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considerable quantities.1 According to O. Weber it is very poisonous, exerting its action chiefly on the nerve-centres. The nervous symptoms which frequently accompany gastric derangement or disease of the intestines may therefore be frequently occasioned by poisons formed in the alimentary canal in consequence of imperfect digestion.
The administration of a brisk purgative or small doses of Epsom salts thrice a day is a most effectual remedy for frontal headache when combined with constipation; but if the bowels are regular, the morbid processes on which it depends seem to be checked and the headache removed even more effectually by nitro-hydrochloric acid or alkalies given before meals. If the headache is immediately above the eyebrows, the acid is best; but if it is a little higher up, just where the hair begins, the alkalies appear to me to be more effectual. At the same time that the headache is removed, the feelings of sleepiness and weariness which frequently lead the patients to complain that they rise up more tired than they lay down, generally dis
Somewhat analogous to the neuralgia of the fifth nerve in Sir Charles Bell's case, or to frontal headache, is the pain which we frequently meet with in persons having decayed teeth. The pain may be felt in the offending tooth itself, but very often it seems to give little or no uneasiness. The patients complain of neuralgic pains above the ear or along the jaw, and will often deny that they have any decayed teeth at all. It would almost seem that neither the irritation in the tooth nor irritation in the intestine alone is sufficient to produce pain, though they do so when acting conjointly; for extraction of the tooth, or stoppage of the cavity with cotton-wool steeped in melted carbolic acid, will often remove the pain although no medicine is given internally, while on the other hand a brisk purgative may also afford relief though the tooth be left untouched. It is best, however, to combine both methods of treatment, and if the tooth is not extracted or stopped, the pain is very apt to return ; and it seems to me probable, though I am by no means certain of it, that this recurrence is connected with the renewal of gastric 1 Kühne, "Physiologische Chemie," p. 58. O. Weber, "Deutsche Klinik," 1864, p. 488.
or intestinal irritation. According to Heincken,1 otalgia may also depend on the presence of irritating matters in the intestine ; and Sir Charles Bell observes that accumulations in the colon will give rise to pains in the loins, spermatic cord, or groin. Pain at the lower angle of the scapula is referred by him to disorder and distension of the duodenum. This pain is very often accompanied by flatulence, and is described by patients as a “pain in the pit of the stomach, shooting through between the blade-bones," and it is not unfrequently termed by them "windy spasms." It is relieved by rhubarb and alkalies given before meals.
Having said so much regarding the fæcal contents of the intestine and their local and remote actions, we must now consider a matter of no less importance, viz., the effect of purgatives upon the secretions which are poured into the intestinal tube by the various glands connected with it. The saliva which flows into the mouth from the submaxillary and parotid glands is swallowed and aids the digestion of starchy food in the stomach, and probably the intestine. A part of its active principle, ptyalin, is reabsorbed, and some of it is excreted in the urine; 2 but as we shall here afterwards see, it is probable that another part is excreted again by the salivary glands and thus does its work twice over. This is at present only a probability as regards ptyalin, but it is a certainty in the case of several substances which are excreted by the salivary glands, such as iodide of potassium, for example, which can be detected with great ease. When this substance is swallowed, it is absorbed from the stomach, passes in the blood to the salivary glands, and is excreted by them much more readily than by the kidneys. It again passes down with the saliva to the stomach, is reabsorbed, and again excreted. Thus it may go round and round for a long time without getting entirely out of the body. (See gastro-salivary circulation, Fig. 2.) If we wish to remove it quickly and completely, we must give a purgative so as to prevent its reabsorption from the intestinal canal by causing its speedy expulsion. The same is the case with other iodides, such as those of lead or iron. Iodine has been shown by Bernard to possess the power of making iron 1 Heincken, "De Morbis Nervorum ex Abdomine," quoted by Sir Charles Bell, op. cit., p. 93. 2 Cohnheim, "Virchow's Archiv," xxviii. p. 250.
pass readily through the salivary glands, the iodide of iron being found in the saliva soon after it has been injected into the blood, while other salts of iron, such as lactate, never make their appearance in it at all. Several years ago iodide of potassium was proposed by MM. Guillot and Melsens as a remedy in cases
FIG. 2.-Diagram showing the manner in which substances are excreted by one organ and reabsorbed by another, so that they circulate a long while in the organism before being expelled.2
of lead-poisoning. The lead, they consider, is present in the body in the form of an insoluble compound which it makes with
1 "Bernard, "Physiologie Expérimentale," tom. ii. p. 99.
2 The absorption of substances excreted by the salivary gland is indicated in the figure as taking place in the stomach, and their circulation is called gastrosalivary; but it is very probable that a considerable portion of them passes through the stomach into the intestines, and that entero-salivary might be a better term. Similarly, the absorption of bile has been represented as taking place in the duodenum, and that of pancreatic and gastric juices in the jejunum, but this is only to avoid confusion in the drawing, and not to indicate the part of the intestine where absorption really takes place.
3 Guillot and Melsens, "Archives Générales de Médecine," 4th sér. iv. p 517; and Melsens, "Annales de Chimie," June 1849.
the tissues, but by the administration of iodide of potassium it is rendered soluble. It then finds its way into the circulation, and is excreted by the kidneys and other emunctories. But the iodide of lead is partly excreted by the salivary glands, for M. Malherbe, of Nantes, and Dr. Sieveking have found it in the saliva of persons suffering from lead-poisoning, and who were being treated by iodide of potassium. The lead salt being swallowed with the saliva, is again reabsorbed, and thus the cure is comparatively slow when patients are treated with iodide of potassium alone. I frequently see patients suffering from lead-poisoning brought on by working in white lead, and for some time I have been accustomed to treat them with five grains of iodide of potassium, three times a day, and a sufficient quantity of sulphate of magnesia or other purgative either thrice or once a day, to keep the bowels very freely open, and cause the expulsion of the lead from the alimentary canal as quickly as it is secreted into it. I have not made comparative experiments on the effect of this treatment and of that by iodide of potassium alone, or by purgatives alone, but from what I remember of cases treated by the late Professor Syme with castor-oil, I am fully satisfied with the treatment I now adopt. The same plan would probably prove equally useful in chronic poisoning by copper or mercury.
But the gastro-salivary circle, as we may term it, from stomach to salivary glands and from salivary glands to stomach again, is not the only one in which those metals move. Their circulation in the portal system, or entero-hepatic, as it is termed by Lussana,1 is still more important. (See Fig. 2.) Iron is eliminated in great part by the bile: copper and manganese appear in it also, according to Albini and Moser 2 and it seems probable that manganese, lead, and all the heavy metals pass out of the body by this channel. From the liver they pass into the intestine, are reabsorbed from it, and again pass to the liver and recommence their course. They may be present in considerable quantities in the blood of the portal system without reaching the general circulation or getting a chance of passing out in the urine. They are therefore much more closely locked
1 Lussana, "Lo Sperimentale," tom. xxix. 1872.
2 Quevenne, Albini and Moser, quoted by Lussana, "Lo Sperimentale," tom. xxix. 1872, pp. 340, 343.
up in the entero-hepatic circulation than in the gastro-salivary one, for the salivary glands are supplied by the systemic circulation, and any blood which brings lead or any other substance to them must also carry it to the kidneys. The power of the entero-hepatic circulation to retain metals within the body being much greater than that of the gastro-salivary one, it is evident that the beneficial effects of purgatives in lead-poisoning are due to their removing the metal from the portal circulation still more than their action on the gastro-salivary one which has already been discussed. Other poisons, such as curare and probably serpent's venom, may also circulate in considerable quantity in the portal system without reaching the systemic circulation, and probably this is one of the causes, though by no means the only one, which renders these substances to a great extent innocuous when swallowed.1
But the circulation of iron, lead, curare, &c., in the portal system, important though it may be, is of far less interest than the circulation of the bile itself. For the sake of convenience I have merely stated that lead, mercury, &c., are excreted in the bile, and have hitherto assumed that bile circulates in a similar way in the portal system, without giving any reason for doing so.
It used to be thought by many that bile was formed in various parts of the body, and was simply excreted by the liver. This view is now given up by most physiologists, who believe that bile is formed by the liver only. But in altering their views regarding the function of this organ they went too far, and supposed that it only formed bile, which, when it had once found its way into the intestine and mixed with the intestinal contents, became decomposed and finally expelled with the fæces. A year or two ago, however, Schiff 2 found that this view of the hepatic functions was too limited, and that the liver removed bile from the blood or excreted it as well as formed or secreted it.3 He observed that when all the bile was drawn away from the liver by means of a fistulous opening in the gall-bladder after ligature of the 1 Lussana, op. cit.
3 Although it is not correct to do so, I use the term "secreted," here as synony. mous with "formed," for the sake of conveniently distinguishing between the formation of bile in the liver and its removal from the blood.