the most familiar example.* The change thus effected by what is often an inconsiderable deposit of purulent matter in some part of the body-remote, it may be, from those parts especially affected by the disease-is, in truth, one of the most singular facts in pathology. For there are cases in which we cannot reasonably interpret it as a mere transfer of irritation, but must look to the actual nature and amount of the discharge, as that which gives relief to the system; thus furnishing another argument for the doctrine which derives many of these idiopathic fevers, and analogous diseases, from actual changes within the blood itself. And the same principle applies, on the other side, to those various cases, where the sudden suspension of an habitual discharge brings on symptoms in other and remote parts of the body; having no common aspect, yet manifestly to be referred to one specific morbid cause.

Other illustration of these views of metastasis may be drawn from the remarkable connexion between certain morbid actions of the kidney, and disordered states of the brain;-traceable in every degree, from the slight influences upon ordinary sleep, to the most serious affections of the latter organ; often occurring very suddenly; and manifestly depending, not on mere alteration of the quantity of urine, but chiefly perhaps on the imperfection of the secretion as respects the removal of particular ingredients of the blood, which are thereby injuriously retained in the system.†

* The physicians of antiquity paid more attention to this subject of the crisis of disorders, whether by abscess or otherwise, than do those of our own time and they are justified by its practical importance. I need not state proofs of what is so well known in their writings, from the time of Hippocrates downwards.

:

Some of the variations in the effect of wines and other fermented liquors, in producing intoxication, doubtless depend on this important relation between the functions of the kidneys and the brain.

these cases have not yet been studied to their full extent, though of late much more carefully than heretofore. The same general remarks will apply to certain affections of mucous membranes - bronchitis and asthma for example— which are frequently the subject of similar sudden translation; — involving in some cases, it may be, mere transference of blood, as where bronchitis supervenes upon hæmorrhoids; but in other instances, changes in its quality, produced by the new and altered secretions which take place.

*

one of

I have alluded already to the close connexion by metastasis between the intestinal membranes and the skin;the most important relations in the animal economy in state of health; and entering, more or less, into every part of the history of disease. Disorders of digestion, alterations of secretion, changes of temperature, the influence of acrid or poisonous substances, and numerous other cases, are attended by a reciprocity of action between these two surfaces; often marked enough to form a character for description, and in every instance deserving notice, both as pathological facts, and suggestions for practice. The rapidity of some of these translations, and varying rate of others, is a remarkable part of their history; of which multiplied examples might be given, were they not rendered needless by their familiarity.

As the title of this chapter includes the subject of meta

* I have notes of some singular cases of this kind; one, for example, in which there existed for many years a frequent and well marked alternation of headaches with hæmorrhoids; each very severe in degree, and both almost altogether removed by the supervention of chronic bronchitis ; which latter disorder has since continued, constantly and severely, for a long period of years. In the same case I have repeatedly seen a temporary translation for a few hours to the head, producing even delirium ; which again was as suddenly relieved by the recurrence of a copious bronchial secretion. The connexion distinctly marked between bronchitis and hæmorrhoids, I have noted in several instances.

stasis chiefly in connexion with the circulation, I shall not do more than refer to that part of it which includes the more direct action of the nervous system in producing these changes. This is in itself a wide and curious topic of research; expounding the character of a large class of diseases, and embracing the whole subject of nervous sympathies, to whatsoever class of nerves they belong, and whether direct or reflex in kind. While thus slightly alluding to it, I may observe that a complete work on the metastasis of disease, in its most general acceptation, is still a desideratum in medical literature, and would possess great value. But to execute it rightly, all implicit adherence to names and systems must be laid aside. Some of the most important results are obtained from sources, and by observing relations, to which these methods of arrangement afford no clue; and which must escape notice, if the latter are rigorously pursued. Various examples to this effect have been given in the present and preceding chapters; and many others will be furnished by the experience of every observant physician.

551

CHAP. XXXI.

ON THE USE OF DIGITALIS.

AFTER all that has been written upon this medicine, there is reason to doubt whether its capabilities have yet been brought into full use. An agent which can thus alter the heart's action, and, under management, safely sustain this alteration for a considerable time, is a very important one in the hands of the practitioner; affording means wherewith to control, more or less directly, all the actions of the system. It is, however, this singular sedative effect on the heart, and the occasional suddenness of the change so produced, which creates an apprehension as to its use, not warranted by what we learn from exact observation. Though employing the medicine somewhat largely in practice, I do not recollect a case in which I have seen any injurious consequences from this cause; none such, certainly, as were not speedily relieved by its discontinuance, and other means of easy adoption.

I am far from inculcating neglect of the symptom just mentioned. But while admitting that deviation below the average standard of the pulse is less frequent and considerable than excess above it, and that certain morbid states of the brain are sometimes thus indicated, I feel assured that alarm is too readily taken in the early effects of digitalis on the heart, even should intermittent action be one of these. Similar effects occur habitually from so many other causes affecting the body without injury which can be especially referred to this symptom, that if there be justification on other grounds for sustaining the action, and care given

watching it, the practice may generally be pursued without any risk sufficient to countervail the good.

More attention too is required, than is always bestowed, in estimating the actual changes in the pulse. It is not enough to feel it once, or in one posture only. The difference between recumbency and the upright posture will often totally alter its character; and it should be examined also after some cordial has been given, to ascertain the facility of bringing it back to its ordinary state. These and other precautions, by better determining the real amount of deviation produced, afford securities for the continued use of the medicine which are of great practical value.*

The manner of employing digitalis is undoubtedly of much consequence. I feel assured, on experience, that the combination with tonics and stimulants not only does not impair some of its specific effects, but even extends them by giving larger scope to its administration. This may be inadmissible when a direct sedative effect is required (though here, as in the case of Dr. Ferrier's original suggestion of digitalis and steel in phthisis, the line cannot always distinctly be drawn); but when the action of the kidneys is especially sought for, and in habits already debilitated by disease, such combinations are often of the greatest value. That with iron seems to me more beneficial in many cases than with bark;

These suggestions regarding the pulse apply to many other cases, where we seek to know the effects of disease upon it; and not, as here, the influence of the remedy. The value of its indications is often forfeited by the slight and careless manner in which they are taken. An inference may be formed at one moment, or under one posture, which the lapse of five minutes, and change of position, will altogether belie. It is true that this is less the case in fevers and inflammatory diseases; but there are many others where the view of the disorder and method of treatment may be wholly perverted by trusting to a single observation. All recent inquiry into the pulse shows the need of attention to these points.