Such cases as these show the fallacy of regarding insanity purely as a speciality, or of treating it by remedies addressed to the brain only; and they also tend to prove that the mind, so far from being a distinct entity, is indeed "the most dependent of all bodily functions." Here the salvation of a man's reason depended upon the evacuation of a few pints of fluid from

his chest.

ON TISSUE-DESTRUCTION IN THE FEBRILE STATE,

AND ITS RELATIONS TO TREATMENT.

BY DR. ANSTIE.

THE present paper is published under special circumstances, and can only be regarded as an instalment of what must hereafter become a very extensive inquiry. In the further series of observations with regard to the function of alcohol in pyrexia, which I am now carrying out, certain facts in the natural history of the pyrexial state have for the first time become known to me, and as they conflict in a considerable degree with the general statements of previous writers, I think it advisable at once to place them before the profession. It will be seen that they have very important bearings, not only on the pathology but on the treatment of pyrexia.

There is one maxim in pathology which physicians have for some time past been inclined to adopt without reserve, namely, that the persistence of the febrile state at a certain high standard and for any considerable number of days, involves of necessity a large tissue-consumption, and that this destructive process almost invariably involves, to a large extent, the muscular and other nitrogenised tissues of the body. The evidence of this destruction of nitrogen-containing tissues is readily to be found in the fact that, notwithstanding the diminution or even entire cessation of nitrogenous food-supplies, the ureadischarge is as high as, and usually very much higher than, in health. Besides, it is sufficiently obvious, in most cases of severe typhoid fever, pneumonia, and other intensely febrile affections, that great wasting of the muscular tissues takes place before the period of convalescence sets in.

Now the extended inquiry which I have been lately carrying on has shown, in a very surprising manner, the possibility of a total absence of urea-increase during the course of an intense pyrexia of considerable duration. That is the broad fact, in the natural history of the febrile state, which has come out: I now proceed to give details.

Before entering into the question now raised, it is needful to have distinct ideas of what constitutes a genuine urea-excess. The first thing necessary to know is, what is the average ureadischarge of health.

Now it is obvious, in the first place, that the amount of urea will vary enormously according to the character of the diet. It would be impossible otherwise to account for the exceedingly various estimates of the health-range of urea-discharge which have been given by excellent observers. In Parkes's work on the urine, twenty-four authors are quoted whose estimates were all made on males between the ages of twenty and forty; the figures vary from 286.1 to 688 4 grains for the twenty-four hours. The mean of the whole gives an estimate of 512-4 grains urea-discharge daily. But in Senator's recent and most valuable work on pyrexia1 I find, with surprise, that he quotes a statement of Unruh, which would make the normal discharge in men as low as 270 grains (17.466 grammes) in twenty four hours. It is quite certain, however, that unless the individuals from whom this was taken were feeding on a diet unusually poor in nitrogen, some abnormal circumstance must have been present.

The second point to be remembered is that the concurrent results obtained by many observers show that in healthy adult women the daily urea-discharge does not exceed three-fourths of the quantity excreted by healthy adult men similarly circumstanced. According to our modern physiological ideas it would be easy to account for the whole of this difference by the inferior quantity of azotised food consumed by females.

The third point to be remembered is, that in health the urea-discharge is the result, in by far the largest extent, of the decomposition of nitrogenous food within the body.

' Untersuchungen über den fieberhaften Process, p. 95. 1873.

NO. LXIX.

Berlin: Hirschwald,

In the febrile state, on the contrary, there is usually such complete anorexia that the supplies of nitrogenous matter taken are very small, yet the urea-discharge is commonly far higher than in health; sometimes double the amount, or more. Not only in case of a positive increase of urea, under these circumstances, but even when it sinks some way below the normal level, we may still conclude (from the small nitrogenous food supply) that exaggerated tissue destruction has largely to answer for its formation. The question is, can the urea-discharge be so far depressed below the normal rate, in any considerable number of cases of decided pyrexia, as to indicate decidedly that nitrogenous-tissue destruction is taking but little part in the actual ureaformation? The cases which will be brought forward in the present paper certainly tend, as far as they go, to answer that question in the affirmative.

(A.) Typhoid Fever.-In the case of this disease a large body of evidence has been collected, of late years, which appeared to show, with great uniformity, that when the fever was at all severe (as measured by continuously high temperatures, together with any marked delirium, the urea-discharge was constantly above the normal level, at a time when a very small amount of azotised food was being taken. For example, Dr. Parkes,1 besides speaking very definitely, from his own experience, in favour of a regular increase (save in certain abnormal conditions) of urea beyond the normal level (one-fifth on the average), also quotes three important series of observations, by Moos, Brattler, and Warnecke, extending altogether over 78 cases. The significance of the figures will not be perceived unless we remember that the patients were on exceedingly low diet-lower than we should employ in England. Moos (from eighteen cases) gives the average daily discharge as 575.64 grains in first week, 517·92 grains in second week, 404-04 grains in third week, 343.2 grains in fourth week. Warnecke gives, from results of fifty cases (thirty males and twenty females), for men an average discharge of 673.92 grains in first week, 617-44 grains in second week, 482·04 grains in third week, and 361.92 in fourth week; for women, 5304 grains in first week, 471.12 in second week, 375.96 grains in third week, 319.8 grains in fourth week. Brattler gives (from ten cases) 6074

1 Op. cit. 1862, pp. 244 et seq.

grains daily in first week, 592.8 grains in second week, 421.2 grains in third week, 3276 grains in fourth week, 247.6 grains in fifth week. The near approximation of these different series of results is very remarkable. Nevertheless, Parkes himself points out some objections to their conclusiveness; and my own results will be found to fully justify a revision of the usual belief. That is to say, they will show that the exceptions to the rule are probably so numerous as to form an important subject for consideration in regard to fever doctrines and fever treatment. The histories now to be given are of patients in whom neither stimulants, nor any important medicine, were given during the observed period.

The first case which I shall relate is that of Charles Jefferson, aged 25, a small but well-nourished man, who was admitted into Westminster Hospital on the seventh day of typhoid fever, and upon whom the first rose spot was seen on the following day. The examination of the urine unfortunately could not begin till the ninth day. At this time there was no diarrhoea: but I may mention here that even at the period when diarrhoea did come on we did not lose urine from that cause, as the patient intelligently obeyed our orders to pass water into the chambervessel before going to stool. This circumstance shows, of course, that the case was not of the severest type. Full convalescence was established upon the twenty-fourth day, as marked by the cessation of diarrhoea; the temperature had become normal two days earlier. I had intended to print in diagrammatic form the respective curves of mean daily temperature, of urea elimination, and of water elimination, but there was unfortunately no time for this on the present occasion,1 so the figures must be verbally stated. On the ninth day the temperature, though not quite so high as it had been, was nearly 103° on the mean of three observations, the maximum being a good deal higher in striking contrast with this was the fact that only 118 grains of urea were eliminated. During the five following days the temperature had steadily come down and the urea had as steadily gone up; the twenty-four hours' mean temperature on the

1 All the facts connected with the course of fever treated with, and without, alcohol, will be subsequently published in diagrammatic form as well as in verbal description.