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intelligible and scientific than tlie famous aphorism that "jN^atiire abhors a vacuum," They express, however, as clear- ly as it is possible to express any thing so intangible, the ideas intended to be conveyed by the term " substitution^^ the sub- stitution of one morbid Buy Erectalis Online process for another by a sort of hood- winking of the system. But " substitution " has to share the honors with ^^ revulsion'''' or " derivation^'' terms employed to express the accumulation of an excess Erectalis Tablets of blood in the place irritated, which excess is supposed to be drawn, wholly or in part, from Erectalis Online the diseased locality. This idea has at least the merit of being intelligible, and expresses, I think, a partial truth. But it is met by the objection that the extra quantity of blood under a sinapism, for example, is so insignificant that its abstraction could have no appreciable efiect upon a distant organ, with which there may be no direct vascular connection. This objection is valid from the stand-point from which it is taken. Rejecting the idea that either the nerves or the blood-ves- sels play any considerable part in the action of counter-irri- tants, Mr. E.OSS ' has put forward the theory that the effect is produced by a modification of nutrition, communicated from cell to cell of the intervening parenchyma, without regard to whether the tissues be continuous, or, as in the case of internal organs, merely contiguous. The absurdity of his theory is shown by one of his illustrations, that of flatulent colic, re- lieved by a sinapism to the abdomen. He aftirms that the irritation causes a change of nutrition which is propagated from cell to cell through the integument, fasciae, and muscles, until it reaches the inner surface of the parietal peritonaeum, whence it is transferred to the visceral serous surface, and pen- etrates to the muscular coat. Here it produces an im.])roved nut/rition, which gives the muscular fibre sufiicient power to expel the flatus. (!) Except in cases resembling the above, in which the pain results from a mechanical cause capable of being removed by muscular action excited by reflex irritation, I hold that all the benefits resulting from counter-irritation are obtained di- ' " On Counter-Irritation : A Theory constructed by tlie Deductive Method of Investigation," By James Koss, M. D. London, 1869. CIRCULATION^ OF THE BLOOD. 341 rectly or indirectly throiigli the circulation. In the first place, I consider all pain (excluding that from extraneous irritation) as proceeding from imperfect nutrition, even though there be no evidence of inflammation. This is only in accordance with the proposition that there can be no derangement of function without change of structure. ISTow, if the morbid condition be one dependent upon the quantity (not quality) of the blood supplied to the part which is the seat of pain, then, in my view, counter-irritation may be of service, but not otherwise. In the case of inflammatory action, the agency of the vessels will be admitted with less argument. But the difficulty in either case has been that already stated — that the ajpparent chano;e in the circulation is too trivial to be credited with the results observed. I reserve the word " apparent," and on this reservation my entire argument will rest. With the excep- tion mentioned in the foot-note,^ in all the discussions upon this subject, up to the present time, so far as my knowledge ex- tends, attention has been confined to the excess of blood con- tained in the irritated part. If, for example, the entire mass of tissue to which the irritation extends could be cut out at one stroke, and the blood expressed from it, the excess Buy Erectalis of this blood over what would naturally be contained in the same quantity of tissue, would represent what has been considered as the sum total of the change supposed to have been effected in the circu- lation at that point. Or, if the irritation was supposed to be reflected upon some other point, the result there was regarded in the same light. It is here that I think a mistake has been made. The question is not, how much hlood the vessels of the irritated fart ivill hold, hut how much they ivill transmit in a given time. This becomes evident when we consider that a given amount of blood passes through the capillaries of the body in each unit of time, and is transferred from the arterial to the ' The germ, from wliicli the views here given are developed, is de- rived from a lecture by Prof. Virchow, which I heard in 1860, but which I have never seen in print. His reference to the subject was limited to the suggestion that increasing the capillary circulation in the part supplied by an arterial twig implied a diminution of the circulation in the capillaries derived from collaterul branches. 342 CIECPLATION OF THE BLOOD. venous side of the circulation, and that the quantity passing through any one part must afiect that passing through the re- mainder of the body, since the latter must be tlie exact com- plement of the former. Thus, if in a given time four pounds of blood pass through the capillaries of the entire body, and one pound passes through the capillaries of the arms, it follows that three pounds must pass through the remainder of the cap- illary system. ISTow, if we plunge the arms into hot water, and dilate the vessels so that an additional half pound passes through them, the remaining vessels will transmft but two and a half pounds, and the tissues which they supply will be de- prived for the time of one-sixth of their nourishment. It will be perceived that this is a matter entirely apart from the quantity of blood wliich might be contained in the arms if severed from the body. The consideration of the increase of the carrying power of tubes, in comparison with the increase in their diameter, in-

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