the safest, the surest, and the most successful of all the forms it assumes in practice.... In the first place, it completely recognises the autocracy of nature in the cure of acute diseases, and proceeds on the principle that it is not only useless, but injurious, to attempt to suppress or greatly to modify the morbid processes by strong measures of a perturbative or exhaustive kind. "The indications which this mode of treatment seeks to fulfil are chiefly the following:-1st. To place the diseased body in the most favourable circumstances for the development and exercise of its own conservative powers, by the institution of a proper regimen, in the most comprehensive sense of that term. 2nd. To endeavour thereby, or through the use of medicaments, to remove such obstacles to the favourable action of the conservative and restorative powers as may be removable without the risk of checking or injuriously perverting them. 3rd. Applying these measures under a watcliful supervision; not to attempt by any vigorous measures to alter the course of the morbid processes so long as they seem to keep within the limit of safety, and when they transgress, or threaten to transgress this limit, only then to endeavour to modify them by such mild measures as, if they fail in doing good, cannot do much harm. 4th. To be on the watch against possible contingencies, which may demand the employment of measures of exceptional activity, whether in the form of regimen or medicine, and, when required, to apply such measures with the necessary vigour." (p. 239.) So far as this method combats the purely empirical proceedings and the treatment à la Sangrado that we all have seen, we most heartily concur with Sir John Forbes, and we think that if he had much familiar intercourse with physicians of less than twenty years' standing. and had the opportunity of judging of their practice, he would find that the prevailing fault is not so much a tendency to trust over much in drugs, as to be sceptical of their utility. There is a scepticism which leaves its holder in a slough of despond-a scepticism which, having no positive basis whatever, vacillates with the wind of public opinion or with the accidents of daily life. The medical man whose knowledge is of a calibre to allow him to become the prey of such scepticism, may be regarded as the most unfortunate man under the sun, for no professional act of his can be attended with any degree of moral satisfaction; he will be inclined to say with Dr. Cayol, "Les systèmes en médecine sont les idoles auxquelles on sacrifie des victimes humaines." But there is another scepticism, which is the characteristic of all men of science, which coexists with the warmest love of his profession and a full faith in the powers of his art, in the heart of the zealous and earnest physician; it is the scepticism which leads him to be suspicious of his own observations and of his deductions, until by repetition and by comparison with the results obtained by others, he has placed his conclusions on the firmest basis upon which a scientific fact can rest. Such is the scepticism which has ever distinguished the most elevated in our ranks,-we think that the general advancement of the profession, and the greater humility which that increased knowledge has brought with it, have spread more generally that form of scepticism which we would uphold as a laudable feature of our times. Still we are also satisfied that while many of the views advocated by Sir John Forbes are in a great measure the views held by the majority of physicians of the present day, we have a more positive knowledge of the extent and limits of the powers of Nature on the one hand, and of the real uses of drugs on the other, in the cure of morbid states, than has been possessed by our predecessors. If we keep to the path we are pursuing, and continue to seek to interpret Nature correctly in all her phases, making Physiology our main instructress in the manifestations of disease, but not disdaining any aid obtainable from all the handmaidens of the physician, we shall pass safely through the Scylla and Charybdis of dogmatism and false scepticism. We shall retain our faith in the powers of Nature to cure disease, but we shall no less continue to believe that "the Lord hath created medicines out of the earth, and he that is wise will not abhor them." In the preceding remarks we have sought rather to indicate the spirit that pervades Sir John Forbes' book than to give our readers a summary of its contents. With its spirit we cordially sympathize, for it is a spirit of earnest hatred of all quackery, of manly affection for the high objects of our common profession. We cannot deny that the author appears to us to underrate the value of medicines, but so long as with us the professional man and the tradesman are blended together, and Government takes quackery under its special protection, so long there will be little risk of drugs falling generally into disrepute; and we may say of Sir John, as of the Man of Ross, that "E'en his errors leant to virtue's side." With this reservation, we do not hesitate to repeat that we cordially agree with the author's general views, and recommend his "Legacy to all medical men who earnestly seek for Truth in the daily practice of their surpassingly interesting profession. REVIEW II. Von Gesammelte Abhandlungen zur wissenschaftlichen Medicin. THE founder of the well-known Archiv für Pathologische Anatomie und Physiologie,' the editor of the newest and most elaborate Handbook of Special Pathology and Therapeutics,' has presented us, in a handsome volume, with a collection of some of those researches by which he has exercised so great an influence on the progress of medical science in Germany, and has gained for himself, in a comparatively short space of time, a very high position among the reformers and promoters of our profession. The volume contains some of the author's earliest contributions, which were scattered through various journals, some of which have ceased to appear, and are not easily to be obtained, while, with a single exception, we find none of those essays which have been published in his Archiv.' Virchow's earlier memoirs are of particular interest, as through them we are enabled to understand more readily the views he has laid down in the 'Handbook of Special Pathology and Therapeutics,' and are allowed at the same time to perceive the manner in which he advanced step by step. The individual essays are provided with new paragraphs, and notes are added, in which the results of later researches are recorded, and the memoir on the subject of thrombosis and blocking-up of blood vessels (Virchow's embolia) which has created so much sensation, appears here for the first time in a complete form, the second and greater part having never been published before. Each treatise bears the stamp of the powerful mind of an original inquirer, who examines his subject in every point of view and by all the means at his disposal; who draws his inferences in a logical manner, influenced as little as possible by existing theories, however long they may have been established, however great the authorities in their support. We can do little more than give the titles of the greater part of the essays; but we propose to dwell especially and at some length upon those subjects with which Virchow's name is especially connected. In the first section the author treats, in a philosophical manner, on the nature of man, on animal life, on medical science, on disease, and on epidemic disease (Seuche) in particular. His observations in these paragraphs abound in new ideas and sound criticism. We need only allude to those on pathological systems in general, and on the so-called ontological systems in specie; on cellular pathology, on metastasis and infection. The second section (pp. 59-165) contains Virchow's principal essays on fibrin. 1. Coagulation of Fibrin.*—The author agrees with Nasse and other physiologists, who teach that the coagulation of fibrin is effected by the juxtaposition of molecules, which are to be considered as perfectly invisible. The coagulated fibrin is a completely uniform gelatinous substance, which in larger masses appears always homogeneous, while in membrane-like pieces it assumes, by the formation of plaits and wrinkles, a fibrillating aspect. In 1854, the author adds, that in all his subsequent investigations he never met with any form of coagulated fibrin which could be regarded as of granular appearance. The coagulation of fibrin always commences with a gelatinous stage, in which the fibrin is invariably combined with a certain quantity of serum-water analogous to the water of crystallization. Some fibrin remains in this condition, but in general, after some time, the molecules that were hitherto invisible, approach each other more closely, the fluid between them is squeezed out, contraction-or coagulation, in the stricter sense of the word-takes place. While this process of contraction is advancing, the fibrillating condition becomes more evident, and as the last result of coagulation, the formation of true fibrils cannot be denied. Similar observations may be made on mucus. The gelatinous mucus is completely homogeneous, * Froriep's Neue Notizen, No. 769, Sept. 1845. but by means of water, acids, or alcohol, coagulation is effected, and true fibrils become visible. Fibrin-like mucus in the act of coagulation alters the appearance of such bodies as may be imbedded in it, by making them oval, oblong, caudate, spindle-shaped, &c. This is particularly well seen in cellular formations of a viscid nature, as colourless blood- and pus-globules, and the addition of acetic acid makes it still more evident. 2. Physical Qualities of Fibrin.*-Elasticity is considered as one of the most prominent peculiarities of coagulated fibrin; this peculiarity is attributed, as in caoutchouc, to the high degree of attraction between the molecules; its connexion with electric phenomena is denied, as only the dried fibrin exhibits, when heated, positive electricity, a character which it possesses in common with other proteinaceous substances. During the metamorphosis of the thrombus, the elasticity yields first to fragility, then again to toughness, a state which signifies the histogenetic transformation of the fibrinous coagulum into connecting tissue, the chemical transformation into gelatinous tissue. Viscosity, or the faculty of adhering to adjacent objects, is possessed by fresh fibrin only in a small degree. The opaque spots on the pericardium and peritoneum, the semi-cartilaginous plates in the coverings of the lungs, the spleen, the testicles, without adhesion to the opposite parts, may be quoted in favour of this assertion. It must be confessed, however, that the origin of these alterations is not in all cases due to fibrinous deposit from inflammation; but in some, at all events, we find unquestionable layers of fibrin on serous membranes, without agglutination to the other side. Although, however, fresh fibrin is not considered to be of viscous nature, yet it may become so by chemical transmutation within the organism some time after its extravasation; it may further appear to possess this peculiarity when mixed with other viscous substances, as albumen and colourless blood-globules. 3. Chemical Qualities of Fibrin.t-In this essay Virchow endeavours, according to his own affirmation, to separate the proved facts from the probabilities and theories which abounded on this subject at that time still more than at present. 1. The common fibrin. Although it is true that blood containing fibrin does not coagulate when mixed with a solution of sulphate or carbonate of soda, yet we are compelled to admit "that the presence of fibrin can be recognised only by its coagulation: the coagulated fibrin in an approximative manner by the general characters of proteinaceous bodies, by its insolubility in water, but principally by its morphological and physical qualities." The fat which occurs in combination with fibrin the author found to be composed of 91.90 per cent. fatty acids, and 8-10 per cent. lime (and soda?), free from cholesterine and serolin. These fatty acids of the fibrin appear analogous to those of the nervous tissue, by their containing nitrogen and phosphorus, by their swelling in water, and by their combination with lime. We may add, that Virchow has lately discovered the existence of a fatty substance, similar to that of the nerves and of fibrin, in the yolk of * Zeitsch. f. rat. Med., Band v. pp. 213 ss. ↑ Ibid., Band iv. pp. 262 ss. the hen's egg, in the corpus luteum of cattle, in the spleen, the lungs, in pus, &c., and applies to this body the name myelin (Markstoff).* The salts of fibrin do not exceed 1 per cent.; they consist of phosphate of lime and a small quantity of phosphate of magnesia, and are intimately incorporated with the proteinaceous substance. Virchow attaches a due importance to the presence of those salts for the process of nutrition, and of ossification in particular. The fibrin and albumen deposited in a certain organ may, according to his view, be so changed, that the proteinaceous substance, after having been transformed into soluble extractive matter or fat, is absorbed and carried to the organs of secretion, while the lime remains. This view gains in probability by the result of Schmidt's researches,† who found that the blood of some invertebrate animals contains a combination of albumen with canstic lime and phosphate of lime, which, under the influence of carbonic acid, is decomposed into carbonate of lime, soluble albumen, and phosphate of lime. 2. The formed fibrin.-We are assured of the presence of fibrin in the blood, chyle, lymph, humor aqueus of the eye, in exudations, and believe it to exist in the spermatic fluid. Besides this common coagulating fibrin, another variety has been admitted by some, which is supposed to exist already coagulated in definite forms. The existence of this variety is altogether denied by our author, and especially so in the glandular tissue, or in the muscle, except in the fluid plasma surrounding the primitive fibrillæ. The résumé of Virchow's researches on this subject is, "that the covering of the blood-globules is formed by a proteinaceous substance similar to fibrin, but that the existence of fibrin in the cellular or fibrous tissues as a constituent of their membranes, or nuclei, or contents, is chemically unproved." 3. Concerning the admission of different varieties of fibrin (of the arterial, venous, and inflammatory blood, Magendie and Rokitansky's "pseudo-fibrin," and Mulder's "oxyprotein," &c.), the author observes that he knows only of one kindnamely, the fibrin in the coagulated form. 4. On the Disintegration of Fibrin.-As far as the morphological changes in the breaking down of fibrin are concerned, Virchow agrees in general with Gulliver,§ but he never found them connected with any formation of new cells, but could discover only the remains of those previously admixed. With reference to the chemical processes, he observed the development of hydrosulphuric acid, ammonia, butyric acid, and a solution in some respects similar to albumen, but differing from it by the peculiar change of colour which it shows under the influence of nitric acid, gradually added, and which most resembles the erythroprotid of Mulder. 5. On the Origin of Fibrin and the Cause of its Coagulation in Animal Fluids. In this section we meet first with the question on the pre-existence of fibrin in coagulating fluids. From his own researches and those of others, Virchow is led to the inference : Archiv f. Path. Anatomie, Band vi. p. 562. + Zur vergleichenden Physiologie der wirbellosen Thiere. 1845. Zeitsch, f. rat. Med., Band v. p. 226. On the Softening of Coagulated Fibrin: Medico-Chirurgical Transactions. 1839 |