; and the absorption of intra-alveolar exuda- 
 tions and the recovery of portions of pulmonary 
 tissue is a process recognised as often occurring in 
 phthisis. And the process of evolution in the 
 alveoli is repeated on a larger scale by the systemic 
 processes of recovery ; the functions of respiration, 
 circulation, alimentation, &c., become less and less 
 inexact and incoherent until the normal state is re- 
 established. 
 
 The explanation we have proposed of the hyper- 
 plasia of connective tissue in cirrhosis of the liver 
 and kidneys will be found applicable to the indurative 
 processes of pneumonia and phthisis, These pro- 
 cesses are then evolutional. It may here be remarked, 
 as showing how fibrosis follows from death of the 
 parenchyma, that in atelectasis and collapse, which 
 lead to simple suppression of function and structural 
 atrophy of the proper pulmonary substance, there is 
 but little attendant inflammation, yet often consider- 
 able resulting induration. As in similar diseases of 
 other organs, nutrition greatly influences the growth 
 of connective tissue in the lungs. 
 
 The Lesions as related to the Developmental Rank 
 of the Tissue- Elements. Observe that notwithstand- 
 ing the differences in their aetiological conditions and 
 morbid anatomy, pneumonias and phthisis are disso- 
 lutions of the specialised parts of the lungs. And 
 when there is reason to think that the destroying 
 forces fall equally upon each class of elements, the 
 process begins in the highest elements. This is
 
 160 SPECIAL DISEASE. 
 
 plainly the teaching of the morbid anatomy and 
 physiology and of the facts of aetiology. In croupous, 
 catarrhal, and interstitial pneumonia it is the alveoli 
 that are first affected, and in phthisis the alveoli and 
 bronchioles. The terminal expansions of the pul- 
 monary arteries, and the epithelium of the alveoli, 
 alveolar ducts, and respiratory bronchioles, are the 
 parts that suffer disintegration. By secondary pro- 
 cesses of phthisical infection the tissues may, of course, 
 be attacked in different order. In advanced cirrhosis 
 the smaller vessels and bronchioles are obliterated ; 
 and in advanced phthisis the fundamental tissues, 
 bronchial and connective, may secondarily be exca- 
 vated and destroyed. 
 
 The successive implication of the higher and 
 lower structures is indicated by the tracts of fibroid 
 tissue in cirrhosis and phthisis. First the alveolar, 
 then the interlobular, and, lastly, the peribronchial 
 connective tissues are thickened. 
 
 The remaining pneumonic morbid processes will 
 not, I think, be found on examination to offer insuper- 
 able obstacles to interpretation by these principles. 
 Brown induration of the lungs shows us disintegrations 
 of the higher pulmonary elements from the trans- 
 mission of mechanical pressure through the blood of 
 the pulmonary veins ; also, hyperplasia and integra- 
 tion of connective substance as a sequel of these 
 lesions. Broncho pneumonia from inspired irritants 
 closely repeats the phenomena of pulmonary cirrhosis. 
 Emphysema subscribes to the principle of dissolution 
 in that the least-organised capillaries and alveoli dis-
 
 INFLAMMATION OF THE LUNGS. 161 
 
 appear from innutrition, and mechanical pressure 
 transmitted through the air. And when the morbific 
 forces are distributed mainly about the bronchi, the 
 ensuing bronchitis is marked by damage to special 
 structures and hyperplasia of connective tissue. 
 
 M
 
 162 SPECIAL DISEASE. 
 
 CHAPTER II. 
 
 SPECIAL DISEASES AS EXEMPLIFYING DISSOLUTION 
 AND EVOLUTION CONTINUED. 
 
 1. LOCOMOTOR ATAXIA AND OTHEK DISORDERS 
 OF THE NERVOUS SYSTEM. 
 
 The Structural Changes. That we may appreciate 
 the traits of dissolution in sclerosis of the poste- 
 rior columns of the spinal cord, we must note the 
 changes prior to loss or atrophy of its substance. If, 
 as is believed, the atrophy commences in the posterior 
 root-zones, or columns of Burdach, then the nerve- 
 fibres of this group, before they disappear, exhibit 
 the metamorphosis of degeneration (see chap. iii. 
 5). The medullary sheaths and axis-cylinders 
 are broken up, and fat granules, corpora amylacea, 
 and nuclei appearing, the natural order, distinctness, 
 and unlikeness of the histological components give 
 place to an unarranged blending of simple elements. 
 And when, later, the parenchymatous tissue has 
 passed away and only the overgrown neuroglia re- 
 mains, the change is visibly from the heterogeneous 
 to the homogeneous, from the complex to the simple, 
 and from the special to the general. Also, the altera- 
 tions of structure are identical if the degeneration 
 involves other systems of nerve-fibres or nerve-cells,
 
 DISEASES OF THE NERVOUS SYSTEM. 163 
 
 such as the columns of Goll, the posterior roots, or 
 the posterior and marginal portions of the lateral 
 columns and the posterior horns of grey matter. 
 
 The Functional Changes. The physiological 
 manifestations in nervous disease evince dissolution 
 in terms very readily understood. Of the sensory 
 phenomena of tabes dorsalis, the various parses- 
 thesiae girdle pains, the feeling as if the soles of the 
 feet were resting upon velvet, hypersensitiveness to 
 temperature and insensitiveness to touch, analgesia 
 or polyaesthesia, and loss of the muscular sense, 
 mean that sense-perceptions have lost in precision, 
 that impressions reach the sensorium less bound 
 together (incoherently), and that sensations have 
 become relatively homogeneous. The motor pheno- 
 mena are of the same order. Inability to maintain 
 the erect posture with the eyes closed or open is 
 known to be due, as the term static ataxia denotes, 
 to an imperfect co-ordination of outgoing or ingoing 
 currents, either in the centres of the spinal cord or 
 at the seat of consciousness. And this ataxia or 
 incoherence is shown in walking, in prehension, in 
 speech, and in the movements of the eyes (strabismus 
 nystagmus), and is always accompanied by its token, 
 indefiniteDess of movement. When paresis and 
 paralysis of the limbs or bladder, amaurosis, loss of 
 sexual power, &c., supervene, functions are then 
 most obviously less heterogeneous. 
 
 The microscope has shown us that disintegration 
 is an inalienable character of the spinal lesions. Can 
 this disintegration be connected with the imbibition
 
 164 SPECIAL DISEASE. 
 
 of energy ? It is not yet settled what conjunction 
 of conditions is productive of locomotor ataxia. 
 Syphilis is common but not invariable in the 
 histories of these cases. But the morphology of the 
 spinal changes, and their restriction to functionally 
 related groups of neural elements, do not harmonise 
 with the supposition that syphilis is the supreme 
 causative condition. The supposition may with little 
 risk be rejected. It will be useful in endeavouring 
 to arrive at the causes of tabes to consider the prin- 
 cipal avenues by which disintegrative forces reach the 
 elements of the spinal cord. We may distinguish 
 three. One is through anatomically related parts by 
 direct extension ; another is by the blood-vessels ; 
 and a third by the spinal and cephalic tracts of neural 
 tissue which, through the sympathetic and peripheral 
 nerves, bring the organism into converse with its 
 environment. That tabes does not arise from the 
 extension to the spinal cord of pathological changes 
 in contiguous tissues, we need not stop to demon- 
 strate. Is the disease, then, hsematogenous ? Analogy 
 makes it conceivable and possible that noxae dis- 
 tributed to the spinal cord with the blood might by 
 a selective chemical affinity pick out and destroy 
 limited districts of nerve matter. But, excluding 
 syphilis, there are no evidences of specific blood 
 derangement in the clinical records of typical pos- 
 terior sclerosis ; and it appears unlikely that the dis- 
 order is inflammatory. Therefore the ascription of 
 tabes to irritant blood may be discountenanced. Is 
 the disease, then, attributable to influences reaching 
 the spinal cord through the nerves ? Such appears
 
 DISEASES OF THE NERVOUS SYSTEM. 165 
 
 from the facts to be actually the case. If locomotor 
 ataxia is regarded as a simple degeneration from ex- 
 cessive functional action of distinct tracts of neural 
 substance, the morbid anatomy, symptoms, and clini- 
 cal histories of cases of the disease are not irrecon- 
 cilable. As in all equally complex diseases, various 
 secondary conditions must be placed among the 
 factors ; but the chief factor of ordinary locomotor 
 ataxia, many facts unite to show, is undue functional 
 activity of the sexual system. Admitting provi- 
 sionally that the balance of probabilities is at present 
 in favour of this origin, then the nervous stimuli, 
 having their source in sexual excitement and other 
 nervous and psychical actions, impinge upon definite 
 areas of the spinal marrow, and the energy absorbed in 
 excess works the characteristic disintegrative changes. 
 Destroying the posterior root-zones, there is pre- 
 vented the transmission of duly proportioned aiferent 
 impulses to the cerebellum, with resulting ataxia ; 
 impinging upon the posterior nerve-roots, there is 
 caused first irritation of these and lightening pains and 
 subsequently tissue destruction and anaesthesia. The 
 posterior grey horns being injuriously affected, the 
 various para3sthesia3 ensue, and muscular atrophy is 
 thought to come from degeneration of the ganglion 
 cells of the anterior horns. Paralysis follows disin- 
 tegration of the pyramidal tract, and so on with the 
 remaining lesions and symptoms. It is extremely 
 probable that the disintegrations of ordinary locomotor 
 ataxia are caused by absorbed nervous energy having 
 correlations with the energies of the outer world. 
 The Evolutional Changes. Recovery from the less
 
 166 SPECIAL DISEASE. 
 
 severe forms of tabes is frequent. If function is re- 
 stored after the onset of structural derangements, we 
 must suppose either a reproduction of nerve elements, 
 or the delegation of the lost functions to surviving 
 nerve systems. Muscular adjustments, to maintain 
 equilibrium in walking and other movements, must 
 be counted among the adaptations. The evolutional 
 change of most interest to us is the hyperplasia of 
 neuroglia to repair the loss of nerve matter. Happily, 
 in holding that degeneration of the spinal paren- 
 chyma is the primary change, we are not wholly in 
 antagonism with the opinions of pathologists. Ziegler 
 remarks : ' Some have regarded the neurogliar hyper- 
 plasia as the primary disorder, and the degeneration 
 of nerve substance as secondary to it. There is, how- 
 ever, no real doubt that the degeneration is the pri- 
 mary and essential feature of the disease.' That it is 
 so is entirely confirmed by the a3tiological considera- 
 tions here presented, if these contain the truth, and is 
 upheld by the considerations which follow. 
 
 TJie Changes as related to the Developmental Rank 
 of the Tissue -Elements. If the disease is properly a 
 destruction of the specific elements of the cord, with 
 overgrowth of neurogiia from the taking away of 
 normal impediments to its growth, posterior spinal 
 sclerosis amalgamates with sclerosis of the kidney, 
 liver, and lungs. The higher elements perish and 
 the lower endure. 
 
 And the details of the retrograde process are 
 fulfilments of the corollary from dissolution, as 
 Dr. James Ross has pointed out in his ' Diseases of
 
 DISEASES OF THE NERVOUS SYSTEM. 167 
 
 the Nervous System.' Ganglion cells first lose their 
 elaborate processes, changing from bodies with caudate 
 prolongations to uniform spheres, and lastly appear- 
 ing as indefinite specks. Medullated nerve-fibres 
 first lose their specialised substance of Schwann ; this 
 coagulates, disintegrates, and vanishes, and the more 
 fundamental axis-cylinder is only subsequently de- 
 stroyed. It may here be mentioned that the fibres 
 of the white substance of the cord are first laid 
 down in the embryo as non-medullated fibres, the 
 sheath of Schwann being of later development. 
 
 The several systems of fibres in the spinal cord, 
 as the root-zones and cerebellar tracts, cannot be 
 said to show degeneration in the order of their deve- 
 lopmental rank. The posterior root-zones are deve- 
 loped earlier than the cerebellar tracts, or columns of 
 Goll ; but, as we have seen, in tabes dorsalis the dis- 
 ease begins in the first-named segments. Unlike the 
 units of composition in fibres and cells, the several 
 specialised divisions of the cord are exposed to widely 
 unequal amounts of disintegrative energy ; and this 
 decides the order of the changes of particular segments. 
 Some slight indications are discernible from the 
 physiological side that accessory functions and struc- 
 tures resist the invasions of pathogenic agencies with 
 relative feebleness. At first there is ataxia only 
 when muscular actions are not aided by vision ; but 
 as the disease advances the assistance of the eyes in 
 preserving equilibrium of posture or movement is of 
 little use. Ataxia is first shown in the more com- 
 plicated movements, as in turning round, or * picking 
 one's way,' while simple progression may be per-
 
 168 SPECIAL DISEASE. 
 
 formed less erratically. And when there is ataxia of 
 the upper extremities, the later-developed complex 
 movements, as those required in playing the piano 
 or in writing, are disordered before the more simple 
 movements of gesture or prehension. 
 
 The rest of the diseases of the spinal cord, and 
 those of the encephalon as well, will be found to 
 furnish further illustrations. The spinal lesions of 
 lateral sclerosis, simple, or joined with muscular 
 atrophy, and of multiple and marginal sclerosis, are 
 in intimate nature like the spinal lesions of locomotor 
 ataxia. A constant and fundamental feature is dis- 
 integration of nerve- substance and hyperplasia of 
 neuroglia, with subordinate differences of histological 
 detail in different diseases and cases. But, seldom is it 
 possible, in the present state of knowledge, to say what 
 in these leucomyelopathies the destroying forces are. 
 
 When we pass to the poliomyelopathies, whether 
 the morbid process is degenerative or inflammatory, 
 we find the most general description of it in the 
 formula of dissolution. And each disease bears 
 witness that accessory functions and structures are 
 relatively unstable. Beautifully elaborate and incisive 
 verifications of this truth have been unfolded by 
 Dr. Ross. 1 In poliomyelitis anterior acuta, owing 
 partly to the severity of the morbid process, both 
 fundamental and accessory ganglion cells in the 
 spinal cord are injured. It is, however, as in chronic 
 nerve degenerations, the spinal and muscular paren- 
 
 1 A Treatise on the Diseases of the Nervous System, By James 
 Ross, M.D., LL.D. See 371, 388, vol. ii.
 
 DISEASES OF THE NERVOUS SYSTEM. 169 
 
 chymatous elements which suffer. And, following 
 the death of these, the neuroglia is sometimes found 
 to be increased. 
 
 The myopathic changes of progressive muscular 
 atrophy are a fatty, granular, and in some cases gela- 
 tinous, degeneration of the muscular bundles. The 
 beginning of disintegration is often shown by dicho- 
 tornous or trichotomous division of the fibres. Simul- 
 taneously, or, as some investigators think, antecedently, 
 the interstitial substance of the sarcous elements aug- 
 ments. There appears to be no reason for excluding 
 these changes from the general interpretation adopted 
 for similiar affections of other organs ; namely, to 
 regard the degeneration of parenchyma as the primary 
 lesion, and the hypertrophy of connective tissue as 
 consequent upon the removal of the resistance to its 
 growth which the parenchyma naturally offers. 
 
 The neuropathic changes of progressive muscular 
 atrophy are, again, essentially in the proper nerve 
 matter. And here the implication of the elements 
 according to their position hi the evolutional hier- 
 archy of tissues finds an unexpected attestation. 
 Of the several groups of motor nuclei in the anterior 
 horns, Dr. Ross thinks that those occupying the 
 medio-lateral area are, in the lumbar and dorsal divi- 
 sions, concerned in maintenance of the erect position, 
 and are, therefore, evolutionally considered accessory. 
 This group is disposed to be affected in progressive 
 muscular atrophy. Those nuclei that occupy the 
 median area are found in the cervical division to have 
 grown by marginal increase, and the marginal cells 
 are thought to ' represent a complication on the
 
 170 SPECIAL DISEASE. 
 
 previous structure of the cord corresponding to the 
 complication of muscular adjustments which distin- 
 guishes the hand of man from the anterior extremity 
 of animals.' These also are most liable to be impli- 
 cated when the morbid process involves the cervical 
 anterior horns. And when there is an extension of 
 the disease to the motor nuclei of the medulla oblon- 
 gata, with the symptoms of labio-glosso-laryngeal 
 paralysis, there is a nearly uniform disorder and ex- 
 tinction of functions according to their grade. Recog- 
 nise, in the first place, the general fact that in progres- 
 sive bulbar paralysis the affection is peculiarly one of 
 functions and structures of high specialisation and of 
 comparatively recent appearance in man's evolutional 
 history. The organs afflicted are the tongue, lips, 
 larynx ) and lower facial muscles, those concerned in 
 speech and its auxiliary, facial expression. At the 
 onset of the disease, the more complicated actions of 
 the lips and tongue are executed with difficulty, and 
 finally become impossible ; and the like then happens 
 with the simpler actions. Articulation is lost before 
 phonation. And similarly with the complicated 
 movements of deglutition : the final degradation of 
 this function is seen when the simple vermicular 
 movements of the oesophagus are paralysed. If the 
 disease ends fatally, the most fundamental functions 
 of respiration and circulation are in turn abolished. 
 On the anatomical side it has been ascertained that 
 the disease is a degenerative atrophy of motor cells on 
 the floor of the fourth ventricle. The change com- 
 mences in the hypoglossal and accessory hypoglossal 
 nuclei, and in the nuclei of the glosso-pharyngeal ;
 
 DISEASES OF THE NERVOUS SYSTEM. 171 
 
 advancing to the facial and its accessory nuclei, to the 
 pneumogastric, spinal accessory, and trigeminus. 
 
 Though the causation of progressive muscular 
 atrophy and bulbar paralysis is yet sub judice, much 
 may be said to the effect that energy absorbed by way 
 of nerve channels is the exciting condition. Excessive 
 muscular exertion is an acknowledged factor of the 
 former disease, and immoderate use of the voice and or- 
 gans of speech plays some part in producing the latter. 
 
 May the morbid anatomy of pseudo-hypertrophic 
 paralysis be interpreted in like manner ? The alter- 
 ations in the muscles in this affection are thus given 
 by Dr. Ross : l l The first muscular change which 
 takes place in this disease consists of an increase of 
 the connective tissue which separates the muscular 
 bundles from one another, so that the sheaths of the 
 muscular bundles become greatly thickened. There 
 is also a corresponding increase of the connective 
 tissue which passes between the fibres themselves. 
 ... In this early stage the muscular fibres them- 
 selves do not appear to undergo any very manifest 
 changes, except that, according to Duchenne, their 
 transverse striation becomes fainter, while the longi- 
 tudinal striation becomes more marked. The trans- 
 verse striation is, however, generally quite distinct 
 until a late period of the disease. Duchenne re- 
 garded the proliferation of the connective tissue a 
 the chief cause of the increased size of the muscle ; 
 hence he called the disease 'paralysie myosderosique* ; 
 but other authors believe that the muscle does not 
 increase much in volume until the second stage of 
 
 1 Op. cit. vol. ii. p. 201. Ed. 1882.
 
 172 SPECIAL DISEASE. 
 
 the change occurs. This stage consists of the develop- 
 ment of fat cells in the connective tissue, and also in 
 the newly-formed fibrous tissue, whereby the muscular 
 fibres become widely separated from one another. 
 The muscular fibres now become atrophied and begin 
 to disappear. . . . After a time the muscular fibres 
 and the newly-formed fibroid tissue completely dis- 
 appear, and the entire muscle is represented by fat 
 cells, like those of an ordinary lipoma. The fat may 
 subsequently become absorbed, and connective tissue, 
 with perhaps a few traces of muscular fibres, is all 
 that is left.' 
 
 Whatever view we endorse of the pathological 
 sequences in the muscles in pseudo-hypertrophic 
 paralysis, the principle of dissolution receives ratifi- 
 cation. The distinguishing substance of the muscular 
 tissue is the first to disintegrate and die ; and in dying 
 the organs as a whole become less complex, less 
 special, and less multiform in structure and function. 
 But on every ground the sequences may, I think, be 
 most truthfully read as follows : The sarcous ele- 
 ments, being the most perishable, undergo simple 
 atrophic dissolution ; thereupon, while general nutri- 
 tion is good, the interstitial tissue grows out to repair 
 the loss, and, fat cells developing, there is acquired the 
 semblance of muscular hypertrophy. If the atrophic 
 dissolution continues and nutrition falls low, the fat 
 then becomes absorbed and the interstitial substance 
 itself atrophies, the remnants being, as just seen, 
 strands of connective tissue and traces of muscular 
 fibre. Did the changes begin with connective-tissue 
 hyperplasia, then the disease would be inflammatory,
 
 DISEASES OF THE NERVOUS SYSTEM. 173 
 
 as interstitial growth is commonly understood. But 
 inflammation is disintegrative, whereas hyperplasia 
 is integrative (chap. i. 2, and chap. ii. 1). More- 
 over, pseudo-hypertrophic paralysis does not present 
 the clinical features of an inflammatory affection, and 
 is not generally believed to be of this nature. 
 
 It remains to be said that the corollary from dis- 
 solution finds further general confirmation in the 
 order in which the muscles become paralysed. The 
 disease begins in the lower limbs, especially involving 
 the gastrocnemii, and in the erectors of the spine. 
 These are the muscles which have been developed 
 during the transition from the quadrumanous to the 
 bimanous type. It is remarkable how simian is the 
 appearance of one afflicted with this disease when 
 attaining the erect posture or making an ascent. 1 In 
 the same relation it is also noteworthy that, with an 
 inconsiderable number of exceptions, the malady is 
 confined to children about the age when the first 
 attempts to walk are being made. The suggestion 
 may be ventured that a congenital or acquired feeble- 
 ness of the parenchyma of the muscles affected causes 
 it to succumb to the disintegrative energy received 
 during functional activity. Since it remains an 
 undetermined point whether there are neuropathic 
 changes corresponding to the myopathic changes, 
 reference may be omitted to the observations which 
 have been made of lesions in the anterior horns. 
 
 Other diseases of the spinal cord supply a store of 
 
 1 See Dr. Ross's Diseases of the Nervous System, vol. ii. Plate III., 1. 
 E. 1882.
 
 174 SPECIAL DISEASE. 
 
 facts that may be construed by the principles of dis- 
 solution and evolution. Each affection is in union 
 with every other in so far that functions and struc- 
 tures become relatively indefinite, incoherent, and 
 homogeneous. And in a large proportion of cases these 
 changes may be seen to proceed from the action of 
 disintegrating forces. The many forms of myelitis 
 acute diffused, transverse, disseminated, chronic, &c. 
 bear as cogent testimony to the verity of the formulas 
 as any of the diseases we have considered. No better 
 example is afforded of interstitial hyperplasia as the 
 simple consequence of parenchymatous loss than that 
 of multiple neuritis, whatever the cause may happen 
 to be. The corollary from dissolution that later- 
 evolved attributes are relatively vulnerable meets with 
 many confirmations. The order in which the muscles 
 are affected in acute ascending, or Landry's paralysis, 
 is one that may be mentioned. This order, according 
 to Landry, and quoted by Dr. Ross, is as follows : 
 ' (1) The muscles which move the toes and foot ; then 
 the posterior muscles of the thigh and pelvis ; and, 
 lastly, the anterior and internal muscles of the thigh. 
 (2) The muscles which move the fingers ; those 
 which move the hand, and the arm upon the scapula ; 
 and, lastly, the muscles which move the forearm upon 
 the arm. (3) The muscles of the trunk. (4) The 
 muscles of respiration ; then those of the tongue, 
 pharynx, and oesophagus.' 
 
 Pachymeningitis and leptomeningitis display the 
 phenomena of serous inflammation, in which matter 
 is abundantly set free from the blood, often causing 
 compression of the cord. It would appear to be
 
 DISEASES OF THE NERVOUS SYSTEM. 175 
 
 obligatory to clearly separate this form of secondary 
 injury by mechanical compression from the supposed 
 inroads upon the parenchyma by the connective- 
 tissue growths of ordinary scleroses. The serous 
 and fibrinous exudates of serous inflammation after 
 causing compression may be invaded by fibro-blasts 
 from the contiguous fibrous texture, and ultimately 
 give place to a cicatricial growth (see chap. iii. p. 43). 
 In this wise there is produced an appearance of injury 
 to parenchyma by the encroachment upon it of an 
 hyperplasic connective tissue. But, consistently with 
 foregoing principles, the exudation of serum and 
 fibrine is an effect of inflammatory dissolution, while 
 the growth of connective substance is reparative and 
 evolutional. 
 
 Since the morbid histology of the brain repeats 
 that of the spinal cord, it would be superfluous to 
 inquire whether in their morphological aspects dis- 
 eases of the encephalon answer to the formulas. In 
 their physiological aspects many of these diseases 
 have been expounded by Dr. Hughlings Jackson, Dr. 
 Ross, and Dr. Mercier, from the standpoint of the 
 corollary from dissolution. To their writings, then, 
 the reader is referred. One word only may be said. 
 The so-called functional nervous affections, the dis- 
 eases of the encephalon, those of the encephalo- spinal 
 system as paralysis agitans, hydrophobia, tetanus, 
 &c. and the toxic, febrile, and post-febrile nervous 
 disorders, will be found on examination to show, not 
 more inconclusively than previously-noticed diseases, 
 that they are all one in being disintegrations of matter
 
 176 SPECIAL DISEASE. 
 
 from concomitant absorptions of energy, and accom- 
 panied by transformations of function and structure 
 of the dissolutional type. 
 
 We shall glance next at the fevers. In con- 
 cluding examples in the present category of patho- 
 logical changes, it may be remarked that the morbid 
 anatomy of those organs and tissues whose diseases 
 have not yet been considered shows the traits of dis- 
 solution and the growth of connective tissue to repair 
 parenchymatous loss. Myomalacia cordis from dis- 
 ease of the coronary arteries is one of the most 
 unequivocal illustrations. One of interest is sclerosis 
 of the stomach where degeneration of the gastric 
 tubules smarts at the bottom of the glands in the 
 cells last developed. Others are seen in myocarditis, 
 hyperplasia of the spleen, fibrous hyperplasia of 
 lymphatic glands, inflammations of mucous mem- 
 branes, cirrhosis of the pancreas, fibroid degeneration 
 of the suprarenals, &c. 
 
 2. THE FEVERS. 
 
 Some of the more characteristic structural lesions 
 in the fevers are incisive instances of dissolution. 
 Consider those implicating the skin in small-pox. 
 The papular, vesicular, and pustular stages of the 
 eruption do but mark the hyperaemic, exudative, 
 and suppurative stages of inflammation, which have 
 been seen to correspond with the terms of the for- 
 mula. The epidermis, with its different specialised 
 and co-operative parts, the stratum corneum, stratum 
 lucidum, stratum Malpighii, tactile corpuscles, sudori-
 
 THE FEVERS. 177 
 
 ferous ducts, vessels, and nerves, is brought to the 
 grade of relatively unspecialised, homogeneous, un- 
 organised pus. And the corium, with the cutaneous 
 appendages, sweat-glands and hair- follicles, may be 
 involved in these changes. 
 
 Consider, again, the peculiar lesions in the intes- 
 tines in typhoid fever. Peyer's patches are at first 
 swollen and infiltrated with inflammatory leucocytes. 
 The adenoid tissue and capillary network mainly com- 
 posing these lymph follicles, the intestinal mucous 
 "membrane covering them, the submucous tissue, and 
 even the muscular coat of the intestines, may all be 
 converted into a uniform incoherent mass of simple 
 round cells with dilated blood-vessels. At an ad- 
 vanced stage of the morbid process this mass forms 
 a slough, the dissolution being still more decided. 
 
 In yellow fever so profound and extensive are 
 the structural disturbances that ante-mortem decom- 
 position may almost be said to occur in severe cases. 
 Ordinary putrefactive changes appear, indeed, to set 
 in before death. The blood is infiltrated with biliary 
 and urinary matters ; the heart suffers acute fatty 
 degeneration, and its substance is permeated with a 
 brownish yellow substance ; the liver is yellow and 
 fatty ; the lungs are congested, and the kidneys pre- 
 sent the dissolutional changes of nephritis. And 
 with the remaining diseases of this class diphtheria, 
 scarlet fever, chicken-pox, cow-pox, dengue, erysi- 
 pelas, pyaemia, &c., it could be shown, were it needful, 
 that when the morphological changes are estimable 
 the histological elements are disorganised and made 
 less determinate and less different. 
 
 N
 
 178 SPECIAL DISEASE. 
 
 Of the functional changes, those which the fevers 
 have in common with one another may be noticed 
 more particularly. These are perturbations of the 
 body temperature, and of the cardiac and respiratory 
 functions ; rigors, sleeplessness, delirium, subsultus, 
 and involuntary evacuations. In respect of these 
 several phenomena, the organism's functions are cer- 
 tainly altered as described by the formula of dissolu- 
 tion. Normally the diurnal mean temperature of the 
 body is maintained with remarkable constancy under 
 changing external conditions. The range of varia- 
 tion in health is probably seldom greater than 2*3 F., 
 and the fluctuations are definitely related to rest, 
 exercise, the ingestion of food, the hour of the day, 
 &c. But in febrile states the temperature becomes 
 less stable, the elevations and depressions being ex- 
 treme 6 or more and marked by an irregularity 
 and uncertainty not observed in health. Thus the 
 actions of the mechanisms by which a nearly uniform 
 temperature is preserved become relatively incoherent 
 and indefinite. And the changes in the pulse and 
 respirations, and in the relations of these to one 
 another and to the temperature, may be formulated 
 in the same terms. 
 
 In rigors we see how the temperature sense be- 
 comes indefinite, the feeling of chilliness being an 
 accompaniment of raised internal temperature and 
 independent of external temperature. Also, that in 
 the sleeplessness of fever the regular and specialised 
 rhythms of sleeping and waking become quite per- 
 verted, i.e., changed to irregularity and unspeciality. 
 Subsultus tendinum shows how the heterogeneous,
 
 THE FEVERS. 179 
 
 specialised, and precise actions of the healthy volun- 
 tary neuro-muscular system give place to the pur- 
 poseless, inexact, and simple movements of in volition. 
 And the indecisive, disconnected, vague, rambling, 
 but withal relatively simple, operations of the mind in 
 delirium are of the same order of functional changes. 
 Note how in typhus fever the mental faculties lose 
 their sharpness of expression, so becoming less deter- 
 minate ; there is a vacancy in the eyes and heaviness 
 in the face. Questions are answered slowly, and 
 ideas are confused, showing a laboured and defective 
 co-ordination of the elements of thought. The spe- 
 cial senses taste, smell, hearing, vision, and touch 
 become obtuse, and in the case of the two first- 
 named annulled. Thus the functions of the organ of 
 mind are rendered less different. Then there is the 
 pathognomonic feature of typhus prostration of 
 voluntary and involuntary muscles. Hence result 
 temporary, partial, and complete dissolutions of func- 
 tion, such as total inability to move, constipation, and 
 retention of urine. 
 
 Contemplate also some of the physiological changes 
 of diphtheria, as when asphyxia is caused by the pro- 
 duction of false membrane in the larvnx. Then the 
 normal regularly recurring respirations in determi- 
 nate ratio with the cardiac movements give place to 
 laboured efforts but little integrated with the actions 
 of the heart. If the laryngeal obstruction leads to 
 general convulsions, we have more phenomena of the 
 same general order. And there is complete functional 
 dissolution when sphincters are relaxed and reflex 
 excitability is abolished. The laryngeal obstruction 
 
 N >
 
 180 SPECIAL DISEASE. 
 
 being fatal, the respirations become feeble and more 
 irregular, and finally cease, the heart continuing for 
 a while to beat. Circulation is now completely dis- 
 united from respiration. It may be concluded that 
 changes of the same nature are simultaneously taking 
 place in the finest chemistry of pulmonary and intra- 
 cellular respiration, and in the mechanical factors of 
 blood-circulation. 
 
 By reason of the organs involved, the secondary 
 affections of the nervous system in diphtheria are so 
 convincingly in harmony with dissolution that it may 
 be well to draw attention to them. Paralysis of the 
 pharynx and palatine arch induces dysphagia, cough, 
 and choking. The voice loses its individual quality ; 
 speech becomes less distinct and stammering from 
 implication of the tongue, lips, and cheeks. The 
 features become expressionless, the saliva dribbles, 
 the eyelids droop, and the head cannot be supported 
 by the muscles of the neck. There may be presby- 
 opia, myopia, and diplopia ; or paralysis of the limbs, 
 the heart, muscles of the chest and diaphragm ; para- 
 lysis of the bladder, with dribbling of the urine ; or 
 of the intestines, with constipation. Finally, all the 
 senses may be affected. Incontestably, these pheno- 
 mena have the common trait that they are changes 
 to indefiniteness, incoherence, and homogeneity. 
 
 That the essence of the fevers is the essence of 
 dissolution disintegrations of matter caused by the 
 absorptions of energy there is no lack of proof. The 
 pitting of small-pox vacant spaces remaining in the 
 skin after subsidence of the specific eruption is ob- 
 trusive evidence of local destructions of tissue, by
 
 THE FEVEKS. 181 
 
 which portions of the body are wholly severed from 
 it. When pitting is not a sequel, there are still the 
 disintegrations of inflammation passing into resolu- 
 tion and repair. Small-pox is often complicated by 
 abscesses, haemorrhages, thrombosis, and other dis- 
 integrations. In typhoid fever, the substance of a 
 Peyer's patch may be so thoroughly broken down 
 that ulceration and perforation of the bowel ensue. 
 Albuminuria, of typhoid and other fevers, implies 
 molecular or coarse disintegration of the substance 
 of the kidney, and disruption of the blood. And the 
 granular degeneration of cells in fevers is a rending 
 apart of cell- substance. The examples of material 
 destruction in yellow fever are numerous and striking. 
 It is an aspect of all the phenomena. First, there is 
 the evidence of excessive disintegration found in the 
 urine. This excretion, when it is not suppressed, 
 usually contains an inordinate quantity of urea, 
 ' reaching as much as a thousand grains per diem.' 
 The average in health is 512*4 grains. And in this 
 disease, the excretion of an ounce of albumen in 
 twenty-four hours has been observed. Renal dis- 
 integrations are represented by cells of epithelium, 
 tube-casts, and debris in the urine. Black vomit 
 acquires its notorious quality from abnormal disin- 
 tegrations blood set free from the gastro-intestinal 
 mucous membrane. Black vomit also contains epi- 
 thelial cells and urea. In yellow fever, haemorrhage 
 may take place from the gums, eyes, and ears. The 
 fibrine of the blood is diminished presumably be- 
 cause it is destroyed and there is said to be an 
 unwonted dissolution of red blood-cells. Desqua-
 
 182 si'KCIAL DISEASE. 
 
 mations occur in the kidneys, and the heart and 
 liver evidence those chemical disintegrations of cell- 
 albumen which terminate as fatty degeneration. And 
 the nervous phenomena coma, convulsions, para- 
 lysis, &c. of yellow and other fevers are almost 
 certainly the outcome of molecular and molar demo- 
 litions of tissue. 
 
 Finally we come to the disintegrations which are 
 supposed to signify increased tissue oxidation. In 
 recognising the fact that the febrile state is attended 
 with an enlarged discharge of the products of tissue 
 metabolism, we are not committed to any hypothesis 
 as to the chemical and physical sources of these 
 products, or as to the causes of the heat of fever. 
 Whether the pyrexial state is owing to increased 
 oxidation, or to the liberation of heat that would in 
 the normal state have taken other forms of energy l 
 perhaps heat or chemical energy or whether we 
 must look for an explanation to the actions of the 
 nervous system, is beside our present purpose. That 
 high temperature is invariably accompanied by tissue 
 dissociations does not admit of doubt. The carbonic 
 acid exhaled by the lungs and the nitrogenous ex- 
 creta of the urine are always augmented in fevers. 
 Fevers, too, are accompanied by visible wasting, 
 showing that the involved processes are destructive. 
 
 Are these processes the consequences of absorbed 
 environmental energy? Less unobviously so, per- 
 haps, than the morbid phenomena of any other class 
 
 1 See ' An Introductory Address on the Heat of Fever,' by W. Ord, 
 M.D., F.R.C.P., British Medical Journal, October 24, 1885.
 
 THE FEVERS. 183 
 
 of diseases. Small-pox, cow-pox, and vaccinia no 
 hesitancy is felt in ascribing to the entrance to the 
 blood and tissues, through contagion or inoculation, 
 of some form of virus ; and we believe that the 
 multiplication of this within the body sets up the 
 chain of disintegrations constituting the morbid ana- 
 tomy and physiology of these affections. Facts are 
 thought to warrant the view that a poisonous efflu- 
 vium, elaborated in the overcrowding of human 
 beings, is the determining circumstance of typhus 
 fever. It may be regarded as almost established that 
 typhoid fever has its source in matter which gains 
 access to the organism by way of the alimentary 
 canal. The energy so imbibed causes the disintegra- 
 tions of intestinal catarrh and inflammation of the 
 lynaph follicles, and, by continuity of tissue, its in- 
 fluence is passed on to the mesenteric glands, blood, 
 and other structures. It is supposed by several in- 
 vestigators that the active agent is a bacillus. Of 
 scarlet-fever, and all diseases allied to it by nature, 
 there is now a firmly grounded conviction that their 
 causes exist in external conditioning forces. Their 
 communicability from person to person imposes this 
 conclusion. What the concrete factors are has yet 
 in many cases to be determined. But the goal of 
 research in this field is perhaps well indicated by the 
 recent investigations of Dr. Klein, Mr. Wynter Blyth, 
 and Mr. Power upon the connection of scarlet fever 
 with the inception of a micrococcus. 
 
 The fevers show us as other diseases do the 
 intervolution of dissolution and evolution. Though
 
 184 SPECIAL DISEASE. 
 
 we cannot penetrate to all the details of those pro- 
 cesses by which the general equilibrium of the func-- 
 tions is restored in the acute specific diseases, yet the 
 processes are of the same order as resolution and 
 repair. They are a reversion of the previous dissolu- 
 tion, since the lost qualities are recovered. In the 
 poison-diseases, like scarlet fever and diphtheria, re- 
 covery must be largely effected by gradual elimina- 
 tion of the poison, and by the redintegration of in- 
 flammatory exudates. The focal lesions of typhoid 
 fever supply good examples of the reparative changes 
 in that disease. A solitary or Peyer's gland may 
 undergo resolution, in which event the hyperaemia 
 subsides. The inflammatory extravasations are then 
 absorbed or reaggregated round common centres, 
 matter being integrated and motion lost (chap. ii. 
 1). And the gland re-acquires its normal orga- 
 nisation, distinctness, and variety of functions and 
 structures. 
 
 If the morbid changes end in necrosis, there 
 results from rupture of the follicles a typhoid ulcer. 
 At the site of this repair takes place ; there is a 
 reproduction of cicatricial tissue strictly analogous 
 to the fibrosis of chronic diseases, and, as in those 
 diseases, the higher structures are perceived to be 
 weaker than the lower (cor. 1). Peyer's patches 
 are differentiations of the intestinal lymphatics, are 
 accessory elements in the intestinal mucous mem- 
 brane. 
 
 The changes in the kidneys in scarlet fever and 
 in yellow fever are the verifications of the corollary 
 we observed in the section on Bright' s disease. Others
 
 THE FEVERS. 185 
 
 may be followed out in the functional and nervous 
 phenomena of febrile diseases. Speaking broadly, we 
 obtain glimpses of a conformity to the principle in the 
 invasion of the neuro- muscular and other functional 
 systems, and in the invasion of the mental faculties in 
 fever, especially in typhus fever. 
 
 To lay hold of the fact that the process of equili- 
 bration in acute disease is the opposite of dissolution, 
 dissolution may be contemplated from the dynamic 
 aspect. From this single point of view it is an in- 
 crease in the relative movements of parts and a 
 decrease in the relative movements of wholes. There 
 is a regression from the motions of large masses to 
 the motions of smaller masses, and from the motions 
 of small masses to the motions of compound molecules, 
 and from the motions of compound molecules to the 
 motions of simple molecules. We reverse the terms, 
 of course, for evolution. .Then 'evolution is a decrease 
 in the relative movements of parts an'd an increase in the 
 relative movements of wholes using the words parts 
 and wholes in the most general senses. The advance 
 is from the motions of simple molecules to the motions 
 of compound molecules, from molecular motions to 
 the motions of masses, and from the motions of smaller 
 masses to the motions of larger masses.' A case of 
 typhoid fever will illustrate the general dynamic 
 changes so exhibited. The visible movements of 
 large and small wholes, as the movements of the body 
 and viscera, are derived immediately from the mole- 
 cular motions of the involuntary and voluntary 
 muscles, which molecular motions are in turn re- 
 motely and partly derived from food. Therefore, by
 
 186 SPECIAL DISEASE. 
 
 the terras given above, in dissolution the motions 
 should be given back in this order : the large wholes 
 should yield up their motions to small wholes, and 
 the small wholes their motions to smaller wholes, 
 and these their motions to molecules of descend- 
 ing orders of complexity. Such transference can 
 plainly be traced. In typhoid fever we find an in- 
 crease in the relative movements of the parts and a 
 decrease in the relative movements of the whole. If 
 the molar movements of the body the movements of 
 the body and limbs through space are not altogether 
 arrested, they are notably diminished, and, conform- 
 ably, they appear as added motions of parts. First to 
 be noticed is the increased molecular activity implied 
 by the raised temperature, and that in proportion to 
 the height of the temperature there is indisposition 
 to voluntary movement. Next, the heart, diaphragm, 
 and subsidiary organs of respiration perform their 
 respective rhythmical motions more rapidly ; there 
 are increased movements in the component parts of 
 the spleen and intestinal lymphatics, and of the in- 
 testines, as evidenced by enlargement of the former 
 and the more active contractions of the latter. Then 
 certain structural components of the bowel, in the 
 shape of the solitary and Peyer's glands, undergo 
 such augmentation of their molecular momenta that 
 the histological particles are disunited and acquire 
 independent motions, leaving areas of complete disso- 
 lution typhoid ulcers. If we followed these small 
 disintegrated elements in their subsequent careers we 
 should find their individual motions resolved into the
 
 THE FEVERS. 187 
 
 motions of the smaller units of their composition, and 
 the motions of these resolved into the motions of their 
 compound and simple molecules. With death as the 
 termination, the motions of the organic systems 
 cardiac, pulmonary, secretory gradually abate, and 
 in the end vanish into the invisible motions of dead 
 organic matter, the succeeding changes of decomposi- 
 tion answering to the formula. 
 
 Since recovery from acute disease implies a re- 
 integration of matter and motion, convalescence from 
 typhoid fever will show the evolutional redistribution 
 of motion. The earliest premonition of recovery is 
 a depression of the exalted molecular motions heat 
 vibrations. Coincidently the organic functions 
 respiration and circulation acquire slower rhythms. 
 By increased assimilation, the molecular energy con- 
 tained in alimentary substances is stored up in the 
 tissues and made over to the organs. These smaller 
 motions are then compounded into the molar motions 
 of the individual, and so finally dissipated. It must 
 be admitted that the changes of motion in disease are 
 thus exhibited in an extremely general way. Perhaps 
 this is as much as can be expected where the involved 
 forces are so variously and definitely relationed as in 
 the human organism. 
 
 We shall now take examples of diseases which 
 may involve the entire system, that are not contagious 
 or infectious, and not necessarily attended with coarse 
 lesions. These affections begin as functional disorders, 
 and therefore the structural changes are molecular
 
 188 SPECIAL DISEASE. 
 
 rearrangements. Diabetes will serve to represent the 
 class. 
 
 3. DIABETES AND ALLIED AFFECTIONS. 
 
 The facts of diabetes, and the disorders to be 
 regarded as its congeners, gout and rheumatism, we 
 shall find amenable to synthesis by dissolution and 
 evolution ; and when their affinities of nature and 
 causation have been laid bare, our notions of these, 
 as of other diseases which have been brought under 
 inspection, will, I think, grow in vividness and 
 consonance with fact from the influence of the 
 formulas. 
 
 If we have in mind average, not exceptional, ex- 
 amples, i.e., ordinary cases of diabetes, the morbid 
 anatomy is very indefinite. In its first stages we are 
 obliged to consider the affection a functional one. 
 But such positive changes as post-mor tern examinations 
 have revealed, and those to be viewed as secondary 
 and complicating lesions, exhibit no discrepancy with 
 dissolution. After the repeated illustrations that 
 have been made the mere nomination of them will 
 suffice. 
 
 In a moiety of cases the liver has been found 
 hyperasmic, and in advanced cases with the signs of 
 atrophy ; parallel changes have been discovered also 
 in the kidneys. The pancreas was small, hard, and 
 bloodless in thirteen out of thirty cases reported by 
 Rokitansky. The tongue is commonly smooth and 
 red, and its epithelium is atrophied. Phthisis and 
 pneumonia are very frequent secondary affections, 
 as are boils, carbuncles, and cataract. Morphological
 
 DIABETES. 189 
 
 changes in the nervous system have been described 
 by Dr. Dickinson. These anatomical characters of 
 diabetes, though inconstant and not free from am- 
 biguity, do at any rate appear to be dissolutional. 
 
 From the clinical and physiological sides varied 
 and tangible abnormalities are presented. If we 
 take first the most important, the deliverance through 
 the kidneys of an excess of saccharine matter, we 
 have to learn whether this phenomenon is assimilated 
 by the formula of dissolution. Is the increased ex- 
 cretion of sugar a reduction to relative simplicity, 
 generality, and uniformity of functions and structure ? 
 It must be allowed to mark a change of this nature 
 both in the constitution of the urine and in those 
 physiological actions of which the constitution of the 
 urine is an outward and scrutable sign. When we dealt 
 with the facts of Bright' s disease it was remarked 
 that normal urine has a definite, coherent, and hetero- 
 geneous organisation ; its composition is constant, 
 stable, and complex. And the observation was made 
 that urea in human urine being the last and in a sense 
 highest term in the series of chemical changes which 
 food undergoes in the system, the presence in the 
 urine of bodies intermediate between urea and the 
 crude proteids and carbo-hydrates of the ingesta ren- 
 ders the structure of the urine relatively simple and 
 general. From the dissolutional point of view, we 
 must so regard the excretion in excess of the common 
 urinary constituents oxalic acid, uric acid, urates, 
 phosphates, &c. and a fortiori the excretion of albu- 
 men, sugar, or fat. And if the urine is thus changed, 
 so must be the metabolic processes of which the
 
 190 SPECIAL DISEASE. 
 
 quality of the urine is representative. Therefore, 
 the presence in diabetes of an abnormally large quan- 
 tity of sugar makes the urine less complex and less 
 special than it would have been had such sugar, taken 
 in as aliment, been elaborated by the tissues and the 
 residue cast out as normal excrement. If the sugar 
 may be supposed to take the place of different bye- 
 products of its conversion into animal energies, then 
 the urine, by the presence of the sugar, would be to 
 that extent rendered less heterogeneous. And this 
 abnormal excretion of sugar implies changes of iden- 
 tical character in the metabolic processes, whatever 
 the internal or external cause of these changes, whe- 
 ther a tumour, injury to the brain, or the ordinary 
 cause of diabetes. 
 
 It seems proper, then, to regard the leading fea- 
 ture of diabetes as in agreement with dissolution. 
 Other symptoms of the disease as well may be com- 
 prehended under this formula, namely, diarrhoea or 
 constipation, excessive urination, enuresis, the loss of 
 sexual power, coma, and failure of the mind. But it 
 will be well to pass from these to correspondences 
 with dissolution of greater interest. 
 
 Are the dissolutional changes of diabetes disinte- 
 grations of matter from the taking up of energy ? The 
 question is unanswerable unless we know the causes 
 of the disease ; but pathologists are as uncertain 
 upon the aetiology as upon the pathology of diabetes. 
 What, then, must be said? The following hypothesis 
 of its causation appears to me the only tenable one. 
 
 In the search for causes the principle of dissolu- 
 tion ever conducts us to the interactions of the organ-
 
 DIABETES. 191 
 
 ism and its environment. Fixing attention, then, 
 first upon the external conditions of the untreated 
 diabetic, we are arrested by his immoderate ingestion 
 of amylaceous, saccharine, and other articles of food. 
 Here, I think, lies the prime external factor. The 
 internal change is the failure to convert aliment into 
 the normal forms of animal energy and waste matter. 
 What in the anatomical and physiological senses the 
 fault exactly is we cannot say ; but about the fact there 
 is no doubt. Possibly the change is in the general 
 protoplasm of the body. All the circumstances in the 
 lives of persons suffering from confirmed glycosuria 
 favour, I think, the conclusion -that from the long-con- 
 tinued ingestion of food exceeding in quantity the 
 needs and assimilative capacity of the body, there has 
 followed an exhaustion of those forces through which 
 food is converted into the higher forms of energy- 
 yielding animal substances. The needs of the organ- 
 ism are, of course, relative to various physiological 
 states, and thus the excess may be a relative excess. 
 But it is as we see in other diseases, that undue func- 
 tional activity in the present case the activity of the 
 function of elaborating integrable food-material leads 
 to the abolition of function, or functional atrophy. 
 A condition constant in all forms of atrophy is the 
 predominance of waste over repair, the waste being 
 related to energy absorbed (chap. iii. 4). In 
 diabetes, then, the food taken in is the energy ab- 
 sorbed ; this wears out the organs concerned in the 
 elaboration of the carbo-hydrates of food, just as the 
 immoderate ingestion of proteids will wear out the 
 kidneys. Some forms of albuminuria may, I think,
 
 192 SPECIAL DISEASE. 
 
 be compared with ordinary diabetes in respect of 
 causation and the fact that, crude food-material circu- 
 lating in the system in excess, the excretory organs 
 become the channels of discharge. 
 
 Upon this understanding of the aetiology of dia- 
 betes, we readily make an arrangement of its phe- 
 nomena as they are naturally related. Early in 
 the histoiy of any case, the appetite, in health an in- 
 dication of physiological needs, becomes perverted. 
 Growing by what it feeds upon, the desire for hydro- 
 carbons soon ceases to bear a proper relation to the 
 physiological wants and powers of the system, and 
 appetite becomes a craving. Ministrations to this 
 craving lead at length to the undetermined disinte- 
 grations of function and structure which are the 
 anatomical and physiological bases of confirmed dia- 
 betes. There results inability to deal with even a due 
 amount of hydro-carbonaceous food. An excessive 
 quantity of sugar is thus thrown upon the blood. 
 This sugar naturally seeks an outlet by the kidneys ; 
 and if these organs are unequal to the work of excretion 
 the sugar will find other outlets. The diarrhoea not 
 infrequently associated with diabetes signifies eiforts 
 at elimination by the bowels. There is probably a 
 determination of saccharine matter to the skin. The 
 inordinate thirst of diabetes is a physiological adapta- 
 tion which leads to an increased ingestion of water, 
 and so to the solution and discharge of the sugar. 
 Hence the polyuria. In large part, the remaining 
 symptoms of diabetes are connected with disintegra- 
 tions produced by the blood impurities ; the skin 
 affections, emaciation, exhaustion, and diabetic coma
 
 DIABETES. 193 
 
 may be so explained. It is very interesting to observe 
 in this disease a corroboration of the opinion expressed 
 when we considered the causes of pneumonia and 
 phthisis namely, that the quality of the blood of the 
 pulmonary artery as related to alimentation is an 
 important determinant of certain diseases of the 
 pulmonary tissue. A very common termination of 
 diabetes is by pneumonia and phthisis. We speak of 
 diabetic consumption. It may be concluded that the 
 blood which passes to the lungs from the liver and 
 general system, laden with food-material not prepared 
 for the lung's reception of it, is one of the causes of 
 the disintegrations of diabetic pulmonary disease. 
 
 As we .discriminate those changes in diabetes that 
 are evolutional in character we are reminded that the 
 most approved treatment for the disease is in entire 
 concurrence with the view here taken of its causation. 
 By appropriate measures, which include a restricted 
 consumption of starchy and saccharine matter, partial, 
 and even complete, recovery may be effected. Hyper- 
 trophy of the bladder is a subordinate evolutional 
 change of interest at the present moment. This 
 concomitant of diabetes has only lately been made 
 known to the profession by Dr. Robert Maguire. 
 Clearly, the growth of vesical tissues is consequent 
 on increase of function (diuresis). 
 
 Though certain of the individual phenomena of 
 diabetes exemplify the disappearance of functions in 
 the inverse order of their development, the essential 
 lesion involves a fundamental function. It is pro- 
 bable that the consumption of ' free ' sugar as an 
 
 o
 
 194 SPECIAL DISEASE. 
 
 article of food a custom which later civilisation hns 
 made possible is a potent cause of diabetes. 
 
 Allied diseases, as gout and rheumatism, may be 
 similarly interpreted. There is now a general agree- 
 ment among physicians that rheumatism and gout 
 are due to the presence of a poison in the blood, and 
 that the two diseases are closely related in nature and 
 aetiology. But their affinities with diabetes are less 
 generally recognised. 1 The poison of gout (uric 
 acid) many now believe to be generated by a diet too 
 rich in nitrogenous elements. So that in gout as in 
 diabetes we must consider the ingested aliment as the 
 most important external cause, and the failure to deal 
 physiologically with this aliment as the necessary 
 internal defect. 
 
 Rheumatism probably differs only in the chemical 
 characters of its poison, in certain secondary con- 
 ditions of its production, and in the distribution of it 
 in the system. 
 
 The reader will be prepared to comprehend their 
 phenomena from our special points of view, and also 
 the phenomena of kindred affections, as scurvy and 
 purpura. A concluding word may be said to point 
 out that the appendicular and accessory structures, 
 the cardiac valves, are peculiarly susceptible to the 
 action of the poisons of gout and rheumatism, a fact 
 which falls in with the corollary from dissolution. 
 
 1 See The Croonian Lectures on Some Points in the Pathology of 
 Rheumatism, Gout, and Diabetes. By P. W. Latham, M.A., M.D., 
 F.R.C.P.
 
 DISEASES OF THE MIND. 195 
 
 4. DISEASES OF THE MIND. 
 
 Are affections of the mind to be given a position 
 in pathology that will mark them off as requiring 
 presentment essentially different from that we have 
 employed for other diseases ? Though the subject- 
 matter of subjective psychology comes before the in- 
 vestigator in a form absolutely unique, it is believed 
 that the facts of mental pathology may be dealt with 
 on precisely the lines adopted for the pathology of the 
 body. Psychical activity is here assumed to be the 
 equivalent of cerebral activity. As contraction is the 
 property of muscle, secretion the property of a gland, 
 and the nervous discharge a property of nerve tissue, 
 so is it postulated that feeling, knowing, and willing 
 are properties of cerebral substance. Mind and. body 
 are two aspects of the same thing, as motion and 
 matter are two aspects of the same thing. The 
 proposition will not be understood to identify these 
 properties. On this ground, which, I think, few 
 alienists will disallow, anatomical changes form the 
 physical bases of abnormal mental changes. Cases of 
 insanity, however, singularly seldom supply demon- 
 strable proof that psychical disorders are attended 
 with corresponding structural alterations. By far the 
 larger number of diseases of the mind have not yet 
 been associated by pathologists with a visible morbid 
 anatomy. Dementia, mania, melancholia, delusional 
 and other insanities, afflicting perhaps the bulk of 
 asylum patients, are, on the physical side of their phe- 
 nomena, little understood. Many of these probably 
 fall into the category of what are known as functional 
 
 o 2
 
 196 SPECIAL DISEASE. 
 
 diseases ; molecular rearrangements are their physical 
 counterparts. Of the residue, the morphology remains 
 to be discovered. There are, nevertheless, numerous 
 varieties of mental disorder which have a distinct 
 morbid anatomy ; and to one of these we may at once 
 pass. 
 
 In setting out upon our consideration of diseases 
 of the mind, the affection known as general paralysis 
 of the insane may be chosen as the point of departure. 
 If we first place the chief facts of this common and 
 well-known malady in juxtaposition with the prin- 
 ciples the verity of which we are testing, other forms 
 of insanity can afterwards readily be included in the 
 necessarily rapid aperqu. 
 
 We have to learn whether the sensible bodily 
 changes of general paralysis are the changes pre- 
 dicated by dissolution. They are in every material 
 respect those we have encountered again and again in 
 the analysis of other diseases disintegrations of the 
 substance of the body and a reduction to a deranged, 
 obscure, and general configuration, with integrations 
 of inferior order. If we study the minute characters 
 of the principal lesions of the nervous system, what 
 do we find ? That nerve-fibres both of brain arid 
 spinal cord are without medullary sheath or have been 
 bodily destroyed ; that nerve-cells have withered or 
 have passed wholly out of being. There are also the 
 signs of inflammatory disintegrations. Leucocytes 
 and fluids are seen outside their normal areas of 
 congregation. Vessels are degenerated. By the side 
 of these structural transmutations we find the pro-
 
 DISEASES OF THE MIND. 197 
 
 ducts of formative processes false membranes from 
 pacliy meningitis .and a new growth of connective 
 tissue (see p. 175). Often there is cirrhosis of the 
 kidneys. In this disease as hi other organic diseases, 
 the root-change is a dissolution of the specific elements 
 of the functional systems involved. 
 
 And what are the physiological equivalents of 
 these molar sensible lesions and of those co-existing 
 molecular lesions that are beyond the range of sense- 
 perception ? Are they also uniform with the principle 
 of dissolution ? The bodily symptoms and the motor 
 phenomena of general paralysis we may pass over, 
 since they are reproductions of phenomena already 
 noticed. Occupying ourselves, then, with the leading 
 mental symptoms, let us contemplate these under 
 the usual psychological classification which groups 
 the operations of the mind in an ascending scale of 
 their complexity. We begin with sensation. Do 
 sense-impressions become less definite, coherent, and 
 heterogeneous in general paralysis ? Organic sensi- 
 bility meaning by this the effects upon consciousness 
 of the physiological working of the stomach, kidneys, 
 liver, &c. is vague as compared with special sensi- 
 bility hearing, seeing, &c. Undoubtedly organic 
 sensibility becomes more vague in general paralysis 
 of the insane. One of the best-marked peculiarities 
 of this affection is the insensitiveness of patients to 
 changes in the internal organs. Profoundly destructive 
 actions may be going on in the tissues of the nervous 
 system, kidneys, stomach, and other viscera, yet the 
 general sense is one of lien etre. In still other respects 
 organic sensibility is blunted. By the gluttony of
 
 198 SPECIAL DISEASE. 
 
 general paralytics in the stage of dementia we are to 
 understand that the excitations of the gastric sensory 
 nerves are no longer represented in the sensorium in 
 a manner enabling the individual to eat with dis- 
 crimination ; and so patients surfeit themselves. Or 
 there is no memory of a meal just eaten, and one meal 
 is taken immediately after another. These changes 
 imply a loose compounding of and relative uniformity 
 in the waves of visceral nervous energy going to the 
 abode of consciousness. 
 
 Special sensibility is not as deeply involved in 
 general paralysis as organic sensibility ; there may, 
 however, be local anaesthesia, loss of tactile and 
 muscular sense, also loss of the sense of smell, and 
 colour-blindness. 
 
 These faculties sensations are the unwrought 
 substance of perception and memory. Perception is 
 the mental reference of sensations to objects ; thus a 
 sensation of blue is localised or externalised in the 
 sky. Memory is the reproduction of perceptual im- 
 pressions ; after turning from the sky the perception 
 is recalled in the form of a mental image. Are 
 perception and memory affected in general paralysis 
 in the way dissolution sets forth ? Early in the 
 disease the keen edge, the definiteness, of perception 
 is merely dulled ; but later, hi the stage of fatuity, the 
 power of perceiving things is scarcely greater than 
 that of an infant's. The sounds and sights of every- 
 day life call out no responsive signs, and it may be 
 impossible to bring the patient's mind into relation 
 with distant or minute objects, to cognise which there 
 must be a strict co-ordination and sharpness of facul-
 
 DISEASES OF THE MIND. 199 
 
 ties. And things that are perceived are liable to be 
 immediately forgotten. The events of yesterday can- 
 not be recalled. Appointments slip the memory ; 
 the patient breaks down in conversation because he 
 cannot remember facts and words and their relations. 
 The composite train of images required for the recol- 
 lection of a group of experiences say the incidents 
 of a day's pleasure excursion are offered in fragments. 
 The mnemonic process is marked by indistinctness 
 and relative simplicity of the pictures and a feeble 
 integration of them. Corresponding with the cerebral 
 changes, memory is disintegrated. 
 
 The grandiose ideas of the insane paralytic do not 
 indicate development but degradation of that form of 
 memorising known as imagination the constructive 
 reproduction of images. The imagery in 'exaltation' 
 is not truly constructive : there is lacking a mutual 
 dependence of parts, and the images themselves rarely 
 range beyond a narrow egoism. 
 
 What is the general character of thought, judg- 
 ment, and reasoning ? Since it is out of perceptions 
 and memories that concepts, judgments, and ratiocina- 
 tions are built up, it might be expected that the less 
 elementary faculties would share the changes of the 
 more elementary. To the higher intellectual opera- 
 tions as to the lower, an applicable criterion is that of 
 their clearness, coherence, and speciality. In respect 
 of these qualities, thought, judgment, and reasoning 
 exhibit regressive changes. The person who pur- 
 chases for his own use ' a dozen broughams and 
 twenty parrots ' is one in whom there is no percep- 
 tion of agreement between impulses and needs. In
 
 200 SPECIAL DISEASE. 
 
 one who states the proposition that he is about to 
 ' marry the Queen and all the princesses/ the judg- 
 ment and reasoning are insane because the relation of 
 congruity which should subsist between desires and 
 the possibility of satisfying them is thoroughly con- 
 fused. As to the general symmetry of thought, 
 * incoherence ' is the common term employed to de- 
 note the discontinuous and disconnected utterances in 
 delirium and mania, two constant phases of general 
 paralysis. In variedness or speciality there is, as hi 
 other examples of dissolution, only an apparent in- 
 crease. Thought is not discursive, but is occupied 
 almost exclusively with selfish concerns is quite un- 
 specialised. 
 
 Were it required, it could be shown that on the 
 emotional and volitional sides of mind the process 
 of dissolution can be traced. The simple feelings, 
 the sentiments, and the will, all undergo analogous 
 changes. This will appear as we apply to the mental 
 symptoms of general paralysis the corollary from dis- 
 solution. We may now address ourselves to this 
 task, and leave the causation for later notice. 
 
 Can there be discerned in the disease we have 
 selected to typify insanity a derangement of mind 
 the reverse of its developmental arrangement ? Are 
 the mental faculties we have just hastily viewed de- 
 graded from above downwards ? They are clearly 
 so. Insanity in its medical and medico -legal aspects 
 engrosses attention as it affects conduct. Conduct 
 is the complex action always involving muscular 
 movement of one kind or another by which cha-
 
 DISEASES OF THE MIND. 201 
 
 racter and the relations to environment, especially 
 social, are delineated. It is thus the sum and repre- 
 sentative of all mental endowments, and the last of 
 the series of attributes unfolded by development in 
 the individual, and produced by evolution in the race. 
 That the first indications of mental alienation are 
 alterations in conduct is, then, quite in keeping with 
 the corollary from dissolution. Let us now see how 
 conduct is altered, and note the order of the changes 
 in the mental and moral qualities. 
 
 The symptoms of general paralysis have been 
 grouped by three periods of the disease : the stages 
 of alteration, mania, and progressive dementia. This 
 arrangement it will be convenient for us to keep in 
 mind, though our purposes require a contemplation 
 of the changes in continuous series. 
 
 General paralysis is early betrayed by a change 
 in habits and manners. One who was wont to be 
 cleanly and orderly in his attire becomes uncleanly 
 and slovenly. The self-respecting actions and respect- 
 ful bearing towards others which are distinguishing 
 marks of the higher orders of men give place to inde- 
 cencies and rudeness. The person may be exposed 
 ^ithout regard to circumstances ; foolish assaults may 
 be made upon women ; passionate and inconsiderate 
 orders are given to servants. The punctilious man 
 disregards the times of meals and appointments ; the 
 prudent man spends money lavishly and rashly. 
 Now these alterations of character and conduct sig- 
 nify a loss of lately acquired qualities. The manners 
 and habits of civilised man are among the highest 
 and latest products of human evolution ; and those
 
 202 SPECIAL DISEASE. 
 
 qualities which take their place in one suffering from 
 general paralysis are the qualities of earlier and inferior 
 creatures. The man is, as we say, degraded. It is 
 here as with dissolution everywhere : the root-change 
 is not a something added but a something taken away, 
 and the loss of the higher attributes makes active the 
 latent lower. 
 
 Nearly all the mental features of general paralysis 
 of the insane can be interpreted in this wise. Let it 
 be the highest form of volitional activity say, deli- 
 beration upon a course that is not clear and the 
 business man threatened with the disease is unequal 
 to his situation. He cannot be trusted to decide 
 upon his business affairs. Effort of will as applied 
 to the complex circumstances of social life he is un- 
 able to exercise ; but he may be most wilful in the 
 simpler and lower circumstances, as when bent upon 
 doing mischief in a fit of mania. The superior men- 
 tal quality known as self-restraint is lost early, and 
 the loss can be traced through a descending series. 
 Continued self-restraint leads to habitual action, and 
 habit in moral, social, and intellectual activities decides 
 what we call character. As we have seen, a change 
 in individual character is usually the first to attract 
 attention. Self-control is the subordination of the less 
 specialised endowments to the more specialised ; and in 
 the sphere of control of feeling it is at first only the 
 more specialised feelings over which restraint is lost. 
 The forbearances commonly exercised in the minor 
 social relations disappear, to be replaced by petulance, 
 sulkiness, unreasonable anger, and exacting conduct 
 with servants and family. Then the lower desire to
 
 DISEASES OF THE MIND. 203 
 
 obtain unlawful possession of the property of others 
 ceases to be checked by prevision of possible penalties 
 or by altruistic considerations ; the general paralytic 
 will commit theft. 
 
 Attention, which involves direction and fixing of 
 the thoughts, wanders or is unsteady. Or the atten- 
 tion cannot be engaged when the stage of dementia 
 has been reached. Mania shows an absolute abroga- 
 tion of the capacity to regulate thought by keeping 
 in the mind particular trains of images. The sufferer 
 from this malady is also bereft of the power to inhibit 
 the more active impulses. 
 
 In the different stages of the affection, loss of 
 control is seen over every order of movements. In 
 the early stage there is restlessness, when patients 
 walk and talk incessantly ; and in the final stage 
 involuntary evacuations of the bladder and rectum. 
 Loss of control over the sphincters, a symptom of 
 many diseases, I believe to be the loss of a late ac- 
 quisition. The social conditions of primitive man 
 would not have required that regulated action of the 
 bladder and rectum which existing social conditions 
 impose. 
 
 When we turn to the feelings a like degradation 
 is observable. The higher sentiments, as the moral 
 and aesthetic, are the first to disappear. Lying, theft, 
 and homicidal tendencies are the traits exhibited by 
 the insane paralytic who was once a respected member 
 of society. Dirtiness of person and language are sub- 
 stituted for decency and refinement. There is from 
 first to last a pretty regular transitional change of 
 feelings ; from the superior impersonal ones of sym-
 
 204 SPECIAL DISEASE. 
 
 pathy and affection, and sentiments that are cognate, 
 to the inferior egoistic ones. During the stage of 
 ' exaltation ' a concern for family is almost lost in 
 inordinate self-esteem, vainglory, and other relatively 
 low-level traits. In the closing periods consciousness 
 is mainly occupied with the simplest sensations those 
 of hunger and its satisfaction. 
 
 Recent acquirements are plainly shown to be the 
 least stable in the region of the active faculties. 
 ' The pianist loses his skilled touch ; the actor fails 
 to learn a new part ; the ready salesman no longer 
 has his great facility of selling.' Lastly, the intel- 
 lectual faculties also decay from above downwards, 
 and become less complex, coherent, and hetero- 
 geneous. 
 
 Now we have to see in what manner these losses 
 are occasioned. Between the insanity of general 
 paralysis and diseases of the body we have found an 
 absolute unity in the broadest characters of their 
 phenomena. Neither morphologically nor physio- 
 logically does paralytic insanity form an exception 
 to the ultimate clause of the formula of dissolution. 
 But is it not exceptional in its causation ? Can the 
 disintegrations of mind and body be connected with 
 concomitant absorptions of energy ? 
 
 When we looked at the diseases of the spinal cord 
 it was found convenient to differentiate the paths by 
 which disintegrating forces reach its parenchymatous 
 elements. It was seen that, speaking generally, these 
 paths are in the blood-vessels or in nerve- tracts. We 
 observed how in the case of ordinary tabes dorsalis
 
 DISEASES OF THE MIND. 205 
 
 a disease frequently associated with general paralysis 
 the destruction of fibres in the posterior columns is 
 caused probably by energy received through func- 
 tional systems of nervous tissue. By what channel 
 or channels is taken in the energy which produces 
 the disintegrations of general paralysis ? We are 
 still wanting a satisfactory aetiology of paralytic in- 
 sanity. It is approximately the general professional 
 belief that the ordinary disease is caused by an asso- 
 ciation of conditions. These are excesses of various 
 kinds, and chiefly sexual and alcoholic excesses. 
 The excitements and anxieties incidental to the 
 struggle for wealth and social position are said to be 
 contributory factors. We must, then, for the present 
 recognise at least two paths by which absorbed energy 
 reaches those elements of the brain and spinal cord, 
 the disintegrations of which are the acknowledged 
 lesions. One is by the blood, and the other by the 
 nervous system. The chemical energy of ingested 
 alcohol, on one hand, and the nervous excitements of 
 sexual excess and the strain of life, on the other, are 
 the recognised causal conditions. Without doubt, 
 however, there remain many unrecognised factors. 
 Yet, as far as existing knowledge permits us to speak, 
 it may be said that this form of insanity is just as 
 complete a fulfilment of dissolution as a common burn 
 or a fractured limb. The mind elements in stratum 
 after stratum, from periphery to centre, are extin- 
 guished by the disruptive action of incident energies. 
 If we look at the mind as an organic substance, 
 formed by the compounding and recompounding of 
 simpler elements, general paralysis is its analysis.
 
 206 SPECIAL DISEASE. 
 
 Each step in the process of decomposition brings to 
 view the constituents of the group decomposed ; and 
 these constituents are the symptoms of the several 
 
 stages. 
 
 All diseases of the mind are neither by a3tiology, 
 symptomatology, nor morphology as readily made 
 one in principle with other diseases as is general 
 paralysis. The causes of many forms of melancholia, 
 acute mania, dementia, hysteria, &c., have yet to be 
 made out. Nor has the decomposition of mind in all 
 the other insanities that relatively regular character 
 seen in the disease we have just noticed. Also, as 
 previously remarked, our knowledge is very meagre 
 of the physical correlatives of mental alienation in 
 general. Yet if the concurrences with dissolution 
 are less satisfying than in the case of diseases of the 
 body, there is on the whole much harmony with the 
 principles. Hysteria, hypochondriasis, and melan- 
 cholia are varieties of one species. In each the lower 
 activities assert themselves in consequence of the re- 
 moval of functions by which they are normally kept 
 in subordination. Hysteria shows how the feelings 
 and emotions of sexual life start into prominence 
 with the disappearance of faculties that regulate the 
 social life. Hysterical patients of the worst kind be- 
 come passionate, indecent, untruthful, dishonest, and 
 lazy, but cease to be self-supporting. The energies of 
 the hypochondriac are absorbed in self-contemplation 
 and anxious concern for the health of his body ; 
 while the melancholic lives in a state of fear or de- 
 spair rather for his social, moral, or spiritual welfare.
 
 DISEASES OF THE MIND. 207 
 
 We see the abolishment of the n on -egoistic or higher 
 egoistic of the mental endowments, and the survival 
 of the lower. If an exhaustive examination were 
 made of the physical and psychical phenomena of 
 these and related affections there could be exhibited 
 a general agreement not only with the corollary from 
 dissolution but also with the formula. It is remark- 
 able how consistent with our principles of interpreta- 
 tion are the phenomena of acute mania. It may be 
 caused by fevers, alcoholic poisoning, or the adminis- 
 tration of chloroform. Dr. Savage says : ' The excite- 
 ment and restlessness are results of want of control, 
 not of excess of power. The circulation is feeble and 
 the power of reaction is small. . . . The pallor of the 
 face points to the anemia, and the wide pupil to 
 nervous weakness. . . . Histologically, I have rarely 
 failed to find in fatal cases of acute mania changes 
 in the nerve-cells, more especially in the pyramidal 
 layer. The nerve-processes may be wanting ; the 
 cells may be smaller and indefinite in outline ; and in 
 some cases they are much wasted, or suffering from 
 degeneration of one form or another.' Dementia 
 supplies an exemplification of dissolution almost 
 equalling in probative value that of general paralysis ; 
 and idiocy and imbecility are also degradations to 
 mental simplicity, incoherence, and uniformity. 
 
 Does what we know of general aetiology in insanity 
 authorise the statement that the causes of diseases of 
 the mind and the causes of diseases of the body are 
 alike in nature ? Are both due to the dominion of 
 the forces of the environment, to the consumption of 
 external energy ? Whatever classification is made of
 
 208 SPECIAL DISEASE. 
 
 the ascertained true causes, they are synthesised by 
 the general law. If the predispositions to insanity are 
 ascribed to race, sex, age, or inheritance, the factors 
 about which we are most certain and most interested 
 are definite life-circumstances to which the organism 
 succumbs. These are referred to as domestic trouble, 
 grief, sorrow, adversity, anxiety, overwork ; excite- 
 ments of the social world, of religion, and of the pas- 
 sions ; shock, intemperance in eating and drinking, 
 starvation of body and of mind, idleness, accidents, 
 the poisons of venereal disease, the fevers, preg- 
 nancy, &c. 
 
 It only remains to add that in the region of mind- 
 disease dissolution and evolution are twin processes. 
 As in diseases of the body, inferior evolutions accom- 
 pany every larger dissolution. This is exemplified 
 by the growth and organisation, especially among the 
 chronic insane, of delusions, hallucinations, and the 
 vices of the alienated. The gradual increase and 
 establishment of a delusion of persecution as the out- 
 come of a process of dissolution is in parallelism with 
 the gradual increase and establishment of appetite in 
 diabetes, of convulsions in epilepsy, and of connective 
 tissue in hepatic cirrhosis. In practical medicine 
 these mental excrescences usually monopolise atten- 
 tion. 
 
 The evolutional changes of organic equilibration 
 obtain in madness as in other deviations from the 
 normal, but with special force in acute madness. 
 
 Here we reach the last of our examples ; but were 
 it desirable others could be drawn from every classi-
 
 DISEASES OF THE MIND. 209 
 
 fied group of morbid actions. The detailed applica- 
 tion of the principles to many disorders that have 
 been passed by without mention would, I believe, give 
 a new and better meaning to their phenomena and 
 direct us to the discovery of valuable data. Diseases 
 of the eye and other special organs, and of the circula- 
 tory, digestive, and reproductive systems, furnish in- 
 teresting illustrations. LeucocythaBmia is a notable 
 one of these ; and among functional diseases not one is 
 more instructive than sea-sickness. In this affection 
 we are shown how simple rhythmical molar motions in 
 the environment are used up in effecting molecular 
 changes in each functional system. The oscillations 
 of the vessel probably first conflict with the motion 
 of the blood of the carotid veins, and secondarily 
 with the cardiac rhythms. Thence result anemia of 
 the cerebral vessels and, correlatively, the psychical 
 disturbances of sea-sickness, the latter according re- 
 markably with the terms of dissolution. Low sys- 
 temic arterial tension, constipation, scanty urination, 
 and other pathognomonic symptoms are the tertiary 
 phenomena^ Sea- sickness and the disorders caused 
 by poisons afford some of the most forcible examples 
 of the principle of equilibration (3, pt. iii.).
 
 PART HI. 
 IMPLICATIONS, 
 
 P -2
 
 213 
 
 CHAPTER I. 
 
 THE RESULTS AND CONTINGENT PRINCIPLES. 
 
 1. SUMMARY. 
 
 WE have now followed out with some fulness the 
 illustrations of dissolution and evolution in pathology. 
 It is therefore incumbent to retra verse our steps and 
 take up the results by the way, to carry them to con- 
 clusions of practical utility. 
 
 When we assembled the facts connected with the 
 innermost changes of inflammation we found its 
 numerous complicated essential phenomena synopti- 
 cally exhibited in the brief and simple formula of dis- 
 solution with which we set out. Disintegration was 
 defined as an increase in the centrifugal motions of 
 the units of a structure, and it was seen that inflam- 
 mation is a disintegration. Diapedesis, the emigration 
 of leucocytes, the exudation of serum from vessels, 
 the dilatation of vessels, the production of capillary 
 stomata, and cellular proliferation are one and all 
 phenomena of this nature. And the sequels of in- 
 flammation suppuration, necrosis, sloughing, hae- 
 morrhage, &c., were discovered to be like but more 
 pronounced redistributions of matter. Inflammatory 
 contraction of vessels and inflammatory stasis were
 
 21 t IMPLICATIONS. 
 
 referred to as integrations of matter ; and, not to 
 anticipate subsequent exposition, it was reserved for a 
 later chapter to show that such secondary integrations 
 are not at variance with the principles to be employed, 
 the truth being that evolution and dissolution are 
 indivisible processes. 
 
 It was next observed that inflammation and its 
 consequent suppuration are, with rare exceptions, 
 referrible to the operation of external forces. This 
 sustained the proposition of dissolution that disinte- 
 grations of matter proceed from absorptions of energy. 
 So it was disclosed that inflammation consists in the 
 shaking asunder of the units of an organ or tissue by 
 incident energies ; but since inflammation is a change 
 pertaining only to vessels it is primarily a dislocation 
 of the units of these structures. Inflammation may 
 be paired off with the disintegrations of inorganic 
 aggregates. 
 
 We then went on to learn how the functional 
 quiescence of an inflamed organ is to be accounted 
 for, and afterwards whether inflammation and sup- 
 puration agree with dissolution in being changes from 
 a definite, coherent heterogeneity to an indefinite, in- 
 coherent homogeneity. We found that they do. In 
 this way the particular phenomena previously cog- 
 nised as more or less separate and individual were 
 affiliated with one another by natural cause and 
 effect. 
 
 Resolution and repair corresponded with evolu- 
 tion ; and when we came to consider the retrograde 
 metamorphoses the occasion arose for emphasising a 
 point not to be overlooked : the inseparableness of
 
 SUMMARY. 215 
 
 evolution and dissolution. Attention was called 
 to the fact that either is a differential result of the 
 working of both, and that whichever result ensues 
 as the superordinate change there are subordinate 
 changes of the opposite kind. Coagulation of the 
 blood was shown to be a disintegration of the blood, 
 but the solidification of fibrine a secondary inte- 
 gration. 
 
 It was next brought out that the formula of dis- 
 solution sets before us with much fidelity the most 
 general phenomena of regressive metamorphosis and 
 of diseases produced by animal and vegetable para- 
 sites, the latter presenting obvious minor evolutional 
 changes. 
 
 The facts of infective tumours offered little oppo- 
 sition to unification by the formulas ; but, to give 
 order to the phenomena of true tumour-formation, 
 it was found necessary to attempt to determine the 
 nature and origin of the true tumours. The position 
 was taken that tumour-cells are the agamic progeny 
 of normal tissues, and are thus the outcome of a 
 process of genesis. Many and varied groups of data 
 upheld this view. It was seen to be supported by 
 the embryology of tumours and by their histology, 
 and sanctioned by the general uniformity of their 
 phenomena with the phenomena of reproduction at 
 large. Observations, isolated but too plain to be 
 called in question, upon the causes of tumours neces- 
 sitated the inference that tumour-cells or germs are 
 generated by the tissues in consequence of declining 
 tissue-vitality. Many coincidences with this hypo- 
 thesis were at hand: the proneness of tumours to
 
 216 IMPLICATIONS. 
 
 nppear with advancing life; their predilections for 
 parts remote from the heart or centre of the nutri- 
 ment-distributing system; their origin from struc- 
 tures in which the forces of life are running out, as 
 cicatricial, neoplastic, function! ess, and obsolete tissues. 
 It also coincided that they are often seated at the 
 ends of bones, and at the ends of divided nerves 
 where the power of normal growth and development 
 is deficient ; that irritating and exhausting noxas are 
 prime causes of tumours. As it marks the end of 
 developmental life, the breaking up of tissues into 
 tumour -producing germs is paralleled by repro- 
 ductive phenomena in plants and micro-organisms, 
 and by the multiplication of nuclei in the degenera- 
 tions. The circumstance which makes the ultimate 
 growth of germs into tumours possible is the relative 
 feebleness of the germinating tissues. Survival of the 
 strongest settles the issue of the struggle for nutri- 
 ment between the old and the young cells. 
 
 Though the manifestation of a primordial in- 
 herited trait, the division of tissue-cells into germs 
 must be connected with the influence of the forces 
 that encompass organisms ; heredity decides the form 
 of the dissolution, but circumstances provoke it. 
 
 Regarded in this manner, the phenomena at once 
 fell under the principles of dissolution and evolution. 
 Tissue-histogenesis is a disintegration, and known in 
 a multitude of cases to be related to palpable acces- 
 sions of external energy. 
 
 Development and decay in tumours are alternate 
 processes of evolution and dissolution. 
 
 The facts of cystomata admitted of less satis-
 
 SUMMARY. 217 
 
 factory co-ordination. Knowledge of the causes of 
 cysts is in many cases wholly lacking, and some 
 cysts are adaptations rather than diseases. In the 
 frequency with which cysts occur in connection with 
 disused structures, valuable supplementary evidence 
 is furnished of the validity of the hypothesis given 
 above of the origin and nature of tumours. It is 
 more than credible that many cysts originate from 
 the reproductive activity of normal cells, and that 
 the new-born cells undergo liquefaction. 
 
 In the remarks upon the teratomata, it was 
 pointed out that if they arise, as there is reason to 
 think, in places where the three germinal layers are 
 in contact, teratomata may be dealt with as true 
 tumours ; but they are initiated during gestation. 
 We also saw that malformations are generally attri- 
 butable to disorganising forces which act in the 
 intra-uterine life, and that these forms of disease mark 
 a deviation from the norme that corresponds to dis- 
 solution. 
 
 In the second division of the work, the patho- 
 logical changes previously viewed reappeared in the 
 guise of special and organic diseases. As harmo- 
 nising with the interpretation given of the general 
 processes of disease, it was decided that the growth 
 of connective tissue in chronic affections is evolu- 
 tional, not an inflammatory process. The argument 
 was used that in fibrosis, cirrhosis, and sclerosis of 
 organs and tissues the parenchymatous elements are 
 the first to suffer, and that the interstitial overgrowth 
 is secondary and consequential. Injury or death of 
 the parenchyma favours the growth of interstitial
 
 218 IMPLICATIONS. 
 
 substance simply by diminishing resistance to its 
 growth. Thereupon the data arranged themselves 
 in allied groups, and the organic diseases acquired a 
 new complexion. In the numerous species of kidney 
 and liver disease, facts on every side bore out the 
 interpretation. The distribution of the disease-pro- 
 ducing agents, the microscopic morbid morphology, 
 the characters of the interstitial growth and its rela- 
 tions in time to the injury to the parenchyma, sup- 
 plied a consensus of testimony of considerable weight. 
 And, adding further weight, the supplementary prin- 
 ciple to dissolution was seen to be in perfect unison. 
 If accessory specialised structures are more vulner- 
 able than fundamental ones, the death of the paren- 
 chyma and survival of the connective-tissue ground- 
 work are according to a requirement of law. No 
 matter whether the changes in question were those 
 of acute nephritis from exanthematous fevers, carbolic 
 acid, or other poisons ; or those of chronic cirrhosis, 
 amyloid disease, and mechanical congestion, the 
 corollary was sustained : the dissolution of the ele- 
 ments was seen to follow the opposite order of their 
 evolution. And in finer detail this was observed of 
 the components of parenchymatous substance. In 
 the kidney the convoluted tubules were seen to be 
 less stable than the straight tubules, and the accessory 
 Malpighian tufts more perishable than the fundamental 
 capillaries. 
 
 Bright' s disease and hepatic cirrhosis proved to 
 be as dissolution formulates disintegrations of mat- 
 ter from concomitant absorptions of energy. An 
 essential feature of every form of these affections is
 
 SUMMARY. 219 
 
 the separation of the protoplasm of cells from its 
 former centres of cohesion ; and the facts of aetiology 
 lend a general approval of the proposition that the 
 separation is caused by the reception of surrounding 
 motion. Both in the early and late stages of kidney 
 and liver disease, the normal definiteness, coherence, 
 and heterogeneity of functions and structures is les- 
 sened. The growth of interstitial tissue, the various 
 adaptive modifications of function, and the processes 
 of recovery were recognised as the changes of evo- 
 lution. 
 
 Thus it became possible and obligatory to merge 
 all the particular forms of coarse-lesion diseases of 
 the liver and kidney into a general form. The dis- 
 tinction of species which convenience has necessitated 
 was seen to be artificial ; the differences of kind 
 simply mark differences in the conditions of changes 
 that are always the same in type. And the concep- 
 tion of evolution and dissolution as the complements 
 of one another was as lucidly and beautifully veri- 
 fied by the very intricate phenomena of nephritis 
 and hepatitis as by the simple decomposition of a 
 salt in the laboratory. In any attempt to grasp the 
 entirety of the changes in their true natures and 
 mutual relations, this conception cannot indeed be 
 spared. 
 
 Thence we proceeded to the consideration of 
 lung-affections, and pneumonia and phthisis were the 
 types selected. The changes in these diseases were 
 observed to be uniform in nature with the changes 
 of nephritis and hepatitis. Reflecting upon the pro- 
 bable causes of pneumonia and phthisis, we appre-
 
 220 IMPLICATIONS. 
 
 hended the paths by which noxfle reach the different 
 histologies! elements of viscera. It was noted that, 
 in the case of the liver, influences that disturb are 
 mostly conveyed to the parenchymatous cells in the 
 blood of the portal vein ; to the parenchymatous 
 cells of the kidney in the blood of the renal arteries. 
 The blood of these vessels, it was noted, is readily 
 affected by the substances taken in as food. The fact 
 was pointed out that pulmonary arterial blood is also 
 in intimate intercourse with the ingested aliment, and 
 it was argued that pneumonia and phthisis are con- 
 nected with the quantity and quality of the blood of 
 the pulmonary artery. While determining and con- 
 tributory causes were recognised, the opinion was 
 ventured that the necessary internal causes of ordi- 
 nary pneumonia and phthisis are states of the pul- 
 monary blood as related to states of the pulmonary 
 air, and these states are further to be referred to the 
 environment : to the food eaten and the air respired 
 more especially. 
 
 When, in the chapter succeeding, we turned to the 
 diseases of the spinal cord the same general truths 
 were met with. Locomotor ataxia, which we took 
 as representative of a considerable class of neuro- 
 pathies, was found to correspond to dissolution in the 
 involved changes of function and structure, and 
 probably also in' the dependence of these changes 
 on the external agencies with which the organism is 
 in communion. That the destruction of the neural 
 parenchyma in posterior sclerosis is the primary 
 lesion, and the growth of neuroglia a secondary and 
 evolutional phenomenon, is almost beyond such
 
 SUMMARY. 221 
 
 question as might be urged in the case of other 
 fibroid diseases. 
 
 Locomotor ataxia and many other affections of 
 the encephalo- spinal system furnished illustrations of 
 the corollary from dissolution ; but throughout the 
 entire range of neuropathies the principles of disso- 
 lution and evolution were exemplified. 
 
 It was not found necessary to make exceptions 
 of the fevers and so-called diathetic disorders erout, 
 
 o 
 
 rheumatism, and diabetes. In the case of these, and 
 affections of the mind as well, the principles provided 
 bonds of union with the general and special patho- 
 logical states that had been dealt with. When at last 
 reference was made to the remaining portions of the 
 field of disease it was declared to be probable that 
 they also might be gathered in. 
 
 These, then, are the results. We have been 
 brought to recognise that the multifarious pheno* 
 mena of disease are originally and innately identical. 
 Neglecting a few aberrant and equivocal examples, 
 true disease is that which dissolution verbally sym- 
 bolises a disintegration of matter caused by an 
 absorption of surrounding energy. But in the body 
 as out of it simultaneous and successive with dis- 
 solution is the distinct and contrary process of 
 evolution. Together these two processes comprehend 
 not only the changes that are essential to disease, but 
 also its non-essential though inseparable concomitants. 
 What now is the utilitarian outcome of this generali- 
 sation ? What connection has it with the work of 
 prevention and cure ? It is not obviously relevant
 
 222 IMPLICATIONS. 
 
 to the pursuits of those who are practical in this way. 
 Some moot questions of considerable difficulty must 
 be answered before even its indirect bearings upon 
 actual practice can be made clear ; and that it may be 
 ordained as an elementary conception to guide our 
 steps in practice, there will be required a conside- 
 ration of the processes of disease in fresh aspects. 
 The first matter to be dealt with is the hereditary 
 transmission of disease, and to this we may now turn 
 our attention. 
 
 2. HEREDITY AND DISEASE. 
 
 Are morbid traits of function and structure 
 passed on from one generation to another as we know 
 healthy traits to be ? Or, to state more exactly the 
 inquiry to be answered, can there be conceded to 
 heredity an equal sphere of action in pathology as 
 in physiology ? And if not, what are the limita- 
 tions ? These questions are among the most peremp- 
 tory which modern medicine puts to those who are 
 engaged with its advancement. If the energies of 
 the external world are the true sources of every 
 pathological change and I think few who have fol- 
 lowed me thus far will be disposed to deny this it 
 is plainly to be seen that a knowledge of the physical 
 factors of disease is of greater or less value as the 
 factor heredity is feeble or active. Diseases dependent 
 upon known external causes are for the most part 
 controllable, but diseases that are inherited are for 
 the most part out of the reach either of measures of 
 prevention or cure. But apparently no one doubts
 
 HEREDITY AND DISEASE. 223 
 
 that perhaps the majority of diseases are inherited. 
 Phthisis, gout, rheumatism, diseases of the mind and 
 nervous system, skin diseases, hemophilia, and others 
 too numerous to mention, are generally believed either 
 to be greatly under the influence of heredity or 
 actually transmitted. It is true that those who are 
 least swayed by belief in morbid inheritance speak 
 of inherited predispositions to disease. I hold this 
 to be a weaker form of the same habit of thought, 
 the same mode of interpretation, minus the spirit 
 which has been quenched by accumulating experi- 
 ences. But to the minds of the majority many 
 diseases are as heritable as normal characters. I 
 think it almost certain that heredity plays a very 
 subordinate part in the perpetuation of non-conge- 
 nital or true disease. The question concerning the 
 transmissibility of morbid states appears to me to 
 have been confused by the failure to distinguish the 
 intrinsic nature and conditions of the dissolutional 
 process. 
 
 At the outset of investigation of the subject we 
 are met by the impossibility of entertaining the idea 
 of hereditary transmission in the case of certain 
 common diseases. There is felt an intellectual repul- 
 sion towards any suggestion that typhoid fever or 
 acute pneumonia, for example, are due to the operation 
 of heredity. Why is this ? Innumerable diseases 
 resembling them in all essentials are every day spoken 
 of as inheritable and inherited. It is because our 
 positive or presumed knowledge of the causes of 
 pneumonia and typhoid fever precludes conception of
 
 224 IMPLICATIONS. 
 
 them as independent of the forces amidst which the 
 organism moves. We are unable to think of these 
 diseases apart from the real or supposed action of the 
 environment. When a disease is known or believed 
 to proceed from sensible external influences heredity 
 cannot be imagined to play any part in its genesis, 
 for that the morbid process may continue, its cause 
 with which the effects are one and indivisible must 
 also continue. This cause is not in the microcosm, 
 within which inheritance only works, but in the 
 macrocosm. A still better illustration of the point 
 is afforded by scarlet-fever and rheumatism. The 
 accumulated observations upon the circumstances of 
 its appearance and spread have satisfied physicians 
 that scarlet-fever is in causal relation to something 
 that enters the body from without. Hence no one 
 now thinks of it as inheritable. (I say now, for it is 
 not many years since the exanthemata were vaguely 
 looked upon as diseases to which all young flesh is 
 heir.) But rheumatism is not definitely attributable 
 to the environment ; its aetiology is hidden from us, 
 and many, therefore, regard it as handed down by 
 descent. Yet how nearly alike, even in extrinsic 
 characters, these two diseases are, is shown by the 
 existence of scarlatinal rheumatism ; but in intrinsic 
 characters there is no difference between them : they 
 are both disintegrations of the body. Whichever we 
 take of the presumably inherited diseases cancer, 
 diabetes, epilepsy, chorea, &c. this we find con- 
 stantly : it has not yet been associated with the defi- 
 nite action of environing forces ; and whichever- we 
 take of the diseases known to depend absolutely upon
 
 HEREDITY AND DISEASE. 225 
 
 the conditions of life we find no genuine belief in 
 its transmissibility. Speaking generally, for there are 
 notable exceptions, inheritance is supposed to be most 
 clearly attested in diseases that are least understood. 
 As knowledge progresses and true causes come into 
 the region of light, heredity recedes further and further 
 from view. Formerly there was prevalent a belief in 
 the transmissibility of many common ailments which 
 modern research has shown to arise from ordinary 
 physical conditions. 
 
 Thus we are brought to the conclusion that 
 heredity is excluded from the aetiology of certain 
 fevers and inflammations because they are positively 
 known to proceed from outer actions. But it has 
 been seen in the course of this work that all inflam- 
 mations and fevers are disintegrations of the body, 
 and, with some obscure exceptions, known also to 
 proceed from outer actions. And almost certainly 
 the retrograde metamorphoses, the neoplasms, and 
 organic and functional diseases share this general 
 character and this condition of inflammations and 
 fevers. Observe the startling thought called forth 
 by these reflections. All true diseases may be unin- 
 heritable, and the constant attribution of non-con- 
 genital morbid states to hereditary influences may be 
 fallacious. How shall we comport ourselves towards 
 a possible conclusion so momentous and alien to 
 universal opinion ? Before giving in adherence we 
 must at least reckon with the reasonable grounds of 
 that opinion. 
 
 Let us first take account of the purest examples 
 of inherited disease those which give most counte- 
 
 Q
 
 226 IMPLICATIONS. 
 
 nance to the prevailing belief. These are the cases 
 of racial degeneration in men and animals, of idiot 
 families, of inherited abnormalities like cleft-palate, 
 duplication of fingers, congenital deaf-mutism, &c. 
 Here the deviation from the normal type agrees with 
 dissolution. What is the comment to be offered f 
 That these are congenital, not true diseases. Conge- 
 nital differs from non- congenital or true disease in that 
 the inferior grade of mental and physical qualities is 
 due, as far as the individual is concerned, to the stage 
 at which development ceases. There is no degrada- 
 tion of the individual life ; the higher type is simply 
 not attained. In true disease, however, there is a 
 loss in the individual of functional and structural 
 traits such loss as we witness in inflammation, fevers, 
 and diseases generally. These are an unbuilding of 
 the organism ; but in congenital defects and in family 
 and racial degeneration the organism is not unbuilt : 
 it does not build. Inheritance as seen in congenital 
 diseases of th's class cannot, then, be adduced as 
 evidence of the transmissibility of true disease. And 
 of that class of cases represented by congenital 
 syphilis the contention is to be offered that parent 
 and offspring being infected as one organism these are 
 not cases of inheritance. 
 
 But the phenomena of many true diseases are 
 thought to support the doctrine of their transmission 
 by descent. Diseases of the vessels, gout, phthisis, 
 paralysis, and others are called to mind. How must 
 be confronted the evidence upon which rests the 
 assent which is given to the supposed inheritance of 
 these ? As the phrase is, gout runs in families, and
 
 HEREDITY AND DISEASE. 227 
 
 so do phthisis, paralysis, and the rest. Here I am / 
 persuaded from the considerations which follow, that \ 
 inheritance is simulated in part by the recurrence of 
 causes. The subtle, unseen factors of gout, phthisis, x , 
 insanity, &c., the absorbed energies which set up the / 
 disintegrations of these diseases, are repeated in the \ 
 lives of individuals of successive generations, and in ( 
 the lives of individuals of collateral family branches, \ 
 and there is lent an appearance of hereditary descent, f 
 Of these and very many other affections alleged to be 
 derived through inheritance it may justly be said 
 that the causes run in families. This repetition of 
 pathogenic conditions in the lives of genealogically 
 related individuals is generally ignored in current 
 explanations of the origin of diseases by inheritance. 
 The omission surely vitiates if it does not nullify 
 every such explanation. 
 
 Consistently, it will, I think, be uniformly found 
 that the general conditions of the lives of those who 
 suffer from diseases assumed to be inherited are the 
 conditions of the lives of progenitors. The habits 
 of life of the gouty or phthisical child do not differ 
 materially from the habits of life of the gouty or 
 phthisical parent. But we shall learn in the next 
 section that diseases are repeated in descendants 
 not solely because the life- conditions are repeated. 
 Heredity is probably in some degree concerned, but in a 
 form which it is very important to distinguish from 
 ordinary inheritance. 
 
 To this argument something further may be said, 
 sho wing why diseases are, presumptively, for the greater 
 part refractory to transmission by descent. True dis- 
 
 Q 2
 
 IMPLICATIONS. 
 
 eases, we have just seen, cannot be separated from their 
 causes ; and causes, being of the environment, are not 
 handed down. But there are additional reasons for 
 the feeble hold which heredity has upon pathological 
 states. When we discriminate between the variations 
 of function and structure that are passed on by parent 
 to offspring and those that are not, we are forced to 
 see that natural selection, working always in confede- 
 ration with heredity, seizes upon favourable variations. 
 Natural selection appropriates organismal acquisitions. 
 But analysis discloses the fact that diseases are losses, 
 not gains ; are unfavourable variations, and offer no 
 ' purchase ' for the co-operative influence of these two 
 modes of action. Here, then, is another reason for the 
 non-transmissibility of disease. There are others 
 still. In general, diseases unfit the individual for 
 sexual activity by diminishing the surplus energy 
 required for reproduction ; therefore the diseased are 
 less prone than the healthy to beget children. Then 
 many diseases are said to be transmitted where 
 transmission is clearly impossible from the circum- 
 stances of the cases. Cancer, thought to be heritable, 
 occurs most frequently at the close of sexual life ; and 
 pseudo-hypertrophic paralysis, in which hereditary 
 influence is asserted to be well marked, is a disease of 
 childhood its victims do not propagate. But more 
 important than influences of this sort is that influence 
 which springs from the differences of nature and 
 conditions between normal and abnormal traits. 
 Normal structures were evolved in long periods of 
 time, and have been transmitted through generations 
 unnumbered ; therefore, the tendency to their per-
 
 HEREDITY AND DISEASE. 229 
 
 petuation by inheritance must be immensely pre- 
 dominant over any tendency to the perpetuation by 
 inheritance of the transitory changes of disease. I 
 believe that the ' vestiges ' of once useful structures 
 owe their astonishing persistence to the fact that they 
 have become deeply pressed into the organic arrange- 
 ment by the selection and transmission of such struc- 
 tures for secular periods. This makes intelligible the 
 rarity with which deprivation of a limb or other part 
 leaves any impress upon offspring. Though circum- 
 cision has been practised among the Jews for ages, it 
 has not produced congenital preputial imperfection in 
 the race. Nor do we ever find that amputation of a 
 limb or loss of the cortex of the kidney from Bright' s 
 disease is followed by corresponding anatomical de- 
 ficiencies in children. In the African transported 
 to northern latitudes, the dark skin persists through 
 indeterminable generations provided there is no 
 cross-breeding but the endemic diseases of his race 
 are not transported with him. 
 
 Hitherto all reasoning upon the heritableness of 
 diseases has proceeded on the tacit assumption that 
 morbid changes are subject to the same law of vital 
 action as healthy changes. It has been discovered, 
 however, that the two are dissimilar both in nature 
 and in the circumstances of their genesis. The 
 traits we every day recognise as inherited are the 
 results of an infinity of co-ordinate actions. There 
 may be instanced the bony framework of the face, 
 the colour of the iris, the gait, special mental apti- 
 tudes. All these, and attiibutes of the same order, 
 represent a vast integration of forces, groups of
 
 2oO IMPLICATIONS. 
 
 organised energies. It is this organisation which 
 gives them individuality and makes their hereditary 
 transmission possible. They are, in other words, 
 self-existent, have being independent of the original 
 conditions out of which they grew. Thus, that 
 inherited functions and structures may unfold them- 
 selves in the developing embryo the only pre-requi- 
 sites are certain general conditions of blood-supply, 
 temperature, &c. The special conditions of their 
 evolution are not required. Vision is possible to the 
 human infant immediately after birth, the eyes being 
 developed in utero without the aid of that light- 
 energy which was all essential for their evolution in 
 the race. Now it is quite contrary with most true 
 diseases conceived as processes of dissolution. These 
 are disorganisations, and are therefore not self- existent. 
 To what extent tumours as true diseases are possible 
 exceptions may be left for future consideration. 
 
 So that many direct and indirect pieces of evi- 
 dence cohere to defend the inference, necessitated by 
 the nature and conditions of disease, that heredity is 
 probably very feebly concerned in the continuance of 
 morbid states. The universal belief in the heritable- 
 ness of disease is probably not a faithful expression 
 of the truth. We may, then, for the time being and 
 the purposes of future work, conclude that diseases 
 are the issue of interactions between the individual 
 and his environment ; that even in the individual, 
 * the deepest causes of true diseases lie external to the 
 organism.' Of diseases in the race it has been largely 
 shown inductively in previous chapters that they are 
 in the first instance externally derived ; and this fact
 
 HEREDITY AND DISEASE. 231 
 
 requires us to remember that heredity. where proved 
 to account for disease in the individual is never a vera 
 causa. It is the transmission of attributes from one 
 generation to another, but is not itself originative; 
 we are in such a case referred back to the lives of 
 individual ancestors in the search for causes. 
 
 Out of this argument the reader has doubtless 
 culled the principle of practice it contains. If true 
 diseases are rarely inherited and they are the proceeds 
 of actions and reactions between the body and forces 
 that fall upon it, the ruling precept of practical 
 medicine must clearly be the detection and removal 
 of causes. This is the fundamental principle we shall 
 presently enforce ; but before doing so there must be 
 considered one which is ancillary to it in the hands 
 of the practitioner the principle of organic equilibra- 
 tion, or vis medicatrix natures. 
 
 3. ORGANIC EQUILIBRATION. 
 
 We have observed again and again that dissolu- 
 tion and evolution are co-existent and sequent to one 
 another. As the various changes of disease passed 
 before us and we distinguished the two orders into 
 which they may be separated, we were led to regard 
 the growth of connective tissue in the organic affec- 
 tions as an adaptive change. Not of malign influence, 
 but subserving the welfare of the organism. We 
 placed it in the same category as resolution and 
 repair. And a like disposition was made of those 
 processes by which functional equilibrium is restored
 
 232 IMPLICATIONS. 
 
 in the acute systemic diseases. Now these several 
 kinds of action are, from the practical point of view, 
 best conceived as illustrations of the principle of 
 equilibration. The principle of equilibration in its 
 most developed form we owe to Mr. Spencer ; and it 
 will, I think, be seen to lie at the very root of sound 
 medical conceptions, and to give a meaning of sin- 
 gular beauty to many of the common phenomena 
 of disease. 
 
 Equilibration is exhibited throughout all nature ; 
 and repair, resolution, adaptation, &c., are examples 
 of it upon the view that life consists in the main- 
 tenance of an adjustment between inner functions 
 and outer incident forces. For illustrations from the 
 inorganic world the reader may turn to ' First Prin- 
 ciples,' chap. xxii. The following extract is from 
 Mr. Spencer's exposition of equilibration as we wit- 
 ness it in the living body : ' The sensible motion con- 
 stituting each visible action of an organism is soon 
 brought to a close by some adverse force within or 
 without the organism. When the arm is raised, the 
 motion given to it is antagonised partly by gravity 
 and partly by the internal resistances consequent on 
 structure ; and its motion, thus suffering continual 
 deduction, ends when the arm has reached a position 
 at which the forces are equilibrated. The limits of 
 each systole and diastole of the heart severally show 
 us a momentary equilibrium between muscular strains 
 that produce opposite movements ; and each gush of 
 blood requires to be immediately followed by another, 
 because the rapid dissipation of its momentum would 
 otherwise soon bring the mass of circulating fluid to
 
 ORGANIC EQUILIBRATION. 233 
 
 a stand. As much in actions and reactions going 
 on among the internal organs as in the mechanical 
 balancing of the whole body, there is at every instant 
 a progressive equilibration of the motions at every 
 instant produced. Viewed in their aggregate, and 
 as forming a series, the organic functions constitute 
 a dependent moving equilibrium a moving equili- 
 brium of which the motive power is ever being 
 dissipated through the special equilibrations just ex- 
 emplified, and is ever being renewed by the taking-in 
 of additional motive power. Food is a store of force 
 which continually adds to the momentum of the vital 
 actions as much as is deducted from them by the forces 
 overcome. All the functional movements thus main- 
 tained are, as we have seen, rhythmical ( 85) ; by 
 their union compound rhythms of various lengths 
 and complexities are produced, and in these simple 
 and compound rhythms the process of equilibration, 
 besides being exemplified at each extreme of every 
 rhythm, is seen in the habitual preservation of a 
 constant mean, and in the re-establishment of that 
 mean when accidental causes have produced diver- 
 gence from it. When, for instance, there is a great 
 expenditure of motion through muscular activity, 
 there arises a reactive demand on those stores of 
 latent motion which are laid up in the form of con- 
 sumable matter throughout the tissues ; increased 
 respiration and increased rapidity of circulation are 
 instrumental to an extra genesis of force that 
 counterbalances the extra dissipation of force. This 
 unusual transformation of molecular motion into 
 sensible motion is presently followed by an unusual
 
 234 IMPLICATIONS. 
 
 absorption of food the source of molecular motion ; 
 and in proportion as there has been a prolonged draft 
 upon the spare capital of the system is there a ten- 
 dency to a prolonged rest during which that spare 
 capital, is replaced. If the deviation from the ordinary 
 course of the functions has been so great as to derange 
 them, as when violent exertion produces loss of appe- 
 tite and loss of sleep, an equilibration is still eventu- 
 ally effected. Providing the disturbance is not such 
 as to overturn the balance of the functions, and 
 destroy life (in which case a complete equilibration 
 is suddenly effected), the ordinary balance is by-and- 
 by re-established ; the returning appetite is keen in 
 proportion as the waste has been large ; while sleep, 
 sound and prolonged, makes up for previous wakeful- 
 ness. Not even in those extreme cases where some 
 excess has wrought a derangement that is never 
 wholly rectified is there an exception to the general 
 law ; for in such cases the cycle of the functions is 
 after a time equilibrated about a new mean state, 
 which thenceforth becomes the normal state of the 
 individual. Thus, among the involved rhythmical 
 changes constituting organic life, any disturbing force 
 that works an excess of change in some direction is 
 gradually diminished, and finally neutralised by anta- 
 gonistic forces, which thereupon work a compensating 
 change in the opposite direction, and so, after more 
 or less of oscillation, restore the medium condition. 
 And this process it is which constitutes what physi- 
 cians call the vis medicatrix naturceJ 
 
 Now the common formative changes of disease are 
 plain manifestations of this principle of organic action.
 
 ORGANIC EQUILIBRATION. 235 
 
 When the parenchymatous substance of an organ is de- 
 stroyed, there is a disturbance of the statical balance 
 of forces, and the interstitial tissue may grow out to 
 restore the equilibrium. And when the heart enlarges 
 in arterial and valvular disease, there is an analogous 
 structural adjustment to re-establish the equilibrium 
 of the circulation. But the principle obtains whenever 
 the normal play of the functions is disordered. The 
 state of health is one to which the energies of the 
 system are bent with the highest strength of the 
 organism. It seems inevitable that since the type 
 of physiological action we call the norme is the pro- 
 duct of all ancestral intercourse with the environment, 
 this type of action must present considerable stability 
 in the face of forces tending to change it. As these 
 forces are insignificant in comparison with the aggre- 
 gate of forces which have produced normal functions, 
 they cannot, unless they annihilate them, do more 
 than temporarily modify the moving equilibrium. 
 (This is in harmony with the argument on the inherit- 
 ance of pathological states, that ordinarily the changes 
 of disease in parents are obliterated in offspring by 
 the overwhelming organisation of evolutionally pro- 
 duced actions.) A poisonous but not fatal dose of 
 alcohol sets up a new series of rhythms in the func- 
 tional systems. Presently the poison is consumed 
 or expelled, and there is a gradual re-establishment 
 of the previous balance. So, too, of the effects of the 
 agents that cause acute disease. When, in chronic 
 disease, the perturbations are continuous, and do 
 not greatly depart from the mean of normal physio- 
 logical actions, there is also a more or less successful
 
 23G IMPLICATIONS. 
 
 concert of predominating energies to preserve that 
 ii loan. 
 
 Still, it may be said, granting the existence of 
 self- restorative powers such as here described in 
 general form they are vaguely recognised by most 
 people we do not know of them in detail. Yet the 
 individual actions by means of which the general 
 balance of functions is recovered as in the specific 
 fevers must be physical actions, assimilable with 
 familiar physiological changes. They are so, un- 
 doubtedly ; and I believe the most important of them 
 are the common forms of physiological perturbation. 
 We may look at some concrete instances. 
 
 The pyrexia of fever, when brought into relation 
 with its causes and the needs of the organism to deal 
 with those causes, may be construed as conservative 
 and beneficent. It is, I think, in the highest degree 
 probable that febrile heat, whatever the mechanism of 
 its production, facilitates the redistribution of matter 
 and motion involved in equilibrating processes. Take 
 also the sweating of fever of ague and acute rheu- 
 matism. This is clearly to be interpreted as a 
 consequence of the presence in the blood of matter 
 inimical to normal function, and, as an adjustment of 
 function, is calculated to assist in the elimination 
 of the deleterious substances. The sweating is only 
 relatively baneful that is, when contrasted with 
 the functions of the skin in health ; relatively to its 
 cause, it is desirable. It is astonishing how many of 
 the daily occurring forms of disease may likewise be 
 conceived as forms of equilibration. Connected with 
 its antecedents, suppuration is to be understood as a
 
 ORGANIC EQUILIBRATION. 237 
 
 serviceable process. If it arises from the action of 
 micro-organisms or poisons, it is probably useful in 
 localising the distribution of such noxse that is, pre- 
 vents a systemic distribution which would perhaps be 
 fatal. This is the point of view assumed in the recently 
 advanced idea that the leucocytes of pus are ' phago- 
 cytes.' The granuloma also is a species of reaction 
 on the part of the tissues to locally incident noxas, 
 and may be, in reference to the latter, like suppura- 
 tion, the lesser of two evils. That inflammation, 
 unmistakably disintegrative and dissolutional, is rela- 
 tively good appears to be shown by the fact that from 
 the milder forms of it there may be perfect recovery. 
 Admiration should be the uppermost feeling as we 
 contemplate the fertility and delicacy of adjustment 
 implied by resolution. Dropsy is certainly a func- 
 tional adaptation. Without the determination of fluids 
 to the connective-tissue spaces death would seem to 
 be inevitable under the physiological circumstances 
 of dropsy. As the effects of their proximate condi- 
 tions, a multitude of symptoms and diseases are 
 favourable reactions. So ought we to regard the 
 luematemeteis of hepatitis, the epistaxis of puberty, the 
 haemoptysis of phthisis and heart-disease. Cough and 
 pulmonary expectoration, the discharge of matter 
 through the kidneys and bowels in the fevers and 
 chronic diseases, are all relatively advantageous 
 advantageous when joined with their causes. Illus- 
 trations might be taken from almost every disease, 
 but these will have served to establish the point of 
 view. A qualification must, however, be inserted if 
 we are to justly estimate abnormal processes as thus
 
 238 IMPLICATIONS. 
 
 conceived. Wonderful as is the consentaneity of the 
 actions involved, organic equilibration is neither in- 
 telligent nor purposive. The best examples of it in 
 disease are simply the least unfavourable among the 
 pathological changes. And the most deeply organised 
 of them, those that have presumably been taken hold 
 of by selective action and heredity (see infra), are 
 plastic and readily perverted. Only under certain con- 
 ditions and without design does the disordered body 
 make for health. The presence of apparently insig- 
 nificant and trivial circumstances will oftentimes give 
 fatal misdirection to the forces of the organism. 
 
 And now, with this conception before the mind, it 
 is possible to fulfil the promise of the previous section 
 that is, to say in what manner heredity is probably 
 most concerned in the recurrence of diseases in 
 descendants. It is, I believe, in this way. To simi- 
 lar causes there are in those similarly constituted like 
 members of families similar modes of physiology al or 
 pathological reaction. The familiar types of equilibra- 
 tion, as the emesis of poisoning, the high temperature 
 of fever, the dropsy of heart-disease and nephritis, &c., 
 are perhaps inherited. I have elsewhere suggested 
 that natural selection would share in the work of esta- 
 blishing reparative processes in wounds. ' Animals 
 whose wounds were not repaired would strive in the 
 struggle for existence under a heavy disability. The 
 non-union of muscles torn and limbs broken during 
 encounters with prey and enemies would lead to 
 incapacity for further encounters, and a dying off 
 without issue ; while others, whose injuries were 
 repaired, would escape the direct hindrances and
 
 ORGANIC EQUILIBRATION. 239 
 
 indirect dangers to life entailed by unhealed wounds, 
 and would reproduce their kind.' In the same place 
 it is also pointed out that selective and hereditary 
 actions have probably been connected not only with 
 the organisation of modes of adjustment in common 
 diseases, like scarlet fever and measles, but also with 
 the establishing of personal insusceptibilities to the 
 influence of their causes. And I think it may well be 
 supposed that natural selection and heredity have 
 conspired to aid in the survival of such generic forms 
 of equilibration as those we have just now noticed. 
 Given in the lives of parent and child the necessary 
 external causes of gout, or phthisis, or cancer, and 
 there will be approximately the same forms of reaction 
 to them, the same diseases in members of the same 
 family. No one will confound this with the common 
 idea of the inheritance of disease ; nor should it, it 
 appears to me, be confounded with the idea of inherited 
 predisposition to disease. As already argued ( 2), 
 diseases for the most part are not self-existent, and 
 their reappearance in families is determined almost 
 wholly by recurrent environmental conditions. The 
 predispositions of the organism are to normality, not 
 to abnormality. In this view, diseases are less evil 
 than the causes of them, and are presented to us as 
 signifying a contest between the powers within and 
 the powers without. 
 
 4. PRACTICAL DEDUCTIONS AND CONCLUSION. 
 
 What of instant utility may we learn from this 
 research ? Can any tiling be deduced that will 
 promise to give greater consistency and certitude to
 
 240 IMPLICATIONS. 
 
 medical practice ? We seek for the highest conclu- 
 sions of philosophy in conclusions to act. That 
 disease is the expression of a relation between the 
 individual and his surroundings, and that in all 
 pathogenesis there have been external factors, ade- 
 quate proof has, I think, come before us. Must we 
 not, then, both for prevention and cure, ever look at 
 disease from the standpoint of this relation ? There 
 appears to be no escape from the deduction that, 
 given a knowledge of the circumstances of their 
 genesis, a very large majority of diseases might be 
 avoided. And the positive achievements of modern 
 hygiene ratify this deduction. It is frequently 
 possible to so change the organism's conditions, 
 while fulfilling the conditions of health, as to insure 
 prophylaxis. By the same provision, probably, most 
 acquired diseases, prior to the stage of permanent 
 loss of structure, are curable. Cessante causa, cessat 
 effectus. This is true for every symptom and for 
 every group of symptoms. In each case the quest 
 then should be for causes. Often diseases are 
 aetiologically related to the conditions of life only in 
 a remote sense. Such is sometimes the case with 
 calculus, tumours, effusions into cavities, &c. Here 
 we seek out and remove the anatomical causes. But 
 these products of morbid action are truly the effects 
 of an imperfect adjustment to environment, and 
 many of them are preventable by the best uses of 
 existing knowledge that recognises the dependence 
 of disease upon external agencies. Therefore the 
 liigher principle is that which constrains us to fix 
 our eyes on morbid phenomena as parts of an
 
 PKACTFCAL DEDUCTIONS. 241 
 
 unbroken series of changes connected indissolubly 
 with the energies of the outer world. 
 
 The present inquiry teaches that diseases are 
 not self-originated and self-maintained, and that the 
 powers of the physician are therefore not limited by 
 the inexorableness of disease. The first condition 
 for dealing effectually with many common scourges 
 and crippling ailments would be to grasp firmly the 
 necessary circumstances of their origin and being. 
 Fortunately, we are invited to researches in patho- 
 genesis by the relative simplicity of the process of 
 dissolution. Though the factors of disease are often 
 inexplicable to the most diligent and skilled investi- 
 gators, yet when we compare the conditions out of 
 which evolutions and dissolutions respectively arise, 
 those of the former are perceived to be vastly the 
 more complex. In everyday parlance, destruction 
 is more simple than construction. Look at the 
 many interconnected actions involved in the forma- 
 tion of some ordinary evolutional product say, the 
 arrangement of the type of this page. The actions 
 are of varied kinds, and duly and reciprocally pro- 
 portioned. But how simple may be the dissolution 
 of the structure. A single form of energy, as fire, 
 or mechanical motion, will undo in the briefest time 
 the work of the proportioned actions And the 
 destroying force is without definite relations to the 
 forces that oppose it. It is the same in the organic 
 world. The kinds and consensus of energies re- 
 quired for the production of any bodily structure 
 for example, a renal organ are wholly beyond 
 computation ; but a measurable quantity of carbolic 
 
 B
 
 242 IMPLICATIONS. 
 
 acid will loosen all its combined activities and dis- 
 integrate its substance ; will produce the disease we 
 call nephritis. Throughout we find a similar rela- 
 tive simplicity in the causation of diseases. Syphilis 
 depends on the inception of a virus ; paralysis follows 
 the extravasation of blood from a ruptured vessel ; 
 insanity, the shock of a' bereavement. Absolutely, 
 however, diseases are often most complex in causa- 
 tion, and aetiological investigation is beset with diffi- 
 culties. There is not infrequently a multiplicity of 
 causes, and intricate sequences of them. And life is 
 a moving equilibrium. Disease, as the physician en- 
 counters it, is always dynamic ; hence in part the 
 variableness of its phenomena. The physiological 
 term of the relation between inner functions and 
 outer forces eludes the observer by its mobility. An 
 equal difficulty lies in the complicated relations of 
 the internal changes of disease, in the order of 
 succession of the changes, and in the nature of the 
 external causes. A great number of those diseases, 
 whose aetiology is as yet closed to us, are un- 
 doubtedly the consequences of extremely unobtru- 
 sive habits and circumstances. Influences coming 
 from without, and suspected by only a few observers, 
 are, I think, the efficient instigators and maintain- 
 ers of unhealthy processes that maim and destroy 
 thousands. Chief among the as yet unrecognised 
 influences I should place those in action upon the 
 fundamental functions of alimentation, oxidation, and 
 excretion. In everything environment sums up the 
 food we eat, the air we breathe, the work we do, &c. 
 and in the mutual interactions of the involved
 
 PRACTICAL DEDUCTIONS. 243 
 
 functions, there may be discovered the means of 
 prevention and cure in a host of maladies, bodily 
 and mental. It is an apothegm of Dr. Hughlings \ 
 Jackson that diseases are flaws in an evolutionary 
 system. Within the known boundaries of this 
 system there is, I believe, a body of knowledge with 
 vast and momentous implications for the physician. 
 
 From all that has passed before us, it must be 
 admitted that the thing of most importance in 
 practical medicine, equally for therapeusis as for 
 prophylaxis, is to know the organismal and environ- 
 mental conditions out of which diseases are born. 
 Not the internal factors alone, or the external factors 
 alone, but the two sets of factors in relation. Yet 
 hardly of less consequence in the management of 
 cases must be a scientific conception and utilisation 
 of the self-restorative powers. It is anomalous and 
 a reproach that only the scantiest allusions to the 
 processes of organic equilibration are to be found in 
 text-books. No place is given to the general prin- 
 ciple. Yet without an understanding of it in its 
 general and special applications all thought about 
 diseases in their dynamical aspects must of necessity 
 be rude and erring. It is not hazardous to say that 
 most of the empiricism of medicine is traceable to 
 ignorance of the living body as a conservative 
 arrangement of forces. Homoeopathy, allopathy, 
 hydropathy, and kindred dogmatic systems will con- 
 tinue as exclusive methods of practice as long as 
 the vis medicatrix natures remains an unrecognised 
 principle of medical science. 
 
 While insisting upon this conservatism of the
 
 244 IMPLICATIONS. 
 
 organism as an agency in the cure of morbid states 
 it will be well to revert to some remarks made 
 towards the close of the last section. Serious will 
 be the misapplication of these considerations if they 
 are deemed to approve what is known as the ' ex- 
 pectant ' method of treatment. This would be to 
 assume perfection in natural processes that are the 
 outcome of natural weakness. Rightly, the unintel- 
 ligent though bounteous operations of the vis medi- 
 catrix natures must be under the empire of the intel- 
 ligent mind. Purposeless, blind, and with a narrow 
 range of action, this organised power, while entering 
 into all our calculations in treating disease, should 
 be the mere instrument of the physician, controlled 
 and directed by him. It must be subsidiary to his 
 intelligence an intelligence which can lead him to 
 conclusions utterly beyond its reach. Organic equi- 
 libration unaided by knowledge and skill may be 
 powerless to prevent the formation of a calculus 
 or to remove such a body when impacted in the 
 pelvis of the kidney ; and we have an example of the 
 limitations of its beneficence where the life-conserv- 
 ing cardiac hypertrophy of Bright' s disease assists 
 in the fatal bursting of a cerebral blood-vessel. 
 
 It will not pass unobserved that in pathology 
 organic equilibration also requires the important 
 practical view that disease marks an inability of the 
 organism to cope with the energies that invest it. 
 Disease is a struggle between the body and its con- 
 ditions ; hence the conditions are weakened as the 
 organism is strengthened. Here is recognised an- 
 other internal factor in the cure of disease. Though
 
 PRACTICAL DEDUCTIONS. 245 
 
 external causes demand, as we have given to them, 
 paramount attention, the relativity of the disease-pro- 
 ducing influence of environing forces has an impor- 
 tant and many-sided bearing on treatment. Agencies 
 that are maleficent under one set of circumstances 
 may be harmless or beneficent under another. The 
 estimation of these variables would appear to be 
 in the special province of practical medicine. The 
 physiological norme itself is variable in historical 
 time and geographical space and in the lives of in- 
 dividuals ; and since it is the sum of co-ordinate 
 conditions, the removal of the causes of disease is 
 the institution of determinately proportioned circum- 
 stances, which, theoretically, should never be exactly 
 repeated in the cases treated. Here, surely, may be 
 found an unanswerable argument against therapeutic 
 rules and dogmas. We are not led to believe that 
 there can be an enduring system of therapeutics based 
 on the physiological influence of chemical and phy- 
 sical forces in artificial combinations, precious as 
 are some of the rational and empiric truths the 
 system embodies. It is only required that we should 
 understand pathology to see that diseases and symp- 
 toms are not separate and individual, to be treated 
 separately and individually, but that they are phe- 
 nomena constituting a series, each member of which 
 will persist as long as its antecedents persist. 
 Whether the restoration to health is compassed by 
 natural equilibration or by art, knowledge of the pro- 
 cesses involved should in either case be received into 
 the institutes of medicine. 
 
 If we have concluded truthfully, the most neces-
 
 246 IMPLICATIONS. 
 
 sary knowledge for the rational treatment of disease 
 is physiology and pathology as one science in its 
 widest and deepest connections wide, as including 
 the phenomena and interrelations of health and dis- 
 ease ; and deep, as drawing the sap of its life from 
 biology, chemistry, and physics. Concerning those 
 useful means of medical treatment that do not obey 
 the canons enunciated, they would have place in such 
 a scheme where a rational justification is possible by 
 appeals to settled truths ; but empiricism, serviceable 
 as well as hurtful, has a position outside the pre- 
 cincts of the estate of science. 
 
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