A STUDY Ix\ MORBID AND NORMAL PHYSIOLOGY. 



241 



nation in fever. Having no new evidence to offer I again make an extract from 

 tlie article of Prof. Sanderson, in whicli he shows that there is in fever an increased 

 metamorphosis of tissue. After a discussion of various analyses he says : 



"The general conclusion to be derived from the whole series is tliat in the early stage of fever a 

 patient excretes about three times as much urea as he would do on the same diet if he were in health 

 the difference between the fevered and the healthy body, consisting chiefly in this, that whereas the 

 former discharges a quantity of nitrogen equal to that taken in, the latter wastes the store of nitrogen 

 contained in its own juices. That this disorder of nutrition is an essential constituent of the febrile 

 process is indicated by the fact that it not only accompanies the other phenomena of fever durin" 

 their whole course, but precedes the earliest symptoms and follows the latest. That it anticipates 

 the beginning of fever was first demonstrated by Dr. Sidney Ringer in his investigation of the 

 relation between temperature and the discharge of urea in ague. That the same condition continues 

 after the cri.sis has past, i. e., the temperature has begun to sink, has been shown by Dr. Squarey 

 from his investigation of eighteen cases of typhus, in all of which the daily excretion of urea was 

 measured, and the variations of temperature were observed during the whole course of the disease, 

 and the observations were continued until convalescence was completely established. In these cases 

 it was found that, whereas the bodily temperature which in this disease rises rapidly at the beginning, 

 and keeps up without sensible abatement during a period which often extends to the middle of the 

 second week, usually Ijcgins to fall after the tenth day, the daily rate of discharge of urea, although 

 usually above the normal during the first week, did not attain its maximum until the temperature 

 had been falling for some days. 



"The question of the source from which the urea increment of fever conies is one which can be 

 better discussed subsequently. At present it is sufficient to notice that the anticipation of the obvious 

 symptoms of illness, particularly of the pyrexia, by the increased excretion of urea, as well as the 

 continuance of the urea excess during the epicritical period, plainly indicate that pyrexia is not the 

 agent by the direct influence of which the increased secretion of urea is produced. 



"Another consideration suggested by the same facts is this, that the mere increase of the percentage 

 of urea discharged, affords an inadequate measure of the waste of nitrogen, i. e., of albumin, wiiich 

 actually occurs in fever; for to form a just estimate, the overlapping at both ends of the process ought 

 clearly to be taken into account. Moreover, in fever tliere are very frecpiently losses of nitrogen Ijy tlie 

 bowels and skin, as well as by exudations, the amount of which scarcely admits of being determined. 



"It having been established that there is an increased discharge of nitrogen in fever, it remains to 

 state what is known as to its source. There are two sources which are open to discussion, viz.: 

 (1) the albumin of the blood and lym])h, and (2) that of the tissues; or, to use the expressions which 

 the researches of Voit have rendered current in physiology, store allnimin, and tissue albumin. By 

 the former we understand the albuminous constituent of the corpuscles and plasma as well as of the 

 tissue juice or lymph ; by the latter, the material of protoplasm, including that of the blood corpuscles. 



" Here the basis of observation is furnished by researches made by Dr. Salkowski, relating to the 

 proportion of potassium salts discharged by the urine in fever, as compared with that of sodium salts. 

 These researches relate to some twenty cases of various forms of febrile disease in Professor Leyden's 

 wards at Konigsberg. The research began with an investigation of the relative proportions of 

 potassium and sodium salts discharged by the liquid and solid excreta in health, the observer being 

 himself the subject of observation. The diet being mixed, and the nutritive condition nearly that of 

 nitrogen equilibrium as seen by the constancy of the daily discharge of urea (min. 25.3, mas -27.2, 

 mean of seven days 25.69), the daily quantity of pofa.ssium and sodium salts respectively, reck'^med 

 as potash and soda, were: potash, 3.004 grammes; soda, 4.207 grammes; so that of the sum of both 

 alkalies potash constituted 41.4 per cent. 



"In another individual, a clerk, on low diet without meat, affected with syphilis but in good 

 general health, the soda discharge was about the same, but that of the potash much less, so that the 

 potash percentage varied from IS to 2G. From these and other observations it wa.s concluded that 

 the daily potash discharge of a healthy person on fever diet is less than one gramme. 



"The febrile cases investigated were one of relapsing fever, one of erysipelas, and several of 

 pneumonia. In the case of relapsing fever, which was observed during part of the first paro.xysm, 

 31 October, 1880. 



